Collaborative Nurse/Client Plan of Care – LONGTERM CARE

Client Initials: J.G. Age: 77

Allergies: N/A Medical Diagnoses:

Primary: (reason why client is in care now)
Congenital hydrocephalus
DNR status: DNR
Secondary: (other diagnoses that contribute to
the care plan) Intertrochanteric fracture,
delayed union of fracture, pelvic region and
thigh; pervasive developmental disorder,
cervical disc disorder, osteoporosis, mild
cognitive disorder.

ASSESSMENT
ADLs: (independent / one person assist / two person assist / mechanical lift)
1. Personal hygiene (bathing, grooming and oral care) One-person total assistance, Two person
transfers using mechanical lift.
2. Dressing (ability to make appropriate clothing decisions and physically dress oneself) Extensive
two person assist
3. Eating/Diet (the ability to feed oneself/special dietary considerations) One-person extensive
assist
4. Maintaining continence (both mental and physical ability to use toilet) Mechanical lift and uses
briefs for containment too.
5. Transferring (moving oneself from seated to standing and get in and out of bed) Mechanical lift
used.
Nursing Considerations (Technical Skills): Consider the skills and nursing care required
Wound Dressings/Pressure Ulcers Client is at fall risk due to impaired mobility.
Indwelling Urinary Catheter Skills and interventions:
Oxygen Bed alarm should be always working. Bed
Feeding Tube should be at lowest position whenever the
Physical Restraints resident is in it. Place padded mat on bathroom
Other (e.g., Palliative care / head injury) side of the bed. Apply chair alarm to seat of
wheelchair while up.
Psychological / Psychosocial Considerations Long-term Care Considerations
Cognitive Ability / Cognitive Loss: Alert and Dehydration (signs / risk for): Dry sticky mouth,
oriented x1. fatigue, tiredness. Because of reduced fluid
Mood State / Dementia / Acute confusion / intake and declined water retention of the
Depression: Fluctuating mood state due to body.
declining cognitive ability. Falls (history / signs / risk for): At risk for falls
Psychosocial Well-Being: Reduced social due to impaired mobility. Last fall resulted in a
interaction. broken hip which hasn’t healed properly yet.
Communication (verbal / non-verbal / This incident made the client immobile.
alterations in): verbal communication Nutritional Status (nutrition / diet): Client is on
combined with several non-verbal clues. minced diet as prescribed by her dietician.
Social activity involvement participates in Normally tolerates 75-100% of the diet.
activities of interest and tends to enjoy them Pain: On the scale of 0-10, she reported to have
too. 0 pain.
Urinary Incontinence (management of /
products used): Client is incontinent and uses
briefs for containment.
Bowels / constipation (management of):
Incontinent. Uses product for containment.
Treatments/Procedures/Tests: TIME Medications
1.Quarterly resident medication check Apply BID daily to 1% HC PWD in clotrimaderm 1%
skin fold. CR GM
2. monthly weight check 2-tab TID daily Acetaminophen tab 325 mg
3. daily vitals 1 tab PO daily Calcium tab 500 mg
4. Calcium+ albumin every 2 weeks prior to 1 tab PO daily Citalopram 20 mg tab
prolla administration. (citalopram hydrobromide)
1 time a day every 182 days.
5. CBC, lytes, BUN, CREAT every 60 day. Inject 1 ml SC Denosumab syn
every 6 months
6.PASD for positioning, comfort and pressure 1 cap PO at 0800 Hydromorphone hydrochloride
relief. cap 3 mg
Lab Values Normal vs ½ tab PO at 1200 Hydromorphone hydrochloride
Abnormal/Why and 1700 tab 1 mg
WBC 5.9 Normal 1 tab PO at 1800 Melatonin tab 10 mg
Hgb 5.16 Normal 1 tab PO daily Mirtazapine tab 30 mg
PLT 274 Normal 1 tab PO daily Multivitamin tab
PTT 2 tab PRN Senokot tab
INR Give 30 mg po if Tamiflu cap 30 mg
flu outbreak
Na+ 140 Normal 1 tab PO BID at Trazodone hydrochloride tab 50
1200 and 1700 mg
K+ 4.3 Normal 2 tab PO daily Vitamin D
with calcium 500
mg
CRE 65 Normal
BS
Other:
 Normal Findings
Psychosocial No verbal and/or nonverbal
emotional distress expressed by client and/or
significant others.
Pain Scale (0-10) Client indicates verbally and/or
nonverbally that pain is absent.
Integumentary Skin dry and intact. No evidence
of rash, bruising, or compromise. Mucous
membranes moist.
EENT No obvious drainage, redness, swelling,
edema or mechanical or sensory deficits. Visual aids
and/or auditory aids not required.
Respiratory Respirations regular and unlabored.
Chest movement is symmetrical. Breath sounds are
clear and equal bilaterally with good air entry to the
bases. SpO2>95%. No sputum.
Cardiovascular Heart rate strong, regular and
within normal limits. Skin is warm, dry and pink,
with good pulses in extremities. No peripheral
edema. No calf tenderness.
Gastrointestinal Tolerating and consuming ¾ of
prescribed diet. Nausea and vomiting absent.
Abdomen soft, non-distended. BMs within client’s
normal pattern. Good skin turgor. Last BM?
Neurological Alert orientated x3 (to person, place
and time). Behaviour and verbalization are
appropriate to situation.
Musculoskeletal No joint or muscle weakness,
swelling or tenderness. Functional active ROM of all
extremities. Able to ambulate and transfer
independently.
Genitourinary Urine is clear, yellow or amber. No
foul odour. Frequency within client’s normal
pattern. No indicators of urinary output problems.
Reproductive No evidence of edema, discharge,
bleeding or discoloration.
Time T P RR BP
July 21,2022 36.3 91 16 114/81
August 11, 2022 36 93 18 122/78
NURSING DIAGNOSES
Nursing diagnoses are prioritized in order of importance based on the client’s primary problems or
needs.
1. Fall risk related to declining cognitive ability as witnessed by serious fractures resulting from
previous falls.
2. Fluid volume deficit related to inadequate fluid intake as witnessed by dry mouth, dark
colored urine and tiredness.
PLANNING
Physical Assessment
Reduced social interaction due to decreasing cognitive ability.
Signs of aggression and anger displayed randomly.
On the scale of 0-10, 0 pain indicated.
Skin is dry and intact but is pale and flaky in appearance. Bruising
found in lower extremities of the client.
No drainage, swelling and edema found.
The oxygen saturation was 95% RA, respirations were shallow
with equal chest expansion. Breath sounds were loud and clear.
Heart rate was regular and within the safe range. Heartbeat was
very clear with absence of murmurs and swishing. Skin was
warm, dry and a bit pale. No edema found.
Client is on mined diet with regular fluids. Consumes 80-100% of
the diet with any difficulty. Abdomen was soft and non-
distended on palpation. Last bowel movement was recorded as
regular formed stools. Bowel sounds are present in all 4
quadrants.
Alert and oriented x1. Resident might show signs of aggression
whenever her normal routine is disrupted. And might call you
names because of mild cognitive disorder.
Client has reduced strength in lower extremities due to delayed
union of a hip fracture. Has intertrochanteric fracture and
cervical disc disorder too. Has a history of osteoporosis with low
levels of vitamin D as evidenced by lab reports. Client is totally
dependent on caregivers for ambulation and transfers.
Incontinent uses product for containment. Lower urinary output
due to decreased fluid intake.
No edema, bleeding or discoloration found.
O2 O2 Usage VS Normal/Abnormal/Why
Sat
94% n/a Normal within safe range.
95% n/a Normal within safe range.
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 not experience falls in the next 3 1. client will not suffer from any injuries
weeks. related to falls in next 3 months.
2. Client would consume prescribed amount of 2. Client would show reduction in signs of
fluid. dehydration over the next 2 months.
Outcome Criteria
1. The client would be at lower risk for fall related injuries.
2. Reduced signs and symptoms of dehydration.
IMPLEMENTATION
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 and
client/family education and health teaching.
1. Apply chair alarm to seat of wheelchair while client is using it and check to ensure its working.
2. Padded mat on the floor whenever client is in bed.
3. Monitoring input and output of the client by maintaining a fluid balance sheet which would
include episodes of vomiting, diarrhea, intake of fluids etc.
4. Administer electrolyte replacements as needed/as ordered.
5. Ask about oral fluid preferences and provide preferred fluids within the ordered restriction. 
EVALUATION
Monitoring goals and outcome criteria that have been met and/or not met and the client’s
responses to therapy.
1. client doesn’t witness any fall related injury in next 6 months.
2. client has proper fluid intake in order to reduce chances of developing dehydration.

REPORTING (RECEIVING & GIVING)

Hi, my name is Yasmeen Kaur, and I am calling from mill creek
S (Situation)
care center to talk about a 77-year-old, female client named J.G
who I suspect might be at risk for dehydration.
The client was admitted into the facility because she has a
B (Background)
history of Congenital hydrocephalus, intertrochanteric fracture,
delayed union of fracture, pelvic region and thigh, pervasive
developmental disorder, cervical disc disorder, osteoporosis,
mild cognitive disorder. Client is alert and oriented x 1 and has
no known allergies.
On assessment all her vital signs were in the normal range.
A (Assessment)
While interacting with the client she seemed a bit frustrated and
confused. Her skin is intact, dry but lacks turgor. Her mouth and
lips were dry, and her urine was dark yellow and concentrated.
She was feeling unexplained fatigue.
Ask physician to order some electrolytes for the patient, infuse
R (Recommendation/request)
more water based foods in diet and report attending physician
about clients condition if things excavate.