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Running head: GERIATRIC CARE PLAN

Geriatric Formal Care Plan

Vanessa Mickey

Nursing 323: Older Adult Clinical

April 14th, 2017

Nevin Powell, RN, BScN

University of Northern British Columbia – Quesnel

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Student Name: Vanessa Mickey Dates of Care: March 27th – April 5th, 2017

Health Care Setting: Dunrovin – 1N

Demographic Data: Initials of client: RJ Age: 63 Sex: Female

Marital status: Widowed (Since 2013) Religion: Not specified

Admitting Medical Diagnoses: Resident was admitted to Dunrovin – 1N with a history of

multiple sclerosis (MS), Decubitus ulcers, recurrent urinary tract infections (UTIs), a frailty level

6 score, depression, bone infection (Osteomyelitis), chronic neurodegenerative disease, GERD,

and chronic kidney disease (CKD). This resident is positive for MRSA, ESBL, and exhibits

tobacco dependence. This resident has a major decrease in mobility due to her various

comorbidities’, which affects her ability to perform activities of daily living (ADLs) as well as

her instrumental activities of daily living (IADLs). She is incontinent and requires total care with

both ADLs and IADLs.

History of Present Illness: RJ currently has MS alongside other comorbidities that are

debilitating to both her mental, and physical wellbeing; including, decubitus ulcers, recurrent

UTIs, depression, osteomyelitis, chronic neurodegenerative disease, GERD, and CKD.

Allergies: Macrobid (will put resident into a coma), Flagyl, Atenolol, Cefuroxime, Sulfa (will

put resident into a coma), Tobramycin, Penicillin, Dexamethasone, Cholestyramine,

Metronidazole, Questran, and Primaxin.

Past Medical History

RJ’s past medical history is positive for:

1. Recurrent Urinary Tract Infections (UTIs)

2. Bone Infection (osteomyelitis)

3. Multiple Sclerosis (MS) – Has been diagnosed since 1992

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4. Sacral Ulcer

5. Tobacco Dependence (Smoking)

6. Chronic Neurodegenerative

7. Gastroesophageal Reflux (GERD)

8. Frail Elderly Level 6

9. Chronic Kidney Disease

10. Methicillin-resistant Staphylococcus aureus (MRSA)

11. Extended Spectrum Beta-Lactamases (ESBL)

12. Depression

Medical History Surgical History Social History

This resident has been diagnosed with MS since 1992. The resident also has a history of decubitus ulcers, recurrent UTIs, fail elderly level of 6, depression, osteomyelitis, chronic neurodegenerative disease, GERD, and CKD. This resident is positive for MRSA and ESBL, and exhibits tobacco dependence by smoking.

No surgical history was stated in resident’s chart.

The resident currently resides at Dunrovin Park Lodge – 1N in Quesnel, B.C. She has three children who are living on their own, and 2 grandchildren. The resident’s husband passed away in 2013 from a “work accident” which has been difficult for RJ; however, RJ likes to participate in activities such as bingo, and watching TV (hockey, wheel of fortune, and jeopardy).

Vital Signs:

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______________________________________________________________________________Day 1Temperature: Oral 36.4 degrees Celsius Axilla: N/A Rectal: N/ABlood Pressure: Lying: 108/71mm/Hg Standing: N/A (resident cannot stand)Pulse: R 92/min Respirations: 20/minO2 Saturations: 98% at room air (RA)Current Weight: 75.3 kg OR 165.6 lbs.

Day 2Temperature: Oral 36.8 degrees Celsius Axilla: N/A Rectal: N/ABlood Pressure: Lying: 120/72mm/Hg Standing: N/A (resident cannot stand)Pulse: R 74/min Respirations: 18/min O2 Saturations: 96% at RA

Day 3Temperature: Oral 36.5 degrees Celsius Axilla: N/A Rectal: N/ABlood Pressure: Lying: 136/67mm/Hg Standing: N/A (resident cannot stand)Pulse: R 66/min Respirations: 20/minO2 Saturations: 95% at RA

Risk for Altered Body Temperature: Yes

Related to: The resident is at risk for altered body temperature because of immobility and

incontinence, which puts the client at risk for skin break down and urinary tract infections.

Biophysical Dimension

______________________________________________________________________________

Pain/Altered Comfort Lab/Diagnostic Data

P: Resident stated “shooting” pain of “5/10” down her left leg upon waking. Resident often states pain in both legs.

Q: Quality of pain is described as “shooting” R: The pain radiates down left leg. No

reported pain in feet. No reported pain anywhere else.

S: Resident claims the pain is “5/10” depicted by the pain scale.

T: Resident complains that pain to legs is often

The resident is taking PRN Acetaminophen 500mg – 1000mg q6h for pain, and often requests it once in the morning and once in the evening. She is also taking Ibuprofen 200mg tid prn to help with inflammation as a complementary to the pain relieving medication. When using the pain assessment tool on a scale

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times more apparent in the morning, and right before bed.

Resident shows signs of pain as evidence by: grimacing, moaning, and foul language.

Signs and symptoms of pain are more evident while turning resident during morning care and mobilization.

Resident reports pain from “MS and the ulcers”

Resident reports pain to left hip often. Resident reports lower back pain when in

power wheel chair for long periods of time and states that the pain “comes and goes”

of one to ten, zero being no pain at all and ten being the worst pain ever experienced, the resident rated her pain a 5/10 on the pain scale.

Neurologic Lab/Diagnostic Data

Resident is oriented to person, place, and time as evidenced by detailed questions were answered correctly.

No facial droop. Paralysis to lower limbs, and minimal strength

to upper limbs due to MS. Pupils are a size 4 bilaterally and reactive

equally. Immediate memory in tact as evidence by

resident’s ability to repeat “car, tree, and cloud” back after 5 minutes of assessment.

Short-term memory in tact as evidenced by resident’s ability to recall events within the last few days.

Long-term memory in tact as evidenced by resident’s ability to recall events from her past.

Severe decrease in cognitive abilities due to her MS and chronic neurodegenerative disease.

Cranial Nerves assessment:1) CN I (olfactory) – Intact as evidenced by

resident’s ability to identify the smell of coffee correctly.

2) CN II (optic) – Undetermined, did not perform the Snellen chart.

3) CN III (oculomotor)4) CN IV (trochlear)5) CN VI (abducens) – III. IV. & V. tested

together. Residents pupils are size 4, round, symmetrical, and papillary reactions to light are reactive and equal bilaterally.

Mini Mental Status Exam (MMSE) completed. Resident scored 28/30.

Multiple Geriatric Depression Scale (GDS) scores on resident’s file. Resident has a GDS score of 3. A score higher than 5 would indicate further investigation.

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6) CN V (trigeminal) – Both sensory and motor function of trigeminal nerve intact as evidenced by residence ability to sense different sensations of pointy and soft end of swab stick. Temporal muscles equal bilaterally when residence clenches jaw.

7) CN VII (facial) – Undetermined, as Weber’s tuning fork not available.

8) CN IX (glossopharyngeal)9) CN X (vagus) – IX. & X. tested together.

Uvula midline and symmetrical upon resident repeating “ah”. Gag reflex present.

10) CN XI (spinal accessory) – Resident able to move head indicating adequate use of the sternocleidomastoid muscle. Resident able to push shoulders up against resistance indicating adequate upper trapezius muscle strength.

11) CN XII (hypoglossal) – Tongue is midline and symmetrical and does not exhibit any muscle twitching.

Resident's body is slightly tilted to the right due to desire to relieve stress on pressure ulcers.

Atrophy to lower limbs and arms due to immobility caused by MS and neurodegenerative disease.

Resident exhibits equal strength in both hands as evidenced by squeezing writer’s hands simultaneously and on command, as well as let go on command.

Resident’s Glasgow Coma Scale (GCS) score is 15/15.

Resident denies any headaches, numbness, or tingling.

Neurodegenerative Disease:Share common pathogenetic mechanism involving aggregation and deposition of misfolded proteins, which leads to progressive central nervous system disease (Skovronsky, Lee & Trojanowski, 2006).

Cardiac Lab/Diagnostic Data

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History is not positive for myocardial infraction.

Resident’s BP does not show any signs of elevation.

S1 & S2 heart sounds present. No abnormal heart sounds including S3 & S4 present.

Apical pulse present and regular. Both radial pulses present and symmetrical.

Rhythm is consistent, no bounding present. Both pedal pulses are present and symmetrical. No bruits, thrills, murmurs, or rubs present

upon auscultation. Blood pressure completed while resident was

in lying position. BP: 120/72mm/Hg. No concerns.

No neck distension present. Unremarkable capillary refill. Nail beds are pink in color and show no signs

of clubbing. Lips are pink in color. Temperature is consistent in lower limbs as

well as both arms. No edema present.

InspectionPalpationPercussionAuscultation

ECG not on file

Yearly blood tests completed and on file.

Respiratory Lab/Diagnostic Data Resident’s O2 is 94% at room air. No cough or sputum present. Respiratory rate is 20/minute relaxed and

regular. Chest expansion and chest is symmetrical. Breath sounds are regular and clear adequate

air entry throughout all lung fields. Resident does not have any current respiratory

issues.

InspectionPalpationPercussionAuscultation

Pneumovax Inoculation on file (received Nov 2nd/2005).

Tuberculosis Screening Tool on file and is negative for TB.

Gastrointestinal/Nutrition Lab/Diagnostic Data

Abdomen is symmetrical upon inspection. Bowel sounds auscultated in all four

quadrants. Last bowel movement reported was 1 days

ago. Skin is warm to touch and well perfused.

InspectionAuscultationPercussion

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Resident exhibits a good appetite overall, and eats a well balanced diet most days.

Regular diet as tolerated (DAT). Resident is particular about her food and does

not eat foods she does not like. i.e. potatoes, green beans, etc.

PalpationDietician assessment on file.List of all the foods resident does not like is on file.Blood work for electrolyte balance.

Genitourinary/Gynecologic/Reproductive Lab/Diagnostic Data

Resident currently has a size 14 Foley catheter in place for voiding.

Urine is clear amber color and quantity sufficient output.

Does not express any pain in her genitalia area. Resident is incontinent of bowel movements

(BMs) in pad and therefore wears absorptive Tena briefs throughout the day and night.

Resident is changed on a regular basis to prevent infection and further skin break down.

Integumentary Lab/Diagnostic Data Resident’s skin was warm and dry to touch.

No concerns. Skin was pink, and well perfused. Skin turgor indicated resident was well

hydrated. No concerns. Oral mucosa, pink and moist. No concerns. Resident has bath once every week, unless

otherwise indicated due to pressure ulcers. Resident must use products labeled

“unscented” or “regular” because of sensitivities to perfumes, preservatives and other chemicals used in scented products.

Denies having xerosis, pruritus, rashes, or changes in skin pigmentation or color.

Denies any changes to skin with changing of seasons

Toe nails were long. No splitting, discoloration, breaking or separation from nail bed present.

Resident has a pressure ulcer to the left ischial tub. That requires wound care every day.

Serous/sanguineous exudate discharge from left ulcer present. Odor present. Edge of wound is not attached and appears as a ‘cliff”. Peri wound skin is intact, but fragile. Resident states the pain from the wound as a “9/10” during dressing change, but states she does not notice it when up in her chair. Packing was

InspectionPalpation

Braden Scale on file. Score is 14, which indicates resident is at moderate risk for skin breakdown.

Wound assessment and treatment flow sheet.

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completed with 8 inches of iodoform ribbon Treatment followed as per treatment plan and documented in resident’s chart.

**please see “wound assessment and treatment flow sheet in resident’s chart”**

Resident is at risk for moderate skin breakdown due to her immobility and incontinence.

Pressure Ulcers:Pressure ulcers develop based on the amount of moisture, pressure, friction, shearing, and age related malnutrition, anemia, and low arterial pressure that the resident is exposed to. Also, the likelihood of developing pressure ulcers later in life increases as we age. Quality of care is also a contributing factor to the prevalence of developing pressure ulcers (Touhy & Jett, 2012).

Musculoskeletal Lab/Diagnostic Data

Resident is a paraplegic as a result of her MS, and neurodegenerative disease.

Requires a sling during transfers from bed to chair.

Poor muscle tone to lower extremities. Muscle tone is present but weak in upper

extremities. Poor muscle tone throughout is deteriorated as

a result of resident’s inability to mobilize. Resident stated that she was in fact involved in

physiotherapy for a short period of time and was able to lift 10 pound dumbbells.

Resident states that she would like to get back into working out to promote wellbeing.

Resident exhibits no range of motion (ROM) in her legs, and poor ROM in her arms.

Resident uses a power wheel chair for mobility, and requires total daily care.

Frailty Syndrome:Frailty is an independent geriatric syndrome that can be seen in older adults alongside various comorbidities. The resident is gaged at a level 6 frailty, these include both physical and mental decline that leads to risk for morbidity and mortality (Touhy & Jett, 2012).

Physiotherapist appointments available.

Renal/Metabolic Lab/Diagnostic Data

Beginning as early as thirty years old, the kidneys begin to decrease in size and function (Touhy & Jett, 2012).

The kidneys loose about 50% of the nephrons.

On March 16th 2017 the resident’s lab values for her urine analysis showed that her creatinine was 92, which was slightly high. Normal

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The kidneys cortex has a decrease in size and function. The GFR is decreased which causes urine creatinine clearance to require a lower does of medication (Touhy & Jett, 2012).

According to the medical history of the resident, the resident has chronic kidney disease which can lead to numerous complications.

The residents GFR was 57, which is slightly low but expected with the progression of her disease.

Because of these issues the resident has with her kidneys, she is at risk for electrolyte imbalances; therefore, it is important to take her electrolyte levels regularly.

Chronic Kidney Disease:Different disease processes can affect kidney function. Diet, drugs, and disease progression can be key factors in developing CKD (www.bcguidelines.ca/pdf/ckd.pdf).

range for UA creatinine is between 45-84. The resident’s glomerular filtration rate (GFR) was 57, which is low. Normal GFR is greater or equal to 60. Low GFR and high creatinine can be related to client’s chronic kidney disease as well as the clients increasing age a urine test could be used to evaluate pH, and kidney function (Ebersole & Hess, 2012).

GFR less than 60ml/min/1.73 m2 for 3 months is a diagnostic criterion for CKD (www.bcguidelines.ca/pdf/ckd.pdf)

Sodium level was 142, which is normal. (136-145).

Potassium level was 4.3, which is within normal range. (3.5-5.1).

Immune/Hematopoietic Lab/Diagnostic Data

The resident is ESBL+ The resident is MRSA+ The resident receives her flu vaccine every

year, and is up to date on her vaccinations. The resident is incontinent of BM and requires

pad changes frequently throughout the day. By changing the resident’s pad throughout the day infection and further progression of her disease can be avoided.

Pneumovax Inoculation is up-to-date. Resident has been tested for TB and is

negative.

On March 16th 2017 the resident’s lab values were as follows:- White blood cell: 11.4 x 10(9)/L, which is high. Normal range is between 4 and 10 x 10(9)/L.- Red blood cell: 4.43 x 10(12)/L, which is normal. Normal range is between 4.30 and 5.50 x 10(12)/L.- Hemoglobin: 144 g/L, which is normal. Normal range is between 135 and 170 g/L.

Pneumovax Inoculation on file (received Nov 2nd/2005).

Tuberculosis Screening Tool on file and is negative for TB.

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Behavioral Dimension

Activity/Rest & Sleep

The resident stated that she does not sleep well and would like to talk to her doctor about adding a medication to aid in sleep. The resident stated that she believes she suffers from insomnia, and does not sleep well most nights. The resident often takes naps throughout the day as a result from lack of sleep during the night. The resident is immobilized due to her comorbidities, and needs full assistance with ADLs. The resident does require a full lift for transfers. The resident does enjoy shopping and often times will go out on a day pass for some shopping. She also stated that she likes to gamble and often times will go to the casino for fun.

Consumption Patterns

The resident is very particular about what she eats and does not like many foods. However, the resident appears to eat well most of the time. According to the resident’s food log, she eats “good” throughout the day and does not present much of an appetite at night. She does consume her own food throughout the day, and enjoys candy and potato chips. The resident is does not exhibit signs of dysphasia and therefore does not require thickened fluids. The resident denies any history of alcohol consumption, and states that she does not smoke and is not addicted to any illicit substances. Denies any current of past history of drug use. Resident was compliant with all medication administration throughout writer’s clinical shifts.

Sexuality

The resident is female, widowed (as of 2013). She has 3 children and 2 grandchildren. The resident has developed a romantic relationship with her neighbor, and states that he has been a “godsend” since her husband passed away.

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Safety

The resident is a paraplegic and does require all four bed-rails up when in her bed. She has a lift in her room for safe transferring form bed to power-wheelchair, and call bell is always left in reach. Resident’s power wheelchair does have a seatbelt to stabilize and secure her in her wheelchair when in use, and to prevent DE-positioning throughout the day. The resident denies ever wearing glasses throughout her life and states that she has always had very good, clear, concise vision. Resident does not have hearing aids, and states that hearing has never been an issue for her.

Psychological Dimension

Self-Concept/Self-Perception

Upon assessment the resident was cooperative and pleasant with writer. However, the resident does exhibit traits of significant cluster “B” traits on the axis II of personality disorder according to the Doctor’s assessment that is on file. The Doctor believes resident could be showing signs of a personality disorder; however, when a Mental Health Inventory (MHI) was attempted the resident refused to participate and verbalized her anger towards the Doctor. The resident recognizes that she is “very different from others” and states, “my brain is clear and sharp. I make my own decisions. I know what I want and when I want it. I can be hard to deal with and cause conflict among family and staff. I have mood swings and can be verbal but I do feel bad, I struggle to fit in my environment being younger than others”. Resident scored a 3 on the Geriatric Depression Scale, which warrants no further investigation; however, staff should still encourage resident to participate in daily social activities offered through day programs, and to be involved in community events. Staff should also support resident in attending support groups around MS to help the resident explore and express her feelings towards her condition.

Stress/Coping

The client was agitated and standoffish during the six-days of care provided. The resident expressed several times throughout the clinical rotation that she did not want students, but later changed her mind. Resident expressed that she is able to cope with many things much better since building her relationship with her neighbor. Resident also stated that shopping and going to the casino are her ways of coping with life stresses.

Sociocultural Dimension

Role/Relationships

The resident relies mainly on her relationship with her neighbor for support. However, the

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resident does have three children and 2 grandchildren, but does not see them often. She stated that she understands life gets busy and that is why her children are unable to visit often. The resident also stated that although she does not get to see her children often, she still has a good relationship with them. When asked about any past or current history of abuse, the resident denied any experiences of the sort.

Values/Beliefs

No religious beliefs or cultural practices were identified during the interview.

Physical /Environmental Dimension

Living Arrangements/Pets

The resident currently resides in Quesnel at Dunrovin Park Lodge. She is widowed and has 3 children, and 2 grandchildren who she states she does not see often. Resident does not have any pets and enjoys her alone time.

Health System Dimension

Health Perception - Health Management Pattern

Currently, the resident’s primary healthcare provider is Dr. Doe. Dr. Doe believes that RJ is suffering from some sort of mental health disorder with regards to personality. Dr. Doe also believes that RJ is exhibiting signs of early dementia related to her MS, giving rise to her emotional lability and irritability as well as her impulsiveness and lack of planning. Dr. Doe has attempted multiple screening tools; however, RJ refuses to participate in screening tools that suggest she might be mentally ill. The resident is up-to-date with her immunizations. The main priority for this resident is to prevent further skin breakdown, and promote wellbeing through socialization. ADLs are done everyday for this resident, and pad changes are required throughout the day. The resident does not have issues waking up in the morning and is usually up for breakfast around 0800.

Living will: No record of a living will on file.

Code Status/Advanced Directive: M3: Full medical treatments excluding critical care. Resident

specified that she does not want blood products, enteral nutrition, dialysis, or ventilation.

Do you have allergies to meds, foods, latex? Explain: Allergies include: Macrobid (will put

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resident into a coma), Flagyl, Atenolol, Cefuroxime, Sulfa (will put resident into a coma),

Tobramycin, Penicillin, Dexamethasone, Cholestyramine, Metronidazole, Questran, and

Primaxin. Resident denies any allergies related to foods or latex.

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Diet & Routine/PRN Treatments Patient Learning Needs(During days of care)

Resident actively participates in a regular scheduled diet provided by the kitchen. DATThe residents Routine/PRN treatments include:

- Palliative Bowel Routine: PRN- Acetaminophen: 500-1000mg po q6h prn

for pain (max 4000mg/24 hours)- Vitamin B-12 INJ 100mcg/ml: 1-ml

injected (100mcg) IM/SC Bi-weekly PRN- Ibuprofen 200mg: 1 tab tid prn- Lorazepam 0.5mg: Give 1 tab q6h PRN for

anxiety or sleep to a maximum of 4 doses per 24 hours

- Docusate sodium: 2 caps po BID- Baclofen 20mg: 1 tab tid- Bupropion XL 150mg: 1 tab bid- Cranberry caps 250mg: 2 caps qd- Furosemide 20mg: 1 tab bid- Jamp-K8 600mg: 1 tab bid- Ranitidine 150mg: 1 tab bid- Zoplicone 7.5mg: 1 tab hs- Saline nasal 0.9%: Use 2 sprays in each

nostril bid

** All medications are given whole and on a spoon**

Preferred ways to learn: RJ learns best kinesthetically. She expresses that she has to do a task physically to understand the concept. She is very vocal and does not hesitate when she has a question about something. RJ is able to communicate any uncertainties that she has.

Barriers to learning: RJ exhibits challenges when learning new concepts due to her debilitation caused by her MS and neurodegenerative disease. She requires full assistance with ADLs as a result of her paraplegic state. RJ faces challenges due to the progression of disease and requires more care as time goes on, all of which contribute to barriers to learning.

Topics to teach: The resident was informed about the importance of repositioning her in bed q3h to prevent pressure ulcers from progressing and to avoid further skin breakdown. It is important that the resident associates her inability to mobilize with higher risk for skin integrity issues such as breakdown. The resident was also informed on the importance of participating in daily activities that involve socialization to improve her mental wellbeing. Resident also verbalized how important physiotherapy was, and how she would like to start seeing the physiotherapist again to gain some strength back.

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Risk for Injury: The resident is at risk for injury due to the fact that she is a paraplegic and is

unable to mobilize. The fact that she has a catheter and is incontinent of stool also puts this

resident at higher risk for skin breakdown.

Client’s Discharge Planning Needs

Currently, the resident requires a level of professional services that could not be offered

at home; therefore, RJ will most likely live out the rest of her life at DPL. For example, the

resident suffers from chronic UTIs and is susceptible to infections, and needs an advance level of

care most of the time. It would be both unethical, and unsafe to discharge the resident unless this

issues resolved (which it will not).

Appropriate Referrals Needed To Other Members Of The Health Care Team

An appropriate referral needed to other members of the health care team would be to

physiotherapy to assist the resident with rehabilitation to promote strength in her upper body.

Another appropriate referral for this resident would be to support groups regarding MS. The

resident would benefit from attending support groups for several reasons; first, by attending

support groups the resident would have social interaction with other people with MS. Second, by

attending support groups the resident would have an opportunity to express any unprocessed

feelings she has towards her disease. The goal of the support group would be to decrease social

isolation and promote wellbeing. Also, the resident would be at a lessened risk of developing

depression because she would realize that she is not alone.

Client Teaching for Discharge

The resident will not be discharged from DPL; therefore, client teaching for discharge is

not applicable. The resident will not be discharged because her conditions are too debilitating,

and home care/support is not a reasonable solution. Also, the resident does not have family that

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could provide the safe and advanced care she needs.

Lab and Diagnostics

**March 16/ 2017 Blood Work was discussed in Immune/Hematopoietic assessment**

March 16th 2017 Reference Ranges

WBC 11.4 4.0-10.0

RBC 4.43 4.30-5.50

Hgb 144 135-170

Hct 0.45 0.40-0.49

MCV 89.0 82.0-100.0

MCH 31.0 27.0-34.0

MCHC 345 320-360

RDW 13.0 11.6-15.0

Lymph Auto 2.00 1.00-3.30

CO2 24 22-29

Albumin Lvl 28 35-52

Calcium Lvl 2.07 2.15-2.55

**March 8/ 2017 Creatinine and GFR levels were discussed in Renal/ Metabolic

assessment**

March 8th 2017 Reference Ranges

Urea 11.3 3.0-8.0

Creatinine 92 45-84

GFR 57 >=60

Sodium Lvl 142 136-145

Potassium Lvl 4.3 3.5-5.1

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Client Problems

1) Risk for Infection (sepsis) related to the development of opportunistic infections as

evidence by resident’s built-up resistance to most antibiotics and refusal of IM

antibiotics.

2) Impaired skin integrity related to lack of mobility as evidenced by impaired physical

mobility secondary to multiple sclerosis and neurodegenerative disease.

3) Social Isolation related to insufficient community resources as evidenced by feelings of

loneliness attributed to interpersonal interaction below level desired and required for

personal integrity.

4) Impaired physical mobility related to activity limitations secondary to multiple sclerosis

and neurodegenerative disease as evidence by loss of muscle mass, tone, and strength

associated with prolonged disuse and altered nutritional status.

5) Risk for impaired tissue integrity related to accumulation of waste products and

decreased oxygen supply to the skin and subcutaneous tissue associated with reduced

blood flow resulting from prolonged pressure on the tissues as evidence by pressure

ulcers.

6) Chronic pain related to poor tissue perfusion and inability to turn self, secondary to

multiple sclerosis as evidence by resident rates pain 8 on 1-10 scale and grimaces when

turned or mobilized.

7) Sleep pattern disturbance related to decreased physical activity, and discomfort resulting

from current health status as evidence by resident’s statements of “I have trouble

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sleeping”.

8) Social isolation related to manipulative social behavior as evidence by “staff and family

splitting” behavior.

9) Risk for loneliness related to reluctant attitude to participate in social activities as

evidence by limited contact with others.

10) Risk for infection; urinary tract infection, related to introduction of pathogens associated

with an indwelling catheter as evidence by frequent UTIs.

11) Altered nutrition: less than body requirements related to decreased oral intake as evidence

by difficulty feeding self as a result of impaired or limited physical mobility secondary to

multiple sclerosis and neurodegenerative disease.

12) Chronic low self-esteem related to inadequate coping skills as evidence by feelings of

helplessness.

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Date: 09/04/2017

Patient initials: RJ

Student Name: Vanessa Mickey

Nursing Diagnosis

Goals Nursing Interventions

Rationale Evaluation

-Risk for Infection (sepsis) related to the development of opportunistic infections as evidence by resident’s built-up resistance to most antibiotics and refusal of IM antibiotics.

- The resident will remain free from infection as evidenced by negative results of cultured specimens during their duration at DPL.

- The resident will fully understand the repercussions of not taking IM antibiotics.

- Maintain resident’s current mental status.

- Pulse will remain within normal limits throughout resident’s tenancy at DPL.

- Follow appropriate precautions established to prevent transmission of infection (Myers, 2014).

- Avoid invasive procedures whenever possible, if they are necessary, then perform them using sterile technique.

- Client teaching will be completed in order to explore the client’s options with regards to drug therapy and promote comprehension of the complications that can arise from refraining from taking antibiotics IM when needed.

- Evaluate resident’s current mental state through MMSEs and GDSs to ensure that there is no change.

- Will monitor blood pressure and pulse and document it in resident’s chart (Jarvis, 2012).

-Will document presence and quality of central and peripheral pulses in resident’s chart (Jarvis, 2012).

- Will assess

- By following the appropriate precautions (i.e: gown, gloves, mask, etc…) when providing care will prevent further infections from developing and will lessen the risk of opportunistic infections from developing (Myers, 2014).

- Monitoring vital signs helps determine low/high blood pressure, pulse, presence/quality of central/peripheral pulses, and the effects of vasoconstriction. It allows the nurse to see if the client is within a therapeutic range (Jarvis, 2014).

- This resident currently has yearly blood work done.

- This resident currently has a urine analysis done every 3 months.

- Resident’s vital signs are normal and kept within a therapeutic range (i.e: blood pressure, pulse, temperature, etc…) (Jarvis, 2012).

- Resident is aware why it is important to keep her vital signs within the normal range (Jarvis, 2012).

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Client’s Progress Towards Achieving Each Expected Outcome

The resident currently achieves yearly blood work, and a urine analysis every three

months. This expected outcome is met every year, and every three months, respectively. DPL

will request tests more frequently if there are any issues that arise, but otherwise the resident’s

lab analysis is always kept up-to-date. In addition, the next expected outcome is that the resident

maintains vital signs within normal range (Jarvis, 2012). The resident’s blood pressure fluctuated

throughout the six-day assessment; however, this was typical for this resident and the vital signs

still remained within a therapeutic range; therefore, this outcome was met. Finally, the last

expected outcome for the resident was to ensure that the resident understands the importance of

maintaining vital signs within normal range (Jarvis, 2012). This outcome was also met as

evidenced by the resident speaking about how she keeps track of her vital signs. One revision

that could be adjusted is ordering blood work every six months instead of every twelve. By

ordering blood work more frequently it will allow the nurses to see a more general picture of the

resident’s condition; therefore, interventions can be adjusted accordingly.

Discussion of Pathophysiology and Rationale for Nursing Diagnosis

There are many things to consider in the development of sepsis. Remick explains

“[m]any cellular aspects become dysfunctional in sepsis and may be characterized as either

excessive activation or depressed function” (para. 20). The resident is at risk for sepsis because

of her depressed immune function as a result of her comorbidities’. It is important to continue to

monitor this resident for signs and symptoms of sepsis, including increased or decreased body

temperature, decreased heart rate, decreased respiratory rate, increased white blood count, and

arterial CO2 tension less than 32 mm Hg (Remick, 2007). Because this resident has a greater

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GERIATRIC CARE PLAN

susceptibility to infections and is unwilling to take antibiotics intramuscularly, it is important that

infections like sepsis are identified early on to provide the best possible outcome for the resident.

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GERIATRIC CARE PLAN


22

Date: 09/04/2017



Nursing Diagnosis



Impaired skin integrity related to lack of mobility as evidenced by impaired physical mobility secondary to multiple sclerosis and neurodegenerative disease.

- Resident will not develop skin breakdown during her stay at the care facility.

- Resident will be assessed for skin breakdown.

- Assess and clean between skin folds.

- Resident will be educated on the importance of proper fluid and food intake (Jarvis. 2012).

- Resident will be educated on the importance of keeping the skin clean and dry (Jarvis, 2012).

- The resident will be repositioned frequently (Jarvis, 2012).

- The resident’s skin will be monitored for color or texture changes, or lesions (Jarvis, 2012).

- To prevent break down of skin (Lewis et al., 2014)

- Nutrition helps with the normal cellular integrity and tissue repair (Jarvis, 2012).

- If the skin sits in constant moisture it will soften the skin and causes a break in the skin integrity (Jarvis, 2012).

- Positioning the resident helps reduce pressure and shear force to the skin (Jarvis, 2012).

- Regular inspection of the skin can identify problems early (Lewis et al., 2014)

- Reinforce the importance of mobility, turning, or ambulation in prevention of pressure ulcers (Jarvis, 2012).

- When doing morning care assess resident for signs of skin breakdown.

- The resident will understand why it is important to keep skin clean and dry (Jarvis, 2012).

GERIATRIC CARE PLAN

With regards to “reinforcing the importance of mobility, turning, or ambulation in

prevention of pressure ulcers” (Jarvis, 2012) this expected outcome was met. The client was

aware that she needed to be turned and repositioned in order to prevent skin breakdown. The

next expected outcome was to assess the resident’s skin for breakdown when doing morning

care. This outcome was met over the six-day assessment because the writer looked for any

redness or irritation when performing care on the resident. The final expected outcome was that

the resident would understand why it is important to keep skin clean and dry (Jarvis, 2012). This

goal was only partially met. The resident would refuse care periodically despite the fact that she

knew she needed it. There should be no revision necessary for the first goal, the client must be

repositioned in order to prevent skin breakdown; therefore, this plan of care should be continued.

There should be no revision to the second goal as those who provide this resident with care

should always assess for redness and irritation when providing care throughout the day. And

lastly, a revision to the last goal should be to provide the resident with further education on her

condition to promote a full understanding as to why she needs the level of care that is required.


The resident is a paraplegic and is unable to walk due to her MS. She requires a lift for

transfers from her bed to power wheelchair. When there is constant pressure on parts of the body

due to immobility they are at risk for impaired skin integrity. The skin is broken down easily

when its circulation becomes impaired and cell regeneration is reduced. Blood supply is reduced

in places where bony projections are close to the skin and there is little fatty or muscular tissue to

cushion the weight of the body (Gould & Dyer, 2011). Thus, will cause pressure ulcers. Pressure

ulcers are difficult to heal. The skin will become red and inflamed when pressure ulcers first

start, ulceration will follow. To prevent impaired skin integrity, using sheepskin pads or

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GERIATRIC CARE PLAN

floatation devices should protect the resident’s skin. The resident’s position should be changed

frequently to avoid prolonged pressure of the skin. This allows adequate circulation (Gould &

Dyer, 2011). Throughout the six-day assessment the resident was rotated from side to side with

pillows to prevent prolonged pressure on her skin. During the assessment the resident already

had a pressure ulcer to her left hip, which needed to be changed everyday.

24


Date: 09/04/2017



Nursing Diagnosis



Social Isolation related to insufficient community resources as evidenced by feelings of loneliness attributed to interpersonal interaction below level desired and required for personal integrity (Gordon, 2009, p. 356).

- The patient will attend support groups to attain social support and social contacts to maintain well-being.

- The patient will become a part of a community group, this will enhance the sense of belonging and build relationships with others to avoid isolation.

- The nurse will provide the patient with contacts for emotional support.

- Assist resident to identify reasons for feeling isolated and alone and help him to develop a plan of action to reduce these feelings (Jarvis. 2012).

- The nurse will be in contact with the Public Health Unit, having an active relationship with the Public Health Nurse; who will make weekly in home visits to assess the effectiveness of the resources provided to the patient and make further interventions as necessary.

- Schedule time each day to sit and talk with resident (Jarvis. 2012).

- Move resident to a more stimulating environment (Jarvis. 2012).

- Help the resident establish why she is feeling isolated and lonely will help to develop a plan to reduce the risk of social isolation (Jarvis. 2012).

- Assess the residents’s social resources in order to assess the support systems in place for her and the need for additional resources. Gauvin-Lepage, Malo, Lefebvre (2015) note the, “importance of exploring individual and family resources, which could reduce obstacles and foster hope” (p. 38).

- By giving the resident resources it promotes continuity of care. Evans, Davidson, & Sicafuse, (2013) explain that such resources have the “ability to provide a safe, confidential, convenient, and cost-effective method to reach out for help during a crisis or when they need support or information” (p. 486).

- Coordinate with the Public Health Unit weekly visits by the Public Health Nurse, to assess emotional supports and resources effectiveness. Novara, Garro, and Rienzo (2015) emphasize that, “social support acts as

- The resident will maintain relationships with significant others.

- The resident will show no expression or feelings of isolation and loneliness.

GERIATRIC CARE PLAN


In regards to the expected outcome “the resident will maintain relationships with others,”

this outcome was met. The resident remained in constant contact with her neighbor. The final

expected outcome was that “the resident will show no expression or feelings of isolation and

loneliness,” this outcome was not met. The client at times still shows feelings of isolation and

loneliness. The resident did express feelings of isolation and loneliness and stated that she has a

difficult time fitting into her environment because of her age, she feels like she is younger than

everyone else. One revision could be to encourage the resident to make friends with more tenants

instead of just her neighbor. The second revision could just be to support the resident through

times of loneliness and isolation through counseling services.


This resident is completely dependent on the staff and requires full care with ADLs. Loss

of physical mobility has caused this resident to lose all of her independence. This resident enjoys

shopping and going to the casino. It is important that the nurse encourages the resident’s family

to visit in order to increase socialization and prevent loneliness. A substantial decrease in the

physical mobility of a person can cause that person to feel dependent on others and isolated

(Jarvis. 2012). Therefore, the resident is at risk for social isolation due to decrease in physical

mobility secondary to her MS and neurodegenerative disease.

26


CURRENT MEDICATIONS (ROUTINE AND P.R.N.)

Generic name/Trade name:

Acetaminophen/Tylenol Zopiclone/Imovane Lorazepam/Ativan

Classification: Non-Opioid Analgesic & Antipyretic

Nonbarbiturate Hypnotic

Benzodiazepine

Dosage/route/frequency ordered:

500mg/oral TID 7.5mg/ oral before bed

1mg/oral PRN

Why is this client receiving this medication?

Recurrent pain related to MS (Lilley, Harrington

& Snyder, 2011).

This medication is used as a sleep aid (Lilley, Harrington & Snyder, 2011).

This medication is used to decrease agitation (Lilley,

Harrington & Snyder, 2011).

How does this medication work?

Inhibit an enzyme called, prostaglandins. Prostaglandins cause

pain and inflammation after cell injury. It

elevates body temperature by affecting

the heat-regulating center of the brain

known as, hypothalamus. By

blocking prostaglandins being produced in the

central/peripheral nervous systems, non-

opioid analgesics reduce both fever and

inflammation (Lilley, Harrington, Snyder,

2011).

Zopiclone rapidly initiates and

sustains sleep with reduction of total REM sleep and

with preservation of slow wave sleep (Lilley, Harrington & Snyder, 2011).

Enhances GABA effects on brain to

reduce brain activity (Lilley, Harrington & Snyder, 2011).

What side effects are most likely to occur

secondary to this medication?

Common side effects include: rash, nausea,

stomach pain, itchiness, loss of appetite, dark

urine, clay-colour stools and jaundice (Lilley, Harrington, Snyder,

2011).

Common side effects include: clumsiness or unsteadiness,

daytime anxiety, restlessness,

difficulty with coordination, mood or mental changes,

drowsiness, shortness of breath

and tightness in chest (Lilley, Harrington & Snyder, 2011).

Common side effects include:

Sedation, dizziness, weakness,

unsteadiness, depression, loss of

orientation, headache and

sleep disturbance (Lilley, Harrington & Snyder, 2011).


CURRENT MEDICATIONS (ROUTINE AND P.R.N.)

Generic name/Trade name: Baclofen/Lioresal Bupropion/Wellburtin Furosemide/Lasix

Classification: Gamma-aminobutyric acid

“GABA”

Antidepressant Loop diuretic (water pill)

Dosage/route/frequency ordered:

20mg/orally tid 150mg/orally bid 20mg/orally bid

Why is this client receiving this medication?

This medication blocks the activity

of nerves within the part of the brain that controls the contraction and

relaxation of skeletal muscle

(Lilley, Harrington & Snyder, 2011).

This medication is used to treat depression (Lilley, Harrington &

Snyder, 2011).

This medication is used to prevent the body from absorbing too much salt. This allows the salt to instead be passed in the urine.(Lilley, Harrington & Snyder, 2011).

How does this medication work?

Baclofen works by inhibiting both

monosynaptic and polysynaptic reflexes at the spinal level, possibly by

hyperpolarization of afferent

terminals, although actions at

supraspinal sites may also occur and

contribute to its clinical effect


Bupropion works by works by affecting the balance of chemicals that occur naturally in

the brain. (Lilley, Harrington & Snyder,

2011).

Furosemide works by blocking the absorption of

sodium, chloride, and water from the filtered fluid in the

kidney tubules, causing diuresis


What side effects are most likely to occur

secondary to this medication?


confusion, dizziness, nausea,

and unusual weakness (Lilley,

Harrington & Snyder, 2011).

Common side effects include: insomnia,

nausea, pharyngitis, weight loss,

constipation, dizziness, headache, and

xerostomia (Lilley, Harrington & Snyder,

2011).


numbness and/or tingling, headache,

dizziness, and blurred vision


The first thing nurses should know

Nurses should know that bupropion side

Furosemide should not be taken if the

GERIATRIC CARE PLAN

References

Evans, W. P., Davidson, L., & Sicafuse, L. (2013). Someone to listen: increasing youth

help-seeking behavior through a text-based

crisis line for youth. Journal of community psychology, 41(4), 471-487.

doi:10.1002/jcop.21551

Gauvin-Lepage, J., Malo, D., & Lefebvre, H. (2015). Family resilience following a

physical trauma and efficient support

interventions: A critical literature review. Journal of Rehabilitation, 81(3), 34-42.

Gould, E.B., Dyer, M.R. (2011). Pathophysiology for the Health Professions. (4th ed). United

States: Saunders Elsevier.

Gordon, M. (2009). Manual of Nursing Diagnosis (12th ed.). Sudbury, MA: Jones and

Bartlett Publishers.

British Columbia. (2017). BC guidelines. Retrieved from

www.bcguidelines.ca/pdf/ckd.pdf

Jarvis, C. (2014). Physical examination & health assessment (2nd ed.) (A. J. Browne, J.

MacDonald-Jenkins, & M. Luctkar-Flude, Eds.). Toronto, ON: Elsevier.

Jarvis, C. (2012). Physical examination and health assessment (2nd ed.). Toronto, ON: Elsevier

Canada.

Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., Camera, I. M.(2014). Medical-Surgical

Nursing in Canada (3rd Canadian Ed). Toronto ON: Elselvier Mosby.

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GERIATRIC CARE PLAN

Lilley, L.L, Harrington, S., Snyder, S.J. (2011). Pharmacology for Canadian Health CarePractice.

(2th ed). Toronto, ON: Elsevier Canada.

Myers, E. (2014). Rnotes: nurse’s clinical pocket guide. (4th ed). Philadelphia: F.A. Davis

Company.

Novara, C., Garro, M., & Rienzo, G. D. (2015). Coping styles and social support in

emergency workers: Family as a resource.

Romanian Journal for Multidimensional Education /Revista Romaneasca Pentru

Educatie Multidimensionala, 6(1), 129-140.

Academic Search Complete.

Skovronsky, D.M., Lee, V.M., Trojanowski, J.Q. (2006). Neurodegenerative diseases:

new concepts of pathogenesis and their therapeutic implications. US National Library of

Medicine National Institutes of Health, 1, 151-170.

doi:10.1146/annurev.pathol.1.110304.100113

Touhy, A.T., Jett, F.K. (2012). Gerontological Nursing and Healthy Aging. Toronto, ON:

Elsevier Canada

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