Care plan - Edith jacobson care plan PDF

Preview

Summary

Edith jacobson care plan...

Description

Brief RAM Assessment/Data Collection Sheet (To accompany Care Plan Design Form)

Student Name Shakira Davis

Clinical Site

Client’s Initial Code: EJ Code Status: full code Primary Diagnosis fx to left hip post fall PMH: osteoporosis, dizzy spells PSH: none

Date 04/11/2021

Vital Signs: Time 4:10 T: 99 AP: 89

Route: oral Radial: 89

R 15 O2 Sat : 97% BP: 137/82

Admission Date: 04/10/2021

Ht. 152 CM Wt. 47.6 kg RAM Behaviors—Physiologic

Oxygenation (Vital signs above) O2 0 L/M via N/A Lung Assessment: lungs sounds are clear and equal bilaterally.

Pain Assessment: pain is 2/10 on the pain scale with pain in the left hip Allergies NKA

Skin Status: normal

Color: normal

Protection Wounds: no wound present Drains: N/A Last Dressing Change: N/A Type of Dressing N/A

Temperature Cardiovascular Assessment: HR and rhythm is regular, : normal/ positive pedal pulses in BL lower limbs capillary refill is cool and dry Turgor: with in normal limits normal elasticity Nutrition Elimination Diet: NPO after 2100 TF Bolus/Gravity/Pump Bowel N/V/D Urine: continent N/A  Incontinent Type of feeding: n/a  Incontinent Last Void:  Ostomy (type) Appetite: N/A Urine Output:(Description): Rate N/A last shift output 600 ml Last BM: unknown Fluid and Electrolytes Bladder distention? no Description: n/a  Catheter IV(s): PIV Site: Left Abdominal Assessment: Type Size Gauge wrist not assessed Date inserted: Rate 84ml/hr Assessment: site is with in normal limits, dressing is clean dry 1 This is intended as a guide and is subject to change as needed

and intact with no signs or symptoms of infection or infiltration HL/CVP/Other Access Rest and Activity Activity: Bedrest Activity tolerance: low due to fractured hip

Endocrine Neurologic Function & Senses (Pain assessment above) Glucometer Readings: N/A Overall appearance: Review of cranial nerves: Well not evaluated LOC: alert and orientated x4

ROM: limited left lower limb Gait: N/A due to bed rest Transfers: With assistance Sleep: with in normal function

Assessments of Endocrine Function: n/a

appropriate at

Senses: intact MMSE Score N/A Glasgow Coma Score N/A

times flat Paralysis/Paresis N/A

Self Concept Body Image/Religion /Erickson’s Stage Integrity VS despair

Psychosocial Role Function Interdependence Roles/Role Transition Support Systems loss of independence do to Daughter immobility, resulting on dependence on others.

Stimuli Conceptual

Focal Pain, immobility

Medication

Mood & Affect

Residual

Hip FX, Age, Osteoporosis, Dizzy spells/ Ethnicity, Religion, genetics unsteady gait

Dose

Medications Frequency Route

Nursing Considerations

Enoxaparin Sodium

40 mg

Q day

Sub q

Assess for signs of bleeding, unusual bleeding, black tarry stools, hematuria and falls in B/P

Docusate Sodium

100mg

Q day

Oral

Asses cause of constipation, evaluate theraputic response, discontinue if cramping rectal bleeding nausea or vomiting occur.

Morphine sulfate Lactated ringer solution

4mg 84 ml/hr

Q4 hrs PRN One time only

Via IV Via IV

Assess pain, respirations sedation effects on patient Monitor electrolytes and assess for hypervolemia

2 This is intended as a guide and is subject to change as needed

Laboratory and Diagnostic Studies (CBC, UA, Chemistry, Drug levels, Cultures, X-Rays, CT, MRI, etc.) HB 14 Creatinine 0.8 Prothrombin time 11 HTC 42 Cl- 101 APTT 35 Platelets 195 Urea nitrogen (BUN) 20 INR 0.9 WBC 8 HCO3- 24 RBC 4.3 Calcium total 8.6 K+ 3.8 Glucose 102 Na+ 142 Vitamin D 30 Teaching and Discharge Needs Related to Behaviors and Stimuli Patient should be educated on positioning related to injury to left hip patient will be educated on safety measures, activities and fall risk Patient will be educated on the need for assistance with ADL’s

3 This is intended as a guide and is subject to change as needed

Student Name: Shakira Davis

Patient Initials CODE EJ

Instructor: S. Loesch

Date 04/11/2021

Nursing Care Design Sheet Behaviors Non-Observable Observable (Subjective) Complaints of dizziness

(Objective) Immobility

Stimuli Focal, Contextual, Residual Focal: immobility

Contextual: fracture of left Xray showing Complaints of pain intertrochanteric Fracture hip, osteoporosis in left hip Left leg stature is shorter than eight

Nursing Diagnoses NANDA

Nursing Interventions and Rationales

Evaluation of (Impact) Patient Goals/Outcomes

(Best Evidence-Based List 3 in priority order. Rationales with references) Check the one you address. Risk for falls related to altered Transfer patient to a room near Bed rest and use of gait related to unsteady gait the nursing station medication, will keep (nearby location provides more patients pain manageable. secondary to hip fracture constant observation and quick Risk for impaired skin integrity response to call bell) nurseslabs.com R/T immobility Patient will use

nursing measures that

Impaired physical mobility R/T Move items used by patient with in reach such as call bell water facilitate movement and hip Fracture and telephone (Items that are too decreases chances of far from the patient may cause injury, Fracture pan limits Patient Care hazard and can contribute to flexion of hips. Goals/Outcomes falls) nurseslabs.com

Short and Long Term

(Including timeframes) Patient will be free from falls while admitted to hospital

Respond to call bell as soon as possible (This is to prevent the patient from getting out of bed with out any assistance) Nurseslabs.com

Patient will reposition with assistance Q2 hours to prevent skin break down Guarantee appropriate room lighting especially during thr Patient will use call bell when night (Patients especially older in need of assistance R/T adults has reduced visual ADL’s while hospitalized capacity lighting an unfamiliar environment helps increase Patient will verbalize the visibility if the patient must get proper positioning and safety up at night) nurseslabs.com features while hospitalized.

Patient will participate in activities to Increases blood flow to muscles and bone to improve ROM and prevent contractures or atrophy from disuse Patient will improves muscle strength and circulation, to enhance patient control in the situation, and promotes

3 This is intended as a guide and is subject to change as needed

Patient will be fall free for at least four months after discharge

Allow the patient to participate self-directed well being in a program of regular exercise ans gait training (Studied recommend exercises to __ __ strengthen the muscles improve balance and increase bone__ density. Increased physical__ conditioning reduces the risk for falls and limits injury that is sustained when fall transpires) Indicate the Mode nurseslabs.com

Physiologic Mode Self Concept Mode Role Function Mode Interdependence

3 This is intended as a guide and is subject to change as needed...