CARE PLAN

name

Date

Degree Programme in Nursing

School of Health and Social Studie
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Contents
Contents..........................................................................................................................1
1 Introduction............................................................................................................2
1.1 Practical placement. Vitapolis..........................................................................2
1.2 Choosing a client..............................................................................................3
1.3 Client's personal information............................................................................3
2 Main part.................................................................................................................4
2.1 Client's health conditions..................................................................................4
2.2 Needs, weaknesses and strengths of client.......................................................5
2.3 Goals of treatment............................................................................................6
2.4 Medication........................................................................................................6
2.5 Care plan table..................................................................................................8
3 Conclusion............................................................................................................11
3.1 Making the care plan......................................................................................11
3.2 Evaluation of the care plan.............................................................................12
4 References............................................................................................................13
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1 Introduction

1.1 Practical placement. Vitapolis

The place, where I have had my practice is called Vitapolis and it is located in
Kinkomaa, Jyvaskyla. The hospital is surrounded by forests and lakes, which
make this place look beautiful.
This place has a long history. At the beginning of 20th century tuberculosis
was the most serious infection disease in Finland, and Central Finland was
one of the regions with highest incidents. In Jyvaskyla the tuberculosis was
one of the most common reasons of death at this period. So it was decided to
establish Central Finland Sanatorium in 1927. Officially the Sanatorium was
opened in 1930. It was the center of tuberculosis treatment in Central Finland.
However, the wartime changed the work of Sanatorium and tuberculosis
treatment was vastly reduced. The sanatorium was transformed into a military
hospital. Shortly after the war the tuberculosis treatment was restarted and
medical innovations were initiated. Nowadays the hospital is a property of a
management company. (Yhteystiedot ja listatietoa palveluista, 2012)

Today Vitapolis is a big organization with different wards. There is a

rehabilitation ward and a ward of long-term care (pitkaaikaishoito 6), where I
had been having my practice. Residents here are usually people, who need
24/7 help due to different reasons (such as memory disease and other
illnesses). Here people live the last years of their life. They usually come here
straight from the hospital, when they have no more ability to go back home,
cannot serve themselves, dress and even brush their teeth. When they come
here they get full care 24 hours a day.
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1.2 Choosing a client

The client, this project is written about is an old lady. As far as I cannot reveal
the personal information, she is going to be named as a “Lady” in work.
Here I would like to present some reasons why I have chosen this woman to
be my object of research.
Most of the patients in the ward are people who are unable to guide
themselves. They have serious dementia or memory illnesses, which made
the process of choosing a client difficult. As far as I wanted to write my care
plan not only from the medical point of view, but also consider moral
conditions of my client, I decided to choose somebody who has no serious
problems with mental health.
Lady was one of few sane residents in Vitapolis. She has no mental illnesses,
which enabled me to spent a lot of time with her, going deeper and deeper not
only in her medical records but also to her personal life’s story. Secondly. I
would like to point out that it was much easier to work with her, due to the fact
that she was opened for communication with nurses. She was one of the most
active patients and her attitude towards me was has supported me during the
whole practice. However, medical records played a big role in the process of
choosing a client. Lady had rather big list of medications, which made me
more knowledgeable about her illnesses.

1.3 Client's personal information

Lady was born in Vyborg (Russian Federation) in 1927, in a very big family.
Her father was a salesman and her mother was a gardener. There were 7
children in their family, though by now only two of them are still alive. Both
parents were very religious and all the children were raised in the spiritual
atmosphere.
Lady's family moved from Russia when she was still a child of 12 years old.
There are no records about the place where they moved, but it is stated that
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Lady moved to Jyvaskyla at the age of 20. Though we don't know much about
Lady's childhood, she claims that it was full of happiness.
We also don’t have much information if Lady has made any higher studies, but
it is stated that she was studying in an evening school. Unfortunately we
cannot say for sure if she had any kind of definite profession. While living in
Jyvaskyla Lady was working at some place called “Gummerus”. She was very
focused on her work and devoted to it. She also liked to cook and go skiing.
She had a great collection of porcelain dolls.
Lady didn't create a family and has no children. According to it we can say that
she spend all of her time on work and hobbies. Unfortunately, by now Lady
has no relatives, expect for her sister
When getting older, she was living in her flat alone for as long as possible.
She had some phone services to help her. As her illness has got worse, living
along became impossible. One day she fall down on the floor and couldn't rise
up. After that accident she moved to Vitapolis hospital in 2010.
Lady is very communicative; she can easily get along with everyone. She likes
attention and she hates when she doesn't get enough of it. If nurses cannot
do what she wants them to do, she may start to cry to achieve her own goals.
This makes her a little selfish sometimes, but overall, most of the time; she is
very friendly with everyone.

2 Main part

2.1 Client's health conditions

Her health conditions can be described the following way:

 the patient is sane;

 refusal of reanimation;

 individual coping impairment, difficulties with doing the daily activities,

unable of coping with this by herself;
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 cardiovascular alteration, cardiovascular diseases;

 risk of falling down;

 bathing/hygiene deficit;

 dressing deficit;

 physical mobility impairment. The client is using a rollatori to move;

 normal diet, difficulties with digesting of some food;

 own teeth, but need to be brushed by the nurse;

 wearing a diaper, but using the toilet normally;

 hearing difficulties, wearing a hearing device;

 patient is capable of having her meals all by herself.

2.2 Needs, weaknesses and strengths of client

My patient also has her own strengths and weaknesses, which I would like to
describe here.
In my opinion, Lady's main strength is that she is in clear mind and has no
memory problems. This is the root of all of her strengths. Being sane makes
her very communicative with all people around her, which, in its turn, prevents
Lady from feeling depressed because of loneliness. Another great advantage
of Lady is that she is very physically active. She walks herself, and she does
all the activities, she is capable of doing, by herself. And last, but not the
least, advantage is that she understands her health conditions and she is very
motivate to be active. She is always watching her diet and medication.
However, Lady also has weaknesses. She is incapable of doing all the daily
activities by herself, and that is why she cannot live alone. Sometimes Lady
can be very ignorant and doesn't listen to what nurses tell her to do. If she
doesn't want to do something she is told to, nobody can ever make her do it
against her wish.
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2.3 Goals of treatment

The main goal of our treatment is to support Lady in the same conditions as
she is in now, not to make them worse. We need to maintain her condition on
the same healthy level, monitor the existing risks, provide moral support in
case of feeling depressed or lonely.

2.4 Medication

Medications of every day-use.

1) Tramadin (tramadol)
Analgesic. Indications: synthetic opioid used in the treatment of moderate to
severe pain. Not a controlled drug. (Volans and Wiseman, 2008, p 117)
2) Omeprazole
Indication: symptomatic gastroesophangeal reflux disease (GERD) without
esophageal lesions. Proton pump inhibitor acts directly on gastric cells to
reduce acid secretion. Used to treat gastro-esophageal reflux disease, peptic
ulceration and for the eradication of Helicobacter pylori, the organism
associated with many causes of chronic peptic ulcers. (Volans and Wiseman,
2008, p 83)
3) Acetaminophen (paracetamol)
Indication: mild pain or fever. Inhibits synthesis of prostaglandins in the brain,
but does not have action in the periphery and has no anti-inflammatory effect.
Relieves, mild pain but not inflammation. (Volans and Wiseman, 2008, p 3)
4) Glycerin trinitrate
Indication: vasolidator for symptomatic or prophylactic treatment of angina
pectoris. Administrated as sublingual tablets or oral spray for rapid absorption
at onset of symptoms or applied as a gel to skin for sustained absorption in
prophylaxis. May also be used intravenously to treat cardiac failure, during
hypotensive surgery or during cardiac surgery to prevent myocardial
infarction. (Volans and Wiseman, 2008, p 53)
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5) Duphalac (lactulose)
Indication: a synthetic disaccharide (galactose plus fructose) that is not
absorbed but broken down by gut bacteria to nonabsorbable products that
increase the fecal mass by osmotic effects. (Volans and Wiseman, 2008, p
64)

6) Losartan
Indication: angiotensin II with effects similar to angiotensin-converting
enzyme, but more selective. Used as an antihypertensive where it does not
cause dry cough or the allergic reactions. (Volans and Wiseman, 2008, p 68)

Medications of in-need use:

1) Ibumetin (ibuprofen)
Indication: non-steroid anti-inflammatory/analgesic/antipyretic. Reduces
inflammation by inhibition of prostaglandin synthesis, which is a part of
inflammatory process. Used in rheumatoid arthritis and other arthritic
conditions. Used also as a general purpose mild analgesic and as antipyretic
in febrile conditions of childhood. (Volans and Wiseman, 2008, p 58)
2) Imovane (zopiclone)
Indication: a non-benzodiazepine hypnotic used for short-term treatment of
insomnia. May cause a bitter metallic aftertaste, minor gastro-intestinal
disturbances and drowsiness. ( Volans and Wiseman, 2008, p 127)
3) Morphine
Indication: centrally acting narcotic analgesic used for relief of severe pain.
Other potentially useful effects include euphoria and cough suppression.
Adverse effects include respiratory depression, nausea, vomiting,
constipation, hypotension, physical dependence and abuse. Coma with
danger of death in over dosage. ( Volans and Wiseman, 2008, p 76)
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2.5 Care plan table.

Need of care Aim (goal) Planned interventions Intervention Assessment

(Classification: (Classification;SHToL)
SHTaL)
ACTIVITY Client to move ACTIVITY Client get daily ACTIVITY
Exercise deficit around with 1.Rehabilitation exercises by moving 1.Patient is
Client is not able to the help of a exercises. Motivating arong the building with capable of
move on her own walking aid. client to using her the help a walking aid. moving all by
physical strength to Client is encouraged to herself but
move have all meals in the with the watch
dining-room, not in the of a nurse
bedroom, to provide
physical movements.

SELF-CARE SELF-CARE SELF-CARE SELF-CARE SELF-CARE

Bathing/hygiene deficit Client to stay Aiding in washing. Client is assisted in Client is always
Client is not able to clean all the Aiding in dental care. bathing once a week, tidy
take care of her time and assisted in morning
personal hygiene and evening washes in
the WC everyday

Dressing deficit Client to dress Aiding in dressing, Client is aided in Dressing and
up with little grooming. dressing and grooming grooming is
help every morning and fully provided.
evening

SENSORY SENSORY SENSORY SENSORY SENSORY

Auditory alteration Should be 1.Stimulating the sense Providing hearing The sense of
Cant not hear without a able to hear of hearing device and monitoring hearing is
hearing device with a hearing its use. stimulated
device with a hearing
device

Chest pain Chest pain Pain control. Caring for Medication given as The chest
reduction pain. prescribed: pain is
TRAMADIN 50MG reduced.
KAPS once a day

PARA-TABS 1G TABL
one tabl once a day

IBUMETIN 400MG
TABL 1 tabl three times
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a day if needed
MORPHIN 20MG/ML 2-
4mg once a day if
needed
SELF-CONSEPT SELF- SELF-CONSEPT SELF-CONSEPT SELF-
1.Changes in mood CONSEPT 1.Conversations with a Encouraged to talking CONSEPT
To have less personal nurse with the other clients The changes
frequent and nurses every day. become less
changes in Encouraged to go out frequent.
mode for fresh air. Monitoring
the changes in mood
and the root causes of
these changes.
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3 Conclusion

3.1 Making the care plan.

In this chapter I would like to discuss the feeling this care plan has
arisen in me.
The first thing I would like to point out is the fact that I am
definitely sure that making a care plan is a very good experience
and it is going to help me in my future career. I suppose that care
plans are going to be essential part of our studies, and I hope that
by the end of my education I would be able to work on care
planes without any difficulties.
Secondly, I consider care plans very useful for students in terms
of documentation process. When I was having my practical
training I was more concentrated on the practical side of my work
and less concentrated on the documentation aspect. However,
the making of a care plan has showed me that the work of a nurse
doesn’t consist only of a practice. It is also about the
documentation of every step you make.
And finally, this care plan has taught me about a lot of practical
things such as medication process and everyday activity
documentation. I think that my knowledge in terms of
pharmacology has arisen. I have faced the actual medications
and their usage, which made me more prepared to my future
studies.
When it comes to talk about my personal impression about my
practical training, I should say that it was quite a challenge for me.
First few weeks of my practice were shocking. I couldn’t speak
with anyone, but my mentors, I couldn’t communicate with the
patients. I felt angry and sad at the same time. So I set the main
goal for myself: to overcome the language barrier. As time passed
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I started to feel more confident. I observed main phrases of care

and started to communicate both with my patients and
colleagues. By the end of the practice I felt comfortable enough
to communicate with everyone around me, and I hope that most
of my colleagues were satisfied with my work.

3.2 Evaluation of the care plan

During this project I have been working on the main steps of

Nursing Care plan. While writing this work I had achieved the
following goals:
 I’ve described the patient’s personal situation possiböy
many-sided;
 I determined the care requirements of the patient utilising
the FinCCnursing Diagnosis;
 I determined the goals of the nursing interventions;
 I determined the nursing interventions, utilising the
FinCCNursing Interventions;
 I documented the implementation and evaluation of the
care plan,
 I considered all the feeling this project has arisen in me.
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4 References

Yhteystiedot ja listatietoa palveluista leaflet, Vitapolis Healthcare

Centre , 2012. Accessed on 2 March 2013.

Glyn N. Volans and Heather M. Wiseman, 2008. Drugs

Handbook, Palgrave Macmillan. Accessed on 5 March 2013.

Judith A Schilling McCan, 2013. Nursing 2013 Drug Handbook,

Lippincott Williams & Wilkins. Accessed on 10 March 2013.