Question

GERONTOLOGY CLINICAL CARE PLAN Case Study
Mr. M, a 76 year old Hispanic woman has just been admitted to the Dumfries Rehab Nursing Center after undergoing right hip replacement surgery 5 days ago. She has a history of Osteoarthritis, DM II, GERD, Rt Knee replacement surgery 5 years ago. She speaks little English.NKDAMeds--Januvia 100mg daily, Glucophage 1000mg BID, ASA 81mg daily, Calcium 600mg Three times/week, MVI 1 tablet daily, Prilosec 20mg daily.Social--Widow with 10 children, 5 of them in the United states and many grandchildren and great grandchildren, never smoked nor used illicit drugs, occasional alcohol on special occasions; retired housekeeper at age 72, with no pension. Family has raised money for her to be able to able to be in rehab. Patient is on limited social security income. Her husband, who died last year has been the supporting his wife with his own business and had been able to provide health insurance while he was alive. But the business is not doing well at the moment and the children are thinking of closing it down, since no one wants to run it.
Design a nursing care plan for the above patient
--DO NOT USE PAIN AS YOUR NSG DX
--THIS IS INDIVIDUAL WORK; STUDENTS WITH SIMILAR WORK WILL RECEIVE A GRADE OF 0.
--PLEASE TAKE YOUR TIME TO USE YOUR CRITICAL THINKING SKILL TO COMPLETE THIS CARE PLAN.
--2 NSG dx, at least 3 SUBJECTIVE & 3 OBJECTIVE, 6 interventions.

Answer 1

NURSING DIAGNOSIS:

1. Activity intolerance

Subjective assessment :

• not able to walk
• not able to change position
• extreme weakness

Objective assessment: on observation, the client

• looked weak
• not able to move or change position
• not able to perform activities of daily living

interventions:

• set goals of activity for the patient
• evaluate the need for help in daily routines
• assist the patient in changing positions every 2 hours
• help the patient with passive exercises
• assist the patient in meeting nutritional needs including feeding
• assist the client in elimination needs including providing bed pan and urinal at the bedside

2. Risk for pressure injury

Subjective assessment:

• extreme weakness
• not able to move
• not able to change position

Objective assessment:

• no active movements
• not able to get up from bed
• in same position for more time

Nursing interventions:

• assess the skin condition in the pressure points
• provide comfort devices
• assist in passive exercises
• assist in daily routine
• change the position every 2 hourly
• maintain wrinkle free bed