R.M Nursing Care Plan

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R.MNursing Care Plan


Table of Contents

R. M Nursing Care Plan 3

Introduction 3

General Physical Assessment 4

Vital Signs: 5

Safety/Security 5

Initial Observations 5

Maslow Hierarchy of Needs 11

Physiological needs 12

Safety and Security Needs 13

Love and Belonging Needs 13

Self Esteem Needs 14

Self- Actualization Needs 15

Erikson’s Theory of Development 15

Nursing Diagnosis #1 16

Nursing Diagnosis #3 26


Laboratory Results 40

Appendices 42

R.M Nursing Care PlanIntroduction

R.Mis a 92-year-old women currently residing at Alden Terrence nursinghome. She was born in German in 1924 and moved to the United Stateswhere she has been living since her teenage days. She is 68 inchestall and weighs 141lb. She has been admitted to the facility becauseof her inability to take care of herself. The decision was reachedbased on a consensus between the main caregivers. R.M shares a roomwith another patient at Alden Terrence nursing home. She iscompletely immobile and is wheelchair bound meaning she cannot moveby herself. She is incontinent in both bowel and bladder she has noteeth and relies entirely on dentures. She is oriented * 1 (she onlyknows her name. no orientation to place, time and date and situation.

R.Mis a strong Christian of Catholic orientation. Based on informationprovided by the immediate family members, R.M has been happilymarried for over 50 years and worked as a farm attendant during heryoung and active adult life. The resident confirmed R.M has been anactive member of the local community who is widely known for herwelcoming and jovial attitude. R.M is very social and enjoysinteracting with other members within the facility though she suffersfrom memory loss and confusion she is a great player of Bingo. Shekeeps herself busy by socializing with others and playing Bingo. R.Mis on a NAS regular diet with thin liquids and relies on the supportof facility aide to feed. R.M. has an advance directive that includesa full code. Under this code, exclusive permission is often given tothe doctor by the patient to do everything within the possibilitiesof medical practice to revive her life. This would include practicessuch as CPR, insertion of tubes into the lungs to aid breathing anddefibrillation i.e. the passing of an electric shock through afailing heart. Her Power of Attorney is her daughter.

R.M’smedical history consist of Hypertension, Dementia, Depression, muscleweakness and rehabilitation procedure NEC.

GeneralPhysical Assessment



Ethnicity:White, not of Hispanic Origin/German


PrimaryLanguage: English

Occupation:Firm Attendant

Age:92 years old

Dateof Birth: 01/17/1924

Placeof Birth: German

SupportSystem: Daughter Wiscosin

CodeStatus: full code

Height:68 inches

Weight:141 lb



Temperature:98.4 F, (temporal)

Respirations:20 non-labored

RadialPulse: 78 strong and regular

Bloodpressure: 135/75 on left arm, sitting

OxygenSaturation: on room air

PainScale: 0 on the 0 – 10 scale


Environment:room is free of clutter, neat, and clean

Precautions:Fall precautions and risk for skin tears have been appropriatelytaken

Equipmentused: Wheelchair (the patient is completely wheel bound).


Appearance:socializing with other residents, neatly dressed, pleasant andcooperative

Posture:Sits straight up in chair

Affect:Calm, pleasant, and alert with moment of confusion


Hair:grey, clean, and smooth hair, no lesions, bumps, or bruises.

ROM:(active) flexion, extension, rotation, and lateral flexion

Pain:pain on palpitation 0 on a scale of 0-10 before and after performingAROM

Communication:able to communicate with periods of forgetfulness and confusion notedbut is easily re-directed

Mentalstatus: Patient is oriented x1 patient does not understand person,place, and situation. Pt is alert with moments of confusion

Eyeappearance: eye is clear, sclera is white, iris is green, and thereis no redness or drainage present in or around the eye bilaterally.

PERRLA:3/2mm equal and reactive to light bilaterally, traction andcommendation is intact bilaterally

Nose:nose appeared symmetric, straight and uniform in color, mucusmembranes is moist and pink

Mouth:mucus membrane is moist and pink two lower teeth are missing, tonguein midline, gums pink and moist, smile symmetrical


Neck:skin warm to touch, no masses, or tenderness noted no jugular veindistention.

Pain:0 on a scale of 0-10

CarotidPulse: strong and regular bilaterally

ROM:(active) flexion and extension

Gagreflex: Present and strong

Hear:able to hear without hearing aids equal bilaterally

Ears:small amount of cerumen bilaterally, no redness, drainage orbreakdown in or around ear bilaterally


Pain:pain on palpitation 0 on a scale of 0-10

Skin:skin warm to touch, no redness or lesions

Appearance:skin intact

Symmetryof chest: Bilaterally symmetrical, equal rise and fall of chest withrespirations bilaterally

Lungsounds: rise and fall of chest equal bilaterally, anterior upper andlower lobes are clear and equal bilaterally, breathing is non-labored

Heartsounds: clear and strong

Apicalpulse: 64 strong and regular


Shape/Texture:Soft, smooth, no masses or lumps

Skin:no redness or bruising

Bowelsounds: active X4 in all four quadrants

Pain:pain on palpation 0 on a scale of 0-10 in all quadrants


Appetite:patient is fed 50 -75% of her meals. Patient does not eatindependently

Foodintake: patient ate 75% of dinner. Dinner included hot dog, frostedcake, potato chips, and 8oz of lemonade

Diet:NAS, regular diet with thin liquids


Skin:Decreased skin turgor on arms bilaterally, skin warm to touch, nolesions or bruising, aging spots on posterior hand bilaterally

ROM:(active) abduction, adduction, flexion, extension, rotates armsupination, circumduction and pronation bilaterally. Shortness ofbreath noted while doing AROM

Pain:0 pain on a scale of 0-10 before and after performing AROMbilaterally

Strength:hand grasp strong equal bilaterally

Armpulls: strong equal bilaterally

Armpushes: strong and equal bilaterally

Hands:tremors on hands bilaterally

Capillaryrefills: &gt4 seconds equal bilaterally

Radialpulse: strong and regular bilaterally

Brachialpulse: strong and regular bilaterally


Skin:no redness, breakdown, or discharge

Femoralpulse: regular diminished bilaterally


Skin:dry skin cool to touch bilaterally, non-pitting edema on right leg,and hyperpigmentation in lower legs bilaterally. Pt wears elasticstockings (TED Hose) bilaterally. Ted hose were removed when legswere assessed

Pain:0 on a scale of 0-10 before and after AROM

ROM:(active) abduction, adduction, flexion, outward, and inward rotation,and extension equal bilaterally

Poplitealpulse: regular diminished bilaterally

Dorsalpedal: regular diminished bilaterally

Posteriortibia: regular diminished bilaterally


Footpushes: equal and strong bilaterally

Footpulls: equal and strong bilaterally

Skin:feet cool to touch with dry skin bilaterally

Footsensation: foot sensation felt bilaterally

Toenails:short thick nails bilaterally

Capillaryrefills: &gt3 seconds equal bilaterally

Gait:not able to ambulates independently

Balance:not steady


Skin:warm to touch, pink, no lumps, no redness

Pain:0 on a scale of 0-10

Lungs:posterior upper and lower lobes are clear equal bilaterally


Rectum:no redness or skin breakdown


Continence:The patient is incontinent of both bowel and bladder.

Urination:The patient’s urine is pale yellow, clear, and no reported signs ordifficulties in urination. Last bowel movement was 8/22/2016,moderate amount brown and soft

Activityand Rest

ADL`s:patient is independent of all ADLs. The patient is fed, dressed,groomed, and given oral care. The patient is also showered. Thepatient uses a wheelchair thus she is limited in her movements.After meals, RM is brought back to her room.

RMenjoys playing bingo, and she is put to bed after lunch. She alsoenjoys talking to her roommate.

Sleep/RestPattern: Sleeps from 7-8 hours a night in supine position and lateralposition

MaslowHierarchy of Needs

Healthcareprofessionals and consumers are emphasizing on health promotion andillness prevention activities, which are designed to help clients toreduce the risk of illness and maintain maximal health. Nurses aremajor force in the healthcare delivery system, who emphasizes healthpromotion and illness prevention activities as important forms ofhealthcare. Promotive nursing refers to the activities involvinghealth promotion and illness prevention. Nurses assist clients inmaintaining good health and improving their levels of health insteadof merely providing care after illness occurs (Ackley &amp Gail2011). Activities involving health promotion help clients to maintainor enhance their present level of health, whereas the activities ofillness prevention protect clients form actual or potential threatsto health. At the core of promotive nursing is the need to fulfillthe basic human needs. Need is something that is essential to theemotional and psychological health and for survival of humans. Allpeople strive to meet their basic needs. At any given time, anindividual needs may be met, partially met or unmet. A person whoseneeds are met may be considered to be health and a person with one ormore of the needs unmet may be considered as unhealthy.

Oneof the earliest scientists to recognize the nature of human needs andtheir importance in human wellbeing was Abraham Maslow (1868 –1954). Abraham Maslow developed the Maslow’s Hierarchy of HumanNeeds in which he assigned priorities to basic needs under fivecategories. Physiological needs, safety and security needs, love andbelonging needs, self-esteem needs, and self-actualization needs.

Nursingcare is often directed towards meeting unmet needs. Usually innursing, nurses are concerned with physical and psychological needsof each individual. When providing nursing care nurses can use thetheory of hierarchy of human needs by Maslow to determine the needsof the client that are the most important at any given time. Thistheory provides a framework for nursing assessment and forunderstanding the needs of clients at all levels so that the nursinginterventions to meet needs can be planned. For example, whenpatients come to the casualty department, first nurse immediateconcerns are the physiological needs of the patient. He or she willadminister oxygen, if any wound, and takes pain relief measures. Thenurse will then be concerned about the safety of the patient andtakes safety measures while putting the patient on comfortable bed.The nurse then meets love and belonging needs, by asking the familymembers to be there for some time for the patient.


Accordingto Maslow, the physiological need is the most essential need for anyhuman. These needs are located at the base of the hierarchy of needsand tops as a priority for nurses when offering care. Physiologicalneeds are basic needs such as water, oxygen, food, clothing, shelter,elimination, physical activity, and rest. These needs fall underlifesaving and life sustaining dimension. RM’s need for oxygen ismet satisfactorily since she is able to breathe on her own withoutany support. Nutrition wise, RM’s nutritional needs are wellcatered for the facility provides three nutritional meals a day andregular thin liquids. RM requires assistance for elimination sinceshe is neither aware of the place nor the situation. The facilitystaff meets her needs for elimination. The need for physical activityand rest are being met with the assistance of the facility staff. RMis able to move on her own, however, she require assistance to movearound because she is not aware of the environment, place or time. Asfor resting, RM shares a room with another patient. The room is keptclean and neat at all times. RM’s need for security is met by thefacility staff, the room and surrounding are kept clean, free fromclutters and she is provided with ADL’s to prevent her fromfalling. RM’s need for rest and comfort are provided met with theassistance of the facility nurses and aides who provide medication asneeded. With the assistance of the nurses and facility aides, RM isassisted to shower and other ADL’s thus meeting her need foractivity. RM’s sexual procreation needs are met by making sure thatshe is well dressed with the help of the facility aide.

Safetyand Security Needs

Safetyand security needs are involved with self-preservation, physicalsafety, psychological safety, and security. Physical safety connotesthe idea of protecting a person from potential or actual harm. Areasof nursing responsibility included in physical safety are providingcomfort, insisting physical exercise and many others. Nurses carryout a variety of activities to meet clients’ physical safety. Tomeet RM’s safety and security needs, the staff at the facility willensure that the residence is safe and secure. RM’s will be providedany support service that facilitates both psychological, physical,and social safety.

Loveand Belonging Needs

Loveand belonging are the needs or social affiliation in which personexpects meaningful interpersonal relationship, group acceptance, andlove and belonging. All humans have their basic needs followingphysiologic, safety and security needs, which include theunderstanding and acceptance of other in both giving and receivinglove and the feeling of belonging to others. Love and belonging needsare life enhancing needs that one’s relationship with the universe,which requires communication identity, affection, modesty,companionship, and dependence. Individuals who perceive that theirlove and belonging needs are unmet often have a sense of lonelinessand isolation, which may lead to withdrawal and other unexpectedexperience with the client. When these social affiliation needs areunsatisfied, the nurse may observe boredom in clients, apathy, desireto have friends and family visits and other signs. RM’s love andbelonging needs will be met by including family and friends in hercare. A good rapport based on mutual understanding and trust will becreated by demonstrating caring, encouraging communication,respecting privacy and also insisting and encouraging diversionactivities designed to encourage social bonds at the facility.

SelfEsteem Needs

Self-esteemneed is the need for a person to feel good about himself or herselfto feel pride and a sense of accomplishment and to believe thatothers also hold one in high regard. It gives the individualconfidence and independence. When a client first seeks to belong, thepositive values of belong emerge as priorities and should besatisfied if a nurse desires the client to have reach fullestpotential. Instead of just feeling like part of a system of a group,the person who has esteem needs in focus others, prestige and powerthe client may want to be useful in some way, either being personallyinvolved in or by helping in other’s care. So, the esteem needswhich involve self-confidence, usefulness, activeness and self-worth.RM’s need for self-esteem and self worth will be met by acceptingher values and beliefs, encouraging her to set attainable goals, andfacilitating support by family and other people who are significantin heir live. These action will promote a sense of worth andself-acceptance.

Self-Actualization Needs

Thisis the last need in the Maslow’s hierarchy of needs.Self-actualization is the need for an individual to reach his or herpotential through full development of the individual’s uniquecapabilities. Self-actualization is the state of having reached one’sfullest potential and being able to cope with problems. In otherwords, it is the state of fully achieving potential and havingability to solve problem and cope realistically with life situations.RM has already met her self-actualization because she is verycomfortable with herself. Despite the desire to walk again, RM hasexpressed satisfaction with her past life and is confident that withthe support of the medical staff, she will regain her mobility.

Erikson’sTheory of Development

Usingthe psychoanalytical framework, Erik Erikson based his 1963 theory ofpsychosocial development on the process of socialization. Accordingto Erikson, a person spends their whole life constructing, shaping,and reshaping their personality, which is influenced bypsychological, biological, social and environmental factors. Eriksondescribed key conflicts or problems that the individual seeks tomaster during critical periods of personality development. Successfulcompletion of each conflict is built on satisfactory completion ofthe previous stage. However, no core problem is ever entirelyresolved as each new situation will present a conflict in a new form.

Erikson’stheory of psychosocial development is a very critical theory to thenursing process. Furthermore, it application helps nurses and otherpractitioners to analyze patient’s symptomatic behavior in thecontext of the past experiences with the current situation in life.With faulty and strenuous past, the adult life development issignificantly compromised and a sense of self-worthlessness is oftenobserved. Furthermore, the older people for example know that they donot have any chance to make their wrongs. With Erikson’s theory,nurses are able to assist the patient in emerging from each crisisand do well according to the existing standards.

ForRM, she is in the versus despair stage of Erikson’s theory ofdevelopment. In this stage, individuals are observed to possesswisdom and have a sense of integrity. People with wisdom andintegrity in this stage are seen to display comfort and tolerancewith the idea of death. When the attempt to attain integrity andwisdom fails at some point in life, people in this stage show signsof despair. They become deeply disgusted with the external world andare often seen to be contemptuous of institutions and persons aroundthem.

RMreflects a sense of pride in what she has accomplished in life. Shehas shown a commendable amount of self-satisfaction and is adapted toher current situation. RM has shown self satisfaction by being ableto enjoy her life both in her present condition and the past. She hasbeen quoted stating that she is very satisfied with what she hasachieved in life. However, she wishes and expresses the desire towalk again.

NursingDiagnosis #1

NursingDiagnosis #1: Malnutrition-

Thepatient has been observed to have very poor appetite. The followingdefining characteristics were observed: abdominal cramping, aversionto eating, hyperactive bowel sounds, lack of interest in food, poormuscle tone, reported altered taste sensation, reported food intakeless than recommended daily allowance, and satiety immediately afteringesting food.

Objective:Improve patient Nutritional Status, improve the patient food andfluid intake, nutrient intakes, and weight control.

Potentialfor achieving Goals: the patient has a high potential of achievingthe set goals as she has demonstrated good rehab potentials asevidenced by high levels of motivation to participate, activeparticipation w/POT and ability to follow directions.





NOC Goals

#1. Improve Patient Nutritional Status: Food and Fluid Intake

#2. Weight Control

#3 Progressively gains weight toward desired goal

#4. Monitoring weight to remain within normal range for height and age

#5. Educating the patient to recognize the factors contributing to malnutrition

#6. Help the patient to be free of signs of malnutrition

This goals are expected to be achieved by 9/6/2015.

The following activities will be conducted as a ways of managing RM’s Nutrition

The nurse will determine health body weight for R.M’s Age and Height. Refer to a dietitian for complete nutritional assessment if an under 10% of the normal health body is noted or if the RM is rapidly losing weight.

If RM is vegetarian, it is important for the nurse to determine whether she is getting sufficient amount of iron and vitamin B12.

The nurse will evaluate client`s laboratory studies (serum albumin, serum total protein, serum ferritin, transferrin, hemoglobin, hematocrit, vitamins, and minerals

Assess for recent changes in physiological status that may interfere with nutrition.

Provide companionship at mealtime to encourage nutritional intake

Consider six small nutrient-dense meals vs. three larger meals daily to reduce the feeling of fullness.

Studies reported in Ackley &amp Gail2011) have shown that early diagnosis of eating disorder is the most desirable point of consideration for nurses when planning for care. Adopting a multifaceted team oriented approach is highly recommended for proper establishment of the challenges and nutritional needs of a patient. In the developed world, protein-calorie malnutrition (PCM) is the most common form of malnutrition among the elderly studies have shown that PCM most often accompanies a disease process.

Studies have shown that strict vegetarians are at risk for vitamin iron and vitamin B12 deficiencies. As such, special care should be when planning for vegetarian diets for RM. Furthermore, research recommend a special approach to planning the diets of elderly. A dietitian can usually furnish a balanced vegetarian diet (with adequate substitutes for omitted foods) for RM.

An abnormal value in a single diagnostic study may have many possible causes, but serum albumin less than 3.2 g/dl was shown to be highly predictive of mortality in hospitals, and serum cholesterol of less than 156 mg/dl was the best predictor of mortality in nursing homes (

The consequences of malnutrition can lead to a further decline in the patient`s condition that then becomes self-perpetuating if not recognized and treated. Extreme cases of malnutrition can lead to septicemia, organ failure, and death (Ackley &amp Gail 2011). Diarrhea in patients receiving warfare has been suggested as possibly causing lower intake and/or malabsorption of vitamin K

Mealtime usually is a time for social interaction often clients will eat more food if other people are present at mealtimes

Eating small, frequent meals reduces the sensation of fullness and decreases the stimulus to vomiting

Goals #1, #2, #3, #4, #5, and #6 have been met: The patient is currently taking a balanced diet and the necessary nutritional supplements. Patient weight has been controlled.

NursingDiagnosis #2 Immobility- Uses a wheelchair so has limited mobility.

Objective:Improve the client’s mobility status

PotentialFor achieving Goals: the patient has a high potential of achievingthe set goals as she has shown good rehab potentials as evidenced byhigh PLOF, motivated to participate, active participation w/POT andability to follow directions.





Short Term Goals

#1. atient to safely perform bed mobility tasks with Min A with use of side rails and occasional Verbal Cues and occasional Visual Cues for correct hand/foot placement and for proper sequencing in order to participate in self care activities. (Target 6/15/2015)

#2 Patient will safely perform functional transfers with Min A and occasional Verbal Cues and occasional Visual Cues for correct hand/foot placement with reduced risk for falls in order to decrease the level of assistance from caregivers. (Target 6/15/2015)

#3 Patient will safely ambulate on level surfaces 100 feet using RW with Min A with continuous steps and with functional speed and amplitude 50% of the time with reduced risk for falls to increase independence with facility (Target 6/15/2015)

Long Term Goals

#1. Patient will safely perform bed mobility tasks with SBA with use of side rails and occasional Verbal Cues and occasional Visual Cues for correct hand/foot placement and for proper sequencing in order rot participate in activities of daily living and participate in self-care activities. (Target 9/6/2015)

#2. Patient will safely perform functional transfers with SBA and occasional Verbal Cues and occasional Visual Cues for correct hand/foot placement and for proper sequencing with reduced risk for falls in order rot facilitate increased participation with functional daily activities and decreased level of assistance from caregivers. (Target 9/6/2015)

#3 Patient will safely ambulate 300 feet using RW on level surfaces with CGA with reduced risk for falls and with use of activity placing in order to increase independence within facility and to prepare for walk to dine for meals. (Target 9/6/2015)

#4 The patient goal is to be able to walk again.

PT evaluation

Modality Application, Diathermy, Supervised

Therapeutic exercises

Neuromuscular reeducation

Gait training therapy

Therapeutic activities

E-stim other than wound unattended

Frequency of activity

3 times a week

Duration 12 weeks

Intensity Daily

The adopted interventions are widely recommended in contemporary nursing literature for their effectiveness in meeting patient and nursing mobility goals.

Goals Met. The patient has been able to safely perform bed mobility tasks with minimum assistance.

NursingDiagnosis #3

NursingDiagnosis #2 Dementia

Objective:Help the patient maintain improved mentaland psychological function as long as possible.

PotentialFor achieving Goals: the patient has a high potential of achievingthe set goals as she has shown good rehab potentials as evidenced byhigh PLOF, motivated to participate, active participation w/POT andability to follow directions.





NOC Goals

Desired Outcomes

#1. Patient will have appropriate maintenance of mental and psychological function as long as possible, and reversal of behaviors when possible.

#2. Family members will be able understand the patient’s condition and demonstrate understanding appropriate coping skills.

#3. Patient will achieve functional ability at his optimum level with modifications and alterations within his environment to compensate for deficits.

#4. Patient will have improved thought processing or will be maintained at a baseline level.

#5. Patient will be aware and oriented if possible, and reality will be maintain at an optimal level.

This goals are expected to be met by 9/6/2015.

The nurse will assess the patient’s thought processing abilities every shift.

The nurse will also observe the patient for changes in cognitive functioning, disorientation, difficulty with communication, memory changes, and changes in thinking patterns.

Assess the level of cognitive disorders such as change to orientation to people, places and times, range, attention, thinking skills.

Assess level of confusion and disorientation

The nurse will assess patient’s ability to cope with events, interests in surroundings and activity, motivation, and changes in memory pattern

The nurse will assess patient for sensory deprivation, concurrent use of CNS drugs, other concomitant disease processes, poor nutrition, or dehydration, infection,

The nurse will label drawers and use written reminders notes, pictures, or color-coding articles to assist patients.

The nurse will engage in activities that limit the number of decisions that patient makes. The nurse will be as supportive and accommodating as possible. He or she will convey warmth and concern when communicating with the patient.

The nurse will provide opportunity for social interaction, However, it is important for the nurse not to force interaction.

The nurse will instruct family in methods to use with communication with patient. Strategies such as listening carefully, listen to stories even if they have heard them many times previously, and to avoid asking questions that the patient may not be able to answer will be critical for effective communication.

The nurse will assess the degree of impaired ability of competence, emergence of impulsive behavior, and a decrease in visual perception.

Studies have shown that changes in patient mental status may indicate progression of deterioration or improvement in condition.

This activity will provide the basis for the evaluation or comparison that will come, and influencing the choice of intervention.

Confusion may range from slight disorientation to agitation and may develop over a short period of time or slowly over several months. May indicate effectiveness of treatment or decline in condition.

The elderly may have a decreased memory for recent events yet possess active memory for past events and reminisce about the pleasant ones. Furthermore, the patient may show assertiveness or aggressiveness to reimburse for feelings of insecurity, or develop more narrowed interests and have difficulty accepting changes in lifestyle thus making it difficult for them to adapt.

Lack of labeling may cause confusion and change in mental status. Furthermore, the use of reminders will assists patient’s memory on what to do and location of articles.

Patient may be unable to make even the simplest choice decisions and this will result in frustration and distraction. By avoiding this, the patient has an increased feeling of security. Patients frequently have feelings of loneliness, isolation and depression, and they respond positively to a smile, friendly voice, and gentle touch.

This helps prevent isolation. Forcing interaction usually results in confusion, agitation, and hostility.

Comments from the patients may involve reliving experiences from previous years and may be totally appropriate within that context. In early stages of dementia, questions may cause embarrassment and frustration when the patient is presented with another reminder that abilities are decreasing.

Impairment of visual perception increase the risk of falling. Identify potential risks in the environment and heighten awareness so that caregivers more aware of the danger.

Goal #1 Not Yet Met, the patient has not yet registered improved mental and psychological function

Goal #2 met. The family members have demonstrated understanding of the patient’s condition.

Goal #3 Met. The Patient has improved functional abilities and the necessary support modifications have been adopted.

Goal #4 not yet met. The patient still remains significantly challenged in thought processing.

Goal #5. Goal not yet met. The patient is still *1 oriented. Only knows her name.


Aricept Tablet 5 MG,



Expected outcome


Evaluation/Adverse Reactions

Aricept Tablet 5 MG,

Drug Classification:

cholinesterase inhibitors


Give 1 tablet orally in the evening related to Depressive disorder not elsewhere classified (311)

Monitor vital signs.

Assess pain level

Assess other medications for cholinesterase inhibitors content.

Assess other drugs for the presence of anti-cholinergic properties

Assess for not exceeding 10 grams per 24 hours.

Monitor I &amp O

Monitor memory retention capacity

Monitor CBC

Assess any possible side effects

Improved memory. Improved concentration, and daily living skills, communication, alertness and confidence.

Slow progression of dementia

Reduction of forgetfulness

Give medication orally minutes before resting.

Teach patient the signs of toxicity

Advise patient not to use medication with alcohol

Teach signs of chronic overdose:

Side effects:

Poor appetite, nausea, vomiting, diarrhea, headaches, tiredness insomnia. Increase in hepatotoxicity

Ariceptalso known as Donepezil is used to treat mild to moderate dementia inpatients with Alzheimer disease. It is used to help their thinkingand remembering. It is administered by mouth in tablet or oralsolution form. Information about medication obtained from Lee, Jeong,Kim, Park, &amp Dash (2015).

Klor– Con M.



Expected outcome


Evaluation/Adverse Reactions

Klor-Con M

Drug Classification:

Electrode replenisher


Give 1 tablet by mouth one time a day for therapeutic supplement.

Monitor vital signs.

Assess for impaired mechanisms for excreting potassium

Assess for Gastrointestinal Lesions

Assess for Metabolic Acidosis

Monitor I &amp O

Monitor hepatic studies

Monitor CBC

improve the amount of Potassium in the body

The patient will take the medication orally.

To prevent stomach upset, each dose will be taken after a meal and a full glass of water (8 ounces/240 milliliters).

The patient will be advised to not lie down ten minutes after taking the medication.

The mediation will not be broken down before use. This is because breaking the medication increases the amount released thus increasing the chances for side effects.

The patient will be taught signs of toxicity

Side effects:

Stomach upsets, nausea,


gas, and diarrhea

Klor-ConM is a mineral supplement used to prevent and treat low amounts ofpotassium in the blood. Maintaining the right amount of potassium iscritical for normal functioning of the body. The medication will beadministered orally, not to be crashed, and immediately after a meal.The patient will not be expected to lie down until ten minutes oftaking the medication. Information about medication obtained fromSkidmore-Roth, (2014) Mosby`s 2014 Nursing Drug Reference.

SertralineHCI Tablet 50 MG



Expected Outcome


Evaluations/Adverse Effects

Sertraline HCI Tablet 50 MG

Drug classification:

Selective Serotonin Reuptake Inhibitors


Give 1 tablet by mouth one time a day related to Depressive Disorder Not Elsewhere Classified (311)

Assess patient mood

Assess patient level of anxiety

Assess patient sleep habits and energy levels.

Decrease the level of depression

Improve patient mood, sleep, appetite, and energy level.

Reduce anxiety, panic attacks, and fear

Should not be used where pimozide is used.

Medication should not be used if the patient is treated with methylene blue injection

Sertralin should not be used where MAO inhibitors have been taken in the last 14 days.

Fatigue, nausea, diarrhea, insomnia, dyspepsia, loose stools, drowsiness, dizziness, tremor, paresthesia, xerostomia, headache, anorexia, decreased libido, diaphoresis,

Some patients may report abdominal pain, vomiting, agitation, malaise, and hypouricemia, anxiety.

SertralineHCI Tablet 50 MG Selective Serotonin Reuptake Inhibitors used fortreating depressive disorders. The patient will use 1 tablet by mouthone time a day. The medication is expected to improve the patient’smood, reduce anxiety, improve energy levels, and ultimately steer thepatient towards gaining her normal mental status. More information onthe drug can be found on Skidmore-Roth, (2014) Mosby`s 2014 NursingDrug Reference









12.0 – 18.0



Low %

36.0 – 52.0



Normal %

20.0 -50.0

Vitamin B12, SM


Normal PG/ML



Ackley,B. &amp Gail B. L. (2011). NursingDiagnosis Handbook: An Evidence-based Guide to Planning Care.9th ed. Maryland Heights, MO: Mosby.

Lee,J.H., Jeong, S.-K., Kim, B. C., Park, K. W., &amp Dash, A. (2015).Donepezil across the spectrum of Alzheimer`s disease: doseoptimization and clinical relevance. ActaNeurologica Scandinavica.131 (5). 259–267.

Skidmore-Roth,L. (2014). Mosby`s2014 Nursing Drug Reference.St. Louis, MO: Elsevier Mosby, 2014. Print

Budson,P.R. (2011). Memoryloss: a practical guide for clinicians.Edinburgh: Elsevier Saunders.






CBC With Differential












12.0 – 18.0




36.0 – 52.0




80.0 -100.0




26.6 – 32.6




31.6 – 36.9




10.0 – 18.0



7.4 – 10.4




40.0 – 74.0




14.0 – 46.0




4.0 – 13.0




0.0 – 6.0




0.0 – 4.0




150.0 – 450.0

Comp. Metabolic Panel




65 – 110




7 – 23




0.4 – 1.6

Bun/Creat. Ratio


5.0 – 30.0




133- 148




3.3 – 5.1




95 – 112




23 – 31




8.5 – 10.5

Alkaline Phosphatase



46 – 136




5 – 40




8 – 45



3.3 – 5.0

Total Protein


6.0 – 8.5



2.0 – 3.8

Total Bilirubin



0.2- 1.2


Iron saturation %



20.0 – 50.0


Folate Acid, SM

Test Pending

Vitamin B12, SM



193 – 982


Iron, Serum



40 – 150

Iron Binding Capacity



70 – 390

MedicationCurrentlyused by the client


Related Diagnosis

Coclchicine Tablet 0.6 MG. Direction: Give 1 tablet by mouth one time a day for Pain Management

Baby Asprin Tablet Chewable 81 MG, Directions: Give 1 tablet by mouth one time a day for cardio project

Aricept Tablet 5 MG, Directions: Give 1 tablet mount in the evening related to Depressive disorder not elsewhere classified (311)

Depressive Disorder Not Elsewhere Classified (311)

Multivitam/Mineral Tablet. Directions: Give 1 tablet by mouth on time a day for Nutritional Supplement (Use House Stock)

Ascorbic Acid Tablet, Directions: Give 500 mg by mouth one time a day for nutritional supplement.

Sertraline HCI Tablet 50 MG,, Directions: Give 1 tablet by mouth on time a day related to Depressive Disorder Not Elsewhere Classified (311)

Depressive Disorder Not Elsewhere Classified (311)

AmLODIPine Besylate Tablet 10 MG. Directions: Give 1 tablet by mouth one time a day related to Unspecified Essential Hypertension (401.9)

Unspecified Essential Hypertension (401.9)

Dicyclomine HCI Capsule 10 MG. Directions: Give 1 capsule by mouth three times a day for Bowel Management related to Diverticulitis of Colon (562.11)

Diverticulitis of Colon (562.11).

Isosorbide Mononitrate ER Tablet Extended Release 24 hrs 30 MG. Directions: Give 1 tablet by mouth one time a day for Cardio Protect “Do Not Crush”

Sucralfate Tablet 1 GM. Direction: Give 1 Tablet by mouth three times a day for Upset Stomach

Klor-Con M20 Tablet Extended Release. Directions: Give 1 tablet by mouth one time a day for therapeutic supplement.

Trolamine Salicylate Cream 10%. Direction: Apply to painful area topically every 12 hours as needed for pain management.

Lactulose Solution 20 MG/30ML. Directions: Give 2 Tablet by mouth every 6 hours as needed for Fever, Pain management (650 MG) (Not To Exceed 3GM APAP/DAY) “Use House Stock”

Atorvastatin Calcium Tablet 10 MG. Directions. Give 1 tablet by mouth at bedtime related to Other and Unspecified Hyperlipidemia (272.4)


Montelukast Sodium Tablet 10 MG. Directions: Give 1 tablet by mouth at bedtime for Allergy symptoms

Atenolol Tablet 50 MG. Directions: Give 1 tablet by mouth at bed time related to Unspecified essential Hypertension (401.9


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