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    Nursing Care Plan: Assessment Data

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    Dana Cozoroc
    Samantha created a nursing care plan for RM, an 87-year-old female patient with multiple sclerosis who experiences fatigue, incontinence, sleep apnea, vision problems, and mobility issues. Samantha identified RM's fatigue and risk of loneliness as nursing diagnoses and set goals for RM to get better sleep, take daytime naps, and become more socially engaged. Samantha's interventions included assessing RM's fatigue and nutrition, providing sleep aids, encouraging social activities, and monitoring for loneliness. In her evaluation, Samantha found RM was receiving adequate nutrition but still fatigued, and would benefit from medication and naps, while social engagement was improving her risk of loneliness.

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    Nursing Care Plan: Assessment Data

    Uploaded by

    Dana Cozoroc
    107 views2 pages
    Samantha created a nursing care plan for RM, an 87-year-old female patient with multiple sclerosis who experiences fatigue, incontinence, sleep apnea, vision problems, and mobility issues. Samantha identified RM's fatigue and risk of loneliness as nursing diagnoses and set goals for RM to get better sleep, take daytime naps, and become more socially engaged. Samantha's interventions included assessing RM's fatigue and nutrition, providing sleep aids, encouraging social activities, and monitoring for loneliness. In her evaluation, Samantha found RM was receiving adequate nutrition but still fatigued, and would benefit from medication and naps, while social engagement was improving her risk of loneliness.

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    Samantha created a nursing care plan for RM, an 87-year-old female patient with multiple sclerosis who experiences fatigue, incontinence, sleep apnea, vision problems, and mobility issues. Samantha identified RM's fatigue and risk of loneliness as nursing diagnoses and set goals for RM to get better sleep, take daytime naps, and become more socially engaged. Samantha's interventions included assessing RM's fatigue and nutrition, providing sleep aids, encouraging social activities, and monitoring for loneliness. In her evaluation, Samantha found RM was receiving adequate nutrition but still fatigued, and would benefit from medication and naps, while social engagement was improving her risk of loneliness.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    107 views2 pages

    Nursing Care Plan: Assessment Data

    Uploaded by

    Dana Cozoroc
    Samantha created a nursing care plan for RM, an 87-year-old female patient with multiple sclerosis who experiences fatigue, incontinence, sleep apnea, vision problems, and mobility issues. Samantha identified RM's fatigue and risk of loneliness as nursing diagnoses and set goals for RM to get better sleep, take daytime naps, and become more socially engaged. Samantha's interventions included assessing RM's fatigue and nutrition, providing sleep aids, encouraging social activities, and monitoring for loneliness. In her evaluation, Samantha found RM was receiving adequate nutrition but still fatigued, and would benefit from medication and naps, while social engagement was improving her risk of loneliness.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    Nursing Care Plan

    Student Name: Samantha Benn Date: November 19th 2015


    Patients Initials: RM Medical Diagnosis: Multiple Sclerosis

    Assessment Data:
    Objective:
     87-year-old female
     Urgency incontinence (use of briefs)
     Sleep apnea
     Vision difficulties without glasses
     Non-electric wheelchair for mobility aid
     Motor fatigue
     Difficult to understand speech
     Diabetic

    Subjective:
     Patient states “I’m tired” frequently and wishes to stay in bed a little longer before
    getting breakfast.

    Nursing Diagnosis and Related Goals:


    1. Fatigue related to decreased energy production, increased energy requirements to
    perform activities, as evident by patient’s inability to physically get self up and hold
    posture in order to get lifted into wheelchair.
    Goal: Patient will obtain a better sleep at night and will be taking day naps effectively by
    November 27th 2015 at the end of my shift, 13:00.
    2. Risk of loneliness related to lack of physical abilities and decreased mobility, as evident
    by relying on nursing staff to be moved and excessive time spent in her room.
    Goal: Patient will become more involved in the activities that the long-term care facility
    provides by November 26th 2015 at the end of my shift, 13:00.

    Nursing Interventions and Rationale:


    1.
     Assess severity of fatigue on a scale of 0 to 10; assess frequency of fatigue
     Assess adequacy of nutrition, as patient may not be receiving all the nutrients required
    for a day to give patient energy required daily.
     Provide patient with a sleep aid at night until a solid sleep pattern is intact and patient is
    not as fatigued in the morning.
     Use a less energy required lift, so patient is not required to sit up and move around into
    placement for the sit-to-stand lift.
     Review medications for side effects, since certain medications cause fatigue in the
    elderly.
     Allow patient day time naps to regain energy lost in physical activity during the day.
    2.
     Establish a therapeutic relationship and spend time with patient.
     Encourage patient to attend the activities hosted by long-term care facility, if accepted,
    help patient get there by pushing wheelchair.
     Increase patients support system, such as family and friends. Satisfaction with a support
    network is an excellent predictor of emotional health.
     Encourage patient to get to know other residents in the long-term care facility, and
    provide a positive reinforcement when doing so.
     Become alert to verbal and nonverbal cues, that hint a sense of loneliness and despair.
    Determine if there is a presence of suicidal thoughts.

    Evaluation:
    1: Patient is receiving required nutrients daily, but still is fatigued after a night’s sleep. It seems
    medication sleep aid may be required for patient to obtain an adequate amount of sleep. The
    option of the patient to also receive day time naps may also enhance patient’s ability to
    perform certain energy draining tasks later in the day. Overall, it seems like her multiple
    sclerosis is the main reason for the difficult sleep patterns.

    2: Patient is participating in activities provided by the long-term care facility daily. When
    participating in these events she appears content and is showing the ability to socialize. The
    odd time she is alone in her room watching television. It seems that the staff rarely visits to
    check in and develop a close relationship. This still may put her at risk for developing a sense of
    loneliness. So far there is only a slight risk. It is unknown if family or friends visit.

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