blank care plan

8/8/2019 Blank Care Plan

http://slidepdf.com/reader/full/blank-care-plan 1/14



NRSG 3240 Fundamentals

Sleep Aid Use no List:

Alcohol use no Amount/day:Tobacco use no PPD: X Years: = Pack Years

Street drug use no History of use:

PAIN

Location knee and ankle

Chronology (onset,

duration)

tibial plateau fracture

Quality throbbing shooting stabbing sharp cramping dullburning stinging aching tender squeezing pressure

nagging radiating tiringFrequency brief/momentary/transient Intensity/Quantity 3 on scale of 0 to 10 Unable to verbalize

Client’s pain goal: What level of pain would you be comfortable with? 1 Unable to verbalize

Aggravating factors standing/moving

Alleviating factors sitting and meds.

OBJECTIVE DATA

NEUROLOGIC/MUSCULOSKELETAL/SENSORY

Mental status: Alert Oriented X 4 Drowsy Lethargic Disoriented

Confused Semi- comatose

Speech: Clear Unclear Slurred Garbled AphasicMotor: 0 – Flaccid; no evidence of contraction 1 – Evidence of slight contraction

2 – Complete ROM without gravity 3 – Complete ROM against gravity

4 – Complete ROM against gravity with someresistance

5 – Complete ROM against gravity with fullresistance

Gait: Stable Unstable Not observed High Risk for Falls? Yes NoPupils: PERRLA Non-reactive Dilated Constricted

Unequal (describe):Eyes: Redness Pain Discharge Glasses Contacts

Ears: No deficits Hearing loss Hearing aid(s) Right Left

Pain Right Left Drainage Right Left

RESPIRATORY

Breathing effort: Unlabored Labored Describe:Cough None Non-productive Productive Sputum:Breath Sounds: Clear over all lobes Adventitious sounds Location:

Type:

O2 use at home? no

CARDIOVASCULAR

Capillary refill < 2 seconds

Pacemaker no Insertion date:AICD: no Insertion date:Mucus membranes Pink Cyanotic Other Nail beds Pink Cyanotic Other Radial pulses 2+ NormalPedal pulses 2+ Normal

Heart sounds S1 S2 Extra heart sounds

Gross murmur (describe):

GASTROINTESTINAL/NUTRITION

Food allergies: Denies IBW: 100 lbs % of IBW: 77%Oral condition good

Difficulty chewing Difficulty swallowingTube feeding Not applicable Formula: Rate: cc/hour

Route: Nasogastric/nasoenteral Continuous IntermittentFeeding Feeds self Needs assist Total assist Loss of appetite (anorexia)

Abdomen Contour: Flat Rounded Obese Scaphoid

of 14




Palpation: Soft Firm Distended Tender

Bowel sounds RLQ Normal, active RUQ: Normal, active LUQ: Normal, active LLQ: Normal, activeNausea/vomiting None Frequency: Duration:

Bowel habits Usual frequency: 1 per day Last BM:Laxative use None Type & frequency:

Stool consistency: Soft formedStool frequency: n/a

Bowel problems: Rectal bleeding Tarry stools IncontinenceOstomy NoneGENITOURINARY

Urine Color yellow

Urine Appearance: Clear Urine Odor none

Bladder problems: Urgency Pain BurningIncontinence Bladder distention Retention

Catheter: Indwelling: Fr. Straight: Fr. X (# times this shift)Urinary diversion: None Suprapubic Ileal conduit Other Genitalia: Intact Lesions Discharge Itching PainFemale only Obstetrical Hx: G P A

Menses: LMP: Regular SKIN

Color Normal for ethnicity Pale Ashen Gray

Flushed Jaundiced Mottled CyanoticMoisture Dry DiaphoreticTemperature Warm Hot Cool ColdTurgor Good/elastic Fair Poor/ tenting

INDICATE LESIONS ON BODY

Directions: Using the drawing feature in Word, place a dot on affect areas, and then complete the table.

Location (specify) Code

Right tibial plateau fracture

Lesion Codes

1 Edema 6 Burn 11 Other ulcer

2 Rash 7 Incision 12 Central line

3 Ecchymosis 8 Scar 13 Peripheral I.V.

4 Abrasion 9 Dressing 14 5 laceration 10 Pressure ulcer 15

IMPACT OF HOSPITALIZATION:

Developmental stage1 Late adulthood: integrity vs. despair

Explanation: looking back on life and feeling both happiness and despair.

Sociocultural factorsnone

Explanation:

TEACHING/LEARNING:

Learning Needs: Activity Diet Disease/Self-carePre-Postop Equipment Hygiene/grooming

Medication Community resources Disease management

1 Erickson’s stages of growth and development are explained at: http://web.cortland.edu/andersmd/ERIK/welcome.HTML. of 14

http://web.cortland.edu/andersmd/ERIK/welcome.HTML

http://web.cortland.edu/andersmd/ERIK/welcome.HTML




Other: n/a

Other: n/aReadiness to learn: yes Explanation: n/a

Learning Preferences ReadingBarriers to learning: Degree of illness Visual impairment Hearing impairment Age

Motor skills Comprehension Motivation Low literacyOther (explain) n/a

of 14




CLINICAL DATA BASECLIENT DATA:

Age: 55 Sex: female Height: 144.7 cm Weight: 58.97 kg IBW: 100 lbs

Admission Date: 4/12/10 Reason for admission: right tibial plateau infection

Allergies: co deine

MEDICAL DIAGNOSES:

Primary Medical

diagnosis: Righttibial plateau

fracture

Definition: Common Signs & Symptoms: pain,

impaired movement,

Usual treatment:

Secondary Medical

diagnosis: n/a

Definition: Common Signs & Symptoms: Usual treatment:

Chronic illnesses:

n/a

Definition: Common Signs & Symptoms: Usual treatment:

LABORATORY & DIAGNOSTIC DATA

HEMATOLOGY

CBC

Test Normal Most Recent Result

Date

Admission Result

Date

Clinical Significance

WBC 3.07-11.77 7.10 normal

RBC 3.76-5.20 3.98 normal

Hgb 11.6-15.6 11.7 normal

Hct 33.9-45.9 32.5 low; nutritionally deficit or fluid retention.

Platelets 129-355 539 high; acute infection

WBC DIFFERENTIAL


Date

Admission Result

Date


PMN 40-80 69 normal

Bands n/a Lymphocyte

s15-40 18 normal

Monocytes 0-10 12 high; infection. Eosinophils 0-7 1 normal

Basophils 0-2 1 normal

COAGULATION STUDIES


Date

Admission Result

Date


PT/PTT 12.2-41.6 n/a n/a INR 2.0-3.0 n/a n/a CHEMISTRY

SERUM CHEMISTRY


Date

Admission Value Clinical Significance

Sodium 135-145 137 n/a normal Potassium 3.5-5.0 4.6 n/a normal

Chloride 99-109 99 n/a normal

CO2 22-32 29 n/a normal

Calcium 8.5-10.2 10 n/a normal

BUN 5-22 11 n/a normal

Creatinine 0.50-1.17 0.67 n/a normal

Total

Protein4.2-8.0 7.0 n/a normal

Albumin 3.5-5.0 3.3 n/a low; immobilization or infection

Glucose 70-99 99 n/a normal

of 14





Date

Admission Value Clinical Significance

Phosphates n/a n/a n/a n/a

Uric Acid 2.5-7.7 3.6 n/a normal

Alkaline

Phosphatase

30-112 81 n/a normal

LDH 97-190 185 n/a normal

SGOT/AST 15-38 26 n/a normal

Bilirubin 0.2-1.3 0.7 n/a normalCholesterol 114-200 168 n/a normal

BACTERIOLOGY

CULTURES (Blood, Urine, Sputum, and/or Wound)

Specimen type Date/Value Clinical Significance

n/a n/a n/a URINALYSIS


Date

Admission Result

Date


Specific gravity

n/a n/a n/a pH 7.35-

7.45n/a n/a

Glucose 70-99 99 n/a normal

Protein 6.0- 8.0 7.0 n/a normal

Blood/RBC 3.76-5.20 3.82 n/a normal

Bilirubin 0.3-1.2 n/a n/a Bacteria n/a n/a n/a WBC 3.07-

11.77

7.10 n/a normal

Ketones n/a n/a n/a Clarity n/a n/a n/a ARTERIAL BLOOD GAS (ABG)


Date

Admission Result

Date


pH

PACO2

PAO2

HCO3

BE

OTHER LABORATORY STUDIES

THERAPEUTIC DRUG LEVELS (digoxin, theophylline, phenytoin, vancomycin)Drug Normal

Level

Most Recent Result

Date

Admission Result

Date


n/a CARDIAC MARKERS


Date

Admission Result

Date


CK (CPK) n/a n/a CK-MB n/a n/a Troponin

(TRO)

n/a n/a of 14




DIAGNOSTIC TEST RESULTS:

Test Summary of findings for this client Clinical Significance

Chest X-ray Ultrasound Echocardiogram Abdominal series KUB Cardiac cath report

Pathology EKG/ECG CT Scan Other: xray- knee ap lat right. no acute findings. screws in

place.

the screws are in place and no new findings.

of 14




MEDICATIONSDrug Name – Generic

(Trade)

Theragran M Colace Ancef

Client’s ordered dose,

frequency, times & route

1 tab PO Qday 100 mg cap PO Qday 1 g IVP Q8hr

Action/purpose of drug Side effects Nursing Implications Why is this client taking themedication?

What outcome did you

observe for this medication

Drug Name – Generic

(Trade)

Lovenox Crestor Client’s ordered dose,


40 mg/0.4 ml inj SC Q24 hr 1 tab PO SMWF Action/purpose of drug lipid lowering. decreses

cholesterol and triglycerides.

Side effects abdominal cramps, rashes

rhabdomyolysis, constipation,

flatus and heartburn.

Nursing Implications dietary hx, ck levels,

administer with magnesuim,

avoid grapefruit juice. limit

cholesterol, carbs and alcohol.

Why is this client taking the

medication?

to lower cholesterol What outcome did you


n/a

Drug Name – Generic

(Trade)

Client’s ordered dose,


Action/purpose of drug Side effects Nursing Implications Why is this client taking the

medication?

What outcome did you


NUTRITIONType of diet: regular Percentage taken: Bkfst 50 % Lunch n/a %

Calories needed: 1800 Calories consumed: n/a

Fluid intake past 24 hours: 1294 ml Output past 24 hours 1290 ml

Implications of currentnutritional pattern uponhealth outcome/client needs.

n/a

OTHER PRESCRIBED TREATMENTS, PROCEDURES PERFORMED –

ORDER OUTCOME NURSING IMPLICATIONS

n/a n/a n/a

of 14




ORDER OUTCOME NURSING IMPLICATIONS

of 14




NURSING CARE PLANList diagnoses in ORDER OF PRIORITY 2. Use a separate table for each diagnosis. Include diagnositic category, related factors

(“related to”) and defining characteristics (“as evidenced by”) for all actual diagnoses. Include diagnostic category and related factors

for all risk diagnoses. Cite references for both diagnosis and the nursing interventions and rationales.

NANDA Diagnosis # 1: Infection related to right tibial plateau fracture as evidenced by admitting diagnosis

Measurable Client Goals:

• Subject

•Verb

• Conditioner/time

frame

Therapeutic Nursing

Interventions with Rationales

Interdisciplinary Team Roles.

Consider PT, OT, RT, ST, SW,

Chaplain, Dietitian, and MD.

Evaluation of Client Goals

Long-term goal: The patients

infection will get better before

they are discharged from the

hospital. The patient will learn

to ambulate with assistive

devices upon discharge.

Short-term goal: The patients

infection will not worsen on

my shift.

Assessment:

• Assess the patients vital

signs to make sure they are

not elevated.

• Assess the the patientswound to see severity of

infection to monitor and

make sure the infection

does not get any worse.

• Assess the patients pain

level and tolerance tomake sure to treat the

patients pain as well as

infection.

• Assess the patient for fluidloss from the wound.

• Assess the patients ability

to learn so you can inform

them of how to keep the

wound clean and

uninfected.

• Physical therapist to help

client learn to ambulate

with assistive devices.

• Ocupational therapist to

help client keep movementin foot.

• RN-to administer meds.

• MD- to prescribe meds

and treatments

• Case manager to plan for

discharge.

The goal identified for the

client was partially met

Changes need to the plan of

care: n/a

Treatment:

• Clean the patients wound

to ensure no moreinfections.

• Wrap the patients woundto make sure bacteria

cannot get it.

• Change dressing

frequently to make sure it

stays clean, dry and intact.

• Give the patient

medications to treat

infections and to treat pain.

Teaching:

• Teach the client theimportance of keeping

their wound site clean and

covered.

• Teach the patient about

risks for future infections

to prevent future

infections.

• Teach the client and their family how to do dressing

2 See Prioritizing Nursing Diagnoses handout in the Clinical Learning folder of the course web site. of 14




changes so they can

continue to keep their

wound clean when they

are discharged.

• Teach patient how to

ambulate with crutches or

other assistive devices.

of 14




NANDA Diagnosis # 3: Risk for falls related to decreased lower extremity strength as evidence by right tibial plateau fracture.

(NANDA PAGE 312-313)

Measurable Client Goals:

• Subject

• Verb

• Conditioner/time

frame

Therapeutic Nursing

Interventions with Rationales

Interdisciplinary Team Roles.

Consider PT, OT, RT, ST, SW,

Chaplain, Dietitian, and MD.

Evaluation of Client Goals

Client will understand their risk for falls during my shift.

Client will relay back the

importance of getting help toambulate or get out of bed

during my shift.

Assessment:• Assess patients affected

foot so you can document

any changes and assess

their ability to be mobile.

• Assess clients ability to

ambulate with help to

make sure they do not do

anything that will harm

them any farther.

• Take blood pressure to

make sure they are not

hypotensive before making

abrupt movements.

•Physical therapist to help

client learn to ambulate

with assistive devices.

• Ocupational therapist to

help client keep movementin foot.

• RN-to administer meds.

• MD- to prescribe meds

and treatments

• Case manager to plan for

discharge.

The goal identified for theclient was met

Changes need to the plan of

care: n/a

Treatment:

• Administer meds as

prescribed to ensure theclient is being well taken

care of and the doctors

orders are being carried

out properly.

• Encourage client to use

call light to call for help so

they do not injury

themselves while they are

trying to move on their

own.• Encourage client not to

attempt to get out of the

bed so they do not harm

themselves by trying to be

more mobile than they are

capable of..

Teaching:

• Teach patient importance

of fall precautions so they

understand and do not

attempt to do things that

might harm them.

• Teach patient importanceof only ambulating with

help so they realize the

risks related to falls.

• Teach patient importance

of heel protectors to

protect feet from bed sores

and ulcers.

of 14




References

Use APA format and list all references cited in the care plan.

of 14

blank care plan

Documents