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Care Plan #1

Yasmeen Kaur

Practical Nursing, Georgian College

NRSG2001: Medical/Surgical Nursing Theory

Professor: Rhonda Van Der Voort

Due Date: Tuesday, June 20, 2023

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Collaborative Nurse/Client Plan of Care –Medical/Surgical: Acute CARE

CLIENT INFORMATION AND HISTORY (3 Marks)
Client Initials: J.M. Age: 84

Allergies: Caffeine, codeine, sulfa, lactose Medical Diagnoses:

Primary: Admitted with humoral and hip fracture, severe abdominal distention,
Code status : Full code and nausea.
A fracture of the hip refers to “a fracture of the proximal (upper) third of the
femur, which extends to 5 cm below the lesser trochanter.” (Lewis, 2019, pg.
1525). A humerus fracture is a break of the humerus bone in the upper arm.
Nausea is “A feeling of discomfort in the epigastrium with a conscious desire to
vomit.” (Lewis, 2019, pg. 924). Abdominal distention is “a feeling of increased
pressure with swelling in the abdomen.” (Lewis, 2019, pg. 878)

Secondary: Metastatic prostate cancer with involvement of lymph nodes and

skeleton, type II diabetes, hypertension, dyslipidemia, abdominal aortic
aneurysm, spinal lesions, anemia and chronic kidney disease.
 Prostate cancer is “a malignant tumor of the prostate gland. Prostate
cancer is an androgen-dependent adenocarcinoma that is usually slow
growing. The cancer later spreads through the lymphatic system to the
regional lymph nodes. The bloodstream seems to be the mode of
spread to pelvic bones, head of the femur, lower lumbar spine, liver,
and lungs.” (Lewis, 2019, pg. 1371)
 Type 2 Diabetes Mellitus is “a multisystem disease related to abnormal
insulin production, impaired insulin utilization, or both” (Lewis, 2019,
pg. 1868)
 Hypertension is a “sustained elevation of systemic arterial blood
pressure” (Lewis, 2019, pg. 1872)
 Dyslipidemia is “the imbalance of lipids such as cholesterol, low-density
lipoprotein cholesterol, (LDL-C), triglycerides, and high-density
lipoprotein (HDL)” (Kopin & Lowenstein, 2017)
 An abdominal aortic aneurysm is “an irreversible dilatation of the
abdominal aorta. The majority of abdominal aortic aneurysms are
asymptomatic and identified incidentally.” (Hellawell et al., 2020)
 A spinal lesion is classified as “any abnormal change to the spinal tissue
or spinal cord. Some common types of spinal lesions include tumors,
cancers, fluid sacs or any other types of growths that disrupt normal
back function.” (Sinicropi, 2017)
 Chronic kidney disease (CKD) involves progressive, irreversible loss of
kidney function (Lewis, 2019, pg. 1116)
 Anemia is “a deficiency in the number of erythrocytes (red blood cells),
the quantity or quality of hemoglobin, the volume of packed RBCs
(Hematocrit) or a combination of these” (Lewis, 2019, pg. 1864).
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NURSING INFORMATION AND CLINICAL SKILLS (2 Marks)

ADLs: (independent / one person assist / two person assist / mechanical lift)
1. Personal hygiene (bathing, grooming and oral care): “J.M.” is two person assist and requires complete assistance with bathing,
grooming and oral care.
2. Dressing (ability to make appropriate clothing decisions and physically dress oneself): “J.M.” is two person assist. He is able to
choose appropriate clothing but requires assistance from 2 people to dress him.
3. Eating/Diet (the ability to feed oneself/special dietary considerations): “J.M.” requires set up help only but is able to
independently feed himself. He is on a regular diet.
4. Maintaining continence (both mental and physical ability to use toilet): “J.M.” is continent, both mentally and physically.
Currently he is using urinals and a bedside commode as he has generalized weakness and is partially weight bearing on right leg.
5. Transferring (moving oneself from seated to standing and get in and out of bed): “J.M.” is a two person assist using sit to stand lift
currently. He was independent before getting his hip and humerus fractured.

Nursing Considerations: Skills Required for Nursing Considerations:

 Glucometer Checks QID – Before meals
& at bedtime
 IV Located left antecubital – 22 Gauge:
Used for unfractionated heparin.
 Stage 3 pressure wound on coccyx.
 Falls risk.
 Daily head-to-toe assessments.
 Vitals Q8H include assessing for pain and nausea.
 Monitoring PTT levels according to agency because of heparin.
 IV site checked, secured, and flushed every shift.
 Wound dressing should be changed as ordered.
 Wound dressing assessed every shift to ensure dressing intact and to
monitor drainage.
 Doing hourly checks on the client, keeping urinals and call bell within reach.

HEAD TO TOE ASSESSMENT ABNORMAL FINDINGS: (4 Marks)

Psychosocial: No verbal and/or nonverbal
emotional distress expressed by client and/or
significant others.
Pain Scale (0-10): Ideally a client should report a
score of 0 on pain scale without any
interventions.
Integumentary: No evidence of rash, bruising or
edema. Mucous membranes are moist. Color
normal based on ethnicity. Nail beds pink. No
cyanosis.
EENT: No obvious drainage, redness, swelling,
edema. No hearing aids required. Pupils round
and reactive to light.
Respiratory: Chest movement is symmetrical.
Respirations regular and unlabored. Breath
sounds are vesicular/ clear. SpO2>95% on room
air.
Cardiovascular: Heart rate is strong, regular and
within regular limits. Pulses are present in lower
extremities. Skin is warm, dry, and pink. Cap refill
less than 2 sec. No peripheral edema. No calf
tenderness.
Abnormal Findings: Client doesn’t have a good support system. The wife has
advanced dementia and requires full assistance in ADL’S. PSW visits 5 days a
week to care for the couple.
Abnormal Findings: On a scale of 0-10 client reported a score of 8/10 and
reported having extreme pain in pelvic region. According to him, the pain was
being caused due to his fractures and subsides with repositioning and analgesics.
Abnormal Findings: Skin dry and cracked at lower extremities. Stage 3 pressure
wound at coccyx. Radiation induced excoriation in groin.
Abnormal Findings: Client suffers from myopia and uses glasses. Blurry vision in
right side and partially clouded lens.
Abnormal Findings: Client reported having productive occasional cough. Sputum
was clear and thick.
Abnormal Findings: Client has hypertension and baseline of 140/90.
Dyslipidemia is secondary diagnosis of the client which is causing imbalance of
cholesterol in body.

Gastrointestinal: Tolerating and consuming ¾ of Abnormal Findings: Distended abdomen, nausea, no flatus passing, and
prescribed diet. No reports of emesis. Good skin constipation were observed in the client. Decreased bowel sounds in all
turgor. quadrants.
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Neurological: Alert orientated x3 (to person, Abnormal Findings: No abnormal findings in neurological assessment.
place, and time). Behavior and verbalization are
appropriate to a situation.

Musculoskeletal: Ideally a client should have
functional active ROM of all extremities. No joint
or muscle weakness, swelling or tenderness and
should be able to ambulate and transfer
independently.
Genito-urinary: Urine is clear, yellow, or amber.
No foul odor, no sediments present. Bladder non
palpable. No urinary distension.
Abnormal Findings: Generalized weakness and humerus, pelvic fractures which
inhibits full ROM in extremities. Non weight bearing on right leg. Requires
mechanical lift for transfers out of the bed. One person assist with ambulation.
Swelling in right shoulder and pelvic region
Abnormal Findings: Elevated creatinine and bun levels due to decreased
functioning of kidneys. Polyuria, glucosuria and ketonuria evident in client.

Reproductive No evidence of edema, discharge, Abnormal Findings: History of prostate cancer with left testicle removal.
bleeding, or discoloration.

(Kozier,2018).

Time T P RR BP O2 Sat O2 Usage VS Normal/Abnormal/Why?

0800 37.3 52 18 105/58 98% Room air The Normal pulse rate is 60-100 whereas in this
case, pulse rate of 52 is abnormal/ low which is
caused by Ca+2 channel blockers (Amlodipine)
taken by the client (Lewis, 2019, pg. 744). Normal
blood pressure is 120/80. Hence, the bp of 105/58
is considered abnormal (Kozier, 2018, pg. 653).
Amlodipine can cause low blood pressure and
reduced heart rate as it causes the heart muscles
to relax and reduces their contractility which
ultimately causes the BP to drop (Skidmore-Roth,
2020). All other vital signs are within normal
range.
0200 36.5 54 18 118/78 100% Room air The Normal pulse rate is 60-100 whereas in this
case, pulse rate of 54 is abnormal/ low which is
caused by Ca+2 channel blockers (Amlodipine)
taken by the client (Lewis, 2019, pg. 744). All
other vitals are within the normal ranges.

TREATMENTS/TESTS/PROCEDURES (2 Marks)
1. Bone mineral density (BMD) test scheduled on June 17, 2023,
2. Pelvic and humoral CT scan on bi-weekly basis.
3. Urinalysis on June 17, 2023.

LAB VALUES (2 Marks) Normal Reference Range vs Abnormal/Why?

WBC 13 High Normal Range: 5 – 109/L - client has metastatic prostate cancer
Hgb 92 Low Normal Range: 120 – 160 g/L – Due to chronic kidney disease which leads to anaemia.
PLT 290 Normal Normal Range: 150 – 400 x 109/L
PTT 90 High Normal Range: 60 – 70 seconds – High due to heparin.
Na+ 149 High Normal Range: 135 – 145 mmol/L – High due to chronic kidney disease
K+ 4.3 Normal Normal Range: 3.5 – 5.0 mmol/L
CRE 116 High Normal Range: 44-97 mcmol/L – High due to chronic kidney disease
BS (fasting) 10 High Normal Range: 4-6 mmol/L – High due to type 2 diabetes mellitus
RBC 3.12 Low Normal Range: 4.7 to 6.1 million/mcL – Low due to anemia caused by chronic kidney disease.
(Lewis, 2019, pg. 1854 – 1858).
APA, REFERENCES, SPELLING (2 MARKS) =15 MARKS FOR PART ONE
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CARE PLAN PART TWO STARTS HERE

MEDICATION (4 Marks)

1. Hydromorphone: 0.5 mg, PO, Tablet, Q4H, Reason: Opioid analgesic for pain management of hip and humoral fracture.
(Skidmore-Roth, 2021)
2. Humalog: 30 units, SC, Q6H scheduled, Reason: Short acting insulin for diabetes mellitus.
 Sliding scale for dosage based on reading of glucometer, SC, AC (before meals), Reason: Short acting insulin for
diabetes mellitus.
(Skidmore-Roth, 2021)
3. Tylenol: 500 mg, PO, Tablet, QID, Reason: Analgesic antipyretic for pain management.
(Skidmore-Roth, 2021)
4. Metformin: 500 mg, PO, Tablet, Q12H, Reason: Non-sulfonylureas/ Biguanides for type 2 diabetes.
(Skidmore-Roth, 2021)
5. Fragmin: 3000 IU, SC, Once Daily, Reason: Low molecular weight heparin or anticoagulant to prevent clots in patient as
patient is immobile due to fractures.
(Skidmore-Roth, 2021)

6. Rosuvastatin: 10 mg, PO, Tablet, QHS, Reason: Statins for dyslipidemia.

(Skidmore-Roth, 2021)
7. Senokot: 17.5 mg, PO, TABLET, once daily, Reason: Stimulant laxative for constipation.
(Skidmore-Roth, 2021)
8. Aspirin: 50 mg, PO, Tablet, Q12H, Reason: NSAID/Salicylate for chemoprophylaxis of deep vein thrombosis (DVT) as client is
post-op.
(Skidmore-Roth, 2021)
9. Amlodipine: 5 mg, PO, Tablet, QID, Reason: Ca+2 channel blockers for hypertension
(Skidmore-Roth, 2021)
10. Stemetil: 10 mg, PO, Tablet, Q8H, Reason: Antiemetic/ Phenothiazine for severe nausea.
(Skidmore-Roth, 2021)

PLANNING (2 marks)
Planning includes short and long-term goals and outcome criteria which are specific, and client/family centered. Goals are broad,
realistic, and objective whereas outcome criteria are more specific descriptions of how goals will be attained.
Short Term Goals Long Term Goals

1. Client will be able to perform correct body mechanics,
reducing his risk for further injury.
2. The patient will be able to express alleviating pain and
exhibit the ability to conduct activities of daily living
with minimal complaints of discomfort.
1. The client will be able comprehend and accept skeletal
integrity and acknowledge the need for help; identify
and address potential environmental variables; and
exhibit lifestyle modifications encouraging bone
integrity and preventing further injury.
2. The patient will be able to regain mobility and function
at their normal and optimal level.

IMPLEMENTATION (2 marks)
Implementation involves nursing interventions or actions such as: nursing skills, collaborative activities with the client/family or
other health care providers, carrying out doctor’s orders (medication administration) and client/family education and health
teaching. Include a rationale for why, you performed a certain skill, activity and/or health teaching.
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1. Maintain limb rest and provide support to joints of both below and above of the affected limb, especially during movement
or turning. It gives stability and reduces the possibility of disturbing the alignment (Newfield et al., 2007). Support fracture
with pillows and maintain affected part in neutral position with trochanter rolls, or footboard. It prevents unnecessary
disruption of alignment and pressure deformities in the drying cast (Newfield et al., 2007). Check for edema. As swelling
subsides, a readjustment of splint or application of plaster may be done to ensure alignment of the bone (Newfield et al.,
2007). Administer medications prior to activities. It promotes muscle relaxation and encourages the client to participate in
rehabilitative activities (Newfield et al., 2007). Perform and supervise client with active and passive ROM exercises. It
promotes strength and mobility of unaffected muscles and facilitates healing of surrounding trauma (Newfield et al., 2007).

2. Establish realistic goals for improving the patient’s activity level, considering the patient’s physical limitations and energy
level to help improve the patient’s quality of life. Assess vital signs during times of discomfort, including blood pressure,
heart rate and rhythm, and respiration. Assess patient’s signs and symptoms of pain and administer pain medication, as
prescribed. Monitor and record the medication’s effectiveness and adverse effects. Perform comfort measures to promote
relaxation, such as massage, bathing, repositioning, and relaxation techniques. These measures reduce muscle tension or
spasm, redistribute pressure on body parts, and help patient’s focus on non–pain-related subjects (Ralph & Taylor, 2011).
Provide encouragement if the patient achieves even small improvements in his activity level to help restore self-confidence
(Ralph & Taylor, 2011). Encourage the patient to express his feelings about the decreased energy levels that may
accompany advanced age to enhance acceptance (Ralph & Taylor, 2011). Educate and assist in performing proper body
mechanics in sitting, assisted walking as indicated. It provides an avenue for the client to develop a sense of self-reliance
and would guide client appropriately within precautionary measures. (Newfield et al., 2007).

EVALUATION (2marks)
Monitoring goals and outcome criteria that have been met and/or not met and the client’s responses to the nursing care interaction.

1. The client displays proper body mechanics while repositioning in the bed and supports the affected joints while turning. Client
realizes the importance of assistance and uses the call bell for help to reduce the chances of accidental injuries. Client accurately
performs ROM exercises as taught by physiotherapists in supervision. Moreover, clients verbalize their concerns and feelings
whenever they feel anxious or want further education to cope with a situation.

2. Client starts doing isometric exercises with physiotherapist to maintain muscle integrity. Ambulates with partial assistance from
personal support workers and exhibits proper body mechanics while doing so. On a pain scale of 0-10, the client rates the pain to be
a 3 while repositioning and a score of 4 while ambulating. Client showcases the desire to practice relaxation techniques to reduce
the usage of analgesics for pain management.

SBAR REPORT: (3 marks)

I am Yasmeen kaur, a second year registered practical nursing student. I am calling about
S (Situation)
“J.M.”, he is an 84-year-old male admitted to the cancer and palliative unit due to
humoral and hip fracture with severe abdominal distention and nausea.
“J.M.” is allergic to codeine, lactose, sulfa and caffeine. He is a full code. He has a past
B (Background)
medical history of Metastatic prostate cancer with involvement of lymph nodes and
skeleton, type II diabetes, hypertension, dyslipidemia, abdominal aortic aneurysm, spinal
lesions, anemia, and chronic kidney disease. “J.M.” lives with his wife in a community
home setting and has a personal support worker visiting him 5 days a week for his wife’s
Alzheimer’s. While trying to help his wife, he fell from the stairs and ended up with a
fractured humor and hip. He is expressing decreased ambulation and complains about
severe pain and nausea.
On assessment “J.M.” had a temperature of 37.3, pulse of 52, respiration rate 18, blood
A (Assessment)
pressure of 105/58 and Sp02 of 98% on Room air. His pulse rate is a bit low. His diastolic
blood pressure is concerning for me. He is getting unfractionated heparin through a 22-
gauge IV located in the left antecubital. “J.M.” repeated complains about nausea and
distended abdomen. His creatinine and bun levels are elevated due to impaired kidney
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functioning.
I recommend reassessing the patient for a different medication for nausea as Stemetil is
R (Recommendation/request)
not working for her. Her dosage of amlodipine should also be reassessed as her pulse is
always in the range of 50-54. Moreover, can we please do some additional tests to
evaluate his kidney functioning.
APA, REFERENCES, SPELLING (2 MARKS) = 15 Marks

REFERENCE PAGE FOR BOTH PART ONE AND TWO, MAY REUSE REFERENCES FROM PART ONE FOR PART TWO
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References

Hellawell, H. N., Mostafa, A. M. H. A. M., Kyriacou, H., Sumal, A. S., & Boyle, J. R. (2021). Abdominal aortic

aneurysms part one: Epidemiology, presentation and preoperative considerations. Journal of

perioperative practice, 31(7-8), 274–280. https://doi.org/10.1177/1750458920954014

Kopin, L., & Lowenstein, C. (2017). Dyslipidemia. Annals of internal medicine, 167(11), ITC81–ITC96.

https://doi.org/10.7326/AITC201712050

Kozier, B., Erb, G., Berman, A., Snyder, S. J., Frandsen, G., Buck, M., Yiu, L., & Stamler, L. L. (2018).

Fundamentals of Canadian Nursing: Concepts, Process and Practice (4th Canadian ed.).

Toronto, ON: Pearson.

Lewis, S, Bucher, L., Heitkemper, M., Harding, M., Barry, M., Lok, J., Tyerman, J., & Goldsworthy, S.

(2019). Medical-Surgical Nursing in Canada: Assessment and Management of Clinical

Problems (4th Canadian ed.). Toronto: Elsevier.

Newfield, S. A., Cox, H. C., Sridaromont, K. L., & Maramba, P. J. (2007). Cox’s Clinical Applications of

Nursing Diagnosis: Adult, Child, Women’s, Mental Health, Gerontic, and Home Health Considerations.

F A Davis Company.

Ralph, S. S., & Taylor, C. M. (2011). Sparks & Taylor’s Nursing Diagnosis Reference Manual. LWW.

Sinicropi, S. (2017, August 8). What Are Spinal Lesions? | Minnesota Spine Surgeon - Dr. Sinicropi. Dr. Stefano

Sinicropi, M.D. https://sinicropispine.com/what-are-spinal-lesions/

Skidmore-Roth, L. (2020). Mosby’s 2021 Nursing Drug Reference. Mosby.

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