Practical Nursing Humber ITAL Mini Care Plan

Step 1 Analysis
Student Name: Date:
Week:
Client Age
Living
Diet
Activity
Diagnosis Problem
s
Accommodati
Level
Initials
on
J.C

28

Hospital- CCC

Regular,
G-Feed

Step 1 Assessment All Modes

Physiological (all systems)
Ventilation
Diagnosis:
Anoxic brain injury
History:
None
Lifestyle:
Trache on O2
Assessments:
O2Sat: 92%
R: 18
Rhythm: Steady
Breathing effort: Relaxed
Inspection:
Cough: No
Sputum: Yes, thick and straw
colored
Symmetrical expansion: Yes
Auscultation:
Breath sounds: Soft
o Bronchial: Present
o Vesicular: Present
o Bronchial
Vesicular:Present
Crackles: Yes
Wheezes: No
Medications:
None
Lab Values:
Total CO2: 47 mmHg
Cardiovascular
Diagnosis:
None
History:

No
Activity,
Bedridden

Adaptive/
Ineffectiv
e
+/-

Anoxic Brain Injury, Scrotal

Wound

Problem

-Pt is at risk for low

oxygen absorption

+
+
+
+

-pt is at risk for

subcutaneous
emphysema,
pneumothorax and
hemotomas

+
+
+
+
+
+
+
+
+
-

-Pt is at risk for a

respiratory infection and
difficulty breathing due to
thick sputum

-Pt at risk of chronic

pulmonary disease, URTI,
fluid overload and
pneumonia

+
- Pt is at risk for cardiac
arrhythmias and seizures
+
+

 None
Lifestyle:
- smoker: No Alcohol: No
Assessments:
P:80
b/min and regular
BP: 115/70
O2Sat:92%
on O2
Capillary refill: less than 2
seconds
Inspection:
Skin color: Tanned and pink
Nail beds: Pink
No pallor
No abnormal pulsations visible
on pericardium
Auscultation:
S1 & S2 identified: Present
No murmurs present
Palpation:
Pulses palpable:
o Dorsalis pedis: Present
o Radial: Present
Edema: No
Medications:
- none
Lab Values:
Troponin: 7.3
CK: 25
INR: 1.1
Fluid & Electrolytes
Diagnosis:
-None
History:
- G-Feed
Lifestyle:
-Regular flushes
-Timed feedings
Assessments:
Amount of Fluid taken orally: None
IV: None
Flushes: 1000 ml of water/day

+
+
+
+
+
+
+
+
+
+
+
+
+
+
+

-Pt at risk of pulmonary

hypertension, pulmonary
embolus
- Low creatnine levels increase
the patients risk for type two
diabetes

+
+
+
+
+
+

- Pt is at risk for dehydration

and discomfort due to dry
mucus membranes

G/NG Feeds:1400 ml of feed/day

Inspection:
- G-Feed has no visible secretions of
signs of infection.
Palpation:
Skin turgor: Quickly retracts
back
Edema: No visible signs
Lab Values:
Na: 138
Potassium: 4.0
Chloride: 100
Urea:4.4
Creatinine 25 umol/L
Nutrition
Diagnosis:
-None
History:
-G-Feed
Lifestyle:
-Regular flushes/day
-Times feedings/day
Assessments:
H: 175 cm
W: 79 kg
Type of Diet: G-Feed
(Isosource)
Appetite: Timed
feedings/3x/day
Inspection:
- Skin has no tears or redness
Palpation:
-Soft, no hardening in abdomen
Auscultation:
-Bowel sounds present in 4x
quadrants
Medications:
-Sodium Bicarbonate
-Ranitidine
-Cotazym
Elimination

+
+
+
+
+
+
-

+
-

- Low creatnine levels increase

the patients risk for type two
diabetes

+
+
-Pt at risk for N/V, stomach
bloating and dislodgement

+
+
+
+
+

-Pt at risk for N/V, stomach

bloating and dislodgement

+
-

+
-

-At risk of frequent urination,

N/V, muscle pain and twitching
-At risk of fever, chest pain and
constipation
-At risk of bowel blockage,
D/N/V, stomach pain and
cramping

Diagnosis:
- None

Assessments:
Catheter: yes
Colostomy: no
Urinary output: >30ml/hr
Amount: 1000 ml/day
Color: yellow
Odor: foul
Other: Sediment present in
urine
Infection: no
Bowel Habits: Irregular
Abdomen: Soft, no hardening,
symmetrical
BS x 4 quadrents: Present
Inspect: Skin shows no tears
or redness
Palpate: Soft, no hardening
Auscultate: Bowel sounds
present x4, vascular sounds
present

Medications:
Sodium Docusate
Lactulose
Saccharomyces

Lab Values:
Creatnine: 25 ummol/L
Urea: 4.4
Sodium: 138

Activity & Rest

Diagnosis:
None
History:
None

and urethral injury

-Pt at risk for loss of muscle
tone and weight gain

History:
- Catheter
Lifestyle:
- Low activity
- Bedridden
- Incontinent
- Prone to UTIs

-Pt at risks for frequent UTIs

+
+
+
+
+
+
+
+
+

-Pt at risk for UTIs and skin

rashes
-Pt at risk for kidney failure

-Pt at risks for frequent UTIs

and urethral injury
-Pt at risk for possible UTI or
kidney failure
-Pt at risk for UTI and catheter
being clogged
- Pt at risk for dehydration and
constipation

+
+

+
+

-Pt at risk of cramping, N/V/D

and fluid overload
-Risk of belching, flatulence,
dehydration and cramping
-Risk of constipation, gas and
increased thirst

- Low creatnine levels increase

the patients risk for type two
diabetes

-Pt at risk of weight gain and

decreased muscle tone

Lifestyle:
Immobile
No activity, complete bed rest
Assessments:
(Musculoskeletal Assessments)
- No bilateral strength to
compare
- Pt has regular muscle
spasms/tremblimg
- Pt shows signs of muscle tone
decrese
Physiotherapy:
1x/week to stretch joints and
muscles
Sleep:
Patient sleeps through the
night: yes
Skin Integrity
Diagnosis:
Wound on right buttocks
Inferior scrotal wound
History:
Healed wound on left buttocks
Lifestyle:
Immobile
Assessments:
Skin integrity: Intact
Wounds: 2 wounds
Dressings: Present
Inspection/Appearance
Skin Turgor: Quickly retracts
The Senses
Diagnosis:
Anoxic brain injury
Lifestyle:
Bedridden
No activity
No voluntary muscle
movement
Assessments:
Vision: Good
Hearing: Good
Speech: Impaired
Tactile: Impaired

-Pt at risk for decreased muscle

tone
-Pt at risk for loss of mobility

-Pt at risk for immobility

+
-

+
+

-Pt at risk for infection, redness

and pain
-Pt at risk for infection, redness
and pain

+
-Pt at risk for decrease muscle
tone and bed sores

+
+
+
+

-Pt at risk for infection, redness

and pain

-Pt at risk of limb weakness

and immobility
-Pt at risk for bed sore, low
muscle tone and weight gain

+
-

-Pt at risk for inability to

communicate
-Pt at risk for inability to care
for self, bed sores and
decreased muscle tone
-Patient can experience an
increased risk towards
hazardous situations

- Patient can experience

stomach cramping, nausea,
vomiting, discomfort

 Olfactory: Impaired
Pain: 0 on scale of 0-10
Pain Management: Medication
Medications:
Acetomiophen
Neurological Function
Diagnosis:
Anoxic brain injury
History:
None
Assessments:
Oriented x 1
Mental Status: Incompetent
Behavior: Un-cooperative
Motor Function: Nonoperational
Strength in arms is not equal
bilaterally
Balance is not adequate for
ambulation
Medications:
-Phenytoin
- Baclofen
Endocrine Function/Reproduction
Diagnosis:
None
History:
None
Assessments:
Diabetes: No
Lab Values:
TSH: 1.4
Creatnine: 25
Gamma GT: 742

- Pt at risk of limb weakness

and immobility

+
+
+
+
-

-Pt at risk for falls and hazards

-Pt at risk for falls and hazards
-Pt at risk for falls and hazards
-Pt at risk for falls and hazards

-Pt at risk for falls and hazards

-At risk for decreased
coordination, confusion and
slurred speech
-At risk for SOB, hallucination,
convulsions and muscle
weakness

- Low creatnine levels increase

the patients risk for type two
diabetes
-Ptat risk for heart disease and
liver faiure

Psychological Mode
Self-Concept
Personal self:

+/-

Problem

 Coping mechanism: None

Facial expression: Calm
Gender: Male
Age: 28
Interests to self: Unidentified
Pt is unable to communicate

+
+
+
+
-

Role Function
-Mother involved in regular care
-Pt unable to care for self
-Sister present for visits

+
+

Interdependence
Pt is not dependent due to
brain injury
Pt unable to live alone
Pt is non compliance

-Pt at risk for anxiety and

depression
-Pt at risk for confusion and
depression

-Pt at risk for depression and

loss of self worth

-Pt at loss of independence and

role function leading to
potential depression
-Pt at risk of falls and
depression
-Pt at risk for falls and
depression