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1 Nursing Care Plan Project

2 At the end of this presentation…
 Further understanding of the holistic nature of the nursing intervention process should be
explained through the use of pertinent skills (such as data acquisition, verification, problem
solving, goal setting, and observable changes in client condition as indicated by changes in
overall temperament and diagnostic vitals)
3 Client Demographic
1  Patient Initials: J.G.
 Age: 79 years young
 Sex: M
 Room: 108B
 Date of Admission: 12/08/2010
 Diet: Therapeutic

2  Allergies: NKA
 Mobility: Bed Rest [BR]
 Safety Precaution: Fall
 Type of Isolation : None

4 Client Complains of…
 He has survived multiple CVA (cerebrovascular accidents).
 He is aphasic, dysphagic and hemiplegic
5 Medical Diagnoses
 CVA w/ right sided weakness
 Unspecified hemiplegia on dominant side
 Dyslipidemia
 Osteoporosis NOS
 Hypertension NOS
 Dementia
 Atrial fibrillation
 Depression
6 Present History
1  CVA w/ right sided weakness
 Unspecified hemiplegia on dominant side
 Dyslipidemia
 Osteoporosis NOS
 Hypertension NOS
 Dementia
 Atrial fibrillation
 Depression
2  BPH
 GERD
 DMIWO CMPUNCTURED
7 Past Medical History

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 CVA (R), hemiphygia/aphasia, dysphagia

 Hypertension
 HLD
 PAF
 BPA
 Dementia
 Depression
 BPH
 Osteoporosis
 S/P Hip Surgery
8 Laboratory Values
9 Laboratory Findings
10 Complete Blood Count
11 Head to toe Assessment
12 Neurovascular Assessment
1  The client is alert of his surroundings and is oriented to time, place and person.
 Pupils are responsive and pupils dilate to light.
 Client speech is clear.
 Client is ambulating.
 Client is cooperative and calm.
 Client is responsive to verbal cues and prompts
 Client has no pain
13 Respiratory Assessment
 The rhythm and sounds of both lungs are regular and clear of crackles
 The client has no cough; saliva secretions are clear
 Based on timing respirations for a full minute, client respiration is 20
 The client’s chest is symmetrical


14 Circulatory Assessment
1  Apical, carotid, radial, femoral and pedal pulses are normal
 Client also has a strong and regular heart rate
 Client heart rate is normal at 80 bpm
 Client bp is 120/60 with a temperature of 98.6 degrees F
15 GI Assessment
 The client’s abdomen is soft and firm
 The client has been placed on a normal diet and general appetite of the client is good
 The last bowel movement the client had was small and soft
 The client also has active bowel sounds
 The client’s teeth and gums are normal with no signs of dysphagia

16 GU Assessment
 The client is continent with urine color appearing to be amber

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 The client has no Foley catheter, external or other irrigations

17 Musculoskeletal Assessment
1  Client has no contractures and deformities
 Mobility is in tact
 Client needs assistance to the bathroom
18 Integumentary Assessment
 The client’s skin has a warm temperature
 Tissue integrity is intact
 Client skin color is pink
 Mucous membranes are moist
 Skin turgor is good
19 IVs
 Client has no IVs
20 Medications & Vitamins
21 Medications Summary
1  The client is receiving the following medications:
 Fish oil (Omega 3 fatty acids) @ 500 mg PO BID
 Cranberry fruit (cranberry extract) @ 405 mg 1 – QD
 Chlorophyll 1 tab QD
 Calcium w/vitamin D @ 500 mg/200 zu 1-BID for decreased calcium level
 Prozac (Fluoxetine HCl) @ 5 mg 1-QD Dx depression
2  Reglan (metoclopramide HCl) @ 10mg PO Q 6 hrs. PRN for nausea and vomiting
 Cozaan (Losartan Potassium) @ 100 mg hold if SBP < 110 mm Hg for HTN
 No sweets or concentrates
22 Medication Summary
1  Multivitamin w/ mineral: 1 QD
 Vitamin C (Ascorbic acid) @ 500 mg 1-QD
 Colace (Docusate Sodium) 250 mg 1-QD; stool softener
 Flomax (Tasulosin HCl) @ 0.4 mg PO QHS for BPH
 Milk of Magnesia (Magnesium Hydroxide) @ 30 cc PO GPRN; constipation
2  Tylenol (Acetaminophen) @ 325 mg 2 – PO 4 HR PRN for pain
 Dulcolax (Bisacodyl) @ 10 mg via rectal QD PRN ONLY IF MOM [Milk of Magnesium] IS
INEFFECTIVE
 Mylanta (Magnesium Hydroxide)@ 30 cc PO Q 6HR PRN for stomach upset
 Clonindine @ 0.1 mg 1-QID 8 HR PRN BP> 90 - HTN
23 Medication Summary
1  Namenda (Memantine HCl) @ 10 mg PO daily Dx dementia
 Aspirin @ 81 mg daily Dx CVA N/R sided weakness)
 Aluminum Hydroxide and Simethicone @ 30 cc PO QHS GERD
 Zocore (Simustatin) @ 40 mg PO QHS dx hypercholesteroemia

2  Coumadin @ 6mg PO
 Omeprazole @20 mg GERD
 Olendranate sodium@ 70 mg

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24 Fish Oil
1  Omega 3 fatty Acids
 Action: EPA and DHA (found in fish oils) are cardioprotective
 Use: Prevention of MI
 Adverse Effects: Dyspepsia and Eructation
25 Cranberries
1  Action: Cranberries prevent bacterial adherence to host cell surface membranes
 Use: Prevention of UTI
 Adverse Effects: Large doses may produce GI symptoms (e.g. diarrhea or upset stomach)
26 Chlorophyll
 Action: Aid the body in synthesizing carbohydrates
 Uses: Subside symptoms associated with pancreatitis, reducing colostomy odor, and
decrease constipation
 Adverse Effects: Skin hypersenitivity
27 Calcium w/ Vitamin D
 Action: Promotes the absorption of calcium and decreases parathyroid hormone
concentrations.
 Uses: management/treatment of hypocalcemia
 Adverse Effects: CNS: headache, somnolence, weakness. EENT: conjunctivitis,
photophobia, rhinorrhea. CV: arrhythmias, hypertension. GI: abdominal pain, anorexia,
constipation, dry mouth, liver function test elevation, metallic taste, nausea,
PANCREATITIS, polydipsia, vomiting, weight loss. GU: albuminuria, azotemia, decreased
libido, nocturia, polyuria. Derm: pruritus. F and E: hypercalcemia. Local: pain at injection
site. Metabolic: hyperthermia. MS: bone pain, metastatic calcification, muscle pain. Misc:
allergic reactions (pruritis, rash, urticaria).


28 Prozac
1 Action & Uses
2  Action: Selectively inhibits reuptake of serotonin in CNS
 Uses: Major Depressive Disorder, OCD, Bullimia Nervosa, Panic disorder, Depressive
episodes associated with bipolar I (when used with olanzapine), treatment resistent
depression (when used with olanzapine), Sarafem
3 Adverse Effects
4  CNS: NEUROLEPTIC MALIGNANT SYNDROME, SEIZURES, SUICIDAL THOUGHTS, anxiety,
drowsiness, headache, insomnia, nervousness, abnormal dreams, dizziness, fatigue,
hypomania, mania, weakness.
 Misc: SEROTONIN SYNDROME, allergic reactions, fever, flu-like syndrome, hot flashes,
sensitivity reaction.
29 Reglan
1 Action and Uses
2  Action: Block dopamine receptors in chemoreceptor trigger zone of the CNS and stimulate
motility of the upper GI tract and accelerate gastric emptying
 Uses: Treatment and prevention of nausea and vomiting when NG suctioning is
undesirable, management of gastroesophageal reflux, facilitation of small bowel intubation
in radiographic procedures, prevention of chemotherapy-induced emesis

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3 Adverse Effects
4  CNS: drowsiness, extrapyramidal reactions, restlessness, NEUROLEPTIC MALIGNANT
SYNDROME, anxiety, depression, irritability, tardive dyskinesia.
 CV: arrhythmias (supraventricular tachycardia, bradycardia), hypertension, hypotension.
 GI: constipation, diarrhea, dry mouth, nausea.
 Endo: gynecomastia.
 Hemat: methemoglobinemia, neutropenia, leukopenia, agranulocytosis.
30 Losartan
1 Action and Uses
2  Action: Blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II at
various receptor sites, including vascular smooth muscle and the adrenal glands
 Uses: Management of HTN, prevention of stroke in patients with HTN and left ventricular
hypertrophy
3 Adverse Effects
4  CNS: dizziness, fatigue, headache, insomnia, weakness.
 CV: chest pain, edema, hypotension.
 EENT: nasal congestion.
 Endo: hypoglycemia, weight gain.
 GI: diarrhea, abdominal pain, dyspepsia, nausea.
 GU: impaired renal function.
 F and E: hyperkalemia.
 MS: back pain, myalgia.
 Misc: ANGIOEDEMA, fever.
31 Multivitamin
1 Action
2  Action: Contain fat-soluble vitamins (A, D, and E) and most water-soluble vitamins (B-
complex vitamins B1, B2, B3, B5, B6, B12, vitamin C, biotin, and folic acid). These vitamins
are a diverse group of compounds necessary for normal growth and development. Many
act as coenzymes or catalysts in numerous metabolic processes
3 Uses and Adverse Effects
4  Uses: Treatment and prevention of vitamin deficiencies.
 Adverse Effects: GU: urine discoloration (preparations with B vitamins). Misc: allergic
reactions to preservatives, additives, or colorants.

32 Vitamin C
1 Action and Uses
2  Action: Necessary for collagen formation and tissue repair
 Uses: Treatment and prevention of vitamin C deficiency (scurvy) with dietary
supplementation, supplemental therapy in some GI disease during long-term parenteral
nutrition or chronic hemodialysis

3 Adverse Effects
4  CNS: drowsiness, fatigue, headache, insomnia.
 GI: cramps, diarrhea, heartburn, nausea, vomiting.
 GU: kidney stones.
 Derm: flushing.

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 Hemat: deep vein thrombosis, hemolysis (in G6PD deficiency), sickle cell crisis.
 Local: pain at subcut or IM sites.

33 Docusate Sodium
 Action: Promote incorporation of water into stool leading to softer fecal mass
 Uses: Treatment of constipation associated with dry, hard stools and decreased intestinal
motility
 Adverse Effects: F and E: electrolyte imbalances,, dehydration.
 GI: abdominal cramps, nausea, vomiting, diarrhea.
 Derm: rashes.

34 Flomax
 Action: Decreases contractions in smooth muscle of the prostatic capsule by preferentially
binding to alpha1-adrenergic receptors
 Uses: Management of outflow obstruction in male patients with prostatic hyperplasia
 Adverse Effects: CNS: dizziness, headache. EENT: rhinitis. CV: orthostatic hypotension.
GU: retrograde/diminished ejaculation.
35 Milk of Magnesium
 Action: Neutralize gastric acid following dissolution in gastric contents; Inactivate pepsin if
pH is raised to > 4
 Uses: helpful in GERD, hyperacidity, indigestion, heartburn
 Adverse Effects: GI:diarrhea. F and E: hypermagnesemia

36 Acetaminophen
 Actions: Inhibits synthesis of prostaglandins that may serve as mediators of pain and fever,
primarily in the CNS
 Uses: Mild Pain & fever
 Adverse Effects: GI: HEPATIC FAILURE, HEPATOTOXICITY (OVERDOSE). GU: renal failure
(high doses/chronic use). Hemat: neutropenia, pancytopenia, leukopenia. Derm: rash,
urticaria.
37 Dulcolax
 Action: Stimulate peristalsis and alter fluid and electrolyte transport increasing fluid
accumulation in colon
 Use: Treatment of constipation
 Adverse Effects: GI: abdominal cramps, nausea, diarrhea, rectal burning. F and E:
hypokalemia (with chronic use). MS: muscle weakness (with chronic use). Misc: protein-
losing enteropathy, tetany (with chronic use).

38 Clonindine
 Actions: Stimulate alpha-adrenergic receptors in the CNS, which results in decreased
sympathetic outflow inhibiting cardioacceleration and vasoconstriction centers; prevents
pain signal transmission to the CNS by stimulating alpha-adrenergic receptors in the spinal
cord
 Uses: PO, Transdermal: Mild to moderate hypertension
 Adverse Effects: CNS: drowsiness, depression, dizziness, nervousness, nightmares. EENT:

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dry eyes. CV: bradycardia, hypotension (↑ with epidural), palpitations. GI: dry mouth,
constipation, nausea, vomiting. GU: erectile dysfunction. Derm: rash, sweating. F and E:
sodium retention. Metabolic: weight gain. Neuro: paresthesia. Misc: withdrawal
phenomenon.
39 Namenda
 Action: Binds to CNS N-methyl-D-aspartate (NMDA) receptor sites, preventing binding of
glutamate, an excitatory neurotransmitter
 Use: Moderate to severe Alzheimer's demntia
 Adverse Effects: CNS: dizziness, fatigue, headache, sedation. CV: hypertension. Derm:
rash. GI: diarrhea, weight gain. GU: urinary frequency. Hemat: anemia.
40 Aspirin
 Action: Produce analgesia and reduce inflammation and fever by inhibiting the production
of prostaglandins and decreases platelet aggregation
 Uses: Inflammatory disorders, mild to moderate pain, fever, prophylaxis of transient
ischemic attacks and MI
 Adverse Effects: EENT: tinnitus. GI: GI BLEEDING, dyspepsia, epigastric distress, nausea,
abdominal pain, anorexia, hepatotoxicity, vomiting. Hemat: anemia, hemolysis. Derm: rash,
urticaria.Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS AND LARYNGEAL EDEMA .
41 Simethicone
 Actions: causes the coalescence of gas bubbles and does not prevent the formation of gas.
 Uses: Relief of painful symptoms of excess gas in the GI tract
 Adverse Effects: None
42 Aluminum Hydroxide
 Action: Binds phosphate in the GI tract and neutralize gastric acid
 Uses: Lowering of phosphate levels in patients with chronic renal failure, adjunctive therapy
in the treatment of peptic, duodenal, and gastric ulcers, hyperacidity, indigestion, reflux
esophagitis
 Adverse Effects: GI: constipation. F and E: hypophosphatemia.

43 Zocore
1 Action and Uses
2  Action: Inhibits 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, an enzyme
which is responsible for catalyzing an early step in the synthesis of cholesterol
 Uses: Adjunctive management of primary hypercholesterolemia and mixed dyslipidemias
and secondary prevention of myocardial infarction, coronary revascularization, stroke, and
cardiovascular mortality in patients with clinically evident coronary heart disease
3 Adverse Effects
4  Adverse Effects: CNS: dizziness, headache, insomnia, weakness. GI: abdominal cramps,
constipation, diarrhea, flatus, heartburn, altered taste, drug-induced hepatitis, dyspepsia,
elevated liver enzymes, nausea, pancreatitis. GU: erectile dysfunction. Derm: rashes,
pruritus. MS: RHABDOMYOLYSIS, arthralgia, myalgia, myositis. Misc: hypersensitivity
reactions.
44 Coumadin
 Action: Interferes with hepatic synthesis of vitamin K-dependent clotting factors (II, VII, IX,
and X).
 Uses: Management of MI, prevention of thrombus formation and embolization after

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prosthetic valve placement.

 Adverse Effects: GI: cramps, nausea. Derm: dermal necrosis. Hemat: BLEEDING. Misc:
fever.
45 Omeprazole
1 Action and Uses
2  Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing
the final transport of hydrogen ions into the gastric lumen
 GERD/maintenance of healing in erosive esophagitis

3 Adverse Effects
4  CNS: dizziness, drowsiness, fatigue, headache, weakness.
 CV: chest pain.
 GI: abdominal pain, acid regurgitation, constipation, diarrhea, flatulence, nausea, vomiting.
 Derm: itching, rash.
 MS: bone fracture.
 Misc: allergic reactions.
46 Alendranate
1 Action and Uses
2  Inhibits resorption of bone by inhibiting osteoclast activity
 Treatment of osteoporosis in men

3 Adverse Effects
4  CNS: headache.
 EENT: blurred vision, conjunctivitis, eye pain/inflammation.
 CV: atrial fibrillation.
 GI: abdominal distention, abdominal pain, acid regurgitation, constipation, diarrhea,
dyspepsia, dysphagia, esophageal cancer, esophageal ulcer, esophagitis, flatulence,
gastritis, nausea, taste perversion, vomiting.
 Derm: erythema, photosensitivity, rash.
 MS: musculoskeletal pain, femur fractures, osteonecrosis (primarily of jaw).

47 Nursing Care Plan
Constipation
Impaired Physical Mobility
Impaired Verbal Communication
48 Constipation
49 Client Problem
 The client complains of abdominal pain and inability to have a bowel movement for three
days
50 Client Complaints
1 Subjective
2  Stomach pain
 Rectal Pain
 Feeling fatigued
3 Objective

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4  Vitals:
 BP: 110/90
 T:97.8 F
 P: 75
 Resp: 18
 Abnormal bowel sounds
 Patient is taking iron supplement (Ferrous Sulfate)
51 Nursing Diagnosis
 Constipation r/t low fiber intake, decreased activity, and decreased motility of GI tract AEB
abdominal distention and altered bowel sounds
52 Nursing Goals
1 Short Term
2  Soft and formed stool
 Increased comfort due to stool passage
3 Long Term
4  Maintain passage of soft, formed stool every 1 to 3 days without straining by the time of
discharge.
 Passage of stool without aids
 Understanding measures to decrease constipation
53 Nursing Interventions and Rationales
1  Identify factors (like bed rest, diet, medications) that may contribute to constipation.
 Encourage increased fluid intake, unless contraindication.
 Evaluate meds for possible GI side effect.
2  Assessing causative factors is considered a major first step. Find out the why it's happening
so things can change.
 Fluid intake is important for bowel to promote proper stool and consistency.
 Some medications have constipation as a side effect. The client should know that
medication could be a potential cause of constipation.
54 Nursing Interventions and Rationales
1  Instruct client on a high-fiber diet.
 Encourage physical activity and regular exercise, ambulation, and/or abdominal exercise.
2  Fiber absorbs water, adds bulk, softness to stool, and speeds passage through intestine.
 Exercising is a very common way to facilitate defecation

55 Evaluation

 After 8 hours, the client is able to establish a normal bowel pattern

 Consider if the client is:
 able to tolerate increased fluid intake?
 able to understand and demonstrate the needs of medication?
 importance of fiber to diet

56 Impaired Mobility
57 Client Problem

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 The client complains of:

 Pain and stiffness
 Not being able to move dominant side
 General Fatigue
58 Client Complaints
1 Subjective
2  Pain and stiffness
 not being able to move right side
 fatigue
3 Objective
4  Vitals:
 BP: 118/70
 T: 97.2 F
 P: 68
 R: 22
 Joint edema is not present
 Prolonged bed rest
 Paralysis [right sided]
 Unsteady gait
 Pain
59 Nursing Diagnosis
 Impaired physical mobility r/t musculoskeletal impairment secondary to stroke AEB right
sided paralysis and stroke diagnosis
60 Nursing Goals
1 Short Term
2  Client will perform passive range of motion exercises by end of current shift
3 Long Term
4  Client will demonstrate techniques (e.g. range of motion, turning and positioning,
ambulating with devices) that will attain, continue, or restore ADLs in 7 days
61 Nursing Interventions and Rationales
1  Assess joint mobility, muscle strength, and ability to move q4h
 Teach and monitor ROM
 Assess for pain location, quality and severity prn
 Turn client q2h and prn
 Monitor for skin moisture, turgor and appearance

2  Provide baseline data for comparison
 Promote venous return and maintains joint mobility
 For evaluation and baseline purposes
 Minimize pressure on sacrum, back and buttocks
 Intact skin is mainline of defense against infection

62 Evaluation
 After 8 hours, client has some use of muscles and joints increasing ROM
 Can the client…

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 Perform ROM at end of shift (8 hours)

 Client performing more activity and increasing ADL within a month's time
 Both measures should be considered to indicate successful treatment
63 IMPAIRED VERBAL COMMUNICATION
64 Client Problem
 Client complains of having difficulty speaking
 Vital Signs:
 BP: 120/80
 T: 97.2F
 P: 73
 R: 19
65 Nursing Diagnosis
 Impaired verbal communication related to neuromuscular impairment as evidenced by
ability to understand what others say but cannot speak
66 Nursing Goals
1 Short Term
2  Indicate understanding of communication problems
 Establish method of communication in which client needs can be expressed
 Use resources appropriately
3 Long Term
4  Client will communicate ways to cope with impaired verbal communication
 Family will understand established communication to aid the therapeutic process
67 Nursing Interventions and Rationales
1  Assess type and degree of dysfunction because there are a variety of different aphasic
dysfunctions
 Listen for errors in conversation and provide feedback
2  Assessing the type and degree helps the area and degree of brain involvement and helps
determine the type of communication assistance necessary for the client.
 Considering that the client has a CVA with r/sided heiplegia, the client may have lost the
ability to monitor verbal output and become unaware that communication isn't sensible.
Feedback helps the client understand why some people in their immediate care group are
not understanding them and further clarification can be given.

68 Nursing Interventions and Rationales
1  Post notice at the nurse's station and client's room about speech impairment. Provide a
special call bell if necessary.
 Provide alternative methods of communication and demonstrate alternate communication
with client.

2  Performing measures decreases anxiety related to the inability to communicate and fear
that needs will not be met.
 Provides for communication of needs or desires based on individual situation or underlying
issue

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69 Nursing Interventions and Rationales

1  Anticipate and provide for client's needs
 Talk directly to the client, speaking slowly and distinctly. Use yes/no questions to start and
progress in complexity as client responds

2  Helpful in decreasing frustration when dependent on others and unable to communicate
 Reduces confusion and anxiety at having to process and respond to large amounts of
information at one time. As retraining continues, advancing communication complexity
stimulates memory and further enhances word and idea association.
70 Evaluation
 Client understands the type of communication problems he/she has
 Client and nurse establishes method of communication in which needs can be expressed.
 Resources of the client are used appropriately

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