ATI J.L care plan - n/a PDF

Preview

Summary

n/a...

Description

FOCUSED HEALTH ASSESSMENT FORM Gastrointestinal System Student: Shanise Wise Cluster Data (Subj./Obj. Assessment): Patient Initials/Room #: J.L S: abd flat, skin smooth, no masses. Hyperactive bowel sounds present. Moderate overall Allergies: Sulfa add tenderness. Ileostomy present on the lower right side of abd, draining semi liquid stool with red streaks. “I feel a lot of cramping and discomfort in my stomach”.

Respiratory System Cluster Data (Subj./Obj. Assessment): AP: T = 1:2 ratio. Symmetric chest movements bilaterally. Regular smooth respirations. Breath sounds clear, absence of cough, no adventitious sounds RR:22//25 O2:95% Medications: NONE

Medications: Infliximab IV every 8 weeks

Integument System Cluster Data (Subj./Obj. Assessment): Skin fair/pale, Nail beds pink. Pink, dry mucosa. Absence of erythema, jaundice, cyanosis, pallor, rubor, or grayness. Absence of lesions.

Chief Complaint: GI Bleed

Temperature: 101.8

Secondary- Intermitted gastritis

Medications: Acetaminophen (Tylenol) PO q4h PRN

Other Diagnosis/PMH -

Diagnosis/Medical HX. Primary- Crohn’s disease

Cardiovascular System Cluster Data (Subj./Obj. Assessment): HR elevated, S1 and S2 normal. Capillary refill < 3. Absence of bruits, murmurs, clicks, rubs, and heaving. Absence of edema. HR:114/100/110 BP:100/60 102/62 Medications: NONE

Neurological /Sensory Cluster Data (Subj./Obj. Assessment): Alert and oriented x3. Cooperative and able to follow verbal commands

Medications: NONE

Nursing Orders (Chart Data): Interventions, teaching, treatments, notes Morphine sulfate 4 mg IV bolus q2h PRN Acetaminophen (Tylenol) 650 mg PO q4h PRN Blood transfusion: 2 units packed RBCs Monitor I and O Monitor ileostomy for presence of blood every 1 hr

Genitourinary/Reproductive System Cluster Data (Subj./Obj. Assessment): External anatomy of female genitalia present. Absence of lesions or vulvar deformities.

Metabolic System Cluster Data (Subj./Obj. Assessment): N/A Medications: N/A

Immune System Cluster Data (Subj./Obj. Assessment): N/A Medications: N/A

Output: 500 mL (ileostomy)

Rev. 09/13

Medications: NONE Musculoskeletal System Cluster Data (Subj./Obj. Assessment): N/A Medications: N/A

Psychosocial/Spiritual Cluster Data (Subj./Obj. Assessment): Pt appears to be coping well with hospitalization. Pt asks questions pertaining to care and is cooperative

Significant Diagnostic/Lab Procedures: (Data/Test/Results) CBC (Hct 21, Hgb 7, RBC 2.7, MCH 48, MCV 105, WBC 6,000) Fecal Occult Blood (Positive blood in stool) Type and crossmatch for 2 units PRBCs Ileostomy preformed 6 months ago

Medications: N/A

Student Name_Shanise Wise_________________________________ Patient Initials__J.L________

3326L CARE OF THE ADULT CLIENT: CLINICAL CLINICAL LAB SHEET **LAB TEST/DATE

NORMAL VALUES

PATIENT’S VALUES

RBC 1/18/xx Hemoglobin 1/19/xx

4.0–5.0 x 1012/L (women) 12 – 18 g/dL

2.7 x 1012/L 8 g/dL

Hematocrit 1/19/xx

35 – 45%

24%

RATIONALE FOR ABNORMAL VALUE The value is low because the patient is experiencing GI bleed The value is low because the patient is experiencing GI bleed The value is low because the patient is experiencing GI bleed

Rev. 09/13

** Include: (1) Admission labs; (2) Most recent lab values from the past 24-48 hours.

Rev. 09/13

Client’s Initials: __J.L___ _______________________ Allergies:__Sulfa_____________________________ __

MAIN

WHAT SHOULD YOU DO/KNOW JUST

MEDICATION INCOMPATI -

TESTS & LABS (WHY)

WHY DID YOUR CLIENT GET THIS? HOW DOES IT WORK?

SIDE EFFECTS

BEFORE GIVING THIS RX?

BILITIES FOR THIS CLIENT

(NORMALS) & PT’S.

4 mg 4mg to 15mg Yes, WNL

To relieve pain. Binds with and activates opioid receptors in brain and spinal cord to produce analgesia and euphoria.

Anxiety Chills Confusion Dizziness Hallucination

Be aware that morphine can lead to abuse, addiction, and misuse.

None

UDT (to identify misuse and abuse of opioid drugs)

Acetaminophen (Tylenol) Antipyretic

650 mg 640mg650mg Yes, WNL

To relieve pain. Inhibits the enzyme cyclooxygenase blocking prostaglandin production and interfering with pain impulse generation in the peripheral nervous system.

Agitation Anxiety Fatigue Fever Headache Insomnia

Use cautiously in patients with alcoholism and severe renal impairment.

Don’t mix acetaminop hen with any other medications .

AST, ALT, Bilirubin and creatinine (acetaminop hen may cause hepatoxicity )

Infliximab (Remicade) Anti-inflammatory

N/a

To control moderate to severe Crohn’s disease long-term Binds with cytokine tumor necrosis factoralpha, preventing it from binding with receptors.

Chills Dizziness Fatigue Fever

Know that infliximab therapy shouldn’t be started in a patient with an active infection.

Don’t infuse infliximab in same I.V line with other drugs

Liver function test (severe hepatic reaction may occur)

DRUG BRAND NAME

CLIENT’S DOSE

TIME/ ROUTE

GENERIC NAME DRUG CATEGORY

USUAL DOSE? WNL?

IV bolus Q2h PRN

Morphine sulfate Opioid analegic

PO Q4h PRN

IV Q8wk

Student: _Shanise Wise _________________________________ Date: 11/2/20______________________________

Medication Sheet

DIAGNOSIS

FOR THIS

RX

SBAR Template

S

Situation: Janet Lieberman is a 36-year-old female admitted from the ED for a GI bleed. She had 1 unit of packed RBCs and part of the second unit. The second unit was stopped because I believed she was having a transfusion reaction. Ms. Lieberman reports having a headache and chills.

B

Background: Ms. Lieberman has a history of Crohn’s disease and intermitted gastritis. She had an ileostomy six months and started on infliximab IV every 8 weeks. She is allergic to

Sulfa.

A

Assessment: Most recent vital signs include; BP 110/70, P 110, RR 26, T 101.8, O2 97% When she arrived at the medical surgical unit her hemoglobin was 7 g/dL and her hematocrit was 21%.

R

Recommendation: A prescription for an antipyretic to reduce her fever.

ANALYSIS OF ASSESSMENT CLIENT’S INITIALS J.L

STUDENT’S INITIALS

S.W

OVERALL IMPRESSION OF CLIENT: A 36-year-old female who is Alert and oriented x3 (person, place, time), cooperative, able to follow verbal commands.

ASSESSMENT DATA WHICH SUPPORTS NURSING DIAGNOSIS Subjective: 



“I feel a lot of cramping and discomfort in my stomach.” States “8” on 0-10 pain scale

NURSING DIAGNOSIS

PRIORITY ASSIGNED NURSING DIAGNOSIS

Acute pain r/t abdominal muscle soreness and tenderness secondary to Crohn’s disease

1

Fluid Volume Deficit r/t blood volume loss secondary to Gi bleeding

2

Objective:     

Facial grimacing Moaning Abd guarding upon abd palpation Resp. Rate: 22/25 breaths/min Acetaminophen (Tylenol) PO q4h PRN

Subjective:   

Pt states she felt weak and dizzy Pt states, “I’m feeling more lightheaded and dizzier” Pt states, “I feel like I am going to faint.”

Objective:  Mucous membranes are dry  Pale skin  Temp: 101.8  BP: 103/60  HR:110  Hct 21,  Hgb 7,  Bloody stools

Subjective:  

Pt states, “I have no Ineffective coping r/t Crohn’s disease secondary to support system” Pt states, “I look inadequate coping methods forward to going home in the evening and relaxing with a couple glasses of wine”.

Objective:  Sleep disturbance  decreased use of social support  Stress

3

FAMU SCHOOL OF NURSING CAREPLAN/MAP Adm Hx: A 36-year-old female admitted from the ED for a GI bleed. She has a history of Crohn’s disease with intermitted gastritis and had surgery and an ileostomy six months ago.

Med Dx: GI bleeding with c/o of dizziness, weakness, and abdominal pain.

Key Assessments: Abdominal assessment, endoscopy, and VS

Problem 1 Subjective: “I feel a lot of cramping and discomfort in my stomach.” States “8” on 0-10 pain scale Objective: Facial grimacing, Moaning, Abd guarding upon abd palpation, and restlessness. Resp. Rate: 22/25 breaths/min Temp 101.8 Nsg Dx: Acute pain r/t abdominal muscle soreness and tenderness secondary to Crohn’s disease

Problem 2

Problem 3

Subjective: “I have no support system.” “I look forward to going home in the evening and relaxing with a couple glasses of wine.”

Subjective: Pt states she felt weak and dizzy. Pt states, “I’m feeling more lightheaded and dizzier.” Pt states, “I feel like I am going to faint.”

Objective: Sleep disturbance, decreased use of social support, stress

Objective: Mucous membranes are dry, Pale skin. Temp: 101.8 BP: 103/60 HR:110 Hct 21, Hgb 7, bloody stools

Nsg Dx: Ineffective coping r/t Crohn’s disease secondary to inadequate coping methods

Nsg Dx: Fluid Volume Deficit r/t blood volume loss secondary to Gi bleeding

Treatments: Relaxation techniques Treatments: Prescribed medication therapy

Treatments: Blood transfusion (2 units packed RBCs)

Medications: Morphine sulfate, Acetaminophen

Medications: N/A

Medications:

Goals: During the clinical shift, the patient will experience decreased pain as evidence by: Pain score < 3 on 0-10 scale Stable vital signs Absence of restlessness

Goals: During the clinical shift, the patient will: Assess the current situation accurately Identify ineffective coping behaviors and consequences. Demonstrate lifestyle changes to limit/prevent recurrent episodes

Goals: During the clinical shift, the patient will not experience GI bleeding as evidence by: Normal vital signs (BP: >90/60, Temp: 98.6, HR 60-100) Stable hemoglobin and hematocrit levels Verbalize (2) measures to prevent bleeding

Nursing Actions:

Nursing Actions: Nursing Actions:

1.

Ask the patient about reported pain, documenting its location, character, timing, and relationship to meals, and measures that relive or aggravate the pain; note if certain foods

1. 2. 3.

Assess patient’s understanding and previous methods of dealing with disease process Determine outside stressors Establish a therapeutic relationship

1. 2.

Monitor VS Monitor CBC

2. 3.

4. 5.

precipitate or worsen symptoms Assess reports of abdominal pain or cramping Note nonverbal cues (restlessness, reluctance to move, abdominal guarding, withdrawal, and depression). Investigate discrepancies between verbal and nonverbal cues. Encourage patient to assume position of comfort Administer prescribed medication therapy

4. 5.

1.

2.

3.

4. 5.

Outcomes: Goal met During the clinical shift, the patient will experience decreased pain as evidence by: Pain score 2 or 3 on 0-10 pain scale Temp: 98.6 Absence of restlessness

4.

Rationales:

1.

2.

3.

5.

Rationales:

Foods can act as an antiacid by neutralizing gastric acid for about 30 to 60 minutes. Afterwards, gastric acid secretion may increase. Foods that increase pain should be avoided (Hoffman and Sullivan, 2017, pg.1260). Colicky intermittent pain occurs with Crohn’s disease Vera, 2019) Body language or nonverbal cues may be both physiological and psychological and may be used in conjunction with verbal cues to determine extent and severity of the problem (Vera, 2019) Reduces abdominal tension and promote sense of control (Vera, 2019) Pharmacologic therapy is an effective method of reducing or relieving pain (Smeltzer, Bare, Hinkle & Cheever, 2010, 242).

Encourage use of stress management skills such as relaxation techniques and exercise Make appropriate referral to interprofessional team

3.

4. 5.

Enables the nurse to deal more realistically with current problems. Anxiety and other problems may have interfered with previous health teaching and patient learning (Vera, 2019) Stress can alter autonomic nervous response, affecting the immune system and contributing to exacerbation of disease. Even the goal of independence in the dependent patient can be an added stressor (Vera, 2019) Helps develop trust between patient and healthcare provider (Hoffman and Sullivan, 2017, pg.1282) Refocuses attention, promotes relaxation, and enhances coping abilities (Vera, 2019) Inflammatory bowel disease is a complex disease and requires an interdisciplinary team approach including a case manager, dietician, and any local support groups (Hoffman and Sullivan, 2017, pg.1282)

Outcomes: Goal met During the clinical shift, the patient states she will find new way to manage stress: Walks in the park in the afternoons Eat with a coworker several days a week

Revisions:

Administer fluids, blood or blood products, or plasma expanders Educate the patient about signs of bleeding that need to be reported to a health-care provider Advise patient to avoid risk factors such as overuse of aspirin and NSAIDs, spicy foods, and beverages that contain caffeine

Rationales:

6.

Tachycardia, dyspnea, or hypotension may indicate fluid volume deficit or electrolyte imbalance (Ralph & Taylor, 2011,118). 7. If the patient is experiencing GI bleeding, hemoglobin and hematocrit values may be low (Hoffman and Sullivan, 2017, pg.1260). 8. Replace fluids and whole blood loss and facilitate fluid movement into intravascular space (Ralph & Taylor, 2011, pg.118). 9. Early evaluation and treatment of bleeding by a health care provider reduce the risk for complications from blood loss (Wayne, 2017) 10. Such foods and fluids have stimulatory effects on gastric acid secretion (Hoffman and Sullivan, 2017, pg.1261).

Outcomes: Goal met During the clinical shift, the patient will not experience bleeding as evidence by: BP: 98/60 Temp: 98.2 HR:68 Hemoglobin 12 hematocrit 37% Patient Verbalized (2) measures to prevent bleeding

Revisions: Revisions:

Shanise Wise Clinical reflection NUR 3326 November 2, 2020

This week’s clinical rotation takes place via ATI stimulation. As a group, we had to meet on zoom to receive instructions from the instructor. Before starting the simulation, we had to have a basic understanding of GI bleed. I understand that GI bleed is a symptom of a disorder in the digestive tract. As a nurse, it is important to understand GI bleed, to come up with the best care plan to prevent or control the bleeding. While watching the scenario, I initially noticed that the patient was experiencing cramping and pain in her abdomen. I knew the patient was experiencing these symptoms because she has a history of Crohn’s disease. She stated that stress make the pain worse, and when she is stress, she eats unhealthy foods then get headaches and take ibuprofen. Initially, I thought that she should avoid the use of Ibuprofen because it could worsen the inflammation in Crohn’s disease. I have not encountered any similar situations in the past so there is nothing for me to necessarily compare it to. As I progress in the nursing program, I will have a better understanding of what to do when a patient is in a similar situation. This virtual clinical experience was very helpful, I’ve learned about the different interventions to prevent and control the bleeding of a patient who is experiencing GI bleed. What stressed me out about this virtual stimulation. There weren’t really any stressors during this virtual stimulation. She didn’t have a lot going on as opposed to my previous virtual patients who was admitted for Urosepsis but had other problems going on as well. The nursing skill I used during this virtual clinical experience was Critical thinking, professionalism, and attention to detail. The nursing skill I need to expand on in the future is critical thinking....