345 Care plan 2- final - Care plan created for adult health II - hopefully this can give you a guidance/an PDF

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Care plan created for adult health II - hopefully this can give you a guidance/an idea of how. to create a careplan...

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INDIANA WESLEYAN UNIVERSITY School of Nursing

Patient Data Sheet for Nursing Care Plan *Medical* Student’s Name: Sara Kahler Patient’s Initials: A.S. Age: 49 Sex: M Code Status: Full Race: Caucasian Patient Allergies: NKA Reason for Admission: Shortness of Breath, hypoxia Medical Diagnoses (include major, active Dxs): Obstructive sleep apnea, Hypoxia hyperlipidemia, Hypertension, Diabetes II (uncontrolled), Osteoarthritis, Previous Surgeries: Tonsilectomy, Tracheostomy, Right wrist surgery Type of Diet: Cardiac Cuisine 2gm Activity Ability: Self ambulates Mode of Transfer: Wheelchair Elimination: bowel & Bladder (Continent or incontinent? Catheter? ) Bowel and bladder continent Treatments & Therapies: -Lipoderm patch to ribs -Glucose q4 - Respiratory therapy Abnormal Lab Values – see attached Medications (List 6) – see attached

NURSING CONCERNS LIST for Nursing Care Plan Client ___ Assessments – Refer to Sample for needed information. Strengths

Name ____________________________ Date _________________

Identified Client Stressors

Risk and Family History

Write:

Cultural

Developmental

___1 highest priority nursing diagnosis ____in PES format and ____ include its definition.

Lived in Gas city for 4y Grew up in Grant County - Physical development appropriate for age Holds steady job

Dad died in 2012 - Works 3rd shift for past 10+ years - Disruptive sleep patterns - -Lives in trailer park - States that he is a ‘loaner’ and would rather not have visitors

Risk for loneliness r/t physical isolation, social isolation sleeping during typical waking hours, working third shift

-- Pt. understands everything I communicated with him. - Caucasian - First language is English - Local to Grant County - Does not require assistance with communication - Nonverbal communication is congruent with verbal communication - Client lives in close proximity to family - Interacts with mother daily and speaks fondly of her

-

Stress overload r/t inadequate resources (family, medical, social), chronic illness, familiar demands aeb statements of uneasiness and feeling ‘queasy’, loss of CPAP, financial strains,

-

States stressed and anxious not having a clear diagnosis to cause of breathing exacerbation - States a queasy fealing in stomach due to stress and anxiety - Does not moderate sugar intake although diabetic - Lost CPAP d/t insurance change -Dislikes being hospitalized - Pt states he does not have time off from work,and does not take vacation - Pt also states “ I live paycheck to paycheck”

Definition: “at risk for experiencing discomfort associated with desire or need for more contact with others” (Ackley & Ladwig, 2011, p. 531).

Definition: Excessive amounts and types of demands that require action (Ackley & Ladwig, 2011, p. 804).

lPsychosocia Spiritual

-- Pt is receptive, open, and willing to share about his life. -Pt. is clean and well dressed. -Generativity vs. Stagnation -Emotional response to conversations are appropriate -Body language is congruent with verbal communication -Dress is appropriate for situation -Visits mom daily -Very reasonable and is able to see both sides of issues -Handles conflict by speaking with person directly and management - demonstrated proper technique of insulin administration -asks appropriate questions regarding medication administration

- Completed GED - Mother is in assisted living - Works 3rd shift -Stressed over mom’s care - States does not want visitors to hospital, prefers to be alone

Readiness for enhanced self-care r/t desire to enhance maintaining health, desire to enhance knowledge in strategies for self-care aeb asking questions regarding health care, demonstrating learning from previous teaching of insulin administration Definition: a pattern of performing activities for oneself that helps to meet health-related goals and can b strengthened (Ackley & Ladwig., p, 706)

Denies important or distinctive religious practice -Does not mention God, Faith or other religious topics -Does not regularly attend church services - No meaningful relationships outside of mom/sister

Spiritual Distress r/t loneliness/social isolation, anxiety, chronic illness aeb no religious practices, no meaningful relationships outside of family Definition: Impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself. (Ackley & Ladwig, 2011, p.796).

alPhysiologic

Fluid/Electro: No sunken eyes, neck veins flat. VS: RR: 20 HR: 87 BP: 117/81 Temp: 96.9 O2: 91% Active Bowel Sounds x4. LOC was alert and oriented x3. Has not lost any weight recently. 49 male, Oxygenation: Resp- Thorax is equal bilaterally and elliptical in shape. Breathing rate normal, clear, and non-labored. Cardiovascular- No jugular vein distention Heart sounds- Clear and S1 and S2 heard. Peripheral Pulses- radial: strong, 2+, 87bpm bilaterally. Pedal: strong 2+, 87 bpm Bilaterally. Extremities- skin color even and consistent with genetic background, dry, warm, nails clean, capillary fill – < 3 second. No cough present. Pt. does currently smoke. Elimination: -Abdomen soft, round, and Bowel sounds x4. -Urinates regularly. able to effectively move bowels Tissue Integrity- Skin appropriate for genetic

Fluid/Electrolyte: -BMI: 47.1 - Weight: 142 kg -Saline locked IV L. A.C. -Edema to lower extremities Medications- see attached Oxygenation: -LOC was alert and oriented x3 -Lung sounds are diminished bilaterally, breathing is labored on exertion - Pt on 2L/o2 NC -History of smoking - Pitting edema present on lower legs, - lost CPAP machine due to insurance issues -Hypoxia -COPD Elimination: -States “feels queasy in my stomach” Nutritional status: - More than body requirements - Wt: 142 kg -BMI: 47.1 - Cardiac 2gm Cuisine -did not like offered meal—ate 50% Sensory-Perceptual: - Utilizes glasses Sleep/Rest: -States did not sleep previous night due to typical hospital interruptions - Difficulty sleeping last night due to altered sleep schedule Activity/Mobility: - Impaired mobility due to respiratory exacerbations - impaired walking due to oxygen use -Osteoarthritis Sexuality: -Denies any partner

Impaired gas exchange r/t , ventilation perfusion imbalance, alveolar-capillary membrane changes aeb o2: 91%, o2 2L/NC, diminished breath sounds Definition: excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar capillary membrane (Ackley & Ladwig, 2011, p.402).

INDIANA WESLEYAN UNIVERSITY NURSING CARE PLAN Student

Date

Client

Medical Diagnoses (All active, current, priority Diagnoses) Obstructive sleep apnea, Hypoxia, hyperlipidemia, Hypertension, Diabetes II (uncontrolled), Osteoarthritis,

Assessment: Data Base Intrapersonal Factors Dev: - Physical development appropriate for age - Disruptive sleep patterns Cultural: - Caucasian - First language is English - Does not require assistance with communication - Nonverbal communication is congruent with verbal communication - States stressed and anxious not having a clear diagnosis to cause of breathing exacerbation - Does not moderate sugar intake although diabetic Dislikes being hospitalized Psycho: - Pt is receptive, open, and willing to share about his life. -Pt. is clean and well dressed. -Generativity vs. Stagnation -Dress is appropriate for situation - Completed GED

Interpersonal Factors Develop: - Holds steady job - Dad died in 2012 - Working 3rd shift Cultural: .- Pt. understands everything I communicated with him. - Client lives in close proximity to family - Interacts with mother daily and speaks fondly of her - States that he is a ‘loaner’ and would rather not have visitors Psycho: - Emotional response to conversations are appropriate -Body language is congruent with verbal communication -Visits mom daily -Very reasonable and is able to see both sides of issues -Handles conflict by speaking with person directly and management - Mother is in assisted living - Works 3rd shift

Extrapersonal Factors Dev: - -Lived in Gas city for 4y - Grew up in Grant County Oxygenation: - lost CPAP machine due to insurance Tissue Integrity: Environment safe, clear of obstacles, and appropriate for pt. Safety/Comfort: -Area free of clutter and is clean. Smoke detectors in place, handrails present, and adequate lighting is present. -Anxious to leave hospital setting as soon as possible

-Stressed over mom’s care - States does not want visitors to hospital, prefers to be alone -Demonstrates accurate administration of insulin Spiritual: -Denies important or distinctive religious practice -Does not mention God, Faith or other religious topics -Does not regularly attend church services Fluid/Electro: No sunken eyes, neck veins flat. VS: RR: 20 HR: 87 BP: 117/81 Temp: 96.9 O2: 91% Active Bowel Sounds x4. LOC was alert and oriented x3. Has not lost any weight recently. 49 male, Oxygen: Resp- Thorax is equal bilaterally and elliptical in shape. Breathing rate normal, clear, and non-labored. Cardiovascular- No jugular vein distention Heart sounds- Clear and S1 and S2 heard. Peripheral Pulses- radial: strong, 2+, 87bpm bilaterally. Pedal: strong 2+, 87 bpm Bilaterally. Extremities- skin color even and consistent with genetic background, dry, warm, nails clean, capillary fill – < 3 second. Age- 49 No cough present. Pt. does currently -obstructive sleep apnea

Nutritional status: - Cardiac 2gm Cuisine -did not like offered meal—ate 50% Sleep/Rest: -States did not sleep previous night due to typical hospital interruptions Activity/Mobility: - Impaired mobility due respiratory exacerbations - impaired walking due to oxygen use -Osteoarthritis Sexuality: -Denies any partner

-copd -hypoxia -LOC was alert and oriented x3 -Lung sounds are diminished bilaterally, breathing is labored on exertion - Pt on 2L/o2 -History of smoking - Pitting edema present on lower legs, Elimination: -Abdomen soft, round, and Bowel sounds x4. -Urinates regularly. able to effectively move bowels Tissue Integrity- Skin appropriate for genetic Nutritional Status: - Alert and Oriented x3 -No food allergies. - More than body requirements - Wt: 142 kg -BMI: 47.1 Sensory-Perceptual: -Pt is in a pleasant mood -Pt reports no pain - LOC- alert and oriented x3. - Memory- Sharp and no abnormalities noted. Appropriate attention span, calculation, judgment, and abstract reasoning. Sleep/Rest: -Pt has his own normal sleep schedule for working 3rd shift. -Has been working 3rd shift for 10 years - Difficulty sleeping last night due to altered sleep schedule Activity/Mobility: Body symmetric bilaterally Able to ambulate without assistance Safety/Comfort: Patient is comfortable and in no pain

Nursing Diagnosis: Impaired gas exchange r/t , ventilation perfusion imbalance, alveolar-capillary membrane changes aeb o2: 91%, o2 2L/NC, diminished breath sounds Definition: excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar capillary membrane (Ackley & Ladwig, 2011, p.402). Goals/ Outcomes Interventions from NsgDx Handbook Scientific Rationale from NsgDxHndbk Evaluation of Goals APA Reference needed: author(s) & page number

Short Term Goal Patient will maintain clear lung fields and remain free of signs of respiratory distress for remainder of shift

Primary 1. Held the client deep breathe and perform controlled coughing. Have client inhale deeply, hold breath for several seconds, and cough 2-3x with mouth open

Secondary 1. Position in semi-fowlers with an upright posture at 45º upright position if possible Long Term Goal Patient will verbalize understanding of oxygen supplementation and other therapeutic interventions prior to discharge

Tertiary 1. Teach client how to perform pursed lip breathing and inspiratory muscle training and how to use the tripod position. Have the client watch the pulse ox to note improvement in oxygenation with these breathing techniques

Short Term 1. controlled coughing uses the diaphragmatic muscles which makes the cough more forceful and effective (Ackley & Ladwig, 2011, p.402).

1. Increased oxygenation and ventilation. Research on healthy subjects demonstrated that sitting upright resulted in higher tidal volumes nad minute ventilation versus sitting in slumped posture (Ackley & Ladwig, 2011, p.402).

1. Studies have demonstrated that pursed lip breathing was effective in decreasing breathlessness and improving respiratory function (Ackley & Ladwig, 2011, p.402).

Goal was not met

Long Term Goal was met

Goals/ Outcomes

Interventions from NsgDx Handbook

Scientific Rationale from NsgDxHndbk

Evaluation of Goals

APA Reference needed: author(s) & page number

Short Term Goal

Primary 1.Observe the client for loss of meaning, purpose, and hope in life.

Pt. will express sense of connectedness with self, others, arts, music, literature, or power greater than oneself by the end of nurses 6 hour shift.

Short Term 1.In a quantitative study of 156 clients with cancer and 68 caregivers, Taylor (2006) found that one of the most prevalent spiritual needs was finding meaning.

Goal was not met

Secondary 1.physically present and actively listen to the client. 1.In a grounded theory study, spiritual care included promoting client connectedness with self (Burkhart & Hogan, 2008).

Long Term Goal

Pt. will express sense of hope in the future by the end of nurses clinical experience.

Tertiary 1. Support meditation, guided imagery, therapeutic touch, journaling, relaxation, and involvement in art, music, or poetry. Support outdoor activities.

Long Term Unsure if goal was met

1.In a qualitative survey of chronically ill individuals participants wanted access to a garden, a quiet space available in hospital to think through decision, spiritual help or guidance, swimming, and a choice of genres of music available (Dale & Hunt, 2008).

Nursing Diagnosis: Spiritual Distress r/t loneliness/social isolation, anxiety, chronic illness aeb no religious practices, limited meaningful relationships

Reference List (APA): Ackley, B. J., & Ladwig, G. B. (9th edition). Nursing diagnosis handbook: A guide to planning care. St. Louis, MO: Mosby.

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