shelbycrow.yolasite.comshelbycrow.yolasite.com/resources/Care Plan.docx · Web viewTransfer to PCU with telemetry and standing dysrhythmia alarm. Check vital signs every 4 hours minimum

PATTY HANKS SHELTON SCHOOL OF NURSING rev: 08/10/09 Nursing Process l- Fall, 2012Clinical Plan of Care Student Name: Shelby CrowDate of Care: 10-23-2012Patient Initials:

DEMOGRAPHIC DATADate of Admission: 10/16 Age:_77___ Sex:_F_ Race/Ethnicity: _White_____ Occupation: Accountant

Spirituality/Religious Preference/(Concerns): Unknown CODE STATUS:_ DNR___________

Support System: Patient is married.

Other Pertinent Demographic Data: (ie: lives alone, insurance, housing conditions, socioeconomic status, how far do they live from health care resources, etc):

Patient lives with her husband in Abilene, Texas. They have good health insurance, and good housing conditions. Socioeconomic status: middle class. They do not live far from Abilene Regional Medical Clinic.

*Chart Checked for meds and other orders Yes/No (Describe active physician orders & how implemented)

Transfer to PCU with telemetry and standing dysrhythmia alarm. Check vital signs every 4 hours minimum. Heparin lock with routine flush every 8 hours. Check intake and output every 8 hours, and document the results. STAT EKG for symptomatic chest pain PRN – notify M.D. STAT ABGs for symptomatic respiratory distress that is associated with chest pain. Notify MD. For chest pain, place O2 at 2-4 Lpm by cannula. NTG tab 0.4 mg SL PRN every 5 min x 3 and notify M.D. if additional pain control is required. For dysrhythmias: for PVCs greater than 10/min, couplets, or frequent multi-focal PV.

How Implemented: While I was in the hospital, I noticed that the nurses checked input and output once (which would be once every 8 hours). I personally checked the patient’s vital signs 4 times during my shift, and found out what her vitals were when I first got to the hospital from her primary nurse, Shannon. Shannon flushed her heparin lock once while I was on my shift (every 8 hours). There was a 20 gauge saline lock in her left forearm. The patient was placed on oxygen via nasal cannula while I was at the hospital.

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HISTORY & PHYSICAL Information [past & present, incl. present surgery]

MEDICAL DIAGNOSES: Acute diagnoses R/T current admission disease process and physician’s treatment plan.

Medical diagnoses: Lower leg edema and wounds on lower extremities.Physician’s treatment plan: Medications and wound care set up to come in on Monday.

Physician’s treatment plan: The physician ordered her to be flushed with a heparin lock every 8 hours. He ordered her to put on 2-4 Lpm of Oxygen through nasal cannula for chest pain. For the nurses to check Intake and output every 8 hours. She was on a strict cardiac diet with I&Os. Vital signs were to be checked every 8 hours.

History of recent illness & chief complaint(s) (what brought them to the hospital):

Chief complaint: Worsening shortness of breath. She fell recently on a bed hurting her left knee. Multiple wounds to her lower extremities.

No other acute complaints at this time. Chronic lower extremity edema. “Has too much fluid in her body.” Prior admissions for edema, last admission was two years ago.

Exploration of Co-morbidities or chronic illnesses that may impact current admitting problems.Hypertension: Defined as blood pressure exceeding 140/90 mm Hg. Hypertension may impact the admitting problem of shortness of breath because her body is not receiving the amount of oxygen through the blood that it should, resulting in her lungs not receiving enough blood to work properly.

Marks, Jay W. "High Blood Pressure (Hypertension) Signs, Symptoms, Causes, Treatment - MedicineNet." MedicineNet. N.p., n.d. Web. 22 Oct. 2012. <http://www.medicinenet.com/high_blood_pressure/article.htm>.

Hypothyroidism: A condition in which there is not enough thyroid hormone being produced by the thyroid gland. Hypothyroidism could impact the admitting problem of there being “too much fluid in her body” because hypothyroidism can cause swelling of the arms and legs.

Board, A.D.A.M. Editorial. Hypothyroidism. U.S. National Library of Medicine, 18 Nov. 0000. Web. 22 Oct. 2012. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001393/>.

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Chronic renal insufficiency: The main function of the kidneys is to remove wastes and excess water from the body. Chronic renal insufficiency is defined as the slow loss of kidney function over time. This particular Co-morbidity could relate to the edema in her lower extremities.

Board, A.D.A.M. Editorial. Chronic Kidney Disease. U.S. National Library of Medicine, 18 Nov. 0000. Web. 22 Oct. 2012. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001503/>.

Iron deficiency: Iron deficiency is defined as a condition resulting from a deficiency of iron inside the body. It Is the most common nutritional deficiency and the leading cause of anemia in the United States. The patient’s iron deficiency does not yield a correlation with her admitting problem.

"Iron and Iron Deficiency." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 23 Feb. 2011. Web. 22 Oct. 2012. <http://www.cdc.gov/nutrition/everyone/basics/vitamins/iron.html>.

Anemia: Anemia is defined as a condition in which the body does not contain enough healthy red blood cells. The purpose of red blood cells is to provide oxygen to body tissues.

Board, A.D.A.M. Editorial. Anemia. U.S. National Library of Medicine, 18 Nov. 0000. Web. 22 Oct. 2012. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001586/>.

Morbid obesity: Patients are considered morbidly obese if they are 50-100% (100 pounds above) their ideal body weight. A body mass index value greater than 39 may also be used to diagnose morbid obesity. The patient’s size most likely has a direct correlation with her shortness of breath and hypertension. Morbidly obese patients have more weight bearing down on their airway making it harder for them to breathe.

A.D.A.M., Inc. "Health Guide." Morbid Obesity. N.p., n.d. Web. 22 Oct. 2012. <http://health.nytimes.com/health/guides/symptoms/morbid-obesity/overview.html>.

OTHER (past surgeries, illnesses, etc):Left Knee Surgery in 2010. Her recent fall hurting her left knee could be a major potential problem because of her previous surgery to the left knee, and she hurt her right knee. This injury, included with the size of the patient, leaves her almost completely immobile.

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PATHOPHYSIOLOGY R/T ADMITTING/PRIMARY DISEASE PROCESS[S] (Description of Pathophysiology and typical symptoms of the disease process of the admitting diagnoses. EXPLAIN the symptoms the client is exhibiting):

The patient’s medical diagnosis is lower leg edema. Edema is defined as swelling that is a result of the accumulation of fluid. Edema can be classified as either generalized or localized. I believe the client has dependent edema. It is defined as fluid accumulation in gravity dependent areas of the body causing major edema. The places it appears most frequently is in the feet and legs when the person is standing and in the sacral and buttocks when supine. Edema is defined as ”pitting” edema if a small are large pit is left in the skin after pressure is applied on a certain area. Symptoms associated with edema would include: excessive weight gain, swelling, puffiness, clothes fitting tighter than they used to, and affected joints usually tend to have limited movement. A result of the fluid accumulation would be a greater distance for nutrients and waste products to move between tissues and capillaries. Blood flow can possibly be impaired from severe edema, leading to more problems that are more difficult tot fix. When there is excessive fluid in the body, such as in edema, wounds take more time to heal and return to their normal state. If edema is prolonged, pressure sores and a risk of infection need to be observed for. These symptoms appear to increase with edema lasting longer than desired. The nurse needs to monitor intake and output for patients with edema because dehydration can result from the fluid accumlation and the medications used to treat the edema.

McCance, Huether and (122011). Understanding Pathophysiology [5] (VitalSource Bookshelf), Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07891-7/id/B9780323078917100045_s0045

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PHYSICIAL ASSESSMENT [Standard I, Nurse collects health data ]

ALLERGIES: Milk and Niacin.

Admission Weight: _155.3 kg (337.31 lbs) kg/lbs Daily Weight: __155.3 kg (337.31 lbs) _kg/lbs:

NEUROLOGICAL:GCSEyes Open Best Verbal Response Best Motor Response4 Spontaneous_______ 5 Orientation _______ 6 Spontaneous_______3 To Speech _______ 4 Confused _______ 5 Localizes Pain______2 To Pain _______ 3 Inappropriate_______ 4 Withdraws _______

1 None _______ 2 Incomprehensible___ 3 Flexion1 None _______ 2 Extension _______

1 None _______SCORE: ______ (TIME: ________)

LEVEL OF CONSCIOUSNESS: (circle one)

Awake Alert Somnolent Confused Sedated but Arousable Agitated

Oriented X1 X2 X3 Disoriented to ___________________________ Follows Commands: Yes / No

RESTRAINTS: Yes / No Location:_____________________ Protective Reflexes: none / cough / gag / blink

PERRL(A): Yes/No Pupil size: L Pupil ____ R Pupil_____

Other Assessment/Information:

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CARDIOVASCULAR

Heart Rate - Radial:______________ Apical:________________

Rhythm:_________________________________

PERFUSION:

R - UE Warm/Cool/Cold Dry/Clammy/Diaph Pink/Pale/Cyanotic/Mottled Cap Refill _____sec edema +_____

L - UE Warm/Cool/Cold Dry/Clammy/Diaph Pink/Pale/Cyanotic/Mottled Cap Refill _____sec edema + _____

R - LE Warm/Cool/Cold Dry/Clammy/Diaph Pink/Pale/Cyanotic/Mottled Cap Refill _____sec edema + _____

L - LE Warm/Cool/Cold Dry/Clammy/Diaph Pink/Pale/Cyanotic/Mottled Cap Refill _____sec edema + _____

PULSES: (Rate force 0-4+)

Radial R_______ L________

Carotid R_______ L________

Pedal R_______ L________

Bruit ( + / -) R_______ L________


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RESPIRATORY

Respiratory Rate______________Spontaneous Respirations: None Shallow Deep Unlabored / Labored Symmetrical / AsymmetricalBreath Sounds: RIGHT Clear Bases Decreased Rhonchi Crackles Wheezes LEFT Clear Bases Decreased Rhonchi Crackles Wheezes

Sputum: none / small / moderate/large thin / thick / frothy clear / white / yellow / tan / bloody

SOB: Yes / No SpO2___________% Therapy Driven Protocol (TDP): Yes / No

Suction needed: Yes / No Frequency _______________ By Student____________ Nurse____________

Type Suction: Yaunker/Catheter Nasal___________ Oral____________ Trach_________

Describe all aspects of Respiratory treatment plan:Oxygen therapy (i.e. Nasal Cannula, face mask; liters per minute, bipap, cpap Fi02, etc)

Small Volume Nebulizer (SVN) therapy:

Metered Dose Inhaler (MDI):

Pulmonary Function testing: Yes____ No _____. Discuss from chart.

Comments/Other Assessment/Information:

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SKIN/TISSUE

Pressure Ulcers:

Ecchymosis:

Dressings/Incisions:

Special Care Bed:

Skin Treatments/Procedures:

Turn Schedule (time, position, assistance required):

Deep Vein Thrombosis (DVT) Prophylaxis:

List All Insertion Sites:(Lines, Drains, Tubes, Catheters)

Lymph nodes:(palpable/non-palpable)Cervical:_________________Axillary:_________________Inguinal:_________________ Other Assessment/Information:

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GASTROINTESTINAL

Abdomen: Soft / Firm Non-distended / Distended Non-tender / TenderBowel Sounds: None / Hypo / Active / Hyper x ________QuadrantsLast BM:____________________ Continent / Incontinent Formed / Diarrhea describe:_______________

Stoma: (type)______________ Stoma Output:____________Ostomy Care: Description_____________________ Date / Time device last changed____________________________

Tube Feeding: Yes / NoType______________________ Intermittent dose /Continuous dose. Delivery with Rate ________________

Gastric Access Device: Yes / No Type:(NG/Peg)_____________ Location:_______________Clamped / Low Sx / Tube Feed Gastric Residual_______mLGastric Aspirate: none / green / brown / bloody / coffee grounds / tube feed / irrigant onlyGI Comments:

MUSCULOSKELETALROM and Muscle Strength: (see Table p. 578 Jarvis Physical Exam and Health Assessment – Use Grade 0-5 scale) R UE: R LE: L UE: L LE:Ambulation / Gait:

Contractures: Changes in Joints: Crepitations:

Foot Drop:Comments/ Other Assessment/Information:

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GENITAL/URINARY

Spontaneous Void : Yes / No Continent / Incontinent

Foley Catheter / Condom Catheter / Suprapubic Catheter / Ostomy

Urine:Straw / Yellow / Amber / Bloody Clear / Cloudy Sediment:__________ Odor:_____________

Comments:

VITAL SIGNS:

Time_____ T ___ P _____ R _______ BP _____ SpO2______ ABG________ Time________





Comments/ Other Assessment/Information:

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PAIN

Rating Scale: 0 – 10 / FACES / FLACC Pain rating:__________________ Pain Goal:________________

Patient able to communicate: Yes/No Pain inferred by nonverbal/alteration in vital signs:

Location / radiation of Pain:

Associated Signs/Symptoms/Behaviors:

Onset/duration: Any aggravating or alleviating factors?

STATED CLIENT NEEDS:

ADDITIONAL AND PERTINENT ASSESSMENT DATA

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LAB DATA/DIAGNOSTIC TEST/PROCEDUREList All Values: Normal and Abnormal. If no lab on chart, list Possible diagnostic tests for this admitting diagnosis/diagnoses

Name of Lab or Diagnostic Test/Procedure

Normal Range Admission or Oldest Set Available

Current/Most Recent Set of

Results

What Pathology/Rationale do

TheseResults Indicate

WBCCount

Pagana (102009). Mosby's Manual of Diagnostic and Laboratory Tests [4] (VitalSource Bookshelf),

Retrieved from http://pageburstls.elsevier.com/books/9780323057479

4.1-11.6 9.6 thou/cm

9.6 thou/cm

The patient’s WBC count falls within normal limits. If her WBC count were to be lower than normal, it could indicate bone marrow failure.

RBC



3.85 – 5.25 3.82 mill/cm 3.82 mill/cm

The patient’s red blood cell count is lower than the normal range. This indicates anemia, a dietary deficiency, and renal disease. All of which apply to my patient.

Hemoglobin



11.3 – 15.7 8.7 gm/dL 8.7 gm/dL

The patient’s Hgb levels are lower than the normal range. Lowered Hgb levels can indicate anemia, dietary deficiency, or renal disease.

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Hematocrit



32.2 – 45.3 31.6 % 31.5 %

The patients hematocrit levels are lower than normal. Decreased level could indicate anemia, dietary deficiency, and renal disease.

Name of Lab or Diagnostic Test/Procedure

Normal Range Admission or Oldest Set Available

Current/Most Recent Set of

Results

What Pathology/Rationale do

TheseResults Indicate

MCV



79-95 80.6 fl 82.5 fl

The patients MCV falls within normal limits of

the scale. Normal values are according to age and gender. When the MCV value is increased, the RBC count is larger.

MCH



26-3322.2 pg 22.8 pg

The patient’s MCH was too low during her first lab test. This indicated that the cell has a deficiency of hemoglobin and is hypochromic.

RDW-CV



11.4-14.6 15.4 16.3

The patients RDW-CV is high for the standard range. This indicates

iron-deficiency anemia and hemolytic anemias.

Platelet CountThe patients platelet

count is within normal range. Strenuous

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150-374 296331 exercise can cause

increased levels of platelets and there are decreased levels seen before menstruation.

NUTRITIONAL STATUS

Diet Type: Cardiac diet. Monitoring I&O regularly. Assist with meals: None / Partial / FullDietary Consult:_____________ Special Considerations for diet: ___________________________Intake %: Breakfast _____________% Lunch __________% Dinner ____________% Snack[s] _____________Weight: [frequency]__________ Weight: Admission 153.3 kg (337.31 lb) Current_____________Bowel Movement: ___________(date of last BM, describe if observed)__________________ Emesis:______________TOTAL INTAKEYOUR SHIFT TOTAL OUTPUT YOUR SHIFT BALANCEPO: Urine: In:Enteral: Emesis:IV’s: BM: Out:Blood: Other:Other:Total In: Total Out: Net:

ADLSPER SELF / ASSISTANCE REQUIRED Sensory appliances: Glasses Hearing Aid Other:Bath/shower: __________ Mobility: Per Self / Minimal Asst. / Max Asst.Dress: ________________ Assistive devices:Oral Care: ____________Hair: _________________ Physical Therapy (PT) Time: ______ Speech Therapy Time: ______Other: ________________ Occupational Therapy (OT) Time: _______ Describe therapies:


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Name of MedicationGeneric/Brand

List IV’s with rate & Location

Time of AdminDose/RouteTherapeutic

Range

ClassificationPharmacologic and

Therapeutic

Purpose for this Patient & Nursing Responsibilities with

Administration of Medication

Common Side Effects

Individualized to this client

Patient Teaching Individualized to this

client

Generic: OlmesartanBrand: Benicar

Time: 0900Dose/Route:40 mg PO.

One dose = 40 mg. 2 capsules.

Func Class: antihypertensive

Chem. Class: angiotension II

receptor, antagonist.

The patient takes in order to control her hypertension. Responsibilities: check BP, pulse q4hr, and electrolytes.

Insomnia, chest pain, Diarrhea,

angioedema, upper respiratory infection.

To notify prescriber of mouth sores, fever,

swelling of hands or feet, irregular heartbeat, or

chest pain. That excessive diarrhea may

lead to fall in BP. To rise slowly upon standing.

Generic: Pantoprazole Brand: Panto, Pantoloc, Protonix, Prontonix.

Time: 060040 mg PO once

a day(1 tablet)

Func Class: proton pump inhibitorChem. Class: benzimidazole

The patient takes to suppress gastric secretions. Assess

bowel sounds q8hr, abdomen for pain, swelling and hepatic

studies. Check electrolyte balances.

Insomnia, diarrhea, angioedema, and

weight gain.

To report severe diarrhea; black tarry stools or abdominal

pains. To continue taking even if feeling better.

Generic: PropranololBrand: Apo-

propranolol, Inderal.

Time: 0900 and 210020 mg PO

Two times a day.

Func Class: antihypertensive,

antianginal, antidysrhythmic.

Chem Class: Beta-Adrenergic blocker

For hypertension. Assess B/P, pulse, respirations during beginning therapy. Notify prescriber if pulse <50 bpm systolic B/P <90 mmHg. I&O daily. Weight daily.

Depression, fatigue, Bradycardia, CHF, pulmonary edema,

dysrhythmias, weight change, facial swelling,

diarrhea.

Do not discontinue abruptly. To take at the

same time every day. To make position changes

slowly to prevent fainting. To avoid OTC

medications.Generic: Ezetimibe

Brand: ZetiaTime: 0900.10 mg PO

daily. 1 tablet.

Func Class: Antilipemic; cholesterol absorption

Inhibits absorption of cholesterol, causes reduced hepatic cholesterol stores.

Assess diet history: fat content,

Fatigue, diarrhea, angioedema.

Compliance is needed. A high-fat diet should be

decreased.

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inhibitor. lipid levels.




Range


Therapeutic



Common Side Effects



client

Generic: AlbuteralBrand: Accuneb

Time: During RT.

3 mL INH every 4 hours per respiratory

therapy.

Adrenergic Beta 2 agonist,

sympathomimetic, bronchodilator.

Reversible airway obstruction, Acute bronchospasm. Asses

respiratory function and evidence of allergic reaction.

Insomnia, dysrhythmias,

dyspnea.

Review package insert with patients to make

sure they know how to use it correctly. Limit

caffeine products. Wash inhaler in warm water

daily.Generic: Ferrous

sulfateBrand: Ferrlecit

IV INF 10 ml/100 ml of NaCl for inj given over 1 hour. Left arm.

Time: 0900125 mg IV QD

HematinicIron Preparation

Iron deficiency anemia. Assess blood studies: Hct, Hgb,

reticulocytes, bilirubin before treatment. Toxicity: nausea,

vomit, diarrhea. Monitor nutrition and elimination.

Hypersensitivity reactions,

constipation, black and red tarry stools.

The iron will turn stools black or dark green.

Avoid reclining position for 25-30 minutes after taking product to avoid

esophageal corrosion. To follow a diet high in iron.

Generic: Hydrocodone

Brand: Hycodan, Tussigon

Time: When needed for

pain.2.5-10 mg

every 6 hours. PO.

Antitussive opioid analgesic/nonopiod

analgesic.

Mild to moderate pain reducer. Assess pain intensity, type,

location one hour before giving product. CNS changes, B/P, pulse, respirations, and

bowel status.

Circulatory depression, respiratory depression, pulmonary edema, dizzyness.

Report any symptoms of CNS changes, allergic

reactions. Physical dependency may result. Change positions slowly

in order to avoid orthostatic hypotension.

Generic: Time: 0700 Thyroid hormone

Hypothyrodism.Assess B/P, pulse periodically during treatment. Weigh daily

Insomnia, tachycardia, cardiac

That product is not to be taken to reduce weight.

To avoid OTC

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Levothyroxine.Brand: Levothroid

125 mg PO once a day. 1

tablet.

Levoismer of thyroxine.

in same clothing, using same scale at same time of the day.

Cardiac status: chest pain, angina.

arrest, dysrhythmias, and

hypertension.

medications. TO avoid iodine-rich food. This product is not the cure

but it controls the symptoms.




Range


Therapeutic



Common Side Effects



client

Generic: Loperamide Brand: Apo-loperamide.

Time: 0900, 1300, 1800,

2100.2 mg PO 4x a day. 1 capsule.

Antidiarrheal

Piperidine derivative.

Uses: Diarrhea.Assess stools: volume, color,

characteristics, frequency. Electrolytes, skin turgor, and

abdominal distension.

Angioedema, hyperglycemia, dry mouth, constipation.

To avoid OTC medications. To use hard candy, sips of water for

dry mouth.

Generic:LorazepamBrand: Apo-Lorazepam

Time: 21002 mg PO every

night at bedtime. 2

tablets.

Sedative. Hypnotic,

antianxiety.Benzodiazepine,

short acting.

Sleep aid. Assess anxiety: decrease, mental status. Renal/hepatic blood status. Physical dependency. Assist with ambulation.

Dizziness, depression, insomnia, orthostatic

hypotension, hypotension,

diarrhea, tachycardia.

The product may be taken with food. To not

use product for everyday stress. Avoid OTC

medications. To rise slowly when standing.

To not discontinue abruptly.

Generic: MeclizineBrand: Antivert

Time: 0900, 1300, 1800, and 2100.

25 mg PO 4x a day. 2 tablets

Antiemetic, antihistamine,

anticholinergic.H1 receptor antagonist, piperazine derivative.

Vertigo (dizziness).Assess vertigo/motion

sickness: nausea, vomit after 1 hour. Observe for dizziness or

drowsiness. Check level of consciousness.

Drowsiness, fatigue, hypotension, dry mouth, urinary

retention, restlessness.

A false negative may occur with skin testing

for allergies. Avoid hazardous activities, alcohol, and other

depressants.

Generic: Atorvastatin Time: 0900.10 mg

AntilipidemicHMG-CoA

Prevention of CV disease by reduction of heart risk in those

Constipation diarrhea

Blood work and eye exam will be necessary

during treatment. Report

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PO daily(1 tablet)

reductase inhibitor. with mildly elevated cholesterol. Assess for

hypercholesterolemia: diet, obtain diet history. Hepatic studies, renal studies, bowel

status.

blurred vision, GI distress, headache, muscle pain, and weakness. Low

cholesterol diet, exercise program. Stay out of the

sun.*All Drug resources were used from Skidmore-Roth, L. (2012). Mosby’s 2013 nursing drug guide reference. (26th Edition ed.). St. Louis, MI: Elsevier.

TWO COMMUNICATION TECHNIQUES used to interact with this patient: (cannot use verbal/nonverbal) Describe how used & Result

1.

2.

PSYCHOSOCIAL STATUS: (circle one)

Euthymic Depressed Anxious Dementia Other

TOBACCO: Never Used / Yes - Used in Past / Yes-Currently

IF YES - Amount:________ ppd # of Years:_________

Smoking cessation information: needed_______ given______ already on a program_____List type of information given__________________________

Currently using: Patch______ Gum_______ Other_______

ETOH: Never Uses / 3-4 x year / 3-4 x month / 1-2 week/ Daily

If daily, how much___________________________

Social Services Consult:_______________________________

Spiritual Consult:____________________________________

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DEVELOPMENTAL STAGE according to Erickson: Indicate what developmental stage your client should be in according to Erickson; then state what developmental stage you believe your client is in. Support your conclusion based on your assessment data (do not forget to cite your source!): My client should be in the Ego Integrity vs. Despair developmental stage. Erikson has this stage for adults that are 65 and older. He believed that older adults need to feel a sense of fulfillment in their lives when they look back. Wisdom should be felt, but regret, bitterness, and despair can be felt if the adult does not feel successful. My client was not in the Ego vs. Despair developmental stage, which is appropriate for her age group. I feel as if she fit into the Generativity vs. Stagnation category. This category is for patients in the age group of 40 to 65 years. They need to feel as if they are making the world a better place, and if they fail to do so, they have shallow involvement in the world. I believe that my patient does not feel successful in her life, part of which might be from not having children. Children can help older adults feel accomplished through their kid’s actions and upbringing. My client was negative about life, and her health status, but was not ready to leave this world. She was not at peace with dying, but at the same time, her daily life consists of sitting in a bed or in a wheelchair because she is immobile and cannot perform ADLs by herself because of her condition and her body weight.

Cherry, K. (2010, August). About.com. Retrieved from http://psychology.about.com/library/bl_psychosocial_summary.htm

LIST ALL NURSING DIAGNOSIS (BY NAME ONLY) PERTINENT TO THE CLIENT (Choose 2 priority nursing diagnoses to write in complete form – Nursing Diagnoses statement, outcome statement (label); interventions, and evaluation):

Acute painExcessive fluid volumeActivity IntoleranceImbalanced Nutrition: more than body requirementsIneffective airway clearanceIneffective health maintenanceRisk for impaired skin integrityImpaired tissue integrityRisk for imbalanced fluid volumeRisk for infectionIneffective breathing patternImpaired physical mobilityImpaired bed mobilitySedentary Lifestyle

Citation for Nursing Diagnosis: Ackley, B. (2011). Nursing diagnosis handbook. (9th Edition ed.). St. Louis, MI: Elsevier.19

Nursing Diagnoses Care Plan Form Citation for Nursing Diagnosis: Ackley, B. (2011). Nursing diagnosis handbook. (9th Edition ed.). St. Louis, MI: Elsevier.ABNORMAL ASSESSMENT DATA TO SUPPORT DIAGNOSES

NURSING DIAGNOSES STATEMENT (DX R/T AEB)

OUTCOME(Must be SMART*)

INTERVENTIONS WITH RATIONALES HOW INTERVENTIONS WERE IMPLEMENTED

EVALUATION OF OUTCOME (MET/NOT MET/PARTIALLY MET) Full narrative to support your evaluation.

Excessive losses through normal routes (diarrhea), extremes of weight (morbidly obese), Hypertension,knowledge deficiency, pitting edema.

Excessive Fluid Volume r/t bilateral lower leg edema aeb pitting edema, excessive diarrhea, morbid obesity, hypertension, and a knowledge deficiency of nutrition.

Have client verbalize three foods that she can eat that have low sodium content by the end of my shift.

1. Generally teach client about nutrition early in the shift. Specifically, which foods are high in sodium. Also, explain different foods that would be beneficial to the client. This is important because patient demonstrated lack of knowledge of foods containing sodium earlier in my shift.

2. Explain to patient why it is crucial to her health that she remains on the low sodium and low fluid diet after she is discharged. Explain edema and how what she is eating is directly affecting the amount of fluid that is retained in her body. This is in order to give the patient more information on her condition in order to explain why it is crucial that she follows directions.

3. Monitor vital signs. This is done to make sure that her heart doesn’t fail from her condition. In order to be discharged to home care, she had to be stable.

I taught my client about the specific I foods to eat on a low sodium and fluid diet with the help of her primary nurse, Shannon at 1800.

I explained to my client the importance of her restricted diet when she was discharged to go home. I taught her about edema along with her primary nurse, Shannon at 1800 during my shift.

I measured vital signs 5 times during my shift and did not notice any major changes in heart rate.

The outcome was met. My client verbalized three foods that she could eat when I specifically asked her before I went to post conference. I had her explain why it is important to stay on your diet and she was able to give me a full summary of how to remove some of the edema by changing her eating habits. I checked her vitals one last time before I left the room and she was stable and her heart rate had not gone down significantly. My patient was discharged about the same time that I left post- conference.

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Nursing Diagnoses Care Plan FormCitation for Nursing Diagnosis: Ackley, B. (2011). Nursing diagnosis handbook. (9th Edition ed.). St. Louis, MI: Elsevier.ABNORMAL ASSESSMENT DATA TO SUPPORT NURSING DIAGNOSES

NURSING DIAGNOSES STATEMENT (DX R/T AEB)

OUTCOME(Must be SMART*)

INTERVENTIONS WITH RATIONALES

HOW INTERVENTIONS WERE IMPLEMENTED

EVALUATION OF OUTCOME (MET/NOT MET/PARTIALLY MET) Full narrative to support your evaluation.

Shortness of breath, pain: knees, toes, head, left arm, and chest. Irritable, uncomfortable, wounds to her lower extremities.

Acute pain r/t injury agents aeb shortness of breath, pain sensation coming from her knees, left arm, feet, chest, toe, and head, and wounds to her lower extremities.

Client will use a self report tool to identity current pain level and establish a comfort-function goal by the end of my shift at the hospital.

Assess pain level in client by using the 0-10 pain scale. This scale helps the nurse know how to help teach or manage the pain the patient is feeling.

Apply Warm and Cool packs to the places on her skin that need immediate comfort. The reason for this is that the heat promotes in the increase of blood to the area, while the cool pads decrease the flow.

Place call light close to the patient’s hand so she can call easily if she needs me to inform the primary nurse of a need for immediate pain medication. The reason for this was, in order to meet the comfort-function goal, the patient needed the pain medication as quickly as possible.

I assessed the patient for pain every time that I walked into the room after my first visit with her. She reported a 9 out of 10 at first, and wanted to achieve at least a 7 or below.

I applied warm and cool packs to my client’s arm where she was having pain two times during my shift.

The patient pressed her call light at 1545 requesting me to ask Shannon, her primary nurse, for her pain medication that she was able to take “as needed.”

The outcome was met. Throughout my shift, the patient was able to use the pain scale and inform me what I needed to do in order to establish a comfort-function goal. By the end of my shift, my patient was at a 6 in pain. This means that I met the goal that she desired earlier in the shift. Through my implementations: checking the pain scale, applying cold/warm packs, and notifying the primary nurse of a need for medications, I was able to meet the outcome that I set for my patient on 8-23-12.

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Grading Criteria – Clinical Plan of Care

Nursing Process l – Fall 2011 Please include a grading criteria sheet with your care plan. Thank you. Section of Care Plan Possible Points Earned Points Comments ----------------Demographic/H & PCompleted

2

Physical AssessmentCompleted

9

Lab/DiagnosticsCompleted

2

Nutrition/ADLs 2

PathophysiologyCompleted

5

Medications/IV FluidsCompleted

5

Communication/Psychosocial Development Completed

2

Nursing DiagnosesCompleted

6

Outcomes Completed 5

Planned Interventions Completed 5

Implementation Documented and Completed

5

Evaluation of Outcomes Completed 2

Total Points Possible 50 Must achieve a minimum score of 37.5 to pass. All sections must be completed and inclusive of the 12 essential components or a zero will be given . Check your syllabus for specific times clinical paperwork is due to your instructor.

GRADED BY:

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Documents

shelbycrow.yolasite.comshelbycrow.yolasite.com/resources/Care Plan.docx · Web viewTransfer to PCU with telemetry and standing dysrhythmia alarm. Check vital signs every 4 hours minimum