Creating a Nursing Care Plan from Case Study

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Patient care planning is the organised assessment and identification of patient problems, the setting of goals, and the establishment of methods and strategies based on best evidenced based practice for achieving them (Uhlrich, Canale & Wendell, 2005). The aim of this assignment is to analyse a case study and create a nursing care plan based on the patient's issues. Initially background information regarding the patient's medical diagnosis is provided and seven prioritised nursing problems have been identified. Focus is made on the key nursing problem-immobility, and discussion is made as to why this issue is important to address and what impact immobility has on other nursing issues. Subsequently collaborative health care roles related to the management of the patient are explored. Following this a nursing care plan has been developed. It includes the aims and goals of the care plan, planning and implementation of care, evaluation of the effectiveness of the treatment and rationale using best evidenced based reasons for the proposed plan.

Body of Assignment

Mrs Winn is a 66 year old retiree and is currently travelling around Australia with her husband. Mrs Win has just undergone a Laparoscopic Cholecystectomy which involves removal of the gallbladder using laparoscopic guidance through several small incisions in the abdomen. The gallbladder is most commonly removed due to cholelithiasis or cholecystitis. "Cholelithiasis is caused by the precipitation of substances contained in bile, mainly cholesterol and bilirubin. Approximately 80% of gallstones are composed primarily of cholesterol; the other 20% are black or brown pigment stones consisting of calcium salts and bilirubin" (Porth & Matfin, 2009, p. 975). Acute cholecystitis is generally due to diffuse inflammation of the gallbladder, usually secondary to obstruction of the gallbladder by gallstones. It can also be associated with sepsis, severe trauma or infection of the gallbladder. Repeated episodes of acute cholecystitis or chronic irritation of the gallbladder by stones may also lead to chronic cholecystitis. Mrs Win also has a history of hypertension, which is defined as persistent blood pressure readings above the normal range (above 120mmHg systolic; 80mmHg diastolic) (Berman, et al., 2008). In addition to this, Mrs Win is suffering from osteoarthritis of the knees which is characterised by the degeneration of articular cartilage in joints (Porth & Matfin, 2009). Mrs Win's hypertension and osteoarthritis are being managed by medication.

Crisp and Taylor (2005) state that the activities of daily living are the activities usually performed in the course of a day, necessary for adequate self-care. Postoperative clients may have problems affecting their ability to independently perform these tasks and it is the goal of health professionals that their patients achieve the same level of functioning or greater after any intervention. Seven of these potential issues relating to the case study are highlighted below.

Pain management is a high priority in managing the care of Mrs Win. She is complaining of abdominal pain 3/10 and shoulder tip pain 5/10. It is essential that pain is managed effectively as it can have a considerable influence on a patient's physical and psychological state and significantly affect her ability to perform any activities of daily living. Informing the patient that shoulder tip pain is a common symptom post Laparoscopic Cholecystectomy will help to reassure the patient that it is not an adverse complication. It is due to air injected intraabdominally during the procedure causing irritation of the diaphragm. The pain is referred to the shoulder tip due to their common dermatome. Pain management following surgery includes drug therapy, positioning, massage, relaxation techniques and diversion (St. Marie, 2002).

Wound care is also a crucial component in Mrs Win's management. She has four abdominal wound sites with a Verivac drain insitu and appropriate care based on best evidenced-based nursing practice is required to encourage healing and prevent infection and further complications (Dealey, 2005).

Another issue to have a significant effect on a patient postoperatively is immobility. It has a substantial effect on all aspects of the patients' life and will be discussed in more detail further on.

In addition, nutrition and hydration is a key element to the recovery of Mrs Win. She is complaining of nausea and only tolerating sips of water orally. Eating and drinking are essential constituents in maintaining body homeostasis and a well balanced diet is crucial to her recovery as it impacts on her ability to perform all activities of daily living. Inadequate nutrition also has a negative effect on the body's capacity to fight infection and maintain good skin integrity. Good nutrition is too important to promote wound healing (Crisp & Taylor, 2005).

Respiratory complications are another potential problem for Mrs Win. She is receiving oxygen via nasal prongs at a rate of 3L per minute and her respiratory rate is 22, which is above the normal range of 10 to 20 breaths per minute (Berman, et al., 2010). She is at risk of developing atelectasis due to surgery, lack of nutritional intake and immobility (Hatfield & Tronson, 2009). Mrs Win is also being administered morphine which could also potentially cause respiratory depression (Porth & Matfin, 2009).

Mrs Win is also at risk of impaired skin integrity due to her age, inadequate diet and restricted mobility. Nursing interventions such as assessing and reporting signs and symptoms of impaired skin, repositioning every 2 hours, and pressure relieving devices need to be in place to reduce the risk of decubitus ulcers (Rosdahl, 2008).

Concern of Mrs Win's psychological state must also be considered. She has a higher than normal respiratory rate and blood pressure which may be signs of anxiety. Appropriate care needs to be taken to reassure Mrs Win and deal with any psychological issues which may arise (Ignatavicius & Workman, 2010).

"Mobility, the ability to move freely, easily, rhythmically and purposefully in the environment is an essential part of living" (Berman, et al., 2008). It is vital to maintaining independence. Physical activity is often how people define their health because psychological wellbeing and the effectiveness of bodily function depend largely on their mobility status. As Mrs Win has just had a Laparoscopic Cholecystectomy her mobility would be significantly affected due to a number of reasons. She is experiencing pain and nausea which would discourage her from attempting to ambulate. Mrs Win is on oxygen therapy and also has drains and intravenous fluid insitu which would restrict her somewhat as to what she can do. She may also be drowsy and fatigued due to the anaesthetic given in surgery. Mrs Win also has a higher than normal respiratory rate which may indicate she is short of breath and this may also deter her from any physical activity. In addition, she may also be anxious about ambulating due to all of these reasons. Impaired mobility has a substantial affect on body functioning and the ability to perform acitivities of daily living. Firstly when a person is upright, the expansion of the lungs is improved and improves endobronchial mucous drainage, decreasing the possibility of chest infection. Intestinal activity is more effective, reducing the chance of constipation and the kidneys are able to drain more effectively lessening the likelihood of urinary retention. Lack of mobility may affect Mrs Win's ability to maintain personal hygiene and therefore also affect her psychological wellbeing. Additionally, Mrs Win is at increased risk of developing pressure ulcers and/or deep vein thrombosis due to her immobility. As exercise increases skeletal muscle blood flow this would also affect Mrs Win as she is receiving intramuscular analgesia and this improves absorption of the drug after injection. Narcotics such as morphine can however cause serious adverse effects such as nausea, dizziness and hypotension which would also affect Mrs Win's ability to ambulate (Bullock & Manias, 2011).

Collaborative roles of other health professionals would be beneficial in the holistic care of Mrs Win. Below are four roles essential to her care.

A physiotherapist's aim is to restore and improve functional ability of the client. They assess the individuals' needs and using various treatment techniques promote the ability to move, reduce pain, restore function and prevent disability. Mrs Win would advantage from the care of a physiotherapist as she is in pain and has decreased mobility following surgery and may have difficulty performing regular tasks. A physiotherapist may also provide appropriate respiratory exercises to reduce the chance of atelectasis and improve pulmonary function. She may also benefit from care planning and exercises to assist in the management of her osteoarthritis (Herbert, Jamtvedt, Mead & Hagen, 2007).

A social worker may also be incorporated into Mrs Win's care planning. Their role is to improve the quality of life by helping them cope with and solve issues in their everyday life. Mrs Win is travelling around Australia with her husband and assumingly away from the support of other family and friends. A social worker may assist in the organisation of any social or practical support needs (temporary accommodation, food, transport etc) (Payne, 2005).

Another health professional worth considering is an occupational therapist. Occupational therapy is designed to address issues relating to the skills required to perform activities of daily living. Their aim is to improve a patient's ability to participate in these activities by modifying the environment to support participation. As Mrs Win has a history of osteoarthritis, recovering from surgery and travelling in a caravan, an assessment by an occupational therapist may be beneficial in her treatment. They may be able to modify her caravan to suit her needs (Crepeau, Cohn & Schell, 2009).

Dieticians have an important role in the management of patients which could be valuable to Mrs Win. They have extensive knowledge about food and nutrition and in order to promote good health they manage the preparation and service of food, design personalised diets and educate individuals on good nutritional practice. A dietician would have an important role in the postoperative care of Mrs Win as she has just had surgery and it is crucial that she consumes a diet suitable to her needs to facilitate a good recovery. A dietician may also assist in educating Mrs Win on the importance of a healthy diet once she leaves hospital (Mahan & Escott-Stump, 2008).


The aim of this assignment was to analyse a case study and create a care plan. Initially the patient's medical diagnosis was explored, following by identification and examination of the top seven prioritised nursing issues. Subsequent to this the top nursing problem-mobility, was considered in more detail. Exploration of the importance of this issue was addressed along with what impact immobility has on other nursing issues. Also discussed is the other health professionals' role in a collaborative health care approach. After this a care plan is developed focusing on the aims and goals, planning and implementation of care, evaluation of the effectiveness of the treatment and rationale using best evidenced based reasons for the proposed plan.