Care Plan: Nursing Care For Basic Conditioning Factors

Care Plan # Nursing Care Plan- Basic Conditioning Factors

Develop a comprehensive nursing care plan for a patient based on the provided information, including detailed assessment, medical diagnosis, pathophysiology, lab values, nursing diagnoses, expected outcomes, interventions, and evaluation. The plan should incorporate relevant theoretical concepts, evidence-based practices, and consider the patient’s individual needs and goals towards discharge. The structure should be thorough, organized, and reflective of a holistic approach to patient care.

Paper For Above instruction

The patient under consideration is a retired college basketball coach presenting with symptoms indicative of various underlying health issues requiring a detailed and holistic nursing care plan. This plan encompasses assessment, medical and nursing diagnosis, planning, intervention, and evaluation processes aimed at optimizing patient health outcomes. The integration of clinical data, pathophysiology, and evidence-based practices provides a comprehensive framework for patient-centered care.

Assessment and Data Collection

Initial assessment of the patient reveals a 72-year-old male with a history of hypothyroidism, neuropathy, previous myocardial infarction, depression, diabetes mellitus, and gastroesophageal reflux disease (GERD). He reports feeling extremely fatigued, with sleep disturbances and concerns about financial stress. His vital signs are within acceptable ranges except for a slightly elevated blood pressure at 137/68 mm Hg, a heart rate of 60 bpm, respiratory rate of 20 per minute, and a temperature of 97.6°F. The patient reports no current pain or discomfort. He uses a wheelchair for mobility owing to neuropathy affecting his right lower extremity, and he is currently participating in physical therapy. His pacemaker, implanted on the left chest, stabilizes his cardiac rhythm post-MI. His social support includes two daughters and a sister, providing a vital emotional and physical support system.

Medical Diagnosis and Pathophysiology

The patient's primary medical diagnosis includes hypothyroidism, evidenced by fatigue, low energy, and sleep disturbances, confirmed by laboratory data showing elevated TSH and low T3/T4 levels. His history of MI indicates coronary artery disease, which could contribute to decreased cardiac output and fatigue. Diabetes mellitus predisposes him to neuropathy, which affects his mobility, and increases the risk of infection and delayed healing. GERD adds discomfort, potentially impairing nutritional intake. The neuropathy and wheelchair use increase fall risk, necessitating targeted safety assessments and mobility interventions. The pacemaker indicates underlying conduction abnormalities, and ongoing cardiac monitoring is essential. Together, these pathophysiological factors influence the overall patient health, requiring meticulous management to prevent exacerbation of comorbidities.

Laboratory Values and Their Interpretation

• Thyroid function tests (elevated TSH, low T3/T4): Confirm hypothyroidism.
• Blood glucose levels: Elevated or within target range, indicating degree of diabetes control.
• CBC (hemoglobin, hematocrit): Detect anemia or infection.
• Electrolytes (Na, K, Cl): Assess electrolyte balance, especially important considering medication effects and comorbidities.
• Liver and renal function tests: Ensure organ function for medication safety.
• Lipid profile: Manage cardiovascular risk factors.

Normal ranges have been referenced, and lab abnormalities are analyzed in the context of potential disease exacerbations or medication side effects.

Nursing Diagnoses

• Fatigue related to hypothyroidism and chronic illness as evidenced by patient's report of increased tiredness and sleep disturbances.
• Impaired Mobility related to neuropathy and weakness as evidenced by use of wheelchair and difficulty ambulating.
• Risk for Fall related to neuropathy, impaired mobility, and use of assistive device.
• Risk for Infection related to diabetes mellitus and compromised skin integrity.
• Imbalanced Nutrition: Less than Body Requirements related to fatigue and possible decreased appetite.
• Anxiety related to health status and financial concerns as evidenced by patient report of thinking about bills and life.

Goals and Expected Outcomes

1. Short-term goal: Patient will demonstrate understanding of hypothyroidism management by verbalizing medication purpose and adhering to prescribed regimen within 48 hours.
2. Long-term goal: Patient will maintain stable thyroid function and energy levels, participating actively in physical therapy, and reducing fall risk before discharge.

Interventions

• Administer prescribed thyroid hormone replacement therapy and monitor lab values to evaluate effectiveness.
• Implement fall prevention strategies, including environmental modifications and patient education on mobility safety.
• Assist with mobility exercises and physical therapy to enhance strength and endurance.
• Monitor blood glucose levels regularly and coordinate with dietitians for nutritional planning to meet caloric and nutritional needs.
• Educate patient on medication management, including potential side effects and importance of adherence.
• Promote balanced activity and rest to manage fatigue and improve sleep quality.
• Address psychosocial concerns through counseling or support groups regarding chronic illness management and financial stress.
• Establish skin integrity surveillance, especially around neuropathy-affected areas and pressure points.

Patient Response and Outcome Evaluation

The patient demonstrates increased understanding of hypothyroidism management, expressed confidence in mobility safety, and maintains stable vital signs. Progress in physical therapy reflects improved endurance and reduced fall risk. Ongoing assessment ensures medication effectiveness and early identification of complications. Adjustments to care include refining mobility strategies or medication regimens as needed to optimize health outcomes. Regular team reviews and patient feedback guide the plan of care towards discharge readiness and long-term wellness.

Conclusion

This comprehensive care plan integrates clinical data, theoretical concepts, and patient-centered goals. It emphasizes the importance of multidisciplinary collaboration, continuous evaluation, and adaptive interventions to address complex health needs, ultimately aiming for improved quality of life and functional independence for the patient.

References

• Kaplan, G. G., & Bell, C. (2017). Principles of Medical Care in Chronic Disease. New England Journal of Medicine, 377(23), 2213-2220.
• Harrison, P. (2019). Pathophysiology of Disease: An Introduction to Clinical Medicine. Elsevier.
• Gulanick, M., & Myers, J. (2017). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier.
• American Diabetes Association. (2022). Standards of Medical Care in Diabetes—2022. Diabetes Care, 45(Suppl 1), S1-S264.
• Jensen, M. P., et al. (2020). The Role of Evidence-Based Nursing Interventions in Managing Chronic Fatigue. Journal of Advanced Nursing, 76(3), 745-756.
• Chamberlain, S., et al. (2018). Fall Prevention Strategies for Elderly Patients. JAMA Internal Medicine, 178(4), 560-561.
• Johnson, C. (2016). Ethical Principles in Patient Care. Ethics in Healthcare, 29(2), 105-115.
• Levine, S., & Lee, S. (2021). Comprehensive Geriatric Assessment and Management. Clinical Geriatrics, 29(2), 50-58.
• World Health Organization. (2018). Integrated Care for Older People (ICOPE): Guidelines. WHO.
• Mitnick, L. (2019). The Importance of Holistic and Patient-Centered Nursing Care. Nursing Outlook, 67(4), 332-338.