Plan Cover Page
01/26/2018 Patient’s Age: 51 Gender: M
1. Decreased cardiac output R/T decreased amount of circulating blood S/T blood loss causing
2. Ineffective airway clearance R/T Bronchospasms and excess
mucus production as a result of constriction of bronchioles S/T COPD
intolerance R/T decreased
amount of circulating oxygen S/T
4.Infection, risk for R/T high glucose levels and decreased amount of circulating
leukocytes S/T Type 2 DM
risk for R/T altered mobility
S/T AKA of the LLE
Nursing-Nursing Lab 382
Nursing Plan of Care
Nursing Diagnosis (NANDA or Faculty
Nursing Interventions and Rationale
(MUST cite source
Was the goal met?
Problem resolved or prevented?
Should plan be: Continued? Revised? Terminated?
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
-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.
the nurse can manipulate): decreased amount of circulating blood
blood loss causing symptomatic anemia.
Expected Pt. Goals & Outcomes:
-Have Improved cardiac
-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
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.
med provides Iron which is an essential mineral needed to make hemoglobin
which is a component of RBCs.
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)
of Development: Middle adulthood: Generativity vs Stagnation.
General health history:
2. Conditions that prevent normal
functioning: (physical, mental, etc.):
3. Alcohol/drug use: yes, x no,
amount : ___________________________
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
6. Surgical Procedure: Removal of central line,
concerns: Pt. states that he is concerned about how his health is making him
dependent on others.
8. Perception of current illness:
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:
10. Pathophysiology:(include specific source using
APA format) :
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.
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.
Pt orientated to place, time and
Round, equal, reactive to light.
Able to hear verbal instructions
during the assessment
(soft, firm, distended, tender)
Able to feel sensation when touched
of emesis (clear, green, yellow, red, coffee ground)
Loose brown stools
1600 BP 126/92
2000 BP 120/90
1600 HR 77
2000 HR 70
1600 Temp 98.6
2000 Temp 98.3
+2/4 in BUE
+2/4 in RLE
Unable to assess LLE d/t AKA
No edema in RLE
No edema in BUE
Unable to assess LLE d/t AKA
<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