Nursing Care Plan

Princess Osatohangbon

Nursing Care Plan

Nursing Care Plan

Student(s) Name: Uvbi Osatohangbon Date:

Medical Diagnosis:

Assessment Data

Nursing Diagnosis and Related Goals

Nursing Interventions and Rationale

Evaluation

Objective

Anorexia diagnosis

Overexercises

Restrictive diet

Weighs 90lbs when needs to weight at least 120lbs.

Started period at age 13, loss of period at 14.

Subjective

Mother says client has been an “anxious child” since she was young.

Reached out for support to mom and older sister.

Clint mentioned that weighting 90lbs make her “fell more confident”

Nursing diagnosis

Imbalanced Nutrition: Less Than Body Requirements related to excessive exercise and restrictive diet as evidenced by excessive weight loss and loss of period.

Goal statement:

Short- term

With patient family we will plan a food schedule and a weight gain plan

Long- term

Have the client and and the family involve in FBT (family based therapy) until target weight is reached

Nursing Interventions

1. Establish a minimum weight goal and daily nutritional requirements

2. Allow the patient to choose what they eat from a selective menu.

3. Establish a therapeutic nurse-patient relationship

4. Consult a dietician

5. Consider other markers for health

6. Identifying emotions and developing coping strategies.

Rationale

1. Patients with anorexia are fearful of gaining weight. Instead of providing a weight range that may cause patients to feel their number is “too high,” working towards a minimum weight number will help.

2. This way, the patient is made to feel like they are in control of the situation while helping them gain confidence.

3. Developing an unbiased relationship with the patient will help build trust, necessary to treat a chronic eating disorder.

4. The dietician should be the best person in providing the most helpful and unbiased nutritional support for people with eating disorder.

5. When the patient begins to have things like better digestion, return of period, improved energy and sleep they are likely at a stable weight.

6. Client can be assisted in recognizing emotions by asking her to describe those feelings and allowing an appropriate time for a response.

Short term – Met

Met with patient and discussed future plans and weight gain goal and food options

Long term – Met

After 2 weeks of being involved in FBT client reached target weight and showed improvement in her health

References

NANDA International & Herdman, T. H. (2021-2023). NANDA International Nursing diagnoses: Definitions and classification 2012-14.

Wiley Blackwell.

Mayo Foundation for Medical Education and Research. (2022, December 15). High white blood cell count causes. Mayo Clinic. https://www.mayoclinic.org/symptoms/high-white-blood-cell-count/basics/causes/sym-20050611

Nursing Care Plan

Nursing Care Plan

Student(s) Name: Uvbi Osatohangbon Date: Fri. July 4th

Medical Diagnosis: right Total Knee with removal of hardware

Assessment Data

Nursing Diagnosis and Related Goals

Nursing Interventions and Rationale

Evaluation

Objective

Had right Total Knee with removal of hardware (2nd Surgery)

No abnormal vitals

Able to move leg with some assistance.

dressing on Rt leg with some bleeding

Foley removed.

HR: 123 Regular

BP: 150/90

Temp: 37.3 C

RR: 18

O2 Sat: 94% on RA

Subjective

“What does PCA stand for…. I didn’t know I had that.”

Denied pain – “No, at least not right now. I’m sure it will probably kick in later.”

“I was told if I push hard at the beginning the therapy is easier later”

Nursing diagnosis

Readiness for Enhanced comfort as evidenced by desire of quickly getting better.

Risk for Infection related to multiple surgery and abnormal vitals

Goal statement:

Short- term

Patients will demonstrate an understanding of ways to manage pain without the use of a PCA before getting discharged. This will be evidenced by the patient’s ability to explain what a PCA is and ways to manage pain once discharged.

Long- term

Patient will meet with a physiotherapy to go over things that he will or will not be allowed to do. Patient will also discuss exercises to do to get better faster that he will complete on a regular basis to help him get better within at least 6 months.

Nursing Interventions

1. Educate patient on what a PCA is and what it stands for and how patient will manage pain after being discharged.

2. Provide a summary of content that was taught.

3. Get patient to reexplain information that was taught to ensure understanding.

4. Have patient meet with physiotherapist to discuss an exercise plan as well as anything patient needs to know about movement.

5. Ensure Patient environment is appropriate for exercises recommended.

6. Provide patient with relaxation techniques that can be used prior to beginning exercise.

Rationale

1. Educating the patient will provide the patient the knowledge to properly manage pain.

2. This will help ensure that the client doesn’t forget the teaching, reinforcing memory.

3. This will allow to observe whether the patient truly understood the teaching.

4. A meeting with physio will provide the patient with the exercises that are best fit for him as well as provide him with information that could help with the healing process.

5. Environmental modifications can help with comfort as well as making it easier to follow an exercise plan depending in what the exercises are.

6. Relaxation techniques such as deep breathing and guided imagery can help reduce anxiousness and tension to promote a state of greater comfort

Short term – Met

Patient was educated about PCA and pain management after discharge and was able to explain the information given.

Long term –Partially Met

Prior to discharge date patient met with Physio went over exercise and things that he can and cannot do. This goal as been only Partially met as there is no way for me to know right now if patient is completing exercises on a regular basis and as 6 months have not yet passed.

References

NANDA International & Herdman, T. H. (2021-2023). NANDA International Nursing diagnoses: Definitions and classification 2012-14.

Wiley Blackwell.

Mayo Foundation for Medical Education and Research. (2022, April 28). Relaxation techniques: Try these steps to reduce stress. Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/relaxation-technique/art-20045368

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