Sample Care Plan Template Page 13
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51Patient’s skin is clean, dry, and intact with no signs of pressure ulcer development.
Risk for pressure ulcer score: 9
Tool used:
Braden Scale
Risk interpretation: Very High Risk
Eyes, Ears, Nose, Throat (EENT)
Assess patient’s EENT:
The patients EENT is within normal limits. The patient’s mucous membranes are moist.
The patient is intubated so he has an endotracheal tube placed that is secured at 25 cm at the
teeth. There are scant thin, white, and clear secretions brought up with inline suctioning. The
patient’s has poor teeth dentition.
Coping-Stress Pattern
Assess patient and family’s coping strategies with psychological, medical, socioeconomic,
cultural, and spiritual issues:
The patient currently lives alone in his trailer with his 2 dogs. His second wife passed
away four weeks ago and the patient on admission was screened for possible suicidal ideation
and depression. The psychiatrist diagnosed the patient with bereavement and determined he had
ineffective coping mechanism. The patient increased his intake of hard liquor after his wife’s
passing as his coping mechanism. During his admission interview he admitted that it had gotten
to the point where he would wake up and have to take a shot of whiskey to stop the tremors and
dry heaves. He came to the hospital because he did not have the money for any more whiskey to
stop the signs of withdrawal. The patient also admitted he drank in excess the same way when
his first wife died.
Socioeconomically, the patient is retired and on a fixed income. He lives in a trailer alone
with two dogs. His second wife had been sick with COPD for a long time before passing and the
medical bills were concerning him.
Role-Relationship Pattern
Assess patient’s primary relationships, marital status, support systems, education level, and
occupation.
nd
The patient is recently widowed for the 2
time. His only living relatives are two
daughters and a brother, but they are all estranged. He is retired with a 40+ year history of
alcohol abuse and two DUI’s. He gave up his driver license after the 2
nd
dui and no longer
drives. Currently, his only support systems are his neighbors at the trailer park. The neighbors
are taking care of his trailer and dogs. During the shift, the neighbors came and visited the
patient in the MICU. They expressed concerned over his condition and requested that we tell the
patient when he was again conscious of their visit and to “not worry about the dogs”. The
neighbor said his wife went in and cleaned the patient’s trailer of alcohol.
Erickson’s developmental stage (mastery or maladjustment):
F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan/12/17/2012
Page 13
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