Care Plan Part I Instructions

Components of Part I

Framework for general client assessment Functional patterns Problematic patterns Reasons for selection of this client Personal factors influencing nutritional status Contextual factors influencing nutritional status 24 hour diet recall Observational exam Comparisons with pyramid Human response in area of nutrition Related factors 2 Data lists

This assignment writes part one of your first nursing care plan .This assignment applies the guidelines for writing care plans. The focus of the plan is on nutrition. The goals of this assignment include : 1. 2. 3. 4. to think of client assessment within some organizing framework to assess an area of human functioning in a structured way to discriminate between subjective and objective data to write a three part diagnosis

A. GENERAL FINDINGS Findings from a general assessment using Gordon's 11 Functional Patterns 1. THE FRAMEWORK: Reasons for using an organizing framework in a nursing assessment. 2. FUNCTIONAL PATTERNS: Assessed patterns that were functional for this person (Name them). 3. PROBLEMATIC PATTERNS: Assessed patterns that were dysfunctional or at risk (Name them. You must briefly explain why). B. THE CLIENT Introduction to this client ( Use client initials only, no names )

1. REASONS FOR SELECTION: Why you thought there might be a problem 2. PERSONAL FACTORS: Factors influencing this person's nutritional status : (age, personality, abilities, priorities, etc.) 3. CONTEXTUAL FACTORS: Factors influencing this person's nutritional situation : (outside pressures, support system, resources, etc.) C. 24 HOUR DIET RECALL 1. INTAKE: Record of all intake of food and fluids in an actual 24 hour period. 2. USUAL INTAKE: Interviewee report of typical eating pattern. 3. OBSERVATIONAL EXAM: Physical and behavioral observations r/t nutritional status.

Use all of your senses to paint a picture of your client. Refer to the Nutritional Survey for areas that must be included in the Observational Exam.

D. CONCLUSIONS 1. COMPARISON WITH PYRAMID: Comparisons of this client's 24 hour diet recall with the Food Pyramid. 2. HUMAN RESPONSE: Statement of a human response (wellness response, potential or actual problem)in the area of nutrition. Use your NANDA list. 3. RELATED FACTORS: Factors related to the human response/ etiology of the problem. 4. EVIDENCE: The Data Lists.

SUBJECTIVE LIST - Subjective data gives relevant quotes from the client OBJECTIVE LIST - Objective data list should be long and relevant. This list will repeat information that you presented earlier, but now you present it as items on a list.

It is the uniqueness of the client in his or her situation that brings a Nursing Care Plan to life. Be sure to match your assessment, priority diagnoses, goals and evaluative measures to the personality, life style and needs of your client.

Sample Care Plan for Part 1

CARE PLAN PART I: Assessment through Diagnosis, Focus on Nutrition (note title for paper) GENERAL FINDINGS (note first main heading) THE FRAMEWORK (note subheading) Gordon (1987) (note use of APA style) devised a theoretical framework for assessment of a nursing client that allows nurses to identify obvious as well as emerging patterns of functioning. Using this framework nurses screen their client for functional as well as dysfunctional patterns ( Kozier, 1991, p.187) (note APA style with page number for paraphrased information) (note new paragraph and skipped line for new topic) An early step in the development of nursing diagnoses for a client is to do a general assessment using some selected framework. As the reader is aware (note use of the third person), there are many nursing frameworks from which to choose. Gordon's 11 Functional Health Patterns is one that is useful for a screening assessment, and is the one designated by the instructor for this assignment. FUNCTIONAL PATTERNS This nurse (you say nursing student of course) visited her selected client in September observing her behavior and asking her questions based on the 11 patterns. In summary there were many areas in which the client was functioning in a healthy way for her age and personal goals. These included the:

Value - belief pattern Sexuality - reproductive pattern Self perception - self-concept pattern Sleep - rest pattern Elimination pattern Health perception - health management pattern

PROBLEMATIC PATTERNS Some areas of dysfunction were noted in the following areas: (note summary of problems) 1. 2. 3. 4. 5. Coping - stress tolerance pattern: loses appetite when stressed Role - relationship pattern: likes to live by herself, limits visiting by others Nutritional - metabolic pattern: hates to cook, losing weight Cognitive - perceptual pattern: poor vision, dislikes change, pain from arthritis Activity - exercise pattern: fatigues easily, torn rotator cuffs, bilateral

Once areas of actual or potential dysfunction have been identified, a nurse must decide which problems should be tackled first. Working on the root of a central problem can clear up other problems that had grown out of that central problem. In this assignment this writer (note use of third person) has been instructed to deal with the nutritional - metabolic pattern; therefore the following sections will focus on that pattern. Information gathered about this client's strengths and needs in the other patterns will be brought as it is useful to solving the nutritional dysfunction. THE CLIENT: MC (note use of initials for client's name) REASON FOR SELECTION (note use of sub heading) MC was selected as a client because she is having a problem maintaining her weight. Before her open heart surgery in 1990 she was overweight : 150 pounds and five feet tall. After surgery she became depressed, and developed pains in her stomach whenever she tried to eat. Her weight fell to below 100 pounds before she felt better and started eating more. In 1995 she was maintaining a weight of 112 pounds. Recently her weight has started to fall again. PERSONAL FACTORS MC is a very independent 88 year old. She loves her home and does not want to live anywhere else, including with her children. While other people find her friendly and happy, social gatherings tire her out. She is happy to get back to her nice quiet house. She does not feel isolated if she doesn't leave the house for days at a time. She says she does not have the energy to travel to visit her children or grandchildren. Nor can she cope with children running around her house. She thereby limits the visits she gets from relatives. In times of stress she does feel abandoned because she is so alone. Even though her children call and ask how she is, she tends to say she is fine, even if she is not. Her blood pressure has been climbing and seems to be related to her increasing fatigue.

While she has a car and does drive it, she has two medical problems that make driving risky. 1. Her central vision in one eye is gone, and glasses are no longer able to correct the blurry vision she has in both eyes. Additional she suffers from night blindness. 2. She has torn rotator cuffs in both arms making impossible for her to lift her arms above mid chest. The arthritis in her hands and feet can cause sudden spasms twisting the part uncontrollably. Once she does drive to the grocery store, she has trouble reading the labels on the food, and lifting heavier items to put them in her cart. Lifting grocery bags to put them in the trunk is even more difficult. Her habits include being very neat and clean and she is concerned about her appearance. The fact that losing weight makes her skin sag more bothers her. There is one skill she never developed, and that is cooking. While her children were growing up the family depended on the talents of a maid for their meals. She refers to the kitchen as "that room next to the garage". Eating has a very low priority for her. She is an intelligent person and remembers instructions if they are concrete and simple. She sees the benefit of having someone else in the house to help her, and is persistent enough to work on getting someone. CONTEXTUAL FACTORS (include useful information about the client's environment and situation) MC is a widowed female who lives alone in the same big house where she spent her married life. She is familiar with the neighborhood. She could practically drive to the grocery store with her eyes closed. All of her friends live in the same town. They call frequently and encourage her to come out with them. Several of them also pose a driving hazard on the road. Her church, her book club, and her historical society are important to her, and she attends, if she is not too tired. Both her friends and her children encourage her to eat out sometimes. They pay attention to her weight and her fatigue level, offering suggestions. All of her adult relatives live out of town and have full schedules allowing only occasional visits. The closest relative, her son, helps her with house maintenance problems, and wants to be helpful. Her grocery store will deliver stock items, but not hot prepared foods from their extensive deli. She has been going to the same doctors for years. They are tracking her heart function, her blood pressure, her arthritis, and her vision. She is generally not considered a candidate for any surgery due to her age. She has a living will stating she does not want extra ordinary means used to keep her alive. She has an excellent relationship with her pharmacist who reviews every medicine to be sure it does not conflict with her other medicines. MC had a student living in her home who did the cooking and the shopping. MC liked the student very much. Unfortunately the student had to move out to live with her family members who recently moved to town. 24-HOUR DIET RECALL

INTAKE Breakfast small bowl of cereal with 2% milk small cup of Tang, an orange juice like drink 1/2 piece of multi grain toast with margarine water for taking her pills, and frequently throughout the day tuna fish on multi grain bread grapes Tab soda small green salad with tomatoes and dressing 1 small slice of ham peas bread and margarine glass of milk

Lunch Dinner

:USUAL INTAKE MC reports this pattern of food intake is typical for her, except that when she is worried or very tired she tends to skip meals. Sometime she eats a Snickers candy bar, or two instead of a meal. OBSERVATIONAL EXAM MC appears cheerful. She is alert and aware of her personal situation as well as what is going on in the world. She is appropriately dressed in clean clothes that seem a bit too big on her. She looks a bit pale. When she prepares a meal she is efficient. The food is bland. She eats a little then pushes the rest around with her fork to make it look like less on her plate. This writer took MC out to eat at a local restaurant. MC's behavior was very different. She took a wide variety of foods from the buffet : fruits, vegetables, starches, and meats. She ate everything on her plate. This writer did need to cut her meat (MC could not do it without standing up to do it) and wipe the food she spilled off her dress. Her mood was brighter, and she indicated that she wanted to do this again. CONCLUSIONS COMPARISON WITH FOOD PYRAMID

Fats, oils, sweets (use sparingly) eats small amounts Milk, yogurt, cheese (2 - 3 servings) 2 Meat, poultry, fish, dry beans, eggs, nuts (2 - 3 servings) 2 Vegetables (3 - 5 servings ) 2 Fruit (2 - 4 servings) 1 Grains: bread, cereal, rice, pasta ( 6 - 11 servings) 4

MC is low in intake in almost every food group. Her diet is basically balanced. She just needs to

eat more. HUMAN RESPONSE ( using Nursing Diagnosis language ) MC is having an actual problem: "altered nutrition: less than body requirements" ( Creasia, 1996, p103). RELATED FACTORS The problem's etiology includes MC's : 1. 2. 3. 4. disinterest in cooking not having someone in the house to help her physical limitations independent spirit

EVIDENCE (the cues that help you recognize the problem + cues that help you solve the problem) (the following is a partial list reflective of the information above to give you examples of the cues to include) SUBJECTIVE LIST " I can't eat when I'm nervous." " I don't want to go out with Betty. She drives like a mad woman." " Look how my skin is hanging off of me." OBJECTIVE LIST scale shows 7 pound weight loss in 4 months MC places tiny portions on her plate MC's friend calls and asks if she can do anything for MC MC uses two hands and struggles to get the milk out of the refrigerator BIBLIOGRAPHY Make one. Include sources cited in your paper. One of your sources should be a nursing care plan book. You must include your nutrition text. A nursing journal article on the problem you identified for your client would be appropriate.