OREM NURSING CARE PLAN

©2004 Guiomar Goransson-Martin

Patient Initial CB Age 50 Gender M Date of Care Mar 21, 2004

PART I: Presenting Diagnosis(es): (A) Gastritis

Surgical Procedure(s) (r/t presenting diagnosis): None

Chronic Disorders: (B) hypertension, (C) diabetes mellitus type 1, (D) peripheral vascular disease, (E) CAD, (G) end stage renal disease

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Definition of Presenting Diagnosis(es)	Clinical Manifestations
(A) Gastritis. Diffuse or localized response of gastric mucosa to injury or infection. (4)	(A) Gastritis. Anorexia, nausea, vomiting, abdominal cramping, diarrhea, epigastric pain, and fever. Painless GI bleeding may occur and is more likely if the person uses aspirin or NSAIDs regularly. (4)
Brief pathophysiology of Presenting Diagnosis(es)	Usual Collaborative Management
(A) Gastritis. Protective mechanisms of mucosa are overwhelmed by presence of bacteria or irritating substances. (Ph Gastritis has a number of causes, including certain drugs; alcohol; bacterial, viral, and fungal infections; acute stress (shock); radiation; and direct trauma. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, and naproxen, can be direct irritants and a cause of gastritis. Bacterial infections also can cause gastritis. The most common type of infection is caused by H pylori which is also responsible for as many as 80% of gastric ulcers and is associated with a transient increase in gastric acid secretion. H pylori is thought to be spread from person to person via oral-oral and/or fecal-oral routes. (4)	(A) Gastritis. NPO to support healing of mucosa and then slowly advanced to liquids and a return to a normal diet. Antacids and histamine 2 receptor antagonists to reduce acid secretion and increase comfort. Temporary IV fluid and electrolyte replacement. Observation for signs of bleeding. (4)

PART II: ASSESSMENT DATA and ANALYSIS

BASIC CONDITIONING FACTORS

Developmental State	Health State
Developmental State Theorist: Erikson References: DeLaune pg. 310 · Generativity vs Stagnation · CB is moving towards Generativity * Age 45+ * View one’s life as meaningful and fulfilling. * Explore positive aspects of one’s life. * Review contributions made by the individual. * States he is satisfied with how she raised his son. * Actively involved with son and 1 grandchild * Stated very happy living with sister	Stated that he is weak and tired most of the time. Hx of chronic conditions for most of adult life: Hypertension diabetes mellitus type 1, peripheral vascular disease CAD end stage renal disease Keeps all his scheduled medical checkups. Advance directives on file No known allergies CB admitted to this hospital d/t diarrhea and gastrointestinal cramping, vomiting Receives hemodialysis 3x/week since 1998 Right arm AV gore-tex fistula. Confined to wheel chair d/t below the knee amputation. Ambulates to bathroom with walker. Received flu shot Jan 2004 Did receive pnuemonia vaccine Did not remember if he received any childhood vaccinations Smokes 1/2-2 packs cigarettes/day for 35 yrs Denies alcohol use
Health Care System	Available Resources
Extreme confidence in his physicians Visits his primary care physicial on a regular basis. Has no qualms about taking prescribed medications and occasionally takes vitamins. Seeks teaching when he is unsure of how to proceed with self-care Has renal/vascular specialist as well as primary physician, neurologist and psychiatrist Has had gastroenterologist attending him during this hospitalization	Receives some social security benefits as well as medicaid and disability Lives with sister in one story house.
Sociocultural-Spiritual Orientation	Environment/Patterns of Living
Baptist Belief in God. African American Born and raised until age 10 in Alabama Moved to Ohio at 11 years of age with parents and sisters Two good male friends Has a “love life” and dates “different” women.	Lives with sister in one story house Smokes 1/2-2 packs cigarettes/day for 35 yrs No other smokers live in house Denies alcohol use Denies drug use Enjoys reading books relating to politics, biographies and some fiction
Family System Divorced Single 24 years Mother and father deceased (reason unknown) Father was 50 when CB was born Two older sisters Lives with one sister who monitor’s CB’s diet and medications Youngest of 3 children CB is father of 2 children, one boy, one girl. CB’s daughter died in car accident at 4 years of age in 1974. CB’s son is still living (30 years old), lives out of state but visits CB frequently Close relationship with son, daughter-in-law and granddaughter	Relevant Life Experiences Amputation of leg Birth of son Death of daughter Divorce Dx of diabetes at 20 yrs of age Was truck driver when employed
Analysis: Highlight BCF Health Care Deficits

PART III: ASSESSMENT DATA and ANALYSIS

DEVELOPMENTAL SELF-CARE REQUISITES

Maturational	Situational
Unable to assess early childhood and adolesence Developmental stage is Later Maturity (1) Marriage Children Has adjusted to his health problems Satisfied with his living conditions. Lives with sister Sister takes care of all dietary and medication needs.	Did not graduate from high school Has not been employed for 20 years Moved to Ohio with family at 11 years of age Chronic conditions Hospitalization for end stage renal disease Divorce Death of child

ANALYSIS: (Highlight Deficits identified)

PART III: ASSESSMENT DATA and ANALYSIS

UNIVERSAL SELF-CARE REQUISITES

Maintain Adequate Intake of Air: Cardiovascular/Respiratory

Subjective Data

Objective Data

· Smokes 1/2-2 packs cigarettes/day for 35 yrs · Denies chest pain · Frequent respiratory infections, at least 3 per year · Shortness of breath occasionally r/t activity · Constant fatigue

Apical, radial pulse equal, +3 Bruit over fistual in R arm Carotid arteriies +2 no bruit Julgular vein, no distension Peripheral pulses +2 Status post percutaneous transluminal coronary angioplasty of the circumflex (Dec 2003) Nitroquick Tab sublingual 0.4 mg prn SL Pulse 73 Peripheral vascular disease Diabetes mellitus type 1 End stage renal disease Hemodialysis 3x week Hypertension Left leg amputated below knee Stump of left leg is well-formed and completely healed Respirations 17, unlabored, equal; anterior, lateral and posterior lung sounds quiet and even. Thorax shape 2x1 symmetrical Skin is warm and dry no edema noted SP02 99% Temperature 37.0º C

ANALYSIS: (Highlight Deficits identified)

Therapeutic Self-Care Demand	Strength	Limitation
Promote cessation of smoking	Adheres to treatments prescribed	Addicted to nictotine

Nursing Diagnosis(es):

Ineffective breathing pattern r/t decreased energy or fatigue AEB C/O shortness of breath during activity, frequent respiratory infections, smoking, and constant fatigue. (5)

UNIVERSAL SELF-CARE REQUISITES

Maintain Adequate Intake of Food and Water: Nutrition/Fluids/Metabolism

Subjective Data	Objective Data
Does not consume alcoholic beverages Nauseated Sister prepares all meals, administers all medications. Sister follows diabetic diet Sister states that sometimes she has to lock the cupboards in order to ensure that CB won’t eat illegal foods.	Consumes 100% 3 meals per day in hospital Nephrocaps Folic Acid/Vit B ComplVITAMIN B 1 cap qd PO · Prevacid 30 mg PO qd Renal Diet Diabetes mellitus type 1 BS 220 Insulin, Human ® Novolin R injection Feeds self Gastritis Height: 6’ Weight: 158 lbs BMI 21.5 Input 500 mL Output 0 mL Skin is warm and dry

ANALYSIS: (Highlight Deficits identified)

Therapeutic Self-Care Demand	Strength	Limitation
Eliminate nausea Stablize blood sugar at normal level	Able to eat complete meals Receiving insulin	Gastritis Illness stresses body, raises sugar

Nursing Diagnosis(es):

Nausea r/t irritation to the GI system AEB gastritis. (5)

Risk for Infection r/t external factors AEB frequent respiratory infections, diabetes mellitus Type I, BS 220. (5)

UNIVERSAL SELF-CARE REQUISITES

Elimination: Bowel/ Bladder/Integument

Subjective Data	Objective Data
Has BM at home normally every 2-3 days Stool is usually formed, brown Sometimes stool is loose Has not noticed blood in stool	Stool maroon or bloody in nature Consistency of stool is watery, not solid Had 3 BM’s on this shift End stage renal disease Urine output absent Hemodialysis Sandostatin Inj 50 mcg/1mL SQ q 12º Uses walker to take self to bathroom Abdomen tender upper left hand quandrant Hyperactive bowel sounds all 4 quadrants Skin is warm and dry, not diaphoretic

ANALYSIS: (Highlight Deficits identified)

Therapeutic Self-Care Demand	Strength	Limitation
Needs to regain normal bowel movements, solid stood Elimination of diarrhea	Compliant with treatment, eats 100% meals 3x day Compliant with medical treatment	Gastritis Inflammation or irritation of bowel

Nursing Diagnosis(es):

Diarrhea r/t inflammation or irritation of bowel AEB gastritis and bloody, watery stools

Risk for fluid volume imbalance r/t to excessive loss AEB 3 bloody, watery stools (5)

UNIVERSAL SELF-CARE REQUISITES

Maintain a Balance Between Activity and Rest

Subjective Data

Objective Data

C/O of shortness of breath occasionally r/t activity Sleeps at least 8 hours each night at home “I’m not getting the amount of exercise I used to get since I lost my leg”

Ambulates independently with walker for short distances Gait is unsteady when ambulating Grip is firm and even in both hands Grooms self each day Able to reach bathroom independently with use of walker Range of motion is limited in all extremities Right below the knee amputation Weight is placed on left leg, arms and walker when ambulating to bathroom Wheelchair is main method of transporting self

ANALYSIS: (Highlight Deficits identified)

Therapeutic Self-Care Demand	Strength	Limitation
Needs to remain safe while ambulating to bathroom with walker Increase in activity	Adequate sleep Is able to move about in bed and in wheel chair	Shortness of breath Does not move during normal course of day

Nursing Diagnosis(es):

Activity intolerrance r/t immobility AEB C/O of shortness of breath occasionally r/t activity and statement “I’m not getting the amount of exercise I used to get since I lost my leg” (5)

Risk for injury r/t sensory or motor deficits AEB right below the knee amputation, unsteady gait when ambulating and shortness of breath during activity.

UNIVERSAL SELF-CARE REQUISITES

Maintain a Balance Between Solitude and Social Interaction

Subjective Data	Objective Data
Lives with sister Has 2 male friends Continues dating females Enjoys visits from son and family

UNIVERSAL SELF-CARE REQUISITES

Promote Normalcy

Subjective Data	Objective Data
No seizures Denies problems with speech, taste, touch Has come to terms with loss of leg Stress r/t hospitalization Sister takes care of all dietary and medication needs. “I wouldn’t know how much insulin to take if it weren’t for my sister giving it to me and checking my blood sugar.”	Affect relaxed, pleasant, not depressed AOx3 Hears whisper from behind PERRLA 4 Diabetes Type I Right below the knee amputation Speech has southern accent but is clear and understandable Independently grooms self CN II III IV intact Unsteady gait

ANALYSIS: (Highlight Deficits identified)

Therapeutic Self-Care Demand	Strength	Limitation
Knowledge r/t checking blood sugar and insulin dosages	Competent at completing most self-care	Dependent on sister for administering insulin and checking BS

Nursing Diagnosis(es):

Difient knowledge r/t drug therapy AEB CB’s statement, ““I wouldn’t know how much insulin to take if it weren’t for my sister giving it to me and checking my blood sugar.”

UNIVERSAL SELF-CARE REQUISITES

Prevent Hazards

Subjective Data	Objective Data
	Side rails x 2 Call light within reach at all times See med list for medications Risk for falls alert AOx3 Restraints not used or necessary

ANALYSIS: (Highlight Deficits identified)

Therapeutic Self-Care Demand	Strength	Limitation
Needs to remain safe while ambulating to bathroom with walker	Hands grip walker steadily	Right below the knee amputation

Nursing Diagnosis(es)

Risk for injury r/t sensory or motor deficits AEB right below the knee amputation and use of walker. (5)

PART VI: REFERENCES:

(1) DeLaune, S., & Ladner, P. (2002) (2nd ed.). Fundamentals of nursing: standards and practice Clifton, NY: Delmar/Thomson

(2) Fischbach, F. (2000). A manual of laboratory & diagnostic tests. (6th ed.) Philadelphia:Lippincott.

(3) Malseed, RT, foreward by, (2004) Springhouse nurse’s drug guide 2004 Springhouse, PA: Springhouse

(4) Phipps,W., Sands, J.K., Marek, JF. (1999) 6^th Edition Medical-surgical nursing, concepts & clinical practice St, Louis, MO: Mosby

(5) Sparks, S.M., & Taylor, C.M. (2001). Nursing diagnosis reference manual: an indispensable guide to better patient care. Springhouse, PA: Springhouse

(6) Spratto, GR, Wood, AL. (2004). PDR, nurse’s drug handbook, 2004 edition. Clifton, NY: Delmar/Thomson