Group 1 Activity : Prepare your Nursing Care Plan Using NANDA

CASE STUDY #1 1

Mrs. Evangelista is a 92-year-old cachectic frail-looking Filipino female who was diagnosed
with dementia 7 years ago. Her oral intake has decreased over the past 6 months and she has
occasional choking spells when being fed. She has lost a significant amount of weight (20 lb.)
over the past year despite complete nursing care provided at home by her 2 unmarried daughters,
who are now in their 60’s. She spends most of her time sitting in a chair or lying in bed, is
dependent in all of her activities of daily living (ADL’s), and had falling incidents twice in the
past year. She cannot carry on an intelligible conversation and can only express herself by
uttering a few incomprehensible words and by using non-verbal gestures. She is incontinent with
bowel and bladder function, and has developed multiple small stage 2 pressure ulcers in her
buttocks.

When the health care provider made a home visit, one of the daughters expressed concern
regarding her mother’s progressive weight loss due to feeding difficulties, and requested that a
PEG tube be inserted. Through her knowledge of other people’s experience she believed that this
intervention would improve the patient’s nutritional status. The health care provider maintained
that it was not an appropriate intervention for this setting and explained the risks and benefits of
the procedure to the family member. The daughter was not quite satisfied or convinced, and
continued to insist on having it placed.

Discussion Topics
1. What cultural values and beliefs could explain the family member’s behavior and her concern
regarding the patient’s declining condition?

2. As the healthcare provider, how can you develop the trust of the family members, and be able
to formulate culturally meaningful and appropriate patient-centered goals that would be
acceptable to family members as well?

Group 2 Activity
CASE STUDY 2
Mr. Ying is an 84 year-old Asian male who lives in an apartment that adjoins his son’s house.
Mr. Ying is accompanied to this clinic visit by his son, who assists with the history. Although
previously outgoing and social, Mr. Ying recently has been limiting his outside activities. Self-
Risk Assessment Mr. Ying completes the Stay Independent brochure in the waiting room. He
circles “Yes” to the questions, “I use or have been advised to use a cane or walker to get around
safely,” “Sometimes I feel unsteady when I am walking,” and “I am worried about falling.” His
risk score is 4. Gait, Strength & Balance Assessment (Completed and documented by medical
assistant) Timed Up and Go: 15 seconds using his cane. Gait: slow with shortened stride and
essentially no arm swing. No tremor, mild bradykinesia. 30-Second Chair Stand Test: Able to
rise from the chair without using his arms to push himself up. Score of 9 stands in 30 seconds. 4-
Stage Balance Test: Able to stand with his feet side by side for 10 seconds but in a semi-tandem
stance loses his balance after 3 seconds. History Mr. Ying stated that for the past year he has felt
dizzy when he stands up after sitting or lying down and that he often needs to “catch himself” on
furniture or walls shortly after standing. His dizziness is intermittent but happens several times
per week. Mr. Ying cannot identify any recent changes in his medications or other changes to his
routine that would explain his symptom. He says there is no pattern and he experiences dizziness
at different times during the day and evening. He denies experiencing syncope, dyspnea, vertigo,
or pain accompanying his dizziness.
Mr. Ying also remarks that, independent of his dizziness symptoms, he feels unsteady on his feet
when walking. His son mentions that he often sees his father “teetering.” Mr. Ying requires help
with bathing. He has started using a cane but doesn’t like to use it inside. When asked about
previous falls, he says he hasn’t fallen. However, he says his elderly neighbor recently fell and is
now in a nursing home. Now he’s fearful about falling and becoming a burden to his family.
Although Mr. Ying has spinal stenosis, a recent steroid injection has relieved severe low back
pain. Now he suffers only from lower back stiffness for several hours in the morning. He denies
any specific weakness in his legs.
Review of Systems
Positive for fatigue, poor vision in his left eye, constipation, nocturia 3-4 times a night, frequent
urinary incontinence, low back stiffness, difficulty concentrating, depression, dry skin,
hoarseness, and nasal congestion.
Physical Exam Constitutional:
This is a thin, alert, older Asian male in no apparent distress, pleasant and cooperative, but with a
notably flat affect. Vitals: Supine – 135/76, 69; Sitting – 112/75, 76; Standing – 116/76, 75. BMI
19. Head: Normocephalic / atraumatic. ENMT: Wearing glasses. Acuity 20/30 R, 20/70 L. CV:
Regular rate and rhythm normal S1/S2 without murmurs, rubs, or gallops. Respiratory: Clear to
auscultation bilaterally. GI: Normal bowel tones, soft, non-tender, non-distended.
Musculoskeletal: Strength: UE strength 5/5 B biceps, triceps, deltoids; LE strength 4+/5 bilateral
hip flexors and abductors; 4+/5 bilateral knee flexors/extensors; 5/5 bilateral AF/AE; 5/5 bilateral
DF and PF. No knee joint laxity. Foot exam shows no calluses, ulcerations, or deformities.
Neurology:
Cognitive screen: recalled 3/3 items. Whisper test for hearing: Intact. Tone/abnormal
movements: Tone is mildly increased in both legs; normal tone in both arms. Sensation is intact
to light touch and pain throughout. Reflexes are normal and symmetric. Psych: PHQ-2 = 4/6.
Identified Fall Risk Factors
 Mr. Ying’s answers on the Stay Independent brochure and the results of the assessment tests
indicate gait, strength, and balance impairments and a fear of falling. He is currently taking two
sedating medications, Claritin and Gabapentin. His orthostatic blood pressure results indicate
postural hypotension.
Other fall risk factors are poor vision, nocturia >2 times a night, incontinence, and depression.
Fall Prevention Recommendations
• Discuss fall prevention, tailoring your suggestions using the “Stages of Change” model.
• Provide the CDC fall prevention brochures, What You Can Do to Prevent Falls and Check for
Safety.
• Attempt to lower the dose of the blood pressure medication Valsartan.
• Counsel on self-management of orthostatic hypotension (drink 6-8 glasses of water a day, do
ankle pumps and hand clenches for a minute before standing, do not walk if dizzy), and provide
the patient brochure,
Postural Hypotension: What It Is and How to Manage It.
• Attempt to lower the dose and/or eliminate the sedating medications.
• Refer for physical therapy for gait assessment, to increase leg strength and improve balance,
and for instruction on how to use a cane correctly.
• Add 1,000 IU vitamin D as a daily supplement to help optimize muscle strength.
• Refer to an ophthalmologist for eye exam, glaucoma assessment, and updated prescription.
• Recommend using night lights or leaving the hall and/or bathroom lights on overnight to
reduce the risk of falling when getting up to void.
• Recommend having grab bars installed inside and outside the tub, next to the toilet, and in the
hallway that leads from his bedroom to the bathroom.
From Case study above : Analyze the conditions , symptoms and other health related problems
of the patient and select your recommendation for the nursing process . Prepare your nursing care
plan using the NANDA
Case study #3 Activity
This final case study is based on what you have learned in the course. Please reflect on the
following prior to completing this case study:
1. What two general characteristics must your documentation include?
2. What are some of the risks or adverse events that may occur in a continuing care or a long
term care setting?
3. For each risk, what are the essential components of your documentation?
Scenario
The following is a fictitious scenario in a long term care setting.
 Use day/month/year and metric time
 Use your name and designation Client Specifics:
 Mrs. Anne Dixon – 87 years old 
Dr. Cyril MacLeod – primary physician
 Family contact – Matthew Dixon, son and named agent on personal directive
 Medical diagnoses – hypertension, osteoporosis, osteoarthritis, mild cognitive impairment,
Type 2 diabetes  Functional – ambulates with a walker, requires assistance with activities of
daily living (ADLs); bathing, grooming, toileting.
Care providers are alerted by hearing a loud crash and yelling in the client’s room. Roommate,
Emily Miles witnessed the fall. At 1300 Anne is found lying on her right side on the floor at the
bedside in front of the night table. She denies loss of consciousness, but is not sure if she bumped
her head. She has a 2 cm abrasion on the right side of her forehead that is oozing blood. She is
moving all her limbs and complains of pain at 6/10 for a “sore right shoulder”. A large amount of
bruising noted to the right shoulder. Vital signs are BP 130/86, T 37.1 C (t), P94, R 22. O2 sat is
95% on room air. PEARL. Anne also tells care provider that she was trying to get the magazine
from her night table so she could get up and read in her easy chair. When she got up, she became
dizzy and fell. She is awake and aware of her surroundings after the fall. Her speech is clear and
coherent and hand grips are strong bilaterally. Physician notified of adverse event at 1315.
Physician orders neurovital signs for 3 hours every 15 minute, 1 tablet of Tylenol # 3 for pain
every 3 hours as required, x-ray of right shoulder. Anne is assisted back to bed with a second care
provider. The laceration on her forehead receives first aid treatment. Family is notified of the
adverse event. Anne is instructed to ask for help when she gets up to read or to use the bathroom.
She is to call the care provider if in pain. The client is left in bed in a safe position
1. What must guide your documentation?
 In your documentation use the nursing process as a guide .
2. What are some of the risks or adverse events that may occur in a continuing care or a
long term care setting?
 Falls
 Refusal of treatment or procedure
 Medication errors
 Equipment failure
 Family complaints or threats
 Facility acquired infection
 Injuries to/from other clients
 Unexpected death 3. In this scenario what is the adverse event and what are the
essential components of your documentation? The adverse event is a fall in a facility. The
following are essential components when a fall occurs:
 Client’s condition when found
 Direct quotes from client
 Physical assessment and injuries identified
 Safety initiatives to prevent further falls
 Physician notification, communication, examination, diagnostic studies
 Family notification
 Evidence of ongoing monitoring
 Other reporting requirements as facility policies and procedures (i.e. incident report,
falls risk assessment
) In this adverse event, the physician was notified. The following checklist is
implemented when notifying a physician or health care professional:  correct date and
time  method of communication  name of physician/health care provider  why you
telephoned – be specific  new orders received or no new orders  Use exact words of
physician or health care professional.

Given the above scenario prepare your nursing care plan using the NANDA
 Case Study #4 Activity – Prepare Nursing Care Plan

CASE STUDY
Patient A is 82 years of age with a history of congestive heart failure, glaucoma, hypertension,
and osteoarthritis. Her current medications are furosemide, potassium, lisinopril, metoprolol,
aspirin, timolol maleate opthamic solution (Timoptic), acetaminophen (as needed), multivitamin,
and a calcium/vitamin D supplement (800 IU daily). She has an appointment with a new
orthopedic physician. During the appointment, the patient complains of persistent arthritic pain
in her knee. The physician prescribes the nonsteroidal anti-inflammatory drug (NSAID)
meloxicam (7.5 mg per day) for pain and inflammation.
Comments and Discussion : From the orthopedic standpoint, prescription of meloxicam is good
practice, as it should help to ameliorate patient A's symptoms. However, from a cardiac
standpoint, this is a risky approach due to the potential side effect of fluid retention and its effect
on the heart. In general, NSAIDs can be dangerous for an individual of Patient A's age. NSAIDs
(including meloxicam, but also over-the-counter options like ibuprofen) have been issued "black
box" warnings by the U.S. Food and Drug Administration (FDA) for the increased risk of:
 Serious and potentially fatal cardiovascular and thrombotic events, including
myocardial infarction and stroke
 Serious adverse gastrointestinal events such as bleeding, ulcer, and intestinal
perforation (higher in elderly patients)

Patient A has a good working relationship with her primary care provider, who has instructed her
to contact him regarding any changes in her medication regimen. She calls her physician prior to
taking the medication, and he advises her not to take the NSAID. Instead, he devises a pain
management plan that minimizes the potential risks. Previously, Patient A was taking
acetaminophen as needed, averaging up to one dose daily. This is increased to twice daily
extended-release acetaminophen (650 mg). For breakthrough pain, tramadol 25 mg every four
hours (as needed) is prescribed. Another option considered was the topical anti-inflammatory
diclofenac sodium 1% topical gel, which would have fewer side effects than systemic agents.
Aside from pharmacotherapy, the patient is scheduled with a physical therapist to create a safe
exercise plan, including strengthening and range-of-motion exercises.