Chapter 2
Thoughtful practice
35
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Plan of Nurs ing Care
Example of an individualised plan of nursing care
Mr John Lee, a 50-year-old management consultant, was admitted to the nursing unit from his doctor’s office. A routine physical
examination 3 months previously had revealed essential hypertension with BP 170/110 and decreased urine creatinine clearance.
During the subsequent 3 months the blood pressure elevation did not respond to diet therapy. Mr Lee admitted that he had not
been successful in adhering to the low-sodium, low-cholesterol weight-reduction diet that had been prescribed for him. He stated,
‘My life is just too busy—I work all hours of the day and night.’ He indicated that in addition to his work he and his wife share the
responsibility for raising their two teenage daughters. He drinks five to seven cups of coffee daily and drinks alcohol only at social
occasions. Admission physical examination revealed BP 194/112, P 96, R 20, T 37
8
C, height 175 cm, weight 95 kg, and slight oedema
of the ankles and feet. Mr Lee stated that his feet are ‘always puffy at night.’ There were several darkened areas (2 cm in diameter)
on the anterior lower legs bilaterally. A brief hospitalisation was planned for thorough evaluation and initiation of therapy. The doctor’s
orders on admission included activity as desired; Lasix, 40 mg bd; monitor vital signs every 4 hours while awake; and 6,300 kJ, 1 g
sodium, low-cholesterol diet.
CHART
2-8
nursing
diagnosis
:
Ineffective health maintenance related to hypertension, stress, obesity, and caffeine intake
Ineffective coping related to role responsibilities at work and home
Non-compliance with dietary regime related to knowledge deficit and lifestyle
collaborative
problems
:
Ischaemic ulcers of lower legs
goals
:
Immediate: Gradual decrease in blood pressure
Intermediate: Initiation of lifestyle alterations to decrease stress
Long-term: Alteration of lifestyle to reduce emotional and environmental stressors
Compliance with dietary regime
Absence of ischaemic leg ulcers
Nursing interventions
1. Monitor BP lying, sitting, and standing
every 4 h
2. Monitor fluid status:
a. FBC
b. Peripheral oedema
3. Promote atmosphere conducive to
physical and mental rest:
a. Encourage alternation of rest and
activity
b. Encourage limitation of visitors
and interactions that are stress-
producing
4. Assist patient to identify barriers to
behaviour changes and to develop
strategies to alter lifestyle to decrease
stress:
a. Discuss relationship between
emotional stress and physiological
functioning
b. Encourage patient to identify stress-
producing stimuli
Expected outcomes
Experiences no further increase in BP
Urinary output adequate in relation to oral
intake
No evidence of peripheral oedema
Alternates periods of rest and activity
Limits visitors to family in the evenings
Avoids stress-producing interactions
Describes stress as a precursor to
alteration in physiological functioning
Identifies lifestyle factors that produce
stress
Identifies lifestyle adjustments necessary
to reduce stress
Outcomes
BP range of 162/112–138/98 since
admission
No variation greater than 5 mm Hg in
systolic or diastolic pressures with
postural changes
No variation between right and left arms
Maximum BP from 24 h after admission
to time of discharge: 138/98
Intake: 1850 mL
Output: 1685 mL
Minimal oedema of feet late in evening
Rests in bed 1 h in morning and 2 h in
afternoon; disconnects telephone
during rest periods
Awake at intervals during night: 8 h of
uninterrupted sleep at night after
initiation of 20 mg Temazepam at
bedtime
Wife and daughters visit 2 h in evening:
patient calm and relaxed after visits
Wife and daughters aware of need to
decrease stress: they consult with
patient about regular family activities
Accurately described relationship
between stress and hypertension
Identified the following stressors:
Self-imposed demands of job;
unwillingness to refer clients
