Care plan 2 PDF

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Summary

Care plan...

Description

Diagnostics/Rationale: Click here to enter text.

Vital signs: 156/74 (83), 78, 98.4 orally, 22 breaths/min, 97% on room air Lung sounds CTA, HRR, pulses 2+ in BUE and BLE. Skin pink and without discoloration t/o. Eye sclera slightly yellow. Pt is awake, alert, oriented, and assisting interviewer with exam. Full ROM in BUE, 2 person assist when transferring, ambulating, or toileting. 50% weight bearing with walker. Goal to progress to 100% while in rehab. Regular diet. Surgical incision on outer left upper thigh is closed, 22 stables CDI, no dressing. Skin surrounding area is pink, without s/sx infection. Currently complaining of pain 6/10 in hip as the ride over was bumpy.

Client Initials: BB Room: Click here to enter text. Admitted: Y Chief Medical Diagnosis: Click here to enter text. Chief Surgical Diagnosis: Click here to enter text. Medical hx: hyperlipidemia, HTN, Alcoholism Surgical hx: Click here to enter text. Allergies: NKDA

Medications hydrocodone-acetaminophen 10-325 q6hr PRN: pain Motrin 800mg po BID Valium 10mg po BID Simvastatin 40mg po qd Metoprolol ER Cozaar 25mg PO qd Azithromycin 500mg PO first day, 250mg po once a day on days 2-5 Ambien 5mp po PRN at HS

Lab/Rationale: Hg 12.5: Normal rage is 13.5-17.5. The low Hg could be due to blood loss during surgery. Monitor next lab value closely to ensure no further Hg loss. Hct 38: Normal range is 45-52. Low Hct could be due to anemia from severe alcoholism. ALD 38: Range 7-30 possibly due to liver issue indicated by yellowing sclera in the eyes due to alcohol abuse AST 44: Normal range 8-46.

Nursing Problem #1 Risk for Suicide due to chronic alcoholism related to loss of significant other

Nursing Problem #2 Impaired physical mobility due to total left hip replacement as evidence by 50% mobility.

Expected Outcome: Patient will acknowledge difficulties perceived in current situation and identify home life factors that can be dealt with during hospital stay and possible enrollment in therapy.

Expected Outcome: Patient will progress to 100% mobility in duration of rehab. Interventions:

Interventions: Independent

Ask Suicide-Screening Questions to identify degree of risk or potential for suicide. Develop therapeutic nurse client relationship, providing consistent care while initiating straightforward communication skills to reduce the risk of patient-nurse manipulation.

Collaborative Independent Collaborative Consult with Social Work and CaseRefer Before activity, observe for and, as if possible, patient to Physical therapy well Management to establish mental health treat pain with massage, pack as occupational therapy toheat assist in to evaluation due to significant loss and poor area, affected or medication. regaining strength and achieve goal of coping mechanisms. 100% mobility. Refer patient to dietitian to evaluate diet and to ensure a rich protein diet to aid in recovery from surgical procedure.

Student Name: Click here to enter text. Allergies: Click here to enter text.

Week: Click here to enter text.

Dates of Care/Room #: Click here to enter text.

Instructions:     

Column 1: List all medications that your patient has on his/her MAR including PRN’s. Write the generic name and trade name of the medication and name the drug classification. Example: Lisinopril (Prinivil)/Ace Inhibitor Column 2: State the reason your patient is receiving the medication (based on history or current medical diagnosis). Example: Hypertension Column 3: What is the intended effect of the medication on this patient’s status? Example: Lower Blood Pressure Column 4: What is one major side or adverse effect of the med that may result in holding med/contacting provider? Example: Hypotension Column 5 Priority Nursing Implications: List the IMPORTANT, specific assessment findings, lab abnormailities, teaching requirements, etc. that must be considered when administering the medication. Example: Hold for SBP 4 on 1-10 scale

All PRN Medications Generic/Trade Classification Hydrocodone-Acetaminophen Give Post-operative for pain >4pain on 1-10 scale (Lortab) Opioid and a non-opioid combination

Zolpidem Sleep (Ambien) due toif no Sedative access of alcohol Give toaid patient having trouble falling that patient currently to sleep asleep, don’t giveuses to patient if he has had benzodiazepines

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Why prescribed for patient?

Criteria for giving/not giving

Situation Initials/Age/Rm #: BB Brief Summary of Primary Problem: Risk for Suicide due to extreme emotional loss and impaired physical mobility as evidence by 50% mobility following total left hip replacement. Day of admission/post-op #: n/a

Background Primary problem/diagnosis: Total Left Hip Replacement Surgery RELEVANT past medical history: hyperlipidemia, HTN, Alcoholism

RELEVANT background data: Patient is a heavy everyday drinker, drinks to pass out. Assessment

Current vital signs: 156/74 (83), 78, 98.4 orally, 22 breaths/min, 97% on room air

RELEVANT body system nursing assessment data: Lung sounds CTA, HRR, pulses 2+ in BUE and BLE. Skin pink and without discoloration t/o. Eye sclera slightly yellow. Pt is awake, alert, oriented, and assisting interviewer with exam. Full ROM in BUE, 2 person assist when transferring, ambulating, or toileting. 50% weight bearing with walker. Goal to progress to 100% while in rehab. Regular diet. Surgical incision on outer left upper thigh is closed, 22 stables CDI, no dressing. Skin surrounding area is pink, without s/sx infection. Currently complaining of pain 6/10 in hip as the ride over was bumpy RELEVANT lab values: Hg 12.5 LOW, Hct 38 LOW, ALD 38 HIGH

TREND of any abnormal clinical data (stable-increasing/decreasing): n/a

Recommendation Suggestions to advance plan of care: Consult with PT/OT to assist in the rehabilitation of mobility, Consult with Social Work and Case Management to evaluate the degree of risk of suicide due to alcoholism related to significant loss Rounding

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© 2016 Keith Rischer/www.KeithRN.com

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