Nursing Care Plan: Hypertension and Hypothyroidism

Care Plan - Alteration in Health Status D/T Hypertension

• Problem: Hypertension (high blood pressure)
• Goal: Maintain blood pressure within an acceptable range.
• Approach(es):
  • Monitor blood pressure as prescribed by a doctor.
  • Monitor for symptoms like shortness of breath, cyanosis, increased weakness, confusion, headaches, chest pain, nosebleeds, and low blood pressure.
  • Take blood pressure before administering medication.
  • Hold medication if systolic blood pressure is below 100 mmHg.
  • Administer medication as ordered by a doctor.
  • Specific medications: Lisinopril 2.5 mg BID for high blood pressure and Inderal (Propranolol) to normalize pulse. Hold either medication if systolic pressure is under 100 mmHg or pulse is under 80.

Care Plan - Alteration in Health Status D/T Hypothyroidism

• Problem: Hypothyroidism (underactive thyroid gland)
• Goal: Maintain Thyroid Stimulating Hormone (TSH) within normal limits.
• Approach(es):
  • Monitor TSH levels through lab work as ordered by a doctor.
  • Administer medication as directed by a doctor.
  • Specific medication: Levothyroxine QD.

Care Plan - COVID-19 Care

• Problem: Positive COVID-19 test.
• Goal: Individual will be free of symptoms and fully recover from COVID-19.
• Approach(es):
  • Follow CDC recommendations for COVID-19.
  • Administer medications as ordered by the physician.
  • Monitor for symptoms (fever, cough, congestion, etc.)
  • If symptoms worsen notify a doctor immediately.
  • Keep the individual isolated to prevent spread of infection.
  • Follow infection control protocols (handwashing, mask-wearing, etc.)
  • Ensure healthcare providers wear appropriate PPE (personal protective equipment).
  • Monitor oxygen saturation and report any values below 90%.
  • Follow guidelines regarding isolation discontinuation.

Care Plan - Disturbed Sleep Pattern

• Problem: Disturbed sleep pattern due to neurological dysfunction.
• Goal: Achieve optimal sleep by establishing a regular sleep pattern.
• Approach(es):
  • Maintain consistent daily schedule for retiring and arising.
  • Ensure a conducive sleep environment (quiet, comfortable, temperature control).
  • Limit staff or other interruptions during sleep hours.
  • Discourage daytime naps unless necessary to meet sleep requirements.
  • Increase daytime physical activity to promote sleep.
  • Administer medication if insomnia is worsening.

Care Plan - High Risk for Injury D/T Client Injuring Self

• Problem: High risk for injury due to self-injurious behavior related to various diagnoses.
• Goal: Reduce or prevent self-injury within three months.
• Approach(es):
  • Maintain a calm and supportive approach to address the client's needs
  • Implement appropriate safety measures to prevent self-harm, ensuring the environment is safe
  • Administer medication as prescribed to manage behavior
  • Closely monitor for self-injury episodes and implement appropriate interventions (e.g., blocking techniques, redirection)
  • Monitor for any worsening of symptoms and report to the RN or doctor immediately.
  • Provide medications for the diagnosed conditions (e.g., for autism, anxiety, SIB and tantrums).

Care Plan - Impaired Verbal Communication

• Problem: Difficulty expressing needs due to cognitive impairment.
• Goal: Successfully meet the client's needs and wants using appropriate communication methods.
• Approach(es):
  • Anticipate the client's needs based on nonverbal cues.
  • Encourage communication attempts and acknowledge successes.
  • Communicate clearly in simple terms.
  • Use gestures and objects to help enhance communication.
  • Report significant changes in condition to the doctor.

Care Plan - Potential of Drug-Related Complications

• Problem: Potential side effects from psychotropic medications.
• Goal: Minimize adverse side effects from medications while managing the diagnosed conditions.
• Approach(es):
  • Monitor for side effects like tremors, involuntary muscle movements, decreased appetite, etc.
  • Document and report any observed side effects to healthcare professionals.
  • Administer medication as prescribed by the physician.
  • Regularly assess medication effectiveness and adjust as needed.

Care Plan - Risk for Aspiration

• Problem: Risk of aspiration pneumonia.
• Goal: Consume meals safely without aspiration.
• Approach(es):
  • Monitor for signs and symptoms of choking or aspiration pneumonia.
  • Report any signs of choking or aspiration pneumonia immediately.
  • Instruct the client to eat slowly and chew food thoroughly.
  • Ensure client consumes small bites and takes small sips of liquids.
  • Monitor for abnormal temperature, respiration, and heart rate.
  • Document all assessments and follow up with RN/Administration or doctor

Care Plan - Risk for Constipation

• Problem: Risk of constipation due to medication and diagnosis/condition.
• Goal: At least one bowel movement every 3 days for 3 months.
• Approach(es):
  • Monitor bowel movements.
  • Encourage adequate fluid intake.
  • Ensure a balanced diet with adequate fiber content.
  • Administer meds as directed for constipation.

Care Plan - Risk for Imbalanced Nutrition

• Problem: Risk of insufficient nutrition due to decreased appetite and related issues.
• Goal: Maintain weight within 10% of ideal body weight within three months.
• Approach(es):
  • Monitor daily food and fluid intake and weight.
  • Engage client in mealtime so they can feel encouraged to eat.
  • Encourage fluids and monitor for dehydration.
  • Administer medications as ordered and monitor for medication side effects.
  • Provide a positive mealtime environment.

Care Plan - Risk for Imbalanced Nutrition R/T Client's SIB of Gagging and Vomiting

• Problem: Risk of insufficient nutrition due to self-injurious behavior of gagging and vomiting.
• Goal: Prevent gastrointestinal bleeding and aspiration.
• Approach(es):
  • Consistent daily routine.
  • Monitor for vomiting, potential bleeding & client safety.
  • Alert RN / medical staff of vomiting episodes.

Care Plan - Risk for Impaired Skin Integrity

• Problem: Impaired skin integrity due to bowel and bladder incontinence.
• Goal: Prevention of skin breakdown within three months.
• Approach(es):
  • Repositioning q 2 hours PRN
  • Keeping the individual clean and dry.
  • Maintaining good skin hydration and lubrication.
  • Monitoring for signs of skin breakdown.
  • Reporting any skin irritations to healthcare professionals immediately.

Care Plan - Self-Care Deficit

• Problem: Self-care deficits due to diagnosis.
• Goal: Safely perform self-care activities with appropriate assistance within three months.
• Approach(es):
  • Provide verbal and physical assistance as needed for ADLs.
  • Establish consistent routines and adequate time frames for tasks.
  • Monitor client's ability to complete tasks and adjust support as needed.