Care Plan

Module III Nursing
AVS Transition

Nursing Process Discussion
Group 3 Case Study

Michael Martinez is a 24-year-old Marine who was involved in a motor vehicle accident (MVA) while on leave. His face hit the dashboard, resulting in a fracture of the mandible.

Yesterday, he underwent a surgical maxillomandibular fixation, (wiring of the jaw) for stabilization of the fracture.

As a result of this surgery, he is unable to open his mouth and is limited to a liquid diet. The restricted diet will be necessary for 4 to 5 weeks until the fracture heals.

One day post op, his vital signs are 120/76, T-99.2, P-82, and R- 20. After medication, his pain level is 3/10. With the exception of facial bruising, his appearance is within normal limits.

Steps of the Nursing Process
Patient Information
Assessment
Objective and subjective data will be entered here. The database presented in the case study will be used. Data is collected and verified from the primary (pt.) and the secondary (family, friends, health professionals, and medical record). Analysis of this data provides the basis for development of the remaining steps in the nursing process.
Subjective: Patient expresses disinterest in a liquid only diet

Objective: wired jaw
Liquid diet
Nursing Diagnosis
After analyzing the assessment data, formulate a priority nursing diagnosis. Remember, a nursing diagnosis is a statement describing the patient’s actual or potential response to a health problem that the nurse is licensed and competent to treat. An actual diagnosis is written in three parts: diagnostic label (problem) ___related to___ as evidenced/exhibited by___.
A risk diagnosis is written in two parts: Risk for (diagnostic label) ___related to___.
Nutrition: less than body requirements related to inability to eat solid foods as evidenced by liquid diet post-surgery
Planning
Goals: Now is the time set patient centered goals. Here you will develop expected outcomes using the seven guidelines in text.
Interventions: Planning includes selection of interventions based on six important factors outlined in your text. Please write the interventions you select below in implementation.
Patient will be free of signs of malnutrition post dinner time each shift
Implementation
Here is where the nurse will carry out the plan of care. Then continue data collection and modify the plan of care as needed and document care provided. What nursing interventions will you provide to enhance patient outcomes?
Assess patient’s weight every shift
Auscultate bowel sounds
Evaluate total daily food intake
Provide high calorie, nutrient-rich dietary supplements
Evaluation
The purpose of evaluation is to support the effectiveness of nursing practice which is patient-centered and patient-driven. This phase measures the patient’s response to nursing interventions and progress towards achieving goals using five elements listed in the text. Did you achieve the goal for this nursing diagnosis? Will you continue the plan of care, revise the plan of care, or discontinue? Reassess patient’s lab value daily for signs of malnutrition. If malnourished call health care provider for further orders
Patient will weight within 10% of normal body weight every morning