Clinical Organization Plan (COP)

Student Name: Atefeh Ebrahimi poor

Student Number: 301369566
Course Code: 125

PART A (Student Objective):

Client Admitting Diagnosis (Definition):
Bilateral pulmonary embolism & DVt (Deep vaine thrombosis)

Client Past Medical History (Definition): Bilateral pulmonary embolism and DVT (Deep vaine thrombosis), oseteoarthiritis, depression, dyslipidemia,
Post menopausal baginal bleeding.

Sex/Gender: Female Age: 82 Years old Cultural Health Considerations: N/A Ht: Wt: (kgs/lbs)

Allergies & Reaction: N/A Code Status: No CPR Current Diet: mechanical thin and soft Regular diet Activity Level: Activity as tolerance. (C base on this
facility, meant requires 2 assisstance and transfer with hoyer lift).

Current Medical Issues and Treatments: Bilateral pulmonary embolism & DVt (Deep vaine thrombosis). Medications: Atorvastation 20mg QHS, Fluticasone/Vilanterol 1
puff Daily, Levodopa 1 tablet BID, Polyethylene glycol 17 g Daily, Senrtraline 100 mg & 50mg 1 capsule, Vitamin D: 1000 units 1 tablet, multivits 1 tablet, Apixaban 5
mg BID, Cyanocobalamin 1000 mcg 1 tablet, Acetaminophen TID, RPN, glycerin rectal PRN 1 Supp, Sodium phosphates PRN, Salbutamol 2 puff Q4H RPN, Voltaren
RPN.

Isolation Status: ✘ Contact Airborne ✘ Droplet

Interprofessional Team Involved in Client Care: Wound Care SLP Social Worker ✘ OT ✘ PT Recreation Therapist Pharmacist Other (please specify):
Main Issues from Change of Shift Report/Transfer of Accountability: Transfer with hoyer lift, check the catherter side and fluid output, and there is no concern about CPR.

System/Functional Assessment Assessment Findings Analysis (Compare to norms, cluster, gaps, inferences, Please identify and explain the Need Affected with
(Criterion 1) (Criterion 2) (Criterion 3) patterns, implications and interventions) rationale based on the Analysis
Collect and organize data (Criterion 4) (Criterion 5)

Neuro  Level of Consciousness Finding (Subjective/Objective): ✘ WNL NWNL Activity & Exercise Sleep & Rest Sensory Skin &
Baseline Status:  Orientation LOC: (0930hr) Hygiene Safety Nutrition Urine Elimination Fecal
 GCS Score: /15 the patient is alert ro person, Elimination Oxygen Self-concept Sexuality
 Sleep Pattern:
 Other Neurological Symptoms: place an time. Rationale:
 Confusion Assessment score* She is awake, aware and
 PERRLA well oriented.
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IMPORTANT NOTE: No patient identifiers from the clinical settings on this document. Please maintain the principles of confidentiality on this
document.
 System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

GCS Score: (0930hr)

Eye opening 4/4
Verbal response: 5/5
Motor response: 6/6
Sleep pattern:
The patient inform that her
sleep was “okay”
Other neurological
symptoms:
(1330 hr), There were no
abnormal neurological sign
shown by the patient.
CAM:
There is no sign of
confusion on the patient
PEERA:
There is no abnormalitie
on patient pupils (the
pupils was round, equal,
and reactive to light and
accommodation)

HEENT  Inspect head, eyes, ears, nose, Finding (Subjective/Objective): WNL ✘ NWNL Activity & Exercise Sleep & Rest Sensory Skin &
Baseline Status: mouth and throat* (1330) Hygiene Safety Nutrition Urine Elimination Fecal
 Use of glasses/hearing Aging can cause changes to a person's Elimination Oxygen Self-concept Sexuality
aids/dentures: Eye:
 Swallowing Function: The patient’s eybrows eyesight and hearing, which can Rationale:
raised symmetrically, include blurred vision and improper Presbycusis, a common age-related
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IMPORTANT NOTE: Do NOT include any patient, staff or institution identifiers on this document. Please maintain the principles of
confidentiality.
System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

sclera are more red or hearing. disorder, includes hearing loss. It

pink color and moist, A functional assessment may cover a usually happens gradually over time as
conjuctive is pink and range of topics, including mobility, a result of modifications to the
moist, PERRLA is WNL. activities of daily living, and auditory nerve and loss of hair cells in
Head: competence using telecare the inner ear(Doenges, 2014).
The patient has short technologies. Sensory impairment is
white hair, dry, and there another factor that affects functioning
is no sign of forign object. because people with vision or hearing
Ear: impairments might still be competent
Patient’s ears are equal but have different coping mechanisms.
bilaterally, there were no Although the preliminary evaluation
object found on the may indicate a decreased functional
patient ears. capacity, it is actually just different.
Nose: Beyond a thorough geriatric evaluation,
The nose is medline no evaluating functioning and associated
sign of other object inside progressions can also help inform
and outside of the patient choices and treatment options (CGA)
nose. (Wieland, 2021).
Mouth & Throat:
Oral cavity is moist but
the tooth were dark
yellow, and has some
crooked tooth.
There is no sign of
abnormality on the ptiant
throat.
Use of glasses/hearing
aids/dentures:
The patient is wearing
hearing aid.
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IMPORTANT NOTE: Do NOT include any patient, staff or institution identifiers on this document. Please maintain the principles of
confidentiality.
 System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

The patient has reading

glasses.
The patient did not have
denture.
There is no sign of
swallowing on the patient

Musculoskeletal  Inspect size and contour of joint Finding (Subjective/Objective): WNL ✘ NWNL ✘ Activity & Exercise Sleep & Rest Sensory Skin &
Baseline Status:  Palpate joint area The patient has pain on The patient has past medical history of osteoarthiritis. Hygiene Safety Nutrition Urine Elimination Fecal
 ROM (Active/Passive) SKB: Elimination Oxygen Self-concept Sexuality
her patella (knee) and it is
 Activity/ADL’s Osteoarthritis is a common joint
 Fall Assessment Score*: larger than right size. 3 Rationale:
disease that impairs mobility and
 Ambulatory Aids: our of 10 A common chronic joint disorder
 Stabilization Devices:
Palpate joint area causes joint discomfort in elderly
linked to aging is osteoarthritis, which
 Gait, Alignment, Balance:
There is sign of pain people. These conditions may result can cause stiffness, discomfort, and
during palpation on client in decreased physical activity and decreased mobility. For older persons
knee. The skin extremely discomfort, especially in areas that with osteoarthritis, managing the
dry, and cold to touch. bear weight. Comprehensive condition is crucial to reducing pain,
ROM (Active/passive) assessment, tailored therapy, and a maximizing joint function, and
The patint range of multidisciplinary approach are enhancing quality of life. Nurses strive
motion is all passive, She necessary to manage chronic illnesses to lessen the effects of osteoarthritis
needs assesstant to move and improve quality of life (Doenges by introducing interventions like
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IMPORTANT NOTE: Do NOT include any patient, staff or institution identifiers on this document. Please maintain the principles of
confidentiality.
 System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

her lower and upper limbs et al, 2014). exercise, pain management, and
ADLs SKB: education. This allows older persons
The client needs hoyer for Nurses help the patient stay active with to keep mobility, participate in
her activity, require 2 exercises suitable for their age and everyday activities, and maintain a
assisstance for bed bath regularly check for symptoms. They higher degree of independence. This
and change brief, the also address pain, provide information strategy is in line with the objective of
patient try to roll her to about cognitive and sensory changes in improving the general well-being and
the side with 1 assisstance. the elderly, and collaborate with a standard of living for senior citizens
Fall assessment aids, diverse team. Additionally, they assist with osteoarthritis (Doenges et al,
High risk of fall with assistive technology, offer 2014).
Ambulatory aids: nutritional guidance, manage
Wheelchair, hoyer lift medications, and consider cognitive
Stabilization device: and sensory issues. Nurses focus on
Client does not have geriatric strategies, monitor
stabilization device. osteoarthritis, assess treatments, and
Gait, Alignment, Balance: adjust care to meet the unique needs of
Unable to assess the older individuals (Potter & Perry,
patient, she use hoyer lift 2023).
and wheelchair.

Pain  Location Finding (Subjective/Objective): Activity & Exercise Sleep & Rest Sensory Skin &
Baseline Status:  PQRSTAU The patient does not have pain ✘ WNL NWNL Hygiene Safety Nutrition Urine Elimination Fecal
Elimination Oxygen Self-concept Sexuality

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IMPORTANT NOTE: Do NOT include any patient, staff or institution identifiers on this document. Please maintain the principles of
confidentiality.
 System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

Rationale:

Cardiovascular:  Temperature (Route): Finding (Subjective/Objective): WNL ✘ NWNL Activity & Exercise Sleep & Rest Sensory Skin &
Baseline Status:  Radial Pulse (Rate, strength, Temperature: 35.8 C Hygiene Safety Nutrition Urine Elimination Fecal
regularity): Elimination Oxygen Self-concept Sexuality
 BP (site, position): axillary SKB:
Radial pulse: 73 bmp, Elderly individuals generally have a lower body Rationale:
temperature due to factors such as a decline in metabolic
normal rhythm rate, reduced muscle mass, changes in thermoregulation, There are a number of physiological changes linked to
Bracial pule: 68 bmp, hormonal shifts, and vascular changes. These age-related aging, such as a decrease in the metabolism that
physiological changes contribute to a lower baseline
normal rhythm temperature in older patients (Potter& Perry, 2023).
produces heat, a loss of muscle mass, a degradation in
the body's ability to regulate temperature, and
Blood pressure: 113/68 hormonal changes (Potter& Perry, 2023).
HHgm NKB:

On her left arm and Nurses need to understand that lower body temperature
supine position. in elderly patients is linked to age-related physiological
changes. This includes factors like declining metabolic
rate, reduced muscle mass, shifts in thermoregulation,
hormonal variations, and changes in vascular function.It's
crucial for nurses to also take into account the influence
of health conditions and medications on body
temperature. This knowledge is vital for providing
effective care, enabling nurses to assess, monitor, and
address the specific temperature regulation needs of
elderly individuals (Potter& Perry, 2023).

Peripheral  Extremity Pulses (present or Finding WNL ✘ NWNL Activity & Exercise Sleep & Rest Sensory Skin &
Neurovascular absent) Hygiene Safety Nutrition Urine Elimination Fecal
 Peripheral Edema (check (Subjective/Objective): Capillary refill Elimination Oxygen Self-concept Sexuality
Baseline Status: bilaterally): Radial: present and weak, SKB:
 Colour: Rationale:
 Extremity Temperature (warm on the patient right hand In older people, a prolonged capillary
or cold) was stronger then other When capillary refill time (CRT) is
refill time (>3 seconds) may indicate longer than three seconds, it may be a
 Cap refill side. impaired circulatory function, which
 Sensation
Bracial: present, weak. sign of possible circulatory
 Tremors may be related to dehydration or compromise. Healthcare practitioners
Dorsalis pedis: present
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IMPORTANT NOTE: Do NOT include any patient, staff or institution identifiers on this document. Please maintain the principles of
confidentiality.
System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

Popliteal: present cardiovascular problems. In order to can quickly and non-invasively

Peripheral edema: There treat circulatory difficulties, healthcare diagnose blood flow problems, such as
is no sign of peripherial practitioners should evaluate the decreased cardiac output or
edema right lower general state of cardiovascular health dehydration, with this assessment.
extremities. and take into account additional Monitoring CRT facilitates timely
Color: research and therapies (Sparks et al, actions to improve cardiovascular
Skin color was the gentic 2011). health by assisting in the early
background color with lots NKB: detection of circulation issues (Sparks
of freckles, patient has The examination of capillary refill time et al, 2011).
skin xerotic. in the elderly is on identifying it as a
Cpilary refill: noteworthy clinical indicator of
3 seconds possible circulatory problems. When
Sensation: present on all evaluating and interpreting this
extremities phenomena, nurses are adept at taking
Tremor: age-related changes and cardiovascular
There werer no sign of problems into account. In order to
tremor find on patient address circulatory issues in the aged
body. population, they are essential in
Extremity temperature spotting variations from normal
was cold. capillary refill times, starting additional
examinations, and carrying out
therapies(Sparks et al, 2011).

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IMPORTANT NOTE: Do NOT include any patient, staff or institution identifiers on this document. Please maintain the principles of
confidentiality.
 System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

Respiratory  Inspect Anterior & Posterior Finding (Subjective/Objective): WNL NWNL Activity & Exercise Sleep & Rest Sensory Skin &
Baseline Status: Chest Symmetry and Shape Inspect Anterior & Posterior Hygiene Safety Nutrition Urine Elimination Fecal
 Use of accessory muscles (yes or Elimination Oxygen Self-concept Sexuality
no) Chest Symmetry and Shape:
 Resp Rate and Depth: both anterior and posterior Rationale:
 O2 sat:
 Supplemental O2:
chest were symmetrical,
 Auscultate Chest Anterior and they were expand at the
Posterior for Air Entry: same time.
 Cough (productive/non-
productive) Chest muscles were relax
mean the patient did not use
her muscle to breath.
Rrespiratory rate and depth:
RR: 19
Depth: normal
O2: 94% on room air.
Auscultate Chest anterior
and posterior for air entery:
there was not any
abnormality sound found on
the patient chest.
Cough(
productive/nonproductive);
The cough was productive.

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IMPORTANT NOTE: Do NOT include any patient, staff or institution identifiers on this document. Please maintain the principles of
confidentiality.
 System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

Abdominal  Inspect Abdomen (symmetry Finding (Subjective/Objective): WNL NWNL Activity & Exercise Sleep & Rest Sensory Skin &
Baseline Status: and contour) Inspection: the client has Hygiene Safety Nutrition Urine Elimination Fecal
 Auscultate Bowel sounds: Elimination Oxygen Self-concept Sexuality
(location; present or absent) round and symmetrical
 Palpate Abdomen: abdominal and skin was Rationale:
 Last Bowel Movement:
little dry and the color was
the genetic background.
Auscultate Bowel sounds:
(location; present or absent):
The patient had Bowel
movement during the
auscultation, and the
abdominal had goggling
sound on her left side, the
sound occure every 5-10
second.
Palpate: No palpation
assessment after
auscultation.
Last bowel movement:
patient had Bowel
movement two days a go,
and she had bowel
movement the same day
almost end of the shift
(1610 hr)

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IMPORTANT NOTE: Do NOT include any patient, staff or institution identifiers on this document. Please maintain the principles of
confidentiality.
 System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

Integumentary  Assess oral cavity (dryness, Finding (Subjective/Objective): WNL ✘ NWNL Activity & Exercise Sleep & Rest Sensory Skin &
Baseline Status: sores) Oral cavity: there were no The main factors affecting skin Hygiene Safety Nutrition Urine Elimination Fecal
 Assess Skin for breakdown, Elimination Oxygen Self-concept Sexuality
redness (bony areas), rashes, oral sire found, and the integrity in older adults include the
lesions oral cavity was moist. impacts of aging, such as decreased Rationale:
 Risk Assessment Score
(Braden)* Skin: production of collagen and elastin, Due to factors like impair mobility,
The patient had mold, which results in skin that is less elderly people with dry skin may be
but the molds were all elastic and thinner. This weakens the more prone to skin-related
round, symmetrical, and skin's natural defenses and increases problems.
the same color and the likelihood of dryness, cracking, Pressure sore risk can increase due
normal. Her skin was and irritation. It also results in to extended pressure on certain
extremely dry with no decreased sebum production. In locations caused by immobility.
signs of bruise or addition, impaired blood flow, Effect on Skin That Is Dry:
irritation. No redness or sluggish cell division, and Pressure points associated with
any bony area and subcutaneous fat loss increase the immobility and dry skin increase
breckdown skin on her. difficulty of repairing damaged skin the likelihood of skin deterioration
Braden scale: and increase its vulnerability to and pressure ulcer formation
Sensor/mental: 4 damage. The immune system's aging (Potter & Perry, 2023).
Moisture: 3 process and heightened susceptibility
Activity: 1 to UV rays impair the skin's ability
Mobility: 2 to fend off infections and raise the
Friction & shear: 2 risk of developing skin cancer.
Understanding these physiological
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confidentiality.
 System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

alterations is crucial to putting into

practice efficient therapies and
preventative strategies to preserve
senior skin health (Potter & Perry,
2023).
NKB:
When it comes to aged skin care,
nurses prioritize sophisticated
assessment skills, utilizing
standardized instruments to detect
possible problems and areas of
sensitivity, as well as advocating for
preventive measures like sanitation,
moisture control, and repositioning.
They develop customized care
regimens for each patient's
particular needs while also providing
education on nutrition and hydration
(Potter & Perry, 2023).

Urinary  Voiding Issues (discomfort, Finding (Subjective/Objective): WNL ✘ NWNL Activity & Exercise Sleep & Rest Sensory Skin &
Baseline Status: burning, pain) The patient is at ease and do Incontinence 82 years old. Hygiene Safety Nutrition Urine Elimination Fecal
 Urine Color Elimination Oxygen Self-concept Sexuality
 Bladder Scanner Result: es not SKB:
 Continence express any pain during vag The causes, risk factors, and Rationale:
 Urinary Drainage/Diversion:
inal contributing factors of urine and fecal The selection of individual
voiding. incontinence in the aging population interventions is influenced by this
Urine color: are all well understood in the scientific information, which is crucial for
its yellow and does not have literature on incontinence in the care planning. Because bladder
smell, elderly. It entails researching the capacity and/or tone are
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IMPORTANT NOTE: Do NOT include any patient, staff or institution identifiers on this document. Please maintain the principles of
confidentiality.
 System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

Bladder scanner result: N/A physiological alterations brought on by compromised, nocturia, frequency,
Continence: aging in the genitourinary and and urgency are prevalent.
The patient is gastrointestinal systems, as well as the Sphincter tone and the pelvic
incontinenceand wears brief effects of concomitant diseases, drugs, muscles of the bladder may also be
and she has urine cather. and neurological disorders on impacted. Note: While more
continence (Doenges et al, 2014). common in older persons, urinary
NKB: incontinence is not regarded as a
individualized treatment plans are typical aspect of aging (Doenges et
created for each patient and their al, 2014).
family, addressing lifestyle changes
and providing information and
emotional support. The promotion of
freedom and dignity is a top priority for
nurses, who also work with
interdisciplinary teams and execute
management initiatives. Plans for
adaptive care that are customized to the
changing requirements of senior
individuals with incontinence are
guaranteed by ongoing monitoring and
assessment. For the best possible
patient care, this dynamic nursing
knowledge demonstrates a dedication
to remaining up to date on the most
recent advancements in incontinence
management (Sparks et al, 2011).
Nutritional  Preferences: Finding (Subjective/Objective): ✘ WNL NWNL Activity & Exercise Sleep & Rest Sensory Skin &
Assessment  Current Diet: The patient is on the Hygiene Safety Nutrition Urine Elimination Fecal
Baseline Status:  Meal Assistance: Elimination Oxygen Self-concept Sexuality
 Amount of Diet Intake (%): soft/thin and regular diet
and there is no Rationale:

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IMPORTANT NOTE: Do NOT include any patient, staff or institution identifiers on this document. Please maintain the principles of
confidentiality.
 System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

preferences.
Meal Assistance: the
patient did not want
assistance for her meal,
she is independent with
eating her meals.
Amount of diet intake %:
almost 75% to 80%

Fluid Balance  Intake & Output (from all Intake Source & Output Source & ✘ WNL NWNL Activity & Exercise Sleep & Rest Sensory Skin &
Baseline Status: sources) Amount Amount Hygiene Safety Nutrition Urine Elimination Fecal
1. PO: From 1. Urine: Urine bag Elimination Oxygen Self-concept Sexuality
was shown at 550
0800 hr to ml Rationale:
1630 hr 2. Emesis:
N/A
patient’s 3. Stool: She had
intake was medium/ soft
stool.
almost 850 4. Drainage
ml of food (specify):
and drink N/A

2. Enteral:
3. TPN: N/A
4. IV: N/A
Total: 850 ml Total: 550 ml urine,
plus her stool
Balance:

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confidentiality.
 System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

Lab Values Lab Results from chart or electronic Lab Result & Date: Nov/26/2023 WNL ✘ NWNL ✘ Activity & Exercise Sleep & Rest Sensory Skin &
system CBC Hgb: 107 L Hygiene Safety Nutrition Urine Elimination Fecal
 Specify the date and results H- High Elimination Oxygen Self-concept Sexuality
being normal or abnormal Hct: 0. 330 L
WBC (diff): 7.7 N
L-Low Rationale:
Platelets: 296 N N-normal
Hgb: normal is 115-165 Red blood cell production and
aPTT/INR -
Na 142 N HCT: normal 0.340-0.490 lifespan can be impacted by chronic
K 4.0 WBC (diff) 4.0- 11.0 inflammatory illnesses such as
Albumin 30 L Platelete : 150-400 rheumatoid arthritis and others.
BUN - Na: 135-147 Effect on Hct/Hgb Inflammatory
Creatinine -
Glucose 5.8 N K: 3.5-5.0 processes can interfere with normal
ABG (pH, PO2, PCO2; 39 Albumin : 35-50 erythropoiesis, which can result in
PCO2, HCO3) Glucose: 4.0-8.0
HCO3; - anemia (Doenges et al, 2014).
PH; -
PO2;-
Cultures & The patient blood results from
Sensitivity Results
(Wound, Blood,
November 26, 2024, indicated that
Sputum): she had inflammation and anemia.
COVID-19 Patients with low hemoglobin (Hgb)
culture was and hematocrit (Hct) levels are often
done a day suffering from conditions that result
before in anemia.
(Jan/24/202
4)
And the
result came
back one
day after
(Jan-

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confidentiality.
System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

25/2024)
and was
negative.

Client Concerns/
Preferences:
SPN2: how
do you feel
being here
at this
facility?
Patient: I
am not use
to be with a
group, I
have been
living alone
since my
husband
died,
almost 15
years.
The patient
concern is
being in the
bigger
facility like
senior
home with
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IMPORTANT NOTE: Do NOT include any patient, staff or institution identifiers on this document. Please maintain the principles of
confidentiality.
 System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

more
people and
she is not
use to it
and how
she can
deal with it.

Family/Support
System: She
does not
hava
family. She
is alone

Psychosocial During your interaction, did the client The patient did not Activity & Exercise Sleep & Rest Sensory Skin &
(Cultural/Spiritual) or family mention about any Hygiene Safety Nutrition Urine Elimination Fecal
Baseline Status: cultural/spiritual preferences or mention anything about Elimination Oxygen Self-concept Sexuality
choices specific to any current spiritual.
treatments that they are receiving Rationale:

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confidentiality.
System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

PART B (Student Objective): Complete the medication research in the below format for all the assigned medications

Name Classification How it works? Why is the Side Effects Nursing Implications
(Generic/Brand) Mechanism of client taking (Common)
Actions this
medication?
Atorvastatin The patient has 1.headache 1. Monitor liver function
1. Atorvastatin Statin works by history of 2. rash tests regularly as statins
(Brand: Lipitor) inhibiting HMG- Dyslipidemia. 3. hyperswnitivity may cause liver
20 mg QHS CoA reductase, Dyslipidemia 4. sinusitis enzyme abnormalities.
an enzyme refers to an 2. Assess for any signs of
involved in the abnormal muscle pain or
synthesis of amount of weakness, as rare cases
cholesterol in lipids (fats) in of serious muscle
the liver. By the blood. It problems have been
blocking this often involves reported.

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confidentiality.
System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

enzyme, it elevated levels 3. Educate the patient on

reduces the of cholesterol, the importance of
production of particularly lifestyle modifications,
cholesterol, low-density including a heart-
thereby lowering lipoprotein healthy diet and regular
total cholesterol cholesterol exercise.
and low-density (LDL-C), also 4. Advise the patient to
lipoprotein known as report any unusual or
(LDL) "bad" severe side effects
cholesterol cholesterol. promptly.
levels(Skidmore, High levels of Administer the medication
2023). LDL-C can with the evening meal or at
contribute to bedtime, as cholesterol
the synthesis is highest during the
development night (Skidmore, 2023).
of
atherosclerosis,
a condition
where plaque
builds up in the
arteries,
potentially
leading to
cardiovascular
diseases.
Atorvastatin is
a statin
medication
prescribed to
individuals
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IMPORTANT NOTE: Do NOT include any patient, staff or institution identifiers on this document. Please maintain the principles of
confidentiality.
System Assessment Assessment Finding Analysis Needs Affected
(Must use proper terminologies)

with
dyslipidemia,
especially
those with high
levels of LDL
cholesterol. Its
mechanism of
action involves
inhibiting
HMG-CoA
reductase, an
enzyme in the
Fluticasone The patient has 1. Nasal Spray (Flonase): Inhaler Administration:
2. Fluticasone Corticosteroid exerts its anti- history of Nosebleeds, nasal dryness, Instruct the patient on
(Brand names: (Inhaled) inflammatory Pulmmonary sore throat, headache. proper inhaler technique,
Flonase, effects by embolism, and 2. Inhaler (Flovent): Thrush including rinsing the
Flovent) 1 puff binding to aslo has a (candidiasis) in the mouth mouth after each use to
Daily glucocorticoid oxygen and throat, hoarseness, reduce the risk of thrush.
receptors, saturation at headache
leading to the 94% and had Nasal Spray Administration:
inhibition of history of Teach proper nasal spray
multiple pneumonia. technique, ensuring the client
inflammatory Fluticasone is understands to aim away from
cells and prescribed to the nasal septum.
mediators individuals
involved in the with Monitor for Side Effects:
inflammatory respiratory Keep an eye on potential side
response. It conditions effects, especially in the
reduces such as asthma oropharyngeal area for inhaler
inflammation in and chronic use and local irritation for
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the airways, obstructive nasal spray use.

making it pulmonary
effective in disease Assess Respiratory Status:
managing (COPD) and Regularly assess the patient's
respiratory pneumonia. It respiratory status and the
conditions helps control effectiveness of the
(Skidmore, and prevent medication in controlling
2023). symptoms like symptoms (Skidmore, 2023).
wheezing,
shortness of
breath, and
inflammation
in the airways
(Smith, 2010).

Levodopa is a History of 1. Nausea 1. Administer with Food:

3. Levodopa Antiparkinsonia precursor to Parkinson. 2. Vomiting Levodopa is often
(Brand names: n Agent dopamine, a Levodopa is 3. Hypotension (low blood administered with a
Sinemet, neurotransmitter prescribed to pressure) meal to minimize
Parcopa) 1 that is deficient individuals 4. Dyskinesias (involuntary gastrointestinal side
Tablet BID in individuals with movements) effects.
with Parkinson's Parkinson's
disease. In the disease to 2. Monitor Blood
brain, levodopa manage Pressure: Due to the
is converted to symptoms such potential for
dopamine, as tremors, hypotension, monitor
helping to stiffness, and the client's blood
restore difficulty with pressure regularly.
dopamine levels movement
and alleviate the (Smith, 2010). 3. Assess for
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symptoms of Dyskinesias: Keep an

Parkinson's eye on the
disease development of
(Skidmore, dyskinesias and
2023). communicate any
changes to the
healthcare provider.

Evaluate Mental Status:

Monitor for hallucinations or
changes in mental status, as
these may occur, especially at
higher doses (Skidmore,
2023).
Sennosides Sennosides are 1. Abdominal cramps 1. Monitor Bowel
4. Sennosides Stimulant stimulate bowel used to relieve 2. Diarrhea Patterns: Assess
(Brand names: Laxative movements by constipation 3. Nausea the patient's bowel
Senokot, Ex- irritating the and promote Electrolyte imbalance with patterns, including
Lax) 2 tablets bowel lining and bowel prolonged use frequency and
QHS promoting the regularity consistency, to
rhythmic (Smith, 2010). determine the
contractions of effectiveness of
the intestines the medication.
(peristalsis).
This helps to 2. Encourage Fluid
alleviate Intake: Advise the
constipation patient to increase
(Skidmore, fluid intake to
2023). prevent
dehydration,
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especially if
experiencing
diarrhea.

3. Educate on Proper
Use: Instruct the
patient on the
appropriate use of
the medication and
emphasize the
importance of
following dosage
instructions.

Caution with Prolonged Use:

Prolonged use of stimulant
laxatives like sennosides may
lead to dependence and
electrolyte imbalances.
Monitor for signs of abuse or
dependence (Skidmore,
2023).
Selective Sertraline works History of 1. Nausea 1. Monitor Mood and
5.Sertraline Serotonin by increasing depression. 2. Diarrhea Behavior: Assess changes
(Brand Reuptake the levels of Sertraline is 3. Insomnia in mood, behavior, and
name: Inhibitor (SSRI) serotonin, a prescribed to 4. Sexual dysfunction suicidal ideation, especially
Zoloft) 100 neurotransmitter treat various Weight changes during the initial phase of
mg& 50 mg in the brain. By mental health treatment.
capsule inhibiting the conditions,
daily reuptake of including 2. Educate on
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serotonin, it major Adherence: Emphasize the

enhances its depressive importance of consistent
availability in disorder, medication adherence for
the synaptic obsessive- optimal therapeutic effects.
cleft, leading to compulsive
improved mood disorder 3. Monitor for Side
and alleviation (OCD), panic Effects: Keep a watchful
of symptoms disorder, social eye on common side effects
associated with anxiety and communicate any
depression, disorder, and concerns to the healthcare
anxiety, and post-traumatic provider.
other disorders stress disorder
(Skidmore, (PTSD) Caution with Discontinuation:
2023). (Smith, 2010). Gradual tapering may be
necessary when discontinuing
sertraline to prevent
withdrawal symptoms
(Skidmore, 2023).
Anticoagulant, Apixaban History of 1. Bleeding (risk of 1. Monitor
Factor Xa inhibits factor Pulmonary bleeding is a Signs of
6.Apixaban (Brand Inhibitor Xa, an essential Embolism and significant concern) Bleeding:
name: Eliquis) 5 mg component in DVT (Deep 2. Easy bruising Watch for
BID the coagulation vaine Nausea signs of
cascade. By Thrombosis) bleeding,
inhibiting factor Apixaban is including
Xa, it interrupts prescribed to unusual
the formation of reduce the risk bruising,
thrombin, of stroke and hematuria,
preventing the systemic and bloody
development of embolism in stools.
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blood clots patients with

(Skidmore, non-valvular 2. Assess
2023). atrial Renal
fibrillation. It Function:
is also used for Apixaban
the treatment is primarily
and prevention eliminated
of deep vein through the
thrombosis kidneys;
(DVT) and therefore,
pulmonary monitor
embolism (PE) renal
(Smith, 2010). function,
especially
in patients
with renal
impairment
.

3. Educate on
Medication
Adherence:
Stress the
importance
of
consistent
medication
adherence
to maintain
therapeutic
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anticoagula
tion levels.

Educate on Lifestyle
Changes: Advise patients on
lifestyle modifications and
potential drug interactions
that may affect bleeding risk
(Skidmore, 2023).

PART C (Student Objective): Based on the analysis completed in PART A, identify one priority need with rationale for the assigned client. Using the nursing
process and in collaboration with the client/interprofessional health care team, formulate a nursing care plan with one nursing diagnosis, three expected
outcomes, six priority nursing interventions and evaluations. Please use the template below to complete the nursing care plan.

Actual or at risk, Nursing Diagnosis can be formulated and must meet the NANDA criteria learned in PNUR104. Similarly, the expected outcomes must be
written in a SMART format. Nursing interventions must be realistic, client-oriented, achievable (within the practice settings) and correlate with the priority need,
nursing diagnosis and expected outcomes. Evaluations must indicate whether the identified nursing interventions were effective or ineffective.

Priority Need (With Nursing Diagnosis Expected Outcomes Nursing Interventions Rationale (for Nursing Evaluation
Rationale) Activity and mobility 1. The client will 1. The nurse will Interventions)
Every shift, the nurse
Activity & Exercise impairment. have the ability collaborate with
Working together with will determine the
to perform ROM OT and PT to
physical therapy (PT) and patient's level of
and switch prived a proper
occupational therapy (OT) activity. She will also
passive to active ROM (range of
1.To create an individual do range-of-motion
ROM by motion) for
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assisting of the client to develoe range of motion (ROM) plan exercises three times
nurse from patient daily is essential, especially in a day and actively
2024-02-05 to activity (ADL) consideration of the client's engage in
2024-03-05. within one osteoarthritis diagnosis. collaborative patient
2. The client will month (from Degeneration of joint education, focusing
be able to 2024-02-05 to cartilage is a feature of on the best
independently 2024-03-05). osteoarthritis, which can positioning
show 2. To improve the greatly impair joint mobility techniques to help
appropriate patient's joint and flexibility. The goal of the patient meet
positioning flexibility, the the nursing intervention is their mobility
practices while nurse will to address the unique joint objectives.
collaborating perform range- restrictions brought on by
with nurses in of-motion osteoarthritis by combining
two weeks exercises three the particular knowledge of
(2024-02-05 to times a day, with OT and PT(Potter &
2024-02-15). a goal of Perry, 2023).
reaching a set
2. Especially those with
goal within a
conditions like
given time
osteoarthritis, can worsen
frame.
joint stiffness; therefore,
3. By offering
strategic positioning by the
direction and
nurse aims to counteract
assistance with
these effects, promoting
appropriate
joint flexibility and
positioning
minimizing the risk of
strategies, the
contractures. By educating
nurse works in
and involving the patient in
tandem with the
proper positioning
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patient to help techniques, the nurse

them achieve contributes to maintaining
independence. optimal musculoskeletal
4. The nurse will function and overall
educate the comfort in the older adult
patient on joint population (Potter &
positioning and Perry, 2023).
flexibility
through practical
demonstrations,
promoting a
better
understanding
and active
engagement in
self-care
practices.

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PART D (Student Objective)- Each student must create a time plan to demonstrate the nursing care process specific to the client assigned. The time plan should
contain interventions from the NCP under the 'nursing activities' column to implement them in the clinical setting.
Time Plan must demonstrate the organization of workload, time management principles, and activities relevant to the assigned client.
Each student must complete the evaluation column at the clinical setting to indicate the nursing activities' outcome. If the actual outcomes are different from
the NCP expected outcomes, modify the nursing care plan after collaborating with the client.

TIME (indicate the time in 24-hour Nursing Activities Evaluation (indicate whether the nursing activities
format) were carried out as per plan- expected outcomes vs
actual outcome)

0730 I received the shift report by my body nurse My patient was admitted at the hospital due to
Fever, hypoxia, required O2, oxygen was less then
92%, pulmonery Embolism.
She is on soft/thin and regular diet. The patient
takes her medication by mouth and no need to be
crush.
The urine bag was changed already, and the patient
does not have pain.
Her activity level is as tolerance, and need 2
assisstance to change the brief and transfer with
hoyer lift (C).
0800 I start the shift with giving her a bed bath and Bp: 113/68 on the left arm
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vital sign, apply cream on her feet to reduce the RR:19

dryness
Pulse: 73 redial
T: 35.8 axilary
1130 I did the head to toe assessment on my patient It has been provided on the chart
and apply cream
GCS score:
Eye opening 4/4
Verbal response: 5/5
Motor response: 6/6

1230 I help her to set up her lunch table and open up

some of her food container and apply cream again
1330 Check my patient again for her lunch and apply She had 90% of her lunch. and she had 450 ml fluid
cream.
1500 Check my patient again and apply cream Her skin looks better then morning and less dry
skin
1630 I changed her brief with other student practical The patient had medium and soft BM
nursing,

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Rubric

Criteria Needs Improvement Satisfactory Additional Instructor

Comments

Data Collection (on 11 ☐ ☐

needs)* (PART A) Data collection on 11 needs and nursing assessment Data collection on 11 needs and nursing assessment complete
incomplete. (Several Important data missing)
Pertinent data addressed within the NCP
Minimal collaboration with client evident specific to
data collected Collaboration with client evident specific to data
collected.

Data analysis* ☐ ☐
Data collected not analyzed and/or validated with Evidence of proper data analysis with nursing resources (textbooks and journals),
(PART A) proper nursing evidences (assessment, textbooks and
journals)
In depth analysis with several inferences to research findings, social determinants of
Superficial data analysis evident with minimal health, physiological norms, pathophysiology, pharmacology and health assessment
reference to research findings,
physiological norms, pathophysiology, pharmacology
and health assessment

Data Analysis not leading to identification of a priority Analyzed data clearly leading into identification of priority need.
need

Priority Need Identification* ☐ ☐

No clear priority need identified Clear identification of priority need with ample support from data analysis
(PART B) OR (health related consequences short and long term clearly identified)
Identified priority need is not accurate with minimal
data analysis (minimal identification of client
consequences)

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Nursing Diagnosis ☐ ☐
No Nursing Diagnosis identified Proper nursing diagnosis well supported with manifestation and etiology criterion.
(PART B) OR The nursing diagnosis meets the NANDA criteria.
Identified nursing diagnosis not specific to the priority
need with several structural concerns where Nursing diagnosis fits well with the data analysis and priority need identified.
manifestations and etiology are not co-relating with the
data analysis/priority need. NANDA format is not
evident
Expected Outcomes (three ☐ ☐
Expected outcomes addressed are not Expected outcomes met the SMART criterion and are specific to the nursing
short term)
meeting the SMART criterion diagnosis addressed.
are not specific to the
(PART B)
nursing diagnosis.
Nursing Interventions with ☐ ☐
Identified six priority nursing interventions are not Identified six priority complete, realistic and achievable nursing interventions. The
rationale (six priority nursing
realistic, achievable and correlating with the interventions are specific to the diagnosis, expected outcomes, client preferences and
interventions) nursing diagnosis, client preferences, desired priority need.
outcomes and priority need.
(PART B)

Evaluation Identified in Time ☐ ☐

No or minimal evaluative components specific to the Proper evaluative components correlating with the nursing interventions and expected
Plan
nursing interventions and expected outcomes evident outcomes are evident in the TIME PLAN submitted.
in the TIME PLAN submitted
(PART B)

Time Plan ☐ ☐
Incomplete evidence of workload organization, time Accurate and complete evidence of workload organization, time management
(PART C) management principles, and nursing interventions principles, and nursing interventions relevant to the assigned client(s)
relevant to the assigned client(s)

Medication Research ☐ ☐
Incomplete medication research and limited knowledge Completes medication research and demonstrates knowledge of pharmacology
(PART D) of pharmacology related to assigned client(s) related to assigned client(s) medication according to CNO Medication Standard
medication(s) according to CNO Medication Standard

Evidence of Professional ☐ ☐
Minimal evidence of Professional nursing references in Use of Professional nursing references evident in the COP
references (e.g. Course
the COP
Textbooks, and Journals)

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APA 7th edition ☐ ☐

Incorrect and/or Inconsistent APA formatting and Consistent and satisfactory APA formatting and referencing errors evident in the
referencing in several areas of the COP COP

Student Name:

Student Number:

Date: Click or tap to enter a date.

Overall Grade:

Referrences

Doenges, M. E., Mary Frances Moorhouse, & Murr, A. C. (2014). Nursing care plans : guidelines for individualizing patient care (9th ed.). F.A.
Davis.

SKIDMORE-ROTH, L. (2023). Mosby’s 2024 Nursing Drug Reference - E-Book. Elsevier Health Sciences.

Smith, K., Riche, D. M., & Henyan, N. (2010). Clinical Drug Data, 11th Edition. McGraw Hill Professional

Astle, B. J., Duggleby, W., Potter, P. A., Anne Griffin Perry, Stockert, P. A., & Hall, A. (2023). Potter and perry’s canadian fundamentals of nursing -
e-book (7th ed.). Elsevier Health Sciences.

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