EXAMPLE OF A CARE PLAN BY BODY SYSTEM FOR There is Nursing Intervention Classification by

DISORDERS OFTENLY SEEN IN THE ELDERLY NANDA (NIC) available. Example Intervention with
POPULATION. Rationale for the nursing diagnosis of Impaired
Skin Integrity:
Here nursing care with a comprehensive
review and assessment of each individual patient. INTERVENTIONS RATIONALES
The data is then analyzed and a specific plan of 1. Assess skin over Signs of impending or
care developed. The format of each nursing care bony prominences existence of bedsore
plan is as followed. Soft tissue for with most common
reddish brown color, sites at sacrum, heels,
1. Nursing diagnosis Warmth, firmness elbows trochanters and
 This is approved by the North American induration, foul scapula.
Odor and drainage.
Nursing Diagnosis Association (NANDA)
4. Assess patient’s It is necessary to assess
*IMPAIRED SKIN INTEGRITY
mobility status, for they are the causes
presence of
1.1. Etiology Urinary/fecal
 These are the related factors for a incontinence, ability
diagnosis. to move in Bed,
a. It is always stated as “Related to sensitivity to pain
external mechanical and edema
factor, shearing, pressure, friction, 5. Provide position Unrelieved pressure will
physical immobilization, altered change q 2 hours, cause beginning of skin
nutritional state, circulation, maintain body breakdown. Proper
sensation and skeletal prominence. alignment and position and support
b. Defining characteristics for each support with prevents contractures.
pillows, trochanter
actual diagnosis such as disruption
rolls, or pad
of skin surface, skin discoloration,
6. Administer debriding Absorbs tissue exudate
destruction of skin layers open
or wound cleansing and assists in healing in
wound, exudate drainage. Those agents as stages III and IV
characteristics are listed for reframe appropriate. decubitus.
for actual diagnosis with prompts to 7. Wash, rinse and dry Removes body
the user to include specific patient skin with mild soap, excretions that
data from the nursing assessment warm water, soft macerate skin and
towel after each predispose patient to
2. Nursing Outcomes (N0C) Tissue Integrity : Skin incontinent episode. breakdown of skin.

 For a nurse to succeed, she must have first Apply skin barrier if
the Goal which should include a time frame appropriate or
external devices.
for evaluation to be specified by the user.
Appropriate outcome criteria specific for 8. Maintain bed that is Prevents discomfort
the patient are suggested through NOC. wrinkle and crumb and ulcer formation.
free. Change if wet
3. Interventions and Rationales. or soiled.
9. Protect all bony Prevent compromised
 They should be comprehensive. They
prominences. Avoid circulation thar reduces
include pertinent continuous assessments positioning on any oxygen and nutrients to
and observations. Common therapeutic reddish or pink area. tissues.
actions originating from nursing and those 10. Apply treatments as Promotes healing of
resulting from collaboration with the appropriate (heat decubitus.
primary caregiver are suggested with lamp, irrigations,
wet-to-dry
prompts for creativity and individualization.
compress,
Patient and family teaching and
whirlpool).
psychosocial support are provided with 11. Raise head of bed no Elevated head of bed
respect for cultural variation and individual higher than semi- promotes pressure on
needs. When indicated, consultation and fowler’s if tolerated. lower torse from sliding,
referral to other caregivers are suggested. causing friction.
12. Instruct patient of Promotes tissue
need for fluid intake integrity and wound
of at least 2 L per healing which is slower
day, high protein in the elderly.
 dietary intake and management, exercise, adjustment of
suggest nutritionist , insulin dosage
if appropriate.
Instruct patient of  Type 2 or NIDDM non-insulin dependent
need for fluid intake  which the body’s insulin dependence is
of at least 2 L per greater than normal in order to achieve
day, high protein
the glucose level. In order to control the
dietary intake and
sugar level of the patient monitoring of
suggest nutritionist ,
if appropriate. weight and diet is needed. If not,
13. Maintain mobility Maintain circulation and effective medicines are prescribed like
and avoid sitting or prevents tissues’ metformin and other anti-diabetic
lying for prolonged pressure. drugs. Early signs of diabetes are
periods polyuria, polydipsia and glycosuria,
14. Instruct patient and Promotes knowledge of polyphagia, and blurred vision.
family how to care skin protection. Hyperglycemia ca affect all of our body
for skin and systems.
complications of
immobility. Complications of Diabetes wherein often
manifested and felt by the elderlies:

Examples of NIC or Nursing Intervention 1. Disturbed sensory perception – (Visual) as

Classification
1. PRESSURE MANAGEMENT
2. PRRESSURE ULCER CARE
4. DISCHARGE OR Maintenance Evaluation
 refers to evaluation of the patient’s goal
and presentation of data related to the
outcome criteria.
Example:
 Patient will exhibit no presence of
decubitus ulceration.
 Patient will have restoration of skin
integrity with appropriate treatment
Modalities.
 Patient will be able to avoid infection and
necrosis to the skin.
 Patient will be able to demonstrate
progressive wound healing of open
ulcer.
 Patient will be compliant with fluid intake
and proper diet.
 Patient/family will be able to perform
wound care.
 DIABETES due to hyperglycemia that results
from impairment of insulin action and or
secretion, Insulin removes glucose from the
blood and converts it for storage in the body
cells and assist in the metabolism of carbo,
proteins and fats.
 Type 1 or Juvenile Diabetes and IDDM
 the pancreas does not produce
sufficient insulin and patients having this
type must be injected with insulin for
life. Control of patient’s sugar is dietary
related to ineffective flow of blood supply. This
may lead to total blindness if taken for granted.
2. Sexual Dysfunction in relation to neuropathy
affecting our nervous system
3. Risk for impaired skin integrity related to skin
changes as a result of aging process, pressure
on skin surfaces, bed rest and immobility,
claudication brought about bey arterial and
venous circulation, alteration in tissue
prefusion. With defining characteristics of
brown spots, thin dry skin, edema, ulcerations
4. Kidney Problem
5. Cardio-pulmonary problem
6. Gangrenous wound leading to amputation
 VASCULAR DISEASE (PVD) the classic signs of
PVD is intermittent claudication involving pain,
tightness or weakness in an exercising muscle
caused by the decrease in blood supply due to
the occlusion of blood to arteries and vein and
lymphatics in the extremities by plaques which
are known as atheroma’s. Pain occurs initially
only upon walking and is relieved with rest.
Pain progresses when and can evolve ischemic
type of pain.
 The patient may experience decrease of
perfusion of tissue crosis and
gangrenee, ischemia, necrosis and
gangrene may be painless due nerve
damage because of if the patient is
diabetic. Pulse is absent in posterior
tibialis. Sudden pain is sometimes felt if
artery is suddenly occluded by an
embolism, or acute thrombosis. For this
arterial bypass maybe recommended.
 Sometimes, amputation is better. When
blood viscosity is increased because of
increased hct. The potential for clotting
is increased
 Anemia
Nursing Diagnosis
 INEFFECTIVE TISSUE PERFUSION related to
Anemia, lack of blood supply, reduced oxygen
supply, hypoperfusion, hypovolemia, valvular
heart disease, coexisting disease process, age-
related vascular changes and even inactivity
 DEFINING CHARACTERISTICS: Pallor,
confusion, chest pain, conduction
disturbances, dysrhythmias, vital sign
changes, ECG changes, delayed capillary
refill time, chest retractions, dyspnea, nasal
flaring, labored breathing, bradypnea,
changes in mental status, weakness,
paralysis, behavioral changes, abdominal
distension, absent bowel sounds, nausea,
vomiting, edema, absent of peripheral
pulses, skin temperature changes, skin color
changes, decreased peripheral tactile
sensation, oliguria, anuria, increased BUN
and creatinine’ decreased hemoglobin and
hematocrit, alteration in absorption of
vitamins and minerals, abnormal arterial
blood gases, abnormal oxygen saturation.
 RISK FOR DEFICIENT FLUID related to bleeding,
Anemia, lack of adequate blood volume.
 DEFINING CHARACTERISTICS: Hypotension,
tachycardia, decreased skin turgor,
weakness, decreased urinary output, pallor,
diaphoresis, decreased capillary refill,
mental changes, restlessness, hemorrhage,
confusion dysrhythmias.
 IMBALANCED nutrition: LESS THAN BODY
REQIREMENTS related to Anemia, inability to
absorb nutrients that are required for red
blood cell production, inability to absorb
Vitamin B 12, nausea, vomiting, GI bleeding,
increased metabolic processes, decreased level
of consciousness, inability to absorb nutrients
because of biologic or psychological factors
 DEFINING CHARACTERISTICS: actual
inadequate food intake, weight loss,
anorexia, absent bowel sounds, decreased
peristalsis, muscle mass loss, decreased
muscle tone, changes in bowel habits,
nausea, vomiting, abdominal distention, lack
of interest in food, abdominal discomfort,
sore and inflamed buccal cavity, depression,
anxiety, social isolation, changes in mental
status, fatigue from work of breathing,
weakness, activity intolerance, GI bleeding.
 ACTIVITY INTOLERANCE related to reduced
oxygen – carrying capability of blood, Anemia,
fatigue, hypoxia and aging.
 Defining characteristics: lethargy, fatigue,
dyspnea, decreased oxygen saturation
levels, with movement or activity, feelings of
tiredness, weakness, chest pain, palpitation,
tachycardia, and hypertension.
TYPES OF ANEMIA: erythrocyte destruction
1. Microcytic anemia - iron deficiency anemia
2. Macrocytic or megaloblastic – Vitamin B12 or
folic acid deficiency. There is the absence of
secretion of the protein by the gastric mthere
mucosa that is needed to absorb vitamin B12.
Common in patients who have stomach
surgery. Pernicious anemia is a type of
megaloblastic anemia.
3. Normocytic or aplastic anemia appears when
bone marrow does not produce RBC. There is
obstruction by either chemical or physical
means such as hemolysis
4. Autoimmune – acquired conditions that
involves premature erythrocyte destruction
from the person’s immune system.
5. Hemolytic – erythrocytes destruction is
increased and cells have short lifespan.
6. Sickle cell anemia – inherited in which hgb. S is
present in the blood. Making hgb fragile and
looked like sickle. That obstructs capillary flow.
Most beblood celeritous.
7. Thalassemia – there is decreased production of
hgb by the bone marrow and abnormal
appearing of blood cells, causing fragility of
bones, facial deformities, growth retardation
and early death due to heart failure. Symptoms
of anemia include severe fatigue, weakness,
shortness of breath, mental changes,
peripheral edema, depression, pallor and
dizziness.
 MENOPAUSE
 It is also known as the change of life,
occurs when the loss of ovarian function
results in the permanent termination of
menstrual flow. Climacteric as they call
this irreversible period there is the
decline of number of ovarian follicles
there is the decline in the hormonal
response stimulation and by the
decrease of estrogen production until
there is not enough to cause the
endometrium to grow and shed. At
menopause estrogen is secreted by the
adrenal glands and by some degree by
fatty tissue that converts androgen into
estrogen. Bone loss increases and
osteoporosis is a common occurrence
and may result in pathologic fractures.
Treatment for menopause is
symptomatic. Estrogen replacement is
the major choice.