TUNG WAH COLLEGE

School of Nursing

NUR1012 Fundamentals of Nursing I

Individual Case Study – Nursing Care Plan

Student Name: Lee Tin Yan, Emma

_______________________________________
Student ID: 21002276
_______________________________________

Part I - Assessment
Personal information • Age:52 • Habits: NKDA, NSND
• Gender: male • Smoking: never
• Marital status: single • Drinking: never
• Religion: Christian • Others: nil
• Significant others: BMI
33.3kg/m^2
Health information • Chief complaint: left wrist pain and limited movement

• Past medical history: nil

• Current medication: nil

Level of consciousness/ • Level of consciousness: alert_____________________

pain/vital signs

• Pain score: 8/10

• Vital signs: temp: 36.5 °C, BP:155/80mmHg, P:85/min, RR:14/min,

SpO2:100% on room air, urine: no sugar or albumin, MEWS:0
Risk assessment • Risk of fall: high
Morse fall scale: score: 55
have history of fall, with impaired mobility, walk with stick
• Risk of pressure injury: nil

Functional assessment • Emotional state: stable

• Communication: clear speech

• Dialect: Cantonese

• Vision: normal

• Hearing: normal

• Self-care ability: independent

• Skin integrity assessment: normal

• Nutrition: BMI: 33.3kg/m^2

• Elimination: normal urination and bowel

Investigations • X-ray: left distal radius fracture

• ECG: heart sound dull and no murmur

 • Blood tests: complete blood count and differential count

Waiting result

• Others: nil

Part II: Identification of problem(s) using 12 Activities of Living

12 AL framework Identification of problems: To identify the Assessment

problems according to patient data

The activity of living Problem: a statement of the patient’s actual or Signs & symptoms (S/S):
that are common to all potential problem
manifestations of the problem
human beings which
identified
helps to guide nurses to
meet patient’s needs to Underlying causes: factors
achieve optimal health “related to’ the patient’s
and well-being. problem
Maintaining a safe W Decrease in the ability to guard self from Related S/S:
environment internal or external threats, such as illness or
injury High morse scores
W Risk for shock
W Impaired tissue integrity
W Risk of fall
W Acute confusion and impaired memory
Underlying causes:
W Impaired skin integrity
☐External environment:
W Risk for imbalance fluid volume
W Sensorimotor deficit (e.g. visual/hearing ☐Internal environment:
impairment)
Have history of falling, with
W Others: impaired mobility, need to use
__________________________________ stick
Communicating W Sensory impairment Related S/S:
- deaf
- dumb
W Difficulty in expression
W Others: Underlying causes:
__________________________________

Breathing W Ineffective breathing pattern Related S/S:

W Impaired gaseous exchange
W Ineffective airway clearance
W Others:
__________________________________ Underlying causes:

Eating & Drinking W Impaired swallowing Related S/S:

W Imbalanced nutrition: less / more than body
requirement
Underlying causes:
W Others:
__________________________________

Eliminating W Impaired urinary elimination Related S/S:

(stress/urge/overflow/reflex/functional
urinary incontinence)
W Bowel incontinence
W Dysfunctional gastrointestinal motility Underlying causes:
W Constipation
W Diarrhea
W Others:
__________________________________
Personal cleansing & W Self-care deficit Related S/S:
dressing
- in maintaining personal hygiene
e.g. bathing, dressing, feeding,
toileting
W Impaired skin integrity Underlying causes:
W Others: -
___________________________________
__________________________________

Controlling body W Impaired thermoregulation e.g. Related S/S:

temperature hypo/hyperthermia
W Others:
__________________________________

Underlying causes:

Mobilizing W Activity/exercise intolerance Related S/S:

W Impaired physical mobility High morse scores
W Fatigue Underlying causes:
(related to decreased cardiac Have history of falling, second
output/ineffective tissue perfusion) diagnosis, walking with walker.
W Risk of fall
W Others:
___________________________________
_
Working and playing W Post-trauma syndrome Related S/S:
W Ineffective relationship
W Inadequate family/social support
W Others:
__________________________________ Underlying causes:
Expressing sexuality W Low self-esteem Related S/S:
W Altered body image
W Disturbance in sexual identity
W Difficulty with sexual relation
Underlying causes:
W Others:
__________________________________

Sleeping & rest W Sleep deprivation Related S/S:

W Disturbed sleep pattern
W Others:
__________________________________
Underlying causes:

Dying  Hopelessness Related S/S:

 Depression
 Pain
 Fear/Anxiety
Underlying causes:
W Others:
___________________________________
Part III: Describe TWO nursing problems and current nursing interventions
with rationales

Nursing problem 1 High risk of fall related to stick used as ambulatory aid, secondary diagnosis
of hyperlipidemia and past fall history within 3 months, as evidenced by
morse fall scale: 55 and past medical history.

Goals/ Expected Goal: Mr. Chan would not fall before discharge.
outcomes
(Specific, Measurable,
Achievable, Realistic,
Timely)

Interventions I: 1. Display falls hazard signage

I: interventions 2. keep bed in low level
(Interventions need to be 3. Inform patient that he is at high risk of fall.
related to the problem
4. Remove unnecessary objects and keep floor dry
and underlying causes.
Categories include: 5. Consider applying safety measure or alarm system
- Assessment 6. Provide shoes which is non-slippery, not tight and fit
- Care & comfort
- Health teaching) 7. Refer dietitian for diet modification and weight control.
R:
1. Inform staff to pay attention to the patient.
R: rationales 2. The height of bed let patient to get in and out of bed easily and
safely.
3. Awareness of risks promotes cooperation and understanding of
fall prevention plan.
4. Reduce likelihood of falling or tripping over objects.
5. When the patient attach the alarm, alarm will inform the staff
6. Prevent falling from slipping on floor
7. Reduce weight to reduce morse score.

Nursing problem 2 Left wrist pain related to left distal radius fracture with dorsal angulation as
evidenced by limited movement by pain, swelling and bruising over left
wrist, NRS of pain:8/10 and X-ray result.
Goals/ Expected Mr. Chan’s NRS of pain reduce to 1-3/10 before discharge.
outcomes

Interventions I:
1. Administer pain killer as prescribed. (Panadol by mouth for every 4
hour)
2. Elevation of left upper limb for edema resolution.
3. Close reduction and long arm cast on left wrist.
4. Evaluate reports of pain (0 to 10, NRS), relieving, and
aggravating factors. Note nonverbal pain, such as changes in vital
signs and behavior.

R:
1. The patient would feel less pain.
2. We can use coaptation splint to give fracture immobilization
when there is excessive tissue swelling. The splint may need to
be readjusted because the edema diminished.
3. The closed reduction is a process for displaced or angulated
fracture. Which is done by forcing the bone's long axis, which
followed by casting or traction.
4. The patient’s emotions can also affect the pain score.

References 1. Aprn Bc, M. D. E., Crrn, M. M. R. M. F., & Bsn Rn, A. M. C.

(2014). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life

Span (9th ed.). F.A. Davis Company.

2. Faan, P. A. R. M. E. G., Faan, P. R. P. P. A., & Cne, O. W. R. M. E.

(2019). Nursing Interventions & Clinical Skills (7th ed.). Mosby.