ECPI RN CARE PLAN 2020 PDF

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Care plan on patient for Acute Care...

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Clinical Care Plan Whitney Smith

NOVEMBER 30, 2020

ECPI CLINICAL CARE PLAN TERM: _258__________ Instructor: _Markle___________

STUDENT NAME: Whitney Smith DATE/ Clinical 11/30/20 DATE/Admission:11/28/20____ PATIENT INITIALS: __R,J_________ ALLERGIES/ Adverse Reaction to: AGE: _86_________ PAIN: Is client experiencing any pain? Yes No Known Allergies Verbal Pain Scale used: _Numbers________ Height: 180.3 cm Weight: 80.7 kg Location: _Legs________________ Duration: _Entire shift___________________ Character: _Anxious_________________ CHIEF COMPLAINT in PT’s own words: “I had a fainting spell during dinner. I do not remember what happened after dinner.” Per daughter, it lasted 8-10 minutes. HISTORY OF PRESENT ILLNESS (HPI)(How, when, where, what and why; of the chief complaint) Patient’s episode was at his home, the night of 11/29 after dinner. Patient has had prior syncope episodes after eating meals. He believes it to be due to his diabetes or blood pressure.

PAST MEDICAL HISTORY Diabetes, previous syncope episodes, pacemaker, prostate cancer, colonoscopy, A-Fib, Anemia, Glaucoma, Hypertension, Hypothyroidism, CAD, HCC, CRI, Hyperlipidemia, Diabetic Neuropathy CURRENT ORDERS (Include Tubes / Drains in this section) Cardiac monitor, ECHO, Orthostatic blood pressures Q4H, Ambulate with assistance

VITAL SIGNS DURING SHIFT Time 0800

BP

HR 190 94

76

RR 19

02Sats /Oxygen 100

Blood Sugars

1300

168 88

76

18

100

1700

173 90

77

18

100

HEENT

Neurologic:

PHYSICAL ASSESSMENT/ On Going throughout day *(To assist completing your Care Plan – Assessment will not be required in writing) Negative for congestion, sore throat, rhinorrhea, sneezing and neck stiffness. Eyes negative for discharge or redness, PEERL. Mucous membranes pink and moist. Neck is supple. LOC: Orientation: Alert and oriented, no acute distress. Positive for fatigue.

Airway patent. Non-labored respirations. Breath sounds clear with good air entry bilaterally. Negative for shortness of breath and wheezing. Cardiovascular: Negative for chest pain or palpitations. Regular rate and rhythm. No peripheral edema. Patient has a pacemaker. Gastrointestinal: Negative for dysuria, urgency, frequency, hematuria, flank pain, decreased urine volume or discharge. Non-distended and non-tender, without guarding or rebound. Genitourinary: Negative for dysuria, urgency, frequency, hematuria, flank pain, decreased urine volume, discharge. Respiratory:

Musculoskeletal: Negative for myalgias or joint pain. Extremities are without swelling, tenderness or deformity, symmetric with normal ROM. Integumentary: Skin is warm and dry. Negative for fever or chills. Psychosocial:

Document: Family dynamics: Patient lives with daughter and is a widow.

Nutritional:

Diet: Heart healthy, low sodium

MEDICATIONS Include All Scheduled medications patient is currently taking

Medication

Action of Medication

Indication for Patient

Side effects/Adverse effects

Nursing actions r/t need of the client

Name/Dose Gabapentin 100 mg capsule Frequency/route dose Oral daily 3x

Painkiller in its own class that mimics GABA receptors.

Name/Dose Warfarin 2.5 mg tablet Frequency/route dose 2 ½ tablets on Thursdays and 2 tablets all other days.

Anticoagulan t inhibits blood clotting. Prevent blood clots.

Diabetic neuropathy.

Drowsiness, dizziness, loss of coordination, tiredness, blurred/double vision and shaking.

Nursing Actions: Assess vision and concentration. Patient Education: May take weeks to take effect. Do not stop taking suddenly.

Bleeding, red or brown urine, black/bloody stool, headache and vomiting blood.

Nursing Actions: Avoid administering with cranberry juice. Instruct to use soft toothbrush and electric razor. Patient Education: Do not start a new medication without Dr’s approval. Take exactly as prescribed.

Name/Dose Baclofen 10 mg Frequency/route dose Oral 1 tablet twice daily

Skeletal muscle relaxant that induces muscle relaxation.

Name/Dose Levothyroxine 88mcg Frequency/route dose 1 tablet by mouth before breakfast

Provides more thyroid gland release.

Diabetic Neuropathy

Hypothyroidism

Drowsiness, dizziness, weakness, tiredness, headache and constipation

Muscle weakness, headache, leg cramps, nervousness and diarrhea.

Nursing Actions: Assess peak action after 4 hours. Patient Education: Start with low dose and can gradually increase. Nursing Actions: Monitor beginning of therapy dosage. Administer with a full glass or water. Patient Education: Take on empty stomach 30-60 minutes before

Name/Dose Cromolyn 4% ophthalmic solution Frequency/route dose 1 drop into each eye Q12h

Allergic eye conditions.

Eye swelling, irritation. Possible undiagnosed eye allergy.

Headache, nasal irritation, cough, wheezing and dizziness.

breakfast. Nursing Actions: Monitor for angioedema or bronchospasm. Patient Education: Blow nose gently. Use only when needed.

LAB DATA & DIAGNOSTIC EVALUATION If the patient does not have recent labs/diagnostic tests, Write what would be indicated for a patient with this diagnosis Include diagnostic test like X-rays, CTs, and MRIs

LAB Ordered

Client Values

Include date Normal Values

CBC with automated diff.

WBC 8.0 RBC 4.33 HGB 12.2 HCI 38.3 MCV 88.5

4.1-11.1 4.10-5.70 12.1-17.0 36.6-50.3 80-99%

Indication for Diseases / Illness Why is the lab drawn? If level low/high specify why r/t patient’s condition or meds? Determine if it is an imbalance that caused his syncope spell.

MEDICAL DIAGNOSIS Anything that affects their admitting condition (diagnosis) or affects their care. MEDICAL DIAGNOSIS (Current)

TEXTBOOK CLINICAL PICTURE Signs and Symptoms

ACTUAL CLINICAL PICTURE What Signs and Symptoms your patient actually exhibited

Clinical Results Unresponsiveness

Lacking responsiveness or

Fainting, memory loss, delirious, personality changes

alertness: dull, insensible, insensitive, numb, stuporous, torpid.

UTI with hematuria

Diabetic mellitus

Infection of the Urinary System.

Burning when urinating, pressure on the bladder, back pain, blood in urine,

Disease in which the body’s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine.

Fatigue, Frequent urination, nausea, dizziness, cloudy urine with a unfavorable smell

PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS List Top 5 diagnosis relevant to patient condition & based on assessment. 1. Decreased cardiac output

2. Ineffective tissue perfusion

3. Acute pain

4. Self care deficit

5. Activity Intolerance

NURSING CARE PLAN Student Name: ________________

Date: ____________________

Patient Initials: _______________

A care plan should start with the major issues for that client. Choose a priority nursing diagnosis for this client. Be sure to include “related to”, “as evidenced by”, or “risk factors” (if at risk diagnosis) for each medical diagnosis. Write at least one/ “expected outcome” measurable goal per nursing diagnosis stated in terms of client achievement - “the client will…”). List at least 7 specific nursing actions (interventions) for the nursing diagnosis and give the scientific rationale for selecting the action you will use to work toward that goal. NURSING DIAGNOSIS (NANDA APPROVED)

EXPECTED OUTCOME (Measurable Goal with dates) ST: within time frame of clinical LT: can be outside of time frame of clinical ST: Patient’s blood Decreased cardiac pressure will be stable by end of shift. output related to hypertension as evidenced by high variations of blood pressure LT: Patient remains free of side effects of medications used to control cardiac output by discharge.

NURSING INTERVENTIONS (What do you plan to do for the client to accomplish the goal? Be specific and include time frames).

Record intake and output.

Closely monitor fluid intake including IV lines. Maintain fluid restriction if ordered.

Administer medications as prescribed,

RATIONALE (Why are you doing this?)

Reduced cardiac output results in reduced perfusion of the kidneys, with a resulting decrease in urine output. In patients with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volumes. Monitor for vital changes depending on the medications, if there is

EVALUATION (If goal not met, need to evaluate why? And what to do to meet goal?) *If results of interventions would be outside of clinical time, you can discuss what you would do with each outcome ST: Goal met

LT: Ongoing

noting side effects and toxicity.

Record BP readings for orthostatic changes (drop of 20 mm Hg systolic BP or 10 mm Hg diastolic BP with position changes). Apply music therapy to decrease anxiety and improve cardiac function.

Assess for increased fatigue and change in LOC.

Educate family and patient about the disease process, complications of disease process, information on medications, need for weighing daily, and when it is appropriate to call doctor. ("Decreased Cardiac Output – Nursing Diagnosis & Care Plan", 2020)

desired or undesirable effect. Stable BP will help in restoring cardiac output.

Music has been shown to reduce heart rate, blood pressure, anxiety, and cardiac complications. Fatigue and changes in LOC are common problems with low cardiac output states. Close monitoring of the patient’s personality and overall energy will help stay on top of potential complications. Early recognition of symptoms facilitates early problem solving and prompt treatment.

NURSING DIAGNOSIS (NANDA APPROVED)

Ineffective tissue perfusion related to decreased cardiac output as evidenced by use of pace maker.

EXPECTED OUTCOME (Measurable Goal with dates) ST: within time frame of clinical LT: can be outside of time frame of clinical ST: Patient exhibits growing tolerance to activity by end of shift.

LT: Patient engages in behaviors or actions to improve tissue perfusion by discharge.

NURSING INTERVENTIONS

RATIONALE

EVALUATION

(What do you plan to do for the client to accomplish the goal? Be specific and include time frames).

(Why are you doing this?) Citation for each rationale

(If goal not met, need to evaluate why? And what to do to met goal?)

Check for optimal fluid balance. Administer IV fluids as ordered.

Sufficient fluid optimizes cardiac output needed for tissue perfusion.

ST: Goal met

LT: Ongoing Promote active range of motion.

Exercise prevents further circulatory compromise.

Explain all procedures and treatments.

This will help eliminate the anxiety of the unknown.

Teach patient to recognize the signs and symptoms that need to be reported to the nurse. Practice deep breathing and coughing exercises.

Assess vitals and LOC frequently.

Early assessment facilitates immediate treatment. Prevent any further complications and keep lungs clear. Frequent assessments can help prevent complications.

Monitor sleep patterns; administer sedative.

Rest is important for conserving energy.

("Ineffective Tissue Perfusion – Nursing Diagnosis & Care Plan", 2020)

NURSING DIAGNOSIS (NANDA APPROVED)

EXPECTED OUTCOME (Measurable Goal with dates) ST: within time frame of clinical LT: can be outside of time frame of clinical Acute pain related ST: Patient describes to Diabetic a pain level of 2-3 on Neuropathy as a scale of 0-10 by evidenced by 1900. reports of pain in legs and facial

NURSING INTERVENTIONS

RATIONALE

EVALUATION

(What do you plan to do for the client to accomplish the goal? Be specific and include time frames) .

(Why are you doing this?) Citation for each rationale

(If goal not met, need to evaluate why? And what to do to met goal?)

Provide pain relief before it becomes severe. Acknowledge the pain level as what the patient states it is.

Provide analgesic before onset of pain before it becomes severe. Nurses have the duty to believe the pain level from their client.

ST: Goal met.

LT: Ongoing.

grimacing.

LT: Patient displays consistent pain coping and mood by discharge.

Teach nonpharmacologic pain management, such as activities or deep breathing.

Assess vitals on a schedule, including pain level.

Nonpharmacologic methods of pain management may include physical cognitive behavior therapy. Opiods, nonopiods and also analgesics are all options. Promote optimal patient comfort. Create a baseline when observing vitals.

Ask patient to rerate pain 30 minutes after analgesic administration.

Assess the affectiveness of treatment.

Provide pharmacologic pain management as ordered. Reposition patient for comfort.

("Nursing Diagnosis for Pain (Acute / Chronic) related to Osteoarthritis", 2020)

Citation Page

Nursing Diagnosis for Pain (Acute / Chronic) related to Osteoarthritis. (2020). Retrieved 8 December 2020, from https://nanda-nursinginterventions.blogspot.com/2012/04/nursing-diagnosis-for-painacute.html#:~:text=Nursing%20Diagnosis%20for%20Pain%20%28Acute%20%2F%20Chronic %29%20related,finger%20and%20at%20the%20bottom%20of%20the%20thumb.

(COVID-19), C., Health, E., Disease, H., Disease, L., Management, P., & Conditions, S. et al. (2020). Types of Diabetes Mellitus. Retrieved 8 December 2020, from https://www.webmd.com/diabetes/guide/types-ofdiabetes-mellitus Normal Laboratory Values for Nurses: A Guide for Nurses. (2020). Retrieved 8 December 2020, from https://nurseslabs.com/normal-lab-values-nclex-nursing/ Normal Laboratory Values for Nurses: A Guide for Nurses. (2020). Retrieved 8 December 2020, from https://nurseslabs.com/normal-lab-values-nclex-nursing/ Ineffective Tissue Perfusion – Nursing Diagnosis & Care Plan. (2020). Retrieved 8 December 2020, from https://nurseslabs.com/ineffective-tissue-perfusion/...