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Nursing Plan of Care

Emily Rittenhouse

Delaware Technical Community College

NUR 320 Health Assessment

Ms. Helen Cameron

April 23, 2023

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The delivery of a care plan is a core component of the nursing practice. This care plan

will address the needs of a patient, Mr. T, who was examined through a physical and interview

assessment. The patient is an adult male patient that has expressed these areas that need

improvement. A care plan has been developed for the patient's two identified current issues of

gastrointestinal reflux and lower extremity joint stiffness. Addressing health problems will aid in

improved quality of life and aim to prevent future diseases.

The first problem identified for this patient is gastrointestinal reflux. The problem was

subjectively communicated by the patient. The patient states that his stomach has been an issue

for him, and he sometimes requires medications such as Pepto-Bismol as needed. It is also noted

that the patient mentioned reflux at least three times in a ten-minute interview and mentioned a

familial history of digestive issues. A study was completed regarding the management of

gastrointestinal reflux. It was found that reflux can be controlled through several avenues,

including medications, supplements, and changes in diet (Cheng & Ouwehand, 2020). Cheng and

Ouwehand also emphasize the avoidance of trigger agents such as caffeine and alcohol as well as

consuming food low in fat and protein (2020). Another study suggested the correction of eating

habits that can lead to reflux, which the authors include as eating too close to bedtime or

consuming meals too hot in temperature (Yuan et al, 2019). Cheng and Ouwehand discuss the

use of proton pump inhibitors and also recommend the introduction of a probiotic, as it was

noted in the article to be beneficial to the upper and lower gastrointestinal tract (2020). The

patient will be encouraged to avoid foods and substances known to trigger reflux and to

encourage healthy eating habits, such as not eating too close to bedtime or too quickly. Mr. T
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will keep a diary over the next month containing what foods he is consuming and when he is

experiencing gastrointestinal reflux to determine if there is an improvement over that month. The

goal would be for Mr. T to experience fewer episodes of gastrointestinal reflux. The patient will

also be encouraged to follow up with a physician in the Gastroenterology Associates Division to

aid in further reflux management.

The next problem identified for Mr. T is joint stiffness. This was identified by the

physical assessment as well as the interview assessment. The patient reports having surgery on

his right hip after an injury and surgery on his right ACL after an injury. Mr. T also reported that

he takes ibuprofen as needed. The patient also reports having an active job, so improving the

patient's joint stiffness will be important to aid in the patient's active job and lifestyle. Upon

assessment of the back and lower extremities, Mr. T was also noted to have some stiffness. This

patient would benefit from the introduction of strengthening supporting muscles in his body. One

study suggests that strengthening the abdominal muscles will provide overall improvement for

the lower extremities. (Jeong et al, 2020). Another study provides information on a medication

called Turmacin which can supplementally be given to improve joint stiffness (Raj et al, 2020).

The author notes that turmeric has been used for a long time in medicine to improve ailments

such as inflammation and swelling (Raj et al, 2020). The goal for Mr. T would be that he would

experience an improvement in his range of motion and improved ability to maintain his active

lifestyle with the introduction of these interventions. Mr. T will be instructed to keep a daily log

of his joint stiffness over a month to determine if adding exercises and daily medication are

effective. It will also be recommended that the patient follow up with an orthopedic specialist,
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such as Frist State Orthopedics, to aid in medication management and determine if he would

benefit from physical therapy.

For evaluation, it would be important to have a follow-up interview with the patient. Mr.

T was asked to keep a diary of his reflux and joint stiffness. First, it would be important to assess

with the patient how he feels about the changes implemented and to determine if he is satisfied

with these interventions. The nurse would also assess for improvement through the patient's view

of his improvement, the patient's view on his current quality of life, assessment of the patient’s

logbook, and physical assessment. It would also be important to determine what each specialists

had to offer regarding his current health problems. If it was determined that one interventions

was not helpful, the less helpful intervention would need to be reevaluated and a different

intervention would be added if needed.

It is crucial to reflect on the assessment and implementation process to see if changes

must be made. I could have improved upon asking more questions about the problem identified

from the patient's perspective. It would have been helpful to determine more background

information on the reflux, such as if the patient had tried any interventions other than

Pepto-Bismol, if there were foods that triggered it, times of day, or how many days in the week

does he experience reflux. Concerning the joint stiffness, it would be helpful to gather more

background information, such as if he has tried anything other than ibuprofen for joint stiffness,

if anything makes the stiffness better or worse, and if the time of day is a factor in the stiffness. It

also would have been a good opportunity for the nurse to ask the patient what his goals are

regarding his gastrointestinal reflux and joint stiffness. One lesson learned regarding the

assessment process is to ask more open-ended questions instead of closed-ended questions to

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gather more information about the patient. When a problem is identified, gathering as much

background information as possible and then partnering with the patient to meet his goals is

important. Through the lessons and teaching on assessment, I hope to be better able to listen,

assist, and advocate for my patients to improve their overall health and wellness.
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References

Cheng, J., & Ouwehand, A. C. (2020). Gastroesophageal Reflux Disease and Probiotics: A

Systematic Review. Nutrients, 12(1), 132. https://doi.org/10.3390/nu12010132

Jeong, J., Choi, D.-H., & Shin, C. S. (2020). Core Strength Training Can Alter Neuromuscular

and Biomechanical Risk Factors for Anterior Cruciate Ligament Injury. The American

Journal of Sports Medicine, 49(1), 183–192. https://doi.org/10.1177/0363546520972990

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Raj, J. P., Venkatachalam, S., Racha, P., Bhaskaran, S., & Amaravati, R. S. (2020). Effect of

Turmacin supplementation on joint discomfort and functional outcome among healthy

participants - A randomized placebo-controlled trial. Complementary Therapies in

Medicine, 53, 102522. https://doi.org/10.1016/j.ctim.2020.102522

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Yuan, L.-Z., Yi, P., Wang, G.-S., Tan, S.-Y., Huang, G.-M., Qi, L.-Z., Jia, Y., & Wang, F. (2019).

Lifestyle intervention for gastroesophageal reflux disease: a national multicenter survey

of lifestyle factor effects on gastroesophageal reflux disease in China. Therapeutic

Advances in Gastroenterology, 12, 175628481987778.

https://doi.org/10.1177/1756284819877788