Care plan 3

NURSING PROGRAM

Patient Profile

Student Name: Date:

Patient Identification Data

Gender: Age: 60 Race: White Admission Date: 03/12/2011

Drug Allergies: NKDA Resuscitation Status: Full Code

Physiological and Psychosocial Health History (include surgical history and cite year of occurrence):a.) Health history: Liver disease, fatty liver, pancreatitis, hypertension, chronic alcoholism, tobacco abuse, acute renal failure, ascites,

thrombocytopenia, encephalopathy, CVA (stroke)

b.) Surgical history: None

c.) Psychosocial history: Seperated from wife and lives alone. Drinks several glasses of bourbon a day. A pack and a half of cigarettes a day. Lives in a one story home.

Present Illness (briefly describes in a paragraph the patient’s current circumstances with the course of events, including hospitalization if applicable and home medication regimen): Admitted to hospital with c/o abdominal pain onset 4 days prior to admin. Associated symptoms nausea, vomiting, and decreased PO intake. Decreased function following probable subacute infarction and deconditioning from alcohol abuse. DX with pancreatitis, volume depletion acute renal failure, metabolic acidosis. Is in for rehabilitation; estimated stay 14 days.

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Developmental Considerations (expected versus observed):

a.) Expected: Integrity VS. Despair: Can look back on life and have a sense of meaning and purpose to it. Has lived life to the fullest and was able to do all the things they wanted to in life. Despair occurs when the person wishes for second chances because they were unable to do the things they wanted to in life. These people cannot face death.

b.) Observed: Pt states, “I would do a lot of things differently if I had the chance, but this is what I got so I’ll learn to live with it.” Describes retirement as, “not all they say it is” and when asked what he does at home he replied, “just watch t.v.” and that he is “bored and lonely sometimes”. All of these statements show despair. He enjoys his grandchildren when they come to visit; which shows integrity.

MEDICATIONSROUTINE MEDS (including IV meds and solutions)

Medication

(generic and trade names)

Ordered Dosage/Route & Frequency

Why is your patient taking this medication?

What side effects/adverse reactions will you be on

alert for?

What are the most important nursing considerations for the

patient receiving this medication?

Trade name: Norvasc

Generic name: Amlodipine

Classification: Antinanginal, calcium channel blocker, antihypertensive

Ordered dosage: 5mgRoute: Frequency: DailyTimes to be administered: 0900

Is the ordered dose within the recommended range? Yes

Indications: Chronic stable angina pectoris, hypertension

Action: Inhibits calcium ion influx across cell membrane during cardiac depolarization; produces relaxation of coronary vascular smooth muscle and peripheral vascular smooth muscle; dilates coronary vascular arteries; increases myocardial oxygen delivery in patients with vasospastic angina.

Anxiety, dizziness, fatigue, headache, lethargy, light-headedness, paresthesia, somnolence, syncope, tremor,Arrhythmias,hypotension, palpitations, peripheral edema,Dry mouth, pharyngitis,Hot flashes, Abdominal cramps, abdominal pain, constipation, diarrhea, esophagitis, indigestion, nausea, Decreased libido, impotence, urinary frequency, Myalgia,Dyspnea, Dermatitis,

Tell patient to immediately notify prescriber of dizziness, arm or leg swelling, difficulty breathing, hives, or rash.

Suggest taking amlodipine with food to reduce GI upset.

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flushing, rash,Weight loss

Trade name: Tenormin

Generic name: Atenolol

Classification: Antihypertensive

Ordered dosage: 25mgRoute: Frequency: BIDTimes to be administered: 0900 and 2100


Indications: Hypertension

Action: Competitively blocks stimulation of B-adrenergic receptor within vascular smooth muscle; produces negative chronotropic activity (decreases rate of SA node discharge, increases recovery time), slows conduction of AV node, decreases heart rate, negative inotropic activity, decreases O2 consumption in myocardium; also decreases rennin-aldosterone-angiotensin system at high doses, inhibits B2-receptors in bronchial system at higher doses.

Depression,disorientation, dizziness, drowsiness, emotional lability, fatigue, fever lethargy, light-headedness, short-term memory loss, vertigo, Arrhythmias, including bradycardia and heart block; cardiogenic shock; cold arms and legs; heart failure; mesenteric artery thrombosis; mitral insufficiency; myocardial reinfarction; orthostatic hypotension; Raynaud's phenomenon, Dry eyes, laryngospasm, pharyngitis, Diarrhea, ischemic colitis, nauseaRenal failure, Leg pain,Bronchospasm, dyspnea, pulmonary emboli, respiratory distress, wheezing, Erythematous rash, Allergic reaction

If patient also receives clonidine, expect to discontinue atenolol several days before gradually withdrawing clonidine. Then expect to restart atenolol therapy several days after clonidine has been discontinued.

Stop atenolol therapy and notify prescriber if patient develops bradycardia, hypotension, or other serious adverse reaction.

Inform the patient that he may experience fatigue and reduced tolerance to exercise and that he should notify his prescriber if this interferes with his normal lifestyle.

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Trade name: Wellbutrin

Generic name: Bupropion

Classification: Antidepressant—miscellaneous, smoking deterrent



Indications: Depression and smoking cessation

Action: Inhibits reuptake of dopamine

Headache, agitation, confusion, seizures, insomnia, sedation, tremors, suicidal ideation, dysrhythmias, hypertension, tachycardia, blurred vision, auditory disturbance, nausea, vomiting, dry mouth, constipation, rash, sweating, weight loss or gain.

Assess smoking cessation progress after 7-12 wk, if progress has not been made, product should be discontinued. Monitor CBC, differential, check weight weekly. Assess mental status. Monitor urinary retention and constipation. HOLD DOSE IF ALCOHOL IS CONSUMED.

MEDICATIONS Cont…

Trade name: Nexium

Generic name: Esomeprazole

Classification: Anti-ulcer, proton pump inhibitor


Is the ordered dose within the recommended range?Yes

Indications: GERD

Action: Suppresses gastric secretion by inhibiting hydrogen/potassium ATPase enzyme system in the gastric parietal cell; characterized as gastric acid pump inhibitor, since it blocks final step of acid production.

Headache, dizziness, diarrhea, flatulence, hepatic failure, hepatitis, rash, heart failure, pneumonia

Assess bowel sounds q 8 hr, abdomen for pain, swelling, anorexia. Assess hepatic enzymes: AST, ALT, alkaline phosphatase during treatment. Swallow caps whole; do not break, crush, or chew. Administer at least 1 hr before eating. Instruct patient to report severe diarrhea and to avoid alcohol.

Trade name: Hydroxyzine

Generic name: Hydroxyzine

Ordered dosage: 50mgRoute: Frequency: Daily; H.S.Times to be administered: 2100

Indications: Anxiety; prevention of alcohol product withdrawal

Action: Depresses subcortical levels of CNS,

Dizziness, drowsiness, confusion, fatigue, seizures, hypotension, dry mouth, nausea, diarrhea, weight gain

Assess mental status, respiratory status and cough characteristics. Monitor I&O ration. Observe for drowsiness and dizziness. Avoid alcohol.

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Classification: Antianxiety, sedative, hypnotic, antihistamine, antiemetic


including limbic system, reticular formation; anticholinergic, antiemetic, antihistaminic responses; competes with H1-receptor sites.

Trade name: Lactulose PSE

Generic name: Lactulose

Classification: Laxative

Ordered dosage: 20gRoute: Frequency: BIDTimes to be administered: 0900 and 2100


Indications: Lowers blood ammonia level

Action: Increases osmotic pressure; draws fluid into colon; prevents absorption of ammonia in colon; increases water in stool.

Nausea, vomiting, anorexia, abdominal cramps, diarrhea, flatulence, distention, belching, hypernatremia

Monitor glucose levels, blood, urine, electrolytes if used often by patient. Assess cramping, rectal bleeding, nausea, and vomiting. Monitor blood ammonia level. Give with a full glass of fruit juice, water, or milk. Increase fluids by 2 L/day.

Trade name: Thiamine HCl

Generic name: Thiamine

Classification: Vitamin B1

Ordered dosage: 100mgRoute: Frequency: BIDTimes to be administered: 0900 and 2100


Indications: Alcoholism

Action: Needed for pyruvate metabolism, carbohydrate metabolism

Weakness, restlessness, collapse, pulmonary edema, hypotension, tightness of throat, nausea, diarrhea, cyanosis, sweating, warmth, anaphylaxis

Assess nutritional status: yeast, beef, liver, whole or enriched grains, legumes—these are necessary in the diet.

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PRN MEDS

Medication(generic and trade names)

Ordered Dosage/Route & Frequency

Why is your patient taking this medication?

What side effects/adverse reactions will you be on

alert for?

What are the most important nursing considerations for the

patient receiving this medication?

Trade name: Maalox Plus

Generic name:

Classification:

Ordered dosage: 30mlRoute: Frequency: q 6 hoursTimes to be administered: PRN

Is the ordered dose within the recommended range?

Indications: Indigestion, suspension; antacid

Action:

Trade name: Tylenol

Generic name: Acetaminophen

Classification: Nonopioid analgesic

Ordered dosage: 650mg (2 325mg tabs)Route: Frequency: q 6 hoursTimes to be administered: PRN


Indications: Pain and increased temp > 100

Action: May block pain impulses peripherally that occur in response to inhibition of prostaglandin synthesis; does not possess anti-inflammatory properties; antipyretic action results from inhibition of prostaglandins in the CNS.

Drowsiness, nausea, vomiting, abdominal pain, hepatotoxicity, hepatic seizure, GI bleeding, renal failure, leukopenia, neutropenia, hemolytic anemia, thrombocytopenia, pancytopenia, hypersensitivity, cyanosis, anemia, neutropenia, jaundice, seizures, coma, death

Monitor liver function studies: AST, ALT, bilirubin, creatinine. Monitor renal function studies: BUN, urine, creatinine, occult blood; albumin indicates nephritis. Monitor blood studies: CBC, pro-time. Check I&Os. Assess for fever and pain. Assess for chronic poisoning: rapid, weak pulse; dyspnea; cold, clammy extremities

Trade name: Clonidine Ordered dosage: 0.1mg Indications: Hypertension Drowsiness, sedation, Assess pain. Perform blood

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HCl

Generic name: Clonidine

Classification: Antihypertensive, centrally acting analgesic

Route: Frequency: q 6 hoursTimes to be administered: PRN


> 160

Action: Inhibits sympathetic vasomotor center in CNS, which reduces impulses in sympathetic nervous system; B/P, pulse rate, cardiac output decreased; prevents pain signal transmission in CNS by a-adrenergic receptor stimulation of the spinal cord.

headache, fatigue, nightmares, insomnia, anxiety, depression, delirium, orthostatic hypotension, palpitations, hyperglycemia, nausea, vomiting, malaise, constipation, dry mouth, impotence, nocturia, rash, edema, withdrawal symptoms, musecle, joint pain, leg cramps

studies: neutrophils, decreased platelets. Perform renal studies:protein, BUN, creatinine. Monitor baselines for renal/liver function before TX begins. Monitor B/P and pulse. Assess for edema, allergic reactions, and symptoms of CHF.

Trade name: Lorazepam

Generic name: Lorazepam

Classification: Sedative/hypnotic, antianxiety agent

Ordered dosage: 1mgRoute: Frequency: q 3 hours Times to be administered: PRN


Indications: Hypertension (14 days) SBP > 140, DBP > 100, HR > 110

Action: Potentiates the actions of GABA, an inhibitory neurotransmitter, especially in the limbic system and reticular formation, which depresses the CNS.

Dizziness, drowsiness, confusion, headache, anxiety, tremors, stimulation, fatigue, insomnia, weakness, orthostatic hypotension, ECG changes, tachycardia, apnea, cardiac arrest, blurred vision, constipation, dry mouth, nausea, vomiting, diarrhea, rash, acidosis

Assess degree of anxiety, alcohol withdrawal symptoms, and mental status. Monitor B/P, pulse, and respiratory rate. Monitor CBC during long-term therapy. Monitor for seizure control.

POTENTIAL DRUG/DRUG OR DRUG/FOOD INTERACTIONS (significant to this patient):

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Lorazepam - Alcohol: increased CNS depressionTylenol –Alcohol: increased hepatotoxicity and decreased effect

Norvasc – Alcohol and antihypertensives: increased hypotension

Wellbutrin- Alcohol: increased risk of seizures

Clonidine-Alcohol: increased CNS depression

Hydroxyzine- Alcohol: increased CNS depression

Lorazepam- Alcohol: increased CNS depression

LABORATORY/DIAGNOSTIC TESTING

Laboratory/Diagnostic Tests

Date: Date: Date: Implications (for this patient) Normal Values

HCT 31.8

HGB 11.2

WBC 7.53

PLTS 307

NA+ 137 137

K+ 4.5 3.2L

Cl 105 110

CO2 22 21

BUN 17 19

Creatine 1.06 1.14

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TBILI 5.5

Anion Gap 6 L

Ca 8.9

Bun/creat 16.7

Bili 1.7 H

Tot Pro 6.3

Albumin 3.3

A/G Rat 1.1

Alk Phos 128 H

SGOT 69 H

SGPT 52

ClCrCalc 62

MDRD GFR 64

Osmo 275.8

Other laboratory/diagnostic data significant to your patient

Laboratory/Diagnostic Date: Date: Date: Implications Normal Values

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Tests 03/21/2011 03/12/2011 (for this patient)

MRI Probable subacute infarction in central pons, 5-7 days old

Chest X-ray Normal

Transthoracis echocardiography

Mild diastolic dysfunction in L ventricle; mildly calcified annulus in mitral valve; no R-L atrial level shunt in atrial septum; no pericardial effusion, thrombus, mass, or vegetation found in pericardium, extracardiac.

COLLABORATIVE TREATMENTS

Treatment Responsible Staff Time Administered

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Diet: Regular

Dietitian Consult

RN, LPN, UAP

Dietician

Meal time

Q 5 days

Oxygen: Room air

Intake and output RN, LPN, UAP TID, PRN

Vitals RN, LPN, UAP Q 4 hours, PRN

Carb count RN, LPN, UAP PRN

Activity orders RN, LPN, UAP PRN, q 8 hours

Hygeine RN, LPN, UAP PRN, q AM and PM

Safety check RN, LPN, UAP PRN, q 2 hours

Weight RN, LPN, UAP On admin and bi-weekly

Ted hose RN, LPN, UAP On AM and off H.S.

Laxative of choice RN, LPN PRN

Fall precautions RN, LPN, UAP Q 4 hours

PT RN, Physical therapist, PTA Daily

OT RN, Occupational therapist, OTA Daily

Speech therapy RN, Speech therapist Daily

Axis I-V (for Psychiatric patients only):

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NURSING ASSESSMENT DATA

OXYGENATION CIRCULATIONFLUIDS AND

ELECTROLYTES NUTRITION BOWEL ELIMINATION

Medications:

Diagnostic Testing:

Treatments:

Assessment Data:Subjective: Pt reports no recent cough. Smoking HX of a pack and a half a day for 40 years. States, “I quit two weeks ago when I came in here, and I don’t plan to start back up when I leave.”

Objective: Respirations unlabored at normal rate of 18 breaths per minute. Breath sounds are clear and present in all lung fields. Secretions are clear and minimal. Pulse oximetry is 98% on room air. Chest contours, excursion, and expansion are equilateral. Skin and nail beds are pink.

Medications:

Diagnostic Testing:

Treatments:

Assessment Data: WNLSubjective:

Objective: Apical heart rate 66 bpm. Pulse ox 98%. Capillary refill returned in less than two seconds. Nail bed and mucous membranes pink. Peripheral pulses +2, palpable all extremities and equilateral. No edema, calf tenderness, or jugular vein distention. Extremities warm to touch. B/P taken in L arm 111/71.

Medications: Norvasc, Tenormin daily. Clonidine HCl, Lorazepam PRN.

Diagnostic Testing:

Treatments:

Assessment Data:Subjective: Pt reports no sudden weight loss or gain.

Objective: Mucous membranes moist. Skin pink and dry. Vitals WNL. No edema. No jugular vein distention. Skin is elastic without tenting over sternum. Wt: 63.3kg Intake: 1210; Output 650 with a -560 balance. Pt has liver disease, fatty liver, pancreatitis, hypertension, and acute renal failure.

Medications: Thiamin; Nexium daily and Maalox plus PRN

Diagnostic Testing:

Treatments:

Assessment Data:Subjective: Pt states, “I’m not used to eating this many times a day.” And “I get full pretty fast”

Objective: Weight 63.3 kg; Height 167.0cm. BMI: 22.7; within normal limits. Client on regular diet and thin liquids. Only ate 30% of breakfast and lunch. Dentition intact. Hx of GERD.

Medications:

Diagnostic Testing:

Treatments:

Assessment Data:Subjective: Last BM 03/30/2011 in AM. Pt reports he normally has a bowel movement daily. Client says he is mostly continent except when he is unable to make it to the bathroom on time. Wears briefs.

Objective: Abdomen soft, non-distended, non-tender. Bowel sounds normo-active in all four quadrants. Tolerated diet without nausea, vomiting or diarrhea.

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REST AND SLEEP COMFORT ACTIVITY/MOBILITY URINARY ELIMINATION REPRODUCTION

Medications:

Diagnostic Testing:

Treatments:

Assessment Data: WNLSubjective: Bedtime: 1900, awake: 0530. Pt reports daily naps lasting between 30 minutes to 2 hours long. Pt reports feeling rested upon waking. Maintains a sleep cycle adequate to meet personal needs. Pt says that besides occasional nocturia, he does not have night time interruptions.

Objective:

Medications: Tylenol

Diagnostic Testing:

Treatments:

Assessment Data: WNLSubjective: Pt reports absence of any pain or discomfort. Pain scale 1-10; reports a 1.

Objective: He is able to perform ADLs with minimal assistance. Blood pressure, respirations and pulse are WNL.

Medications:

Diagnostic Testing:

Treatments: PT and OT

Assessment Data:Subjective: Pt reports lower extremity weakness.

Objective: Pt’s dominant hand is R. All extremities have full ROM. Absence of joint swelling. Extremities are symmetrical and in alignment. Stands erect, but looks at feet when ambulating b/c a fear of falling due to lower extremity muscle weakness. Pt uses wheelchair; however, is working with PT using a walker. Pt has a veil bed restraint. Alternatives tried were family sitting by the bedside and reorientation of the client. Orders present q 24 hour in chart. Lower extremity muscle weakness impacts abilities to ambulate on own, and his dressing, bathing ADL’s. Works with PT and OT for strengthening.

Medications:

Diagnostic Testing:

Treatments:

Assessment Data:Subjective: Pt reports no pain while urinating. Last void: 03/30/2011 @ 1100. Pt reports nocturia 2 times or more. States, “I cant get there fast enough”

Objective: Output daily: 650. Pt uses urinal at bedside and regular toilet. Urine clear and yellow to amber in color. Wears briefs; mostly at night due to urgency.

Medications:

Diagnostic Testing:

Treatments:

Assessment Data: WNL Assessed genitalia while helping pt with shower.Subjective: Pt says he occasionally performs self-examinations and he goes to his doctor once a year for a routine screening.

Objective: Genitalia unremarkable. No swelling, drainage, or bleeding.

SENSORY SAFETY AND PROTECTION of 24

Environment Physical Legal

Medications:

Diagnostic Testing: MRI- results in lab section.

Treatments: ST

Assessment Data:Subjective: Pt reports no numbness. Pt says he wears glasses but, “they were lost on the way up here”.

Objective: Alert and orientated to person, place, time, and situation. Moves extremities with equal coordination. No parathesia. Verbalization is clear and understandable. Hearing and vision intact. Follows commands. Touch, taste, and smell intact. Does not utilize hearing aides. Pupillary response was quick and even. Pt is being seen by ST for difficulties with problem solving. **Chart indicates AA&O x 2 with moderate confusion; however, I did not find this in my assessment.

Treatments:

Assessment Data:Subjective: MSDS must be obtained by calling someone.

Objective: Pt is on fall management protocol: bed in low position with brake on. Personal belongings are within reach of the client. Call light located on bed. Room is uncluttered with adequate lighting. Armband present. Non-skid shoes are being utilized. Room has hand washing supplies, gloves and sharps containers. The room temperature was comfortable. Fire evacuation plan posted in hallway in front of main nurses station. PPE in stock rooms and pt rooms. Precautions posted on doors

Medications:

Diagnostic Testing:

Treatments:

Assessment Data:Subjective:

Objective: Skin warm, dry and intact. Mucous membranes moist. Pressure areas without redness. Nails clean and intact. Body temperature 98.4 taken orally. No lymph node enlargement. No signs or symptoms of infection present. No impulsive behavior. Veil bed restraint is currently in use, utilized because of nighttime confusion. Alternatives tried were having family sit at the bedside and reorientation of the client.

Assessment Data:Subjective:

Objective: Client is self responsible and takes part in decisions regarding his care. Client is aware of rights and privileges, understands and uses channels of communication. Written plan of care is present indicating client involvement. Client privacy is maintained. No evidence of physical, verbal, emotional or financial abuse. No evidence of neglect. Pt’s resuscitation status: full code.

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SPIRITUAL COPING SEXUALITY BELONGINGSELF CONCEPT/SELF

ESTEEM

Medications:

Diagnostic Testing:

Treatments:

Assessment Data:Subjective: When asked about clients faith he stated, “I do not go to church or anything.”

Objective:

Medications:

Diagnostic Testing:

Treatments:

Assessment Data:Subjective: Pt reports being stressed about monetary situations and if he will go live with his ex wife or not when he is discharged.

Objective: Pt doesn’t show any physical or emotional impact from current stress level of mild. Exhibits adaptive coping behaviors by working with PT, OT, and ST. Also, eating in the dining room with other clients.

Medications:

Diagnostic Testing:

Treatments:

Assessment Data: We did not discuss a lot in sexual behavior.Subjective:

Objective: Gender-role behavior is congruent with self image. Pt is able to form relationships.

Medications:

Diagnostic Testing:

Treatments:

Assessment Data:Subjective: Pt reports having a loving family and has friends. His support system is his ex-wife, one of his good friends. Pt says he is unsure about living arrangements once he leaves but he said he will most likely be living with his ex-wife again and will split the bills.

Objective:

Medications:

Diagnostic Testing:

Treatments:

Assessment Data:Subjective: Client would like to be able to go back to work because he says retirement is boring.

Objective: Chronological age, functional age and developmental stage correlate. Pt recognizes new personal goal such as quitting smoking and possibly drinking.

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Health Promotion and Maintenance / Wellness Needs Plan Development

Instructions/things to think about when completing this section: What else do I need to know? What can I anticipate doing? What other labs or tests might be helpful? What does the client need to know in order to: not get worse or be readmitted; avoid complications; assist in healing; reduce health

risks; improve overall health and wellness, etc. Don’t forget to incorporate culture!

Prioritize1-6 Need Brainstorm All Ideas

2 Developmental Stages and Transitions

Transition from his own home-to hospital- to ex wife’s (stress on her?)

Health Screenings(including immunizations etc.)

Lifestyle Choices(including sexuality, high risk behaviors, etc.)

1 Safety(including environment, mental health, violence, substance or other abuse, freedom from injury or harm in healthcare or any other setting, etc.)

Pt still drinks several glasses of bourbon a day (when not in hospital)

3 Self Care(including nutrition and exercise, etc.)

Pt is receiving adequate nutrition and exercise at the hospital (possible risk of muscle weakness with lack of exercise at home?)

Access and Use of Healthcare

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PATIENT CARE PLAN

Knowledge Base for Choosing Diagnosis (statement and source): Many chronic alcoholics do not consume an adequate diet. Wilkinson V1 pg 419

Effects of chronic alcohol abuse on nutrition: decreased appetite, malabsorption, and vitamin deficiencies especially vitamin B1. Lewis pg 175

NURSING DIAGNOSIS (priority # 1): Imbalanced nutrition: less than body requirements r/t decreased appetite and impaired vitamin absorption secondary to alcohol abuse aeb only eating 30% of meals and Vitamin B1 deficiency.

Assessment Data Expected Outcomes Interventions Rationale (statement & source)Evaluation/ Revisions

Subjective: Pt reports that he gets full easily

Objective: Pt takes vitamin b1 supplement-thiamine

Short Term E.O.: Client will verbalize understanding of causative factors that lead to malnutrition in chronic alcoholism and how to make lifestyle changes accordingly by end of shift 03/30/2011 @ 1300.

Long Term E.O.: Client will display a normalization of laboratory values and be free of signs of malnutrition by time of discharge.

1. Nurse will educate client on the effects alcohol has on appetite. ST (I)

2. Nurse will educate client on the effects alcohol has on absorption of vitamins. ST (I)

3. Nurse will assist client in identifying resources for alcohol cessation and sustained abstinence. ST (I)

4. Nurse will call physician and request a prescription for multivitamin supplements to prevent vitamin deficiencies. LT (C)

5. Nurse will delegate to an UAP to weigh pt daily to assess for weight loss or fluid retention. LT (I)

6.Nurse will assess laboratory data PRN for signs of vitamin deficiencies and malnutrition. LT (I)

1. Chronic alcohol abuse decreases appetite. Wilkinson V1 pg 419

2. Chronic alcohol abuse results in vitamin deficiencies. Lewis pg 175

3. Although cessation of drinking is the short-term goal; sustained abstinence is the primary goal of alcohol dependency. Pts should be referred to and intensive outpatient program for treatment. Lewis pg 176

4. People who use alcohol heavily need multivitamin supplements. Wilkinson V1 pg 620

5. Excessive alcohol use interferes with adequate nutrition by replacing the food in the person’s diet and depressing the appetite. Wilkinson V1 pg 620 To assess for signs of weight loss and malnutrition compare weight to standards and to the clients usual weight. Wilkinson V1 pg 627

1. Met: talked with client in regards to his lack of appetite during lunch.

2.Met: talked with client on need to have thiamine when passing meds.

3. Not met: did not have time or resources

4.Partially met: I did not call the physician but thiamin is already prescribed to client.

5. Not met: cannot delegate

6. Met: checked laboratory results from 03/30/2011

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6.Various laboratory indicators provide information about nutritional status. Wilkinson V1 pg 627

Knowledge Base for Choosing Diagnosis (statement and source):

NURSING DIAGNOSIS (priority # 2):

Assessment Data Expected Outcomes Interventions Rationale (statement & source)Evaluation/ Revisions

Subjective: Client still drinks several glasses of bourbon a day. Client will most likely move in with ex wife for help with ADLS and monetary issues.

Objective: Liver disease, fatty liver, pancreatitis, hypertension, chronic alcoholism, ascites—all clients health HX indicating alcohol abuse

Short Term E.O.: Client will initiate behaviors that prevent further impaired function by end of shift 03/30/2011 @ 1300

Long Term E.O.: Client will utilize volunteer and community resources to assist caregiver while the client lives in her home starting at time of discharge.

1. Nurse will provide information on ways to help stop substance abuse and have client verbalize which ones he feels he would most likely succeed in. ST (I)

2. Nurse will emphasize the importance of exercise to increase muscle strength and avoid deconditioning which will help prevent further impaired functioning. ST (I)

3. Nurse will encourage the client and caregiver to attend counseling/group sessions to help identify problems and to help the client change his lifestyle. ST (I)

4. Nurse will encourage the client to affirm and support the caregiver. ST (I)

5. Nurse will refer client and caregiver to intake coordinator for community services such as; home health, meals, and house cleaning. LT (I)

6. Nurse will facilitate a family conference to share information and develop a plan for involvement in care activities. LT (C)

1. Nurses should help clients identify the steps that they must take to reach goals, and the client will need to make a commitment to follow through on the plan. Wilkinson V1 pg 1051

2.Risk factor for injury: impaired mobility manifesting into impaired strength with accompanying problems in mobility, strength, and endurance. Wilkinson V1 pg 438

3. Counseling and group sessions provide support and promote personal growth. Wilkinson V1 1053

4. Supporting the caregiver’s ability to manage the situation encourages them. Wilkinson V1 pg 220

5. Intake coordinators arrange home services before discharge. Caregiving duties can lead to physical exhaustion, social isolation, resentment, and sadness. Home health relieves some of the burden Wilkinson V1 pg 1075 and 1077

6 .Family is the context for care for an individual person. The family is a resource. Provide teaching to all members. Wilkinson v1 pg 209

1.Partially met: spoke with him in regards to having support from his family and that there are some medications out that could help.

2.Met: taught him several exercises that he could do in bed or in a chair that will strengthen his legs and arms preventing further muscle weakness.

3.Partially met: spoke with client regarding AA

4. Met: talked with client about how he appreciates her.

5.Not met: can’t do

6.Not met: can’t do

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GUIDELINES/CRITERIA FOR WRITTEN CLINICAL ASSIGNMENT: CLIENT PROFILE, HEALTH ASSESSMENT, AND CARE PLAN

CLIENT PROFILE/HEALTH ASSESSMENT1. A patient profile/health assessment is included in narrative form at the beginning of the Clinical Assignment.

This introduces the reader to the patient and should include the following:a. Patient Identification Data: Patient’s age, race, gender, admission date, allergies, and DNR status.

Use of patient identifiers (e.g. person(s), place(s), date(s) of birth, medical or personal ID #’s, etc.) may result in a failing grade for the assignment.

b. Physiological and Psychosocial History to include past health history, surgical history and dates of occurrences. Psychosocial history to include psychological disorders and substance use/abuse issues and support systems.

c. Present Illness (narrative form): brief description in a paragraph the circumstances of the present illness including precipitating events and course of hospitalization.

d. Developmental Comparisons: Expected versus observed.e. Current Medications/Treatments: List medication information including dosage, route, times,

nursing considerations, use, and adverse effects. List medical treatments (ex. specialty mattress, TEDs, dressing changes, ambulation/activity orders, VS, I&O, TCDB, etc.).

f. Laboratory/Diagnostic Test Data: Include pertinent lab and diagnostic tests, dates, results, and normal values, and include significance of results to this patient. Ensure that related nursing considerations are included.

g. Patient Health Assessment: Include information from nursing history, progress notes, patient/family interview, medications, diagnostic testing, and treatments relevant to the particular need. Perform and record the assessment using the needs-based assessment format (see Nursing Assessment Guidelines) and include pertinent information from physician’s physical assessment. Include baseline vital signs, dressings present, activity abilities, assessment of IV, etc.

2. Data to be listed in the assessment column are:a. pertinent/supportive to individual patient problems.b. organized, validated, and complete.c. designated as subjective or objective data (includes verbal and nonverbal communication).

KNOWLEDGE BASE & NURSING DIAGNOSIS The knowledge base is information from at least two current nursing resources sources, which explains how “related to” portion of the nursing diagnosis causes or maintains the patient’s problem and how the assessment data supports the nursing diagnosis. Care planning books may not used as source for knowledge-base. Information must be attained from a primary source (e.g. Wilkinson and Van Leuven).

1. The nursing diagnosis is a statement that describes the human response (health state or actual/potential altered interaction pattern) of an individual/group to life processes.

Remember: An actual nursing diagnosis has been clinically validated by defining characteristics (signs and

symptoms). An actual nursing diagnosis is written with three parts:a. diagnostic category (use current NANDA)b. etiology or contributing factors (the “related to” clause of the diagnostic statement)c. defining characteristics validating the nursing diagnosis (the “AEB” clause of statement)d. DO NOT use medical diagnosis! Should be “fixable” by nurses!

A high risk or risk for nursing diagnosis has validated contributing factors without the presence of defining characteristics; thus a two-part statement is written with the following:a. a diagnostic category.b. contributing factors (risk factors that have influenced the status) ex. High risk for aspiration R/T

reduced level of consciousness.

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EXPECTED OUTCOMES (E.O.)

1. An expected outcome is a statement describing a measurable behavior of patient/family, which denotes a favorable change in status (changed or maintained) after nursing care has been given, and should affect the etiology.

2. Patient E.O.s : a. are derived from problem. Appropriately written outcomes show resolution of or improvement of the

client problem.b. are used to direct interventions to achieve the desired changes or maintenance. Interventions should

address the outcome (e.g. if outcome is “Client will verbalize three methods to prevent skin breakdown,” interventions for this outcome should include client teaching that addresses preventative interventions.

c. are used to measure the effectiveness and validity of the interventions.3. A correctly written patient E.O.:

a. is patient-centered – NOT nurse-centeredb. is patient attainablec. expresses the desired patient behavior that is observable by sight or hearing (this is what the patient

is expected to do, to learn, etc.)d. is measurable (how much? how long? how well? how far?). “Modifiers,” usually adjectives or

adverbs, are used with verbs and serve to explain what, where, when, and how. The condition under which the behavior will occur is also usually given (such as alone, with assistance, with equipment, etc.)

e. includes an achievement time (date – mo/day/yr) when appropriate in acute care settings. Long-term (a week to months) or short-term E.O.s are appropriate in long-term care facilities, rehabilitation units, community health, etc. E.O.s should be designated as short term (ST) or long-term (LT)

f. Measurement of the E.O. achievement can be made easier:i. by using the phrase “as evidenced by” (AEB) to introduce measurable evidence of a

reduction in signs and symptomsii. by adding the expression “within normal limits” (WNL) (defining characteristics of “normal

limits”) as evidenced by (AEB)4. Students are required to have one (1) short-term (ST) and one (1) long-term (LT) E.O. per diagnosis.

INTERVENTIONS & RATIONALEOverall, the care plan will be evaluated for the inclusion of physiological status, psychosocial aspects, developmental tasks, pharmacological interactions, nutrition, and safety.

1. With an actual diagnosis, the intervention should reduce, eliminate, promote, or monitor patient response.2. With a high risk or risk for diagnosis, the intervention should reduce the risks or prevent onset of problem.3. Interventions are individualized to the patient.4. Interventions should be acceptable to the patient.5. Interventions should provide clear instructions for nursing staff.6. Nursing interventions should complement the medical treatment.7. Rationale should be:

a. of appropriate depth for level of student.b. accurate.c. scientifically-based (physiologically or psychologically).d. and reference cited.

8. Interventions and rationale should be of appropriate scope for level of student.

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9. Independent nursing interventions should be labeled (I). Collaborative interventions require a physician’s order and should be labeled (C).

10. The following categories are examples of independent and collaborative interventions:a. Diagnostic (Assessment): Interventions that focus on providing assessment data related to the

problem (e.g., Assess bowel sounds q shift (I) ).b. Therapeutic: Interventions that involve performing specific treatment actions that assist in

preventing, reducing, or resolving the problem (e.g. reposition q 2 hours (I))c. Educative (Teaching/Counseling): Interventions that involve patient/family teaching or counseling

techniques directly related to the problem (e.g. teach patient to perform diabetic foot care (I)).d. Referral (Counseling): Interventions requiring assistance from additional healthcare professionals in

solving the problem (e.g., request a nutritional consultation (C)).11. Students are required to write two (2) to four (4) interventions per EO or six (6) per diagnosis.

Interventions must be in sufficient enough number to assist the patient to meet their expected outcome. (e.g. no less than 2 interventions per one expected outcome but total must be AT LEAST six interventions per diagnosis, and may be more if needed to assist the client to meet outcome!)

EVALUATION 1. Evaluation is reflective of the patient E.O., NOT each intervention.2. Evaluation data are reflective of the measurable and observable patient E.O. criteria with description of

patient progress toward E.O..3. Evaluation data of E.O.s is recorded in one of the following ways:

a. unresolved or ongoing – the diagnosis is still present and the E.O.s and interventions are appropriate.b. revised – the diagnosis is still present, but the E.O.s or nursing interventions require revision. The

revisions or recommendations are recorded.c. resolved – a diagnosis has been resolved and that portion of the care plan is discontinued.

4. The student is required to evaluate each E.O.

GENERAL CONSIDERATIONS 1. Illegible, poorly organized Clinical Assignments will not be accepted.2. Clinical assignments should be typed.3. References should be included. Each course will denote the number and types of references required,

however, a minimum of one of each of the following reference types should be included: pharmacological, laboratory, nutritional, and course-specific texts (e.g., fundamentals, medical/surgical, maternal and child health, pediatrics, mental health). No definitions (medical or standard) may be used as a reference. References are for knowledge base and rationales only. When citing references for knowledge base or rationale using course approved texts (from syllabus), use of the author’s name and page number is sufficient. If using other texts not on the approved course list, then the student must cite reference using full APA referencing format.

4. Written Clinical Assignments are to be turned in using a manila envelope with the students’ name, instructor’s name, and student’s group number on the front of the envelope.

5. NO late or incomplete will be accepted. Papers should be turned in at designated date and time.6. Clinical assignment consists of client profile, health assessment and care plan.

WRITTEN CLINICAL ASSIGNMENT GRADING RUBRIC

The grading rubric will be utilized in each of the Nursing Process courses. However, increased depth and scope of information included in the written clinical assignment will be expected.

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NUR _______ WRITTEN CLINICAL ASSIGNMENT GRADING RUBRIC

Criteria Pass /Fail Criteria Pass /Fail

I. Profile/Assessment Data (Satisfactory assessment data is pre-requisite for grading the rest of the care plan; must be organized, validated and complete)

IV. Interventions #1 #2

Client Profile

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A. Individualized to patient

A. Patient identification and demographic data

B. History complete B. Clear/accurate

C. Developmental considerationsC. Acceptable to patient

D. Pertinent/supportive to individual patient problem

E. Current medications (to include home medications)

D. Comprehensive/complete

F. Current treatments E. Identified as nurse independent (I) or collaborative (C)

G. Lab/Other Diagnostic Testing

Assessment DataIV. Pass/Fail

H. Physical and Psychosocial Assessment: Identified as subjective (S) and objective (O) assessment data (includes verbal & nonverbal communication)

V. Rationales

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interventionI. Organized, validated

II. Nursing Diagnoses (Satisfactory nursing diagnoses are pre-requisite for grading the rest of the care plan.)

#1 #2

B. Are of appropriate depth for level of student

C. Scientifically based with source cited

A. Identifies correct and appropriate priority patient problem(s) V. Pass/Fail

B. Validated by assessment data VI. Evaluation #1 #2

C. Written correctly (e.g. for actual problem the diagnostic statement includes the problem, etiology, signs and symptoms), NANDA diagnosis, prioritized

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A. Reflects expected outcome with description of the patient’s expected outcome

D. Explained through knowledge baseB. Evaluation data supports recommendations

E. Source of knowledge base givenC. Recommendation given (continue, revised, confirmed, resolved, ruled out)

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VI. Pass/Fail

III. Expected Outcomes #1 #2 VII. General Considerations

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B. Appropriate/realistic to diagnosis / interventions

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B. Patient- centeredB. Typed

C. Measurable

D. Time framed (short-term and long term)

C. References appropriate

III. Pass/Fail VII. Pass/Fail

Pass/Fail ___ Faculty Comments: _________________________________________________________________________________________________________________________________________

_-________________________________________________________________________________________________________________________________________________________________________

Instructor’s Signature: ____________________________ Date: ________________________

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Care plan 3

Documents

Transcript of Care plan 3