Southeastern car” 01/26/2018 1600 Pt. states that they feel

Southeastern
Louisiana University

School
of Nursing

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NLAB
382

Care
Plan Cover Page

 

Student:
_Everlyne Tuimur___

Date:
01/26/2018    Patient’s Age: 51    Gender: M

 

Medical
Diagnosis:

Symptomatic
Anemia

CHF

COPD

Type
2 DM

Hyperlipidemia

 

Nursing
Diagnoses Prioritized:

 

1.  Decreased cardiac output R/T decreased amount of circulating blood S/T blood loss causing
symptomatic Anemia

 

2.  Ineffective airway clearance R/T Bronchospasms and excess
mucus production as a result of constriction of bronchioles S/T COPD

 

3. Activity
intolerance R/T decreased
amount of circulating oxygen S/T
Anemia

 

 4.Infection, risk for R/T high glucose levels and decreased amount of circulating
leukocytes S/T Type 2 DM

 

5. Falls,
risk for R/T altered mobility
S/T AKA of the LLE

Southeastern Louisiana
University

School of
Nursing-Nursing Lab 382

Nursing Plan of Care

Student:                                                                                                                                                                                                                                                                        
Date: _____

Age:     _Sex:

Defining
Characteristics

Nursing Diagnosis (NANDA or Faculty
Approved)

Nursing Interventions and Rationale
(MUST cite source
for ALL)
 

Intervention Evaluation

Outcome Explanation
Was the goal met?
Problem resolved or prevented?
Should plan be: Continued? Revised?  Terminated?

 
Subjective
characteristics.
ED notes 01/20/2018 1800
“Pt. had a syncope episode during discharge while trying to get up from the
wheelchair to the car”
 
01/26/2018 1600 Pt. states
that they feel tired easily
 
 
 
 
 
 
 
 
Objective
characteristics.
 
-01/24/2018 Hgb 8.4
-01/24/2018 Hct 24.8
-01/24/2018 Pt. lost 400cc
of blood from bleeding at the chest port site.
-Medical hx.
 CHF
 Hypertension
 
 
 
 
 
 
 
 
 
 
 
 

Dx: Decreased
Cardiac output.
 
 
R/T(etiology
the nurse can manipulate): decreased amount of circulating blood
 
 
Secondary to:
blood loss causing symptomatic anemia.
 
 
Expected Pt. Goals & Outcomes:
-Have Improved cardiac
output.
 
Pt. will:
-Maintain cap refill <3 sec x 4 ext -Have Hgb (13.5-18) -Have Hct (40-54)% -Maintain a stable HR (60-100)     Within: Hospitalization   As evidenced by: -Cap refill <3 sec -Pink, moist mucus membranes -HR (60-100) -Hgb (13.5-18) -Hct (40-54) -   1. Assess Cap refill q4 hrs      -Cap refill measures the amount of blood flow to extremities. A cap refill >3 sec indicates decreased cardiac
output. It also indicates adequate perfusion to the extremities which is also
a goal for the pt.
 
 
 
2. Observe for Cyanosis on
the mucus membranes q2hrs.
    -Cyanosis on mucus membranes would
indicate inadequate perfusion which is caused by a decreased cardiac output.
Pink and moist would indicate adequate perfusion.
 
 
 
3. Monitor HR q4hrs
      -HR affects the amount of blood that is
pumped out, increased HR indicates decreased cardiac output because there is
not enough time to fill up the ventricles before the heart pumps the blood
out.
 
 
 
4. Monitor Hgb, Hct, and
RBC levels daily.
     – Although it may take a while for these
levels to go back to normal, an increase would indicate the level of
effectiveness of the therapy used.
 
5. Administer Ferrous
Sulfate 325mg PO TID.
     – This
med provides Iron which is an essential mineral needed to make hemoglobin
which is a component of RBCs.

 1. 01/26/2018
1600-Cap
refill<3 secs 2000-Cap refill <3 secs    2. 01/26/2018 1600- mucus membrane pink, moist, no cyanosis noted. 2000- mucus membrane pink, moist, no cyanosis noted.    3. 01/26/2018 1600-HR 77 2000-HR 70    4. 01/26/2018 1800- Per MAR Missi, RN administered Ferrous Sulfate 325mg PO The goal was partially met, which is expected. The patient was stable, had adequate peripheral perfusion evidenced by cap refill <3 secs. The patient also maintained a stable heart rate (60-100) and showed no symptoms of cyanosis. However, the hgb and the hct were still low which is expected because it takes more than a week for new RBCs to be produced by the bone marrow. Southeastern Louisiana University College of Nursing & Health Sciences   School of Nursing Nursing Lab 382 MEDICATION FORM   Age :  _____       Sex: ________    Weight: ___________ Drug Allergies: ______________   Diagnosis: _____________________________   Medication Name/Dose/Frequency Medication Classification Func class/ Chem class: Mechanism of Action   Why is your pt. receiving the med? Common Side Effects Drug Interactions PRIORITY Nursing Implications/Concerns Pertinent Labs Other Relevant Information Ferrous Sulfate 325mg PO daily. Func class: Antianemics         Provides Iron which is an essential mineral found in hemoglobin which is a component of RBCs The pt. is receiving this med because he had a significant blood loss that made him anemic. Iron is needed in the production of new RBCs. - Constipation and dark stools -Nausea and abdominal pain -Oral iron supplements decrease absorption of tetracyclines, bisphosphonates, fluoroquinolones -They also decrease the absorption and effects of levodopa and methyldopa. - Doses of Ascorbic acid increase the absorption of iron. -Ace inhibitors may increase the risk of an anaphylactic reaction.  -Assess bowel function for constipation or diarrhea. -Assess for Nausea and vomiting. -Educate the pt. on the need of taking the supplement even after they are discharged.   -Hgb -Hct -RBCs     Chem class Iron supplements           Docusate Sodium 100 mg PO Nightly   Func class Stool softener     Chem class: laxatives Promotes incorporation of water into stools, resulting in softer fecal mass The pt. is currently prescribed an iron supplement which has a side effect of constipation. This med is prescribed to help relieve the constipation. -throat irritations -mild cramps -diarrhea -rashes - Do not administer within 2 hrs of of other laxatives esp. mineral oil. -Assess bowel function (presence of bowel sounds, abdominal distention) -Assess color, consistency, and amount of stool produced.         Albuterol 2 puffs q4hrs Func class: bronchodilator         Binds to beta2- adrenergic receptors in the airway smooth muscle which causes the relaxation of the smooth muscle. The pt. has a hx. Of COPD. He is prescribed this med to prevent an attack and maintain a clear airway. -Paradoxical spasms with prolonged use. - Hypertension -Angina and palpitations -nervousness and restlessness -Hypokalemia.   -concurrent use with other adrenergic agents will have an increased adrenergic effect. -Use with MAO inhibitors may lead to hypertensive crisis. -Beta blockers may negate the therapeutic effects. -Assess lung sounds, BP (N 120/90) and pulse  (N 60-100) before and after drug administration. -Observe for signs of paradoxical spasms such as wheezing. If the condition occurs then hold the medication and notify physician. -Monitor serum K levels (N 3.5-5.0) -K (N 3.5-5.0) -Instruct pt. on the proper use of a nebulizer or a metered dose inhaler. Chem class: adrenergics             Pantoprazole (Protonix) EC     Func class: Gastric proton pump inhibitor Ant-secretory; Antiulcer agent Decreases gastric acid secretion by inhibiting the H+, K+ -ATPase enzyme system responsible for acid production. The pt. is taking this med to treat the erosion, ulceration, irritation or inflammation of the walls of the esophagus associated with GERD 1.. CDAD (Clostridium Difficile-Associated Diarrhea) 2. Hyperglycemia 3. Angioedema 4. May increase liver enzymes   -Monitor bowel function and Assess for S of abdominal pain. - Monitor blood glucose levels prior to administration. - Monitor for S of angioedema which include swelling of face, lips and tongue.   1. AST (N5-35) 2. ALT (N5-35) 3. Alkaline Phosphatase (N28-116) 4. Bilirubin (N0.4-2.0) 5. Glucose (N65-99)   Chem class:     SOUTHEASTERN LOUISIANA UNIVERSITY College of Nursing and Health Sciences School of Nursing Integrative Level Assessment Form   Student Name: Everlyne Tuimur_Date:  ___01/26/2018___Age:  _51_ Sex:  M_    Height:__   , Weight: 223lbs , Allergies (Food & Drug) _Demerol (Meperidine)- Rash_____             Life cycle stage: Early Adulthood (18-29), xMiddle Adulthood (30-55) Elderly (>55)

 

Stage
of Development: Middle adulthood: Generativity vs Stagnation.

 

1.   
 General health history:

-Symptomatic anemia

-CHF

-COPD

-ESRF

-Hyperlipidemia

-GERD

 

2.    Conditions that prevent normal
functioning: (physical, mental, etc.):


Left AKA

 

 

 

3.    Alcohol/drug use: yes, x no,
amount :  ___________________________

 

4. 
Tobacco use: x yes, no, amount (packs/day):­­­_2__, years: Smoked for 30 years before
he quit two years ago.

 

5.    Major medical diagnosis:Symptomatic
anemia

 

6.  Surgical Procedure:  Removal of central line,

 

7.   
Psycho-social
concerns: Pt. states that he is concerned about how his health is making him
dependent on others.

 

8.    Perception of current illness:

Pt.
states that his health has been deteriorating fast, he is concerned not only of
this hospitalization but his overall health. He is aware that his acute blood
loss also affects other illnesses that he is already diagnosed with. 

 

9.    Cultural beliefs related to health:

None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.  Pathophysiology:(include specific source using
APA format) :

 

Anemia

This is a condition in which
the blood has low levels of Hgb, Hct, and RBC’s.

This reduces the amount of
circulation oxygen available for the body.

The patient therefore
presents with symptoms of fatigue, SOB, dizziness, headache, or irregular
heartbeat. This diagnosis is confirmed by a blood CBC test which provides the
levels of Hgb, Hct, and RBC’s. Treatment of anemia depends on the type of
anemia the patient has been diagnosed with. The different types of anemia
include: iron deficiency anemia, vitamin B12 deficiency, folic acid deficiency
anemias. In this pt’s situation, the he has anemia due to acute blood loss.
Treatment will therefore involve a blood transfusion, iron infusion, or iron
supplements. Treatment is long term and will require continuous monitoring of
RBC’s, Hgb, and Hct levels until they are within the normal range.

References.

Hagler, D., Lewis, S. M.,
& Dirksen, S. R. (2017). Clinical
companion to Medical-surgical nursing: assessment and management of clinical
problems. St. Louis, MO: Elsevier.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEUROLOGICAL

GASTROINTESTINAL

Assessment

Day 1

Day
2

Comments

Assessment

Day
1

Day
2

Comments

LOC

Awake, Alert

 

 

BOWEL SOUNDS

Orientation

Pt orientated to place, time and
person

 

 

   Normal (X4)

Normoactive X4

 

 

Speech

clear

 

 

   Hyperactive

 

 

 

Pupils

Round, equal, reactive to light.

 

 

   Hypoactive

 

 

 

 

   Absent

 

 

 

  
Hearing

Able to hear verbal instructions
during the assessment

 

 

Abdomen
(soft, firm, distended, tender)

Soft,
non-distended,
non-tender

 

 

  
Sight

 

 

 

  
Touch

Able to feel sensation when touched

 

 

GASTRIC
SUCTION (Type)

 

 

 

  
Taste

 

 

 

  
Smell

 

 

 

   Continuous

 

 

 

 

   Intermittent

 

 

 

Color
of emesis (clear, green, yellow, red, coffee ground) 

 

 

 

CARDIOVASCULAR

Amount
(cc’s)

 

 

 

Assessment

Day 1

 

Comments

Stools
(describe)
 

Loose brown stools

 

 

B/P

01/26/2018
1600  BP 126/92
2000 BP 120/90

 

 

Last
BM (Date)

1/26/2018

 

 

Pulse rate

1600 HR 77
2000 HR 70

 

 

RELEVANT
HX:
GERD

  
Quality

 

 

 

Temperature

1600 Temp 98.6
2000 Temp 98.3

 

 

Peripheral
Pulses-quality

+2/4 in BUE
+2/4 in RLE

 

Unable to assess LLE d/t AKA

Edema:amt/location

No edema in RLE
No edema in BUE

 

Unable to assess LLE d/t AKA

GENITOURINARY

Cap refill

<3 sec in BUE <3 sec in RLE   Unable to assess LLE d/t AKA Assessment Day 1 Day 2 Comments Vascular Access    Bruit/Thrill No bruits or thrills     Voiding urinal     RELEVANT HX: Hypertension Hyperlipidemia CHF   Incontinent No incontinence     RESPIRATORY Catheter (Type)         Assessment Day 1 Day 2      Irrigation (Type)       Color: Pink mucus membranes     Appearance (color, character) Clear, Pale yellow, no foul odor     Nailbeds/ Mucous Membranes Mucus membranes moist. Convex carved nails, smooth and  intact with the epidermis.     GENITALIA Respiratory Rate 18 even, and unlaboured        Discharge  No discharge noted     Pattern/Symmetry Regular, no use of accessory muscles.        Odors No odors noted        Lesions       BBS (clear, wheeze, crackles, rhonchi BBS clear posteriorly and anteriorly.        Circumcised x        Uncircumcised       Cough productive/ nonproductive No cough     RELEVANT HX:   Sputum (describe)       Oximeter        Suction/Type           Notes:    N/C @______L/M          Mask @ %          Other:            Pleuravac®          Water seal          Suction (amt)          Drainage       RELEVANT HX: COPD  

x

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