Advanced Adult Health NR4435 Weekly Care Plan

Student Name: Santana Francisco Clinical Site: MICU VA_ Date: __________
Client Initials: _AM_______Age: _84____Sex: _M_____ Admission Date: 01/29/16
Cultural Considerations: widower, 2 daughters, 4 grandchildren, Baptist, Basketball favorite sport
Actual Nursing Diagnosis #2

Priority Nursing Diagnosis #1

Impaired physical mobility r/t decreased muscle
control AEB tremors
Subjective data:
Client stated that he has an unsteady gait, doesnt
like to walk because he, walks like a drunk man
Client stated that his feet feel like sponges (numb)
Pain: 0
Objective data:
Clients hands tremor excessively when trying to
eat
Client has 1+ edema in left lower leg with
sores/scabs and dry skin with some discoloration
Blood sugar 219 at 1100

Decreased Cardiac output r/t altered heart rhythm AEB varying EKG
readings, low blood pressure recordings and soft heart sounds
Subjective data:
Client stated that he decided to go to hospital because he felt a
fluttering in his chest
Stated that he would have sensation to urinate but nothing would come
out
Objective data:
Has a pacemaker
B/P: 0800- 83/71; 0900:96/80; 1000:93/75; 1100:85/90
HR: 0800:117; 0900:87; 1000: 93; 1100: 102
Soft heart sounds
Troponin: 0.10-high
Temp: 0900: 96.9F
Creatinine: 3.08-high
V-tach & multifocal atrial tachycardia evidenced on EKG
Decreased breath sounds in R&L lungs; on 4L of O2 Nasal Cannula
Orange/cloudy urine on admit
1000ml Urine Output from 0700-1430 from foley

Functional Health Pattern: Activity-Exercise

Admitting Medical Diagnosis:

Sepsis

Risk for Nursing Diagnosis #3

Risk for falls r/t impaired physical mobility AEB
clients unsteady gait when walking
Subjective Data:
Client states that his feet feel like sponges and
he cant feel what is underneath him when he
walks
Objective Data:
84 years old
Unsteady gait
Clients hands tremor excessively when trying to
eat
Lives alone
Has difficulty hearing
Experiencing sleeplessness from inability to
sleep previous night
No assistive devices available to walk with

Client Outcome
Client Outcome
1.
2.

Client will demonstrate a willingness to feed himself

during meals by the end of the clinical shift
Client will independently change positions in bed
every 2 hours to prevent development of pressure
sores

1.

Client Outcome
1. Client will maintain a blood pressure between
90/60- 120-80 throughout the clinical shift
2. Client will maintain a urine output of 30 ml/hr
throughout the clinical shift
Interventions & Rationales

Interventions & Rationales

1.Performed assessment and recorded baseline vitals on arrival which were
HR: 117BPM; BP: 80/71 RR: 15 Temp: 96.1F Pain: 0 and decreased lung
sounds in R&L lungs. Also noted that client has trace edema in left lower
leg with sores and discoloration. Getting baseline data provides
opportunities to track changes Doenges,Moorhouse, Murr, 2006 p.128
2.Used pillows to prop clients feet once edema was noted. Also placed
pillows underneath his knees to maintain position of function and reduce
risk of pressure ulcers Doenges,Moorhouse, Murr, 2006 p.354
3. Encouraged client to feed himself during meals despite the tremors he
experiences in his hands during activity which is important because it gives
him a sense of independence Doenges,Moorhouse, Murr, 2006 p.355

1. Performed assessment and recorded baseline vitals on arrival which

were
. HR: 117BPM; BP: 80/71 RR: 15 Temp: 96.1F Pain: 0 and
decreased lung sounds in R&L lungs. Getting baseline data provides
opportunities to track changes Doenges,Moorhouse, Murr, 2006 p.128
2. Administered/ hung piperacillin/Tazobactam 2.25g in 50ml over
30 min q 6H as a prophylactic antibacterial drug because sepsis is a
systemic inflammatory response to a documented or suspected
infection Lewis, Dirksen, Heitkemper, Bucher, 2014 p.1636

3. Administered/maintained supplemental oxygen 4L via nasal

cannula to increase oxygen to available tissues
Doenges,Moorhouse, Murr, 2006 p.128

1.The client will not experience any falls by the end

of the clinical shift
2. The client will identify 2 risk factors that
contribute to his fall risk by the end of the clinical
shift
Interventions & Rationales
1.Performed assessment on arrival and client was oriented x4
because cognitive function affects ability to perceive fall risk
Doenges,Moorhouse, Murr, 2006 p.228
2. Reviewed clients medication record and discovered client
takes atorvastatin which can cause muscle pain/spasm which
can contribute to fall risk. Client stated that he was aware of this
Doenges,Moorhouse, Murr, 2006 p.228
3. Assessed clients muscle strength by having him grab my
hands and squeeze tight. He could squeeze tightly but displayed
tremors in hands during activity but not at rest. This contributes
to his fall risk as he may not be able to catch himself quickly
during a fall as coordination affects safety Doenges,Moorhouse,
Murr, 2006 p.228

4. Put bed rails up on both sides after each assessment to provide safety

4. Promoted rest by turning off lights and keeping the TV

related to numbness client feels in feet and his tremors

Doenges,Moorhouse, Murr, 2006 p.355
5. Encouraged client to reposition himself in bed every 2 hours (whenever I
came in to do the assessment which was q2h) to prevent the formation of
pressure ulcers and promote self-care Doenges,Moorhouse, Murr, 2006
p.354

Doenges,Moorhouse, Murr, 2006

6. Discussed clients feelings regarding his tremors and

unsteady gait because frustration or powerlessness can
hinder him reaching his goals. Client stated that his tremors
frustrate him but he tries to get as much done as possible.
Client also stated that his unsteady gait has him reluctant to
go do things he enjoys like walking in the park because he
looks like a drunk man because he cannot feel his feet
underneath him. Doenges,Moorhouse, Murr, 2006 p. 354

Evaluation
1. The goal was met as the client fed himself during
breakfast and lunch by the end of the clinical shift

2.The goal was not met as the client did not

reposition himself when asked to do so throughout
the clinical shift.

volume on low in order to maximize sleep periods since client

reported an inability to sleep the night before

p.129
5. Monitored vital signs every hour to monitor
therapeutic response of all activities Doenges,Moorhouse,
Murr, 2006 p.129
6. Monitored cardiac rhythm with nurse Jossy to note
effectiveness of clients pacemaker in relation to his sepsis
diagnosis and the IV fluids he has received since being
admitted Doenges,Moorhouse, Murr, 2006 p.129

4. Assessed clients personality and mood which was

cooperative but very independent which would
influence his willingness to ask for help. This could
affect his attitude toward safety issues and put him at
an increased risk for falls because he does not like to
ask for help Doenges,Moorhouse, Murr, 2006 p.228
5. Discussed clients risk factors for falls which client
stated that his unsteady gait, being 84 years old and
living alone were his risk factors for falls.
Identification of these risk factors helped the client
perceive the reality of his ability p.229
6. Identified needed interventions (with nurse Jossy)
with clients family (2 daughters) as getting him a
walker and the possibility of changing his living
situation to promote a safe environment and individual
safety Doenges,Moorhouse, Murr, 2006 p.228

Evaluation
1.The goal was partially met as the clients blood
pressure fluctuated throughout the clinical shift
with the lowest recording being 83/71

Evaluation
1.The goal was met as the client did not
experience any falls by the end of the clinical
shift

2. The goal was met as the client maintained a

urine output of 30ml/hr throughout the clinical
shift

2.The goal was met as the client identified his

three risk factors being his age, living alone and
unsteady gait by the end of the clinical shift

Doenges, M.E., Moorhouse, M.F., & Murr, A. (2006). Nurses pocket guide: diagnoses, prioritized interventions and rationales (10th ed.).
Philadelphia, PA: [Jackson, WY: F.A. Davis.

Lewis, S.M., Dirksen, S.R., Heitkemper, M.N., & Bucher, L. (2014). Medical- Surgical Nursing: Assessment and Management of Clinical Problems
(9th ed.). St. Louis: Mosby

Review of Systems
Integumentary:
Musculoskeletal:
Respiratory:
Cardiovascular:
Digestive: Endocrine:
Lymphatic:
Immune:
Reproductive:
Urinary:
Nervous: