N101L Care Plan - Nursing Care Plan PDF

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Summary

Nursing Care Plan...

Description

CARE PLAN TEMPLATE Student

Lauren Henry

Instructor

05/18/2020

Professor Tremblay

Patient Initials

Course N101L

JS

Unit/Room

Code Status Full Code Allergies

Date

Cardiothoracic Unit/ Room 517 DOB

03/05/1985

Height/Weight 5’9” 268 lbs.

Latex

Temp (C/F Site)

Pulse (Site)

Respiration

Pulse Ox (O2 Sat)

Blood Pressure

Pain Scale 1-10

100.9°F/Oral

118/ Radial

22 breaths/min

94% on room air

128/80 (Right arm

8/10 to chest, radiates

manually)

to left side/jaw/neck

History of Present Illness including Admission Diagnosis and Relevant Physical Assessment Findings (normal & abnormal) History of present illness: Pt. admitted to ER with acute chest pain x 30 mins. Pt. was lifting weights in his garage and began to feel pressure and burning in his chest that radiates to his jaw, left shoulder, and neck. Pt. is diaphoretic and experiencing SOB. Pt. states that he feels dizzy and nauseous. Pt. is breathing rapidly and shallowly and tripoding. Pt. skin is pale, and cool to the touch. Family history: Father had aortic aneurysm in 2018

Relevant Diagnostic Procedures & Surgeries /Results (include dates, if not found state so) CMP Glucose Sodium Potassium Chloride CO2 BUN Creatinine Calcium ALT AST Alkaline Phos. Albumin

Result 107 (High) 144 mEq/L 3.8 mEq/L 97 mEq/L 26 mEq/L 16 mg/dL 0.9 mg/dL 9.7 mg/dL 34 u/L 26 u/L 67 u/L 4.1 g/dL

Normal Range 65-99 mg/dL 136 to 145 mEq/L 3.5 to 5 mEq/L 90-109 mEq/L 20-35 mEq/L 10 to 20 mg/dL 0.6 to 1.2 mg/dL 9.0 to 10.5 mg/dL 7-56 u/L 5-40 u/L 37-113 u/L 3.5 to 5 g/dL

Mother has type 2 diabetes, diagnosed 2011 Admission Diagnosis: Client admitted to ER with acute chest pain, shortness of breath, and difficulty breathing.

Cardiac Function Tests EKG Cardiac Echo Chest X-ray

Results Normal Sinus Rhythm Normal Clear

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Physical assessment findings: Signs: Client A/O x 3, pupils PERRLA, respirations shallow and rapid at 26 breaths per minute, increased radial pulse of 118 beats per minute, increased brachial blood pressure of 128/80, oxygen saturation of 94% on room air, and an oral temperature of 100.9 °F. Patient was wheeled from

MRI CT Cardiac Enzyme Tests Troponin (normal 0-0.4 ng/ml) CK-MB Test (range 5-25 IU/L) Serum Myoglobin (range 0-85 ng/ml)

No abnormalities No abnormalities Results 0.1 ng/ml 13 IU/L 5 ng/ml

personal vehicle to the ER via a wheelchair, is speaking in short, two to three word phrases. Clients skin is cool and diaphoretic with signs of pallor. Client states that the pain in his chest is 8/10. Client has equal

Date Test taken: 5/22/2020 Surgeries: None ordered.

bilateral breath sounds; heart sounds are present and bounding. Symptoms: Client is complaining of acute chest pain that radiates to his jaw, neck, and left arm. He states that he feels. Like his "chest is burning." Client is having difficulty breathing and is feeling nauseous and dizzy. plant does not normally have any issues with ADLs, and was engaging in physical activity at the onset of incident. Past Medical & Surgical History, Pathophysiology of medical diagnoses (with APA citations) Hypercholesterolemia: Pt. states that he was diagnosed with high

Pertinent Lab tests/ Results (with normal ranges) with dates and rationales Comprehensive metabolic panel (CMP)- a broad spectrum of 14

cholesterol at his last physical exam in 2019, with a total cholesterol of

tests that assess the body for liver function, kidney function,

218 mg/dL. Pt. states that was prescribed Lipitor but did not fill the

diabetic status, electrolyte and fluid imbalances, and/or

prescription or begin the regimen.

parathyroid status (URMC, 2020).

PTSD- pt. sustained physical and mental trauma related to deployment in

EKG- captures electrical activity of the heart via electrodes

Afghanistan. Pt. is actively working with psychologist and other healthcare attached to the skin of the chest. Aids in diagnosis of prior or providers through the VA.

current heart attack (Banasik & Copstead, 2019).

Cervical Spondylosis- Compression of L1, L3, and L5 vertebrae;

Echocardiography- provides images of cardiac structure and

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herniated disc.

movement within the chest via ultrasound. Chest X-Ray- assess for pneumonia or heart failure, which could

Pathophysiology of medical diagnosis:

be the reason behind the chest pain (Banasik & Copstead, 2019).

Hypercholesterolemia: characterized by increased levels of LDL

MRI and CT- used to evaluate levels of coronary plaque,

cholesterol in the blood that contribute to the formation of atherosclerotic

determine their stability, and evaluate CAD risk and/or

plaques. These plaques may develop into coronary artery disease or results

progression (Banasik & Copstead, 2019).

in an aortic aneurysm or stroke. Furthermore, plaques damage to the

Troponin test- measures the plasma protein troponin which is

endothelial lining of the arterial walls. This allows for an increase of LDL

released because of heart muscle damage, often associated with a

particle accumulation within the vessel wall. "LDL is then modified and

heart attack (UCSF, 2020).

taken up via scavenger receptors on macrophages resulting in foam-cell

CK-MB test- measures the amounts of creatine kinase in the

formation." Smooth muscle cells eventually grow over the lesion of lipid

blood, which is found in the heart muscles and other organs.

plaques and can cause occlusion of the vessel (Huff, 2020).

During a heart attack injured muscles will release CK-MB into

Post-traumatic stress disorder (PTSD)- a chronic anxiety disorder that

your blood (URMC, 2020).

results after exposure to trauma. It occurs in 8 to 14% of the US

Serum myoglobin- a small protein that stores oxygen which can

population, and is often a result of military combat, natural disaster, or

also be measured to help diagnose a myocardial infarction

physical assault. Persons affected with PTSD often succumb to major

(URMC,2020).

depression, anxiety disorders struggle with drug and alcohol abuse and engage in suicidal behaviors. Although the pathophysiology is still being researched, some findings indicate that disorders of serotonergic (5-HT) receptor systems in the brain are the cause of PTSD (Baily et al., 2013).

Cervical spondylosis: degeneration of cervical discs with ultimate collapse of the disk space. Mechanical stress is placed upon the vertebral bodies at the end plates which result in the formation of osteophytes (Mattel et al., 2011).

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Intimacy v. Isolation- development of content relationships and a sense of

Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations Socioeconomic status: Patient states he is a senior operations

safety, caring and commitment; the individual has developed love for

manager for Amazon corporation, and he works 70 hours per

another person (Taylor et al., 2019). Pt states that he shares a home with

week, on the night shift; 2300-0100 arrival to 1100 to 1500

his long-time girlfriend and their dog. He states that she is very loving and

departure. He sleeps an average of 7 and 1/2 hours during the day

supportive in the relationship and feels that he can rely on her to help him

but wakes up several times. Patient states that he "tries to eat

with any health care needs. Pt. states that his mother was a nurse and nurse

healthy," but that a lot of time he is eating fast food or

educator for 37 years, and that she is available as a resource if questions

convenience foods. In addition, he consumes 2 cups of coffee

arise post discharge.

before his shift in the evening and 2 red bulls in the late morning

Erikson’s Developmental Stage with Rationale (APA citations)

to “keep energized.” Pt. indicates that he takes trazadone PRN for sleep and bupropion daily PO for depression related to PTSD. Pt states that he feels rundown, and that he spends most of his days off “trying to catch up on sleep.” Cultural: Patient speaks English as his first language, and he was born and raised in the United States. Spirituality: Client does not identify any spiritual orientation. Psychosocial considerations: Client lives with his partner in a suburb in Riverside county. Client states that he has friends at work and spends time/holidays with the family of his partner. He does not have any immediate family in the state of CA. Safety/harm risk: Pt states that he feels safe at home and in the hospital and does not want to harm himself or others.

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Potential Health Deviations, Predisposing & Related Factors; Interventions to Assess or Prevent Potential Health Deviations “At Risk for…” nursing dx (AT LEAST TWO) 1. Risk for unstable glucose level related to excess body weight and

Interprofessional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale With APA citations Discharge referrals/Interpersonal consults: The client may

elevated blood glucose of 107 mg/dL.

need to be referred to other doctors, specialists, or give additional

Interventions: Perform routine finger stick with glucometer to

resources to help manage their condition, and prevent escalation

determine glucose levels. Consider serum testing of HgbA1c.

to additional diseases processes. A cardiologist is necessary to

Educate pt. about nutritional management and follow-up visits

maintain heart health, while a registered dietician can assist with

with primary care physician to continue monitoring levels. Educate pt., about prevention of type 2 diabetes (Phelps et al., 2018). 2. Risk for latex hypersensitivity response related to known allergy. Interventions: Stress to pt. the importance of notifying all medical personnel of sensitivity to prevent contact. Suggest the use of

nutrition and weigh loss goal: Cardiologist: The patient presented with acute chest pain and has a history of high cholesterol, there for a referral to a cardiologist is recommended as they are specialists in treating and preventing diseases associated with the heart and blood vessels. In addition, the patient was experiencing shortness of breath, feelings of dizziness which are also cause for cardiac concerns. A cardiologist

medical ID to communicate allergen. Provide client with a list of

can also educate a patient about risks for heart disease and lifestyle

homebased products that contain latex and emphasize the

modifications they can make to prevent it. Moreover, a

importance of avoiding these items (Phelps et al., 2018).

cardiologist specializes in the treatment of myocardial infarction, heart failure and other dysrhythmias (ACC, 2020). Registered Dietician: A registered dietitian is a specialist on food and nutrition who can translate this information into practical solutions for healthy living. They utilize their expertise to aid and positive lifestyle changes working in community hospitals, public schools, public health care clinics, nursing homes, fitness centers, universities, or

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private practice. they advocate for the advancement of the nutritional status of Americans and people around the world. In addition, they will aid in the development of meal plan specific to a client's needs, such as eating in the reduction of weight and preventing the onset or management of diabetes (AND, 2020).

Diagnostic Label/

Nursing Diagnosis (at least 2)

1. Acute chest pain

Related to

Planning (outcome/goal) Measurable goal during your shift (at least 1 per Nursing diagnosis)

1. Reduce pt. pain to

Contributing Factors

Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) 1. Assess descriptive

Signs and Symptoms

As Evidenced by

Rationale (use APA citations)

Evaluation Goal Met, Partially met, or not Met and Explanation

1. assessing and

1. Pt states that pain

related to disease

4-5/10 within 2 hr.

characteristics of

documenting the

is 5/10 after 45

process as

of admittance.

pain, equality,

pain will aid in

mins of

evidence by pt.

intensity, and

determination of

medication

statement pf pain

location on scale

realistic goals for

administration.

of 8/10.

of 1 to 10.

the patient.

2. Modify patient’s

2. This allows the

environment

patients to

based of patients

actively

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desires to

participate in

promote sleep,

their treatment.

utilizing pillows

3. Provides relief for

and other

the patient's

measures to

discomfort and to

promote comfort.

evaluate a return

3. Administer pain medications and continue to monitor vitals. 4. Allow patient to

to baseline vital signs of the patient. 4. helps establish patient client

verbalize

relationship and

description of

lets the patient

pain and express

know that the

feelings related to

nurse is

their current

concerned about

situation (Phelps

what they are

et al., 2018).

feeling in relation to their pain (Phelps et al., 2018).

1. Monitor

1. Helps detect

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2. Impaired gas

2. Reduce

respiratory status,

changes in gas

2. Pt. can verbalize

exchange related

respiratory rate to

depth, breath

exchange, and

communication in

to pain as

12-20 breaths per

sounds, accessory

detects decreased

sentence

evidence

minute and

muscle use and

or adventitious

formation with

tachycardia and

reduce radial

auscultate breath

breath sounds.

the absence of

abnormal

pulse below 100

sounds every 4

Reassessment of

labored

breathing pattern.

bpm within 2 hrs.

hours. Monitor

vitals shows

breathing. Pt.

of admittance.

vital signs and

positive or

respirations

ABG.

negative changes

reduced to 16

in patient baseline

breaths per

supplemental

status (Phelps et

minute and radial

oxygen via nasal

al., 2018).

pulse of 88 bpm.

cannula at 4 liters

2. Helps increase

2. Administer

per minute. 3. Encourage patient

oxygenation to tissue, raising

to express feelings

saturation levels,

about procedures

also provides

and thoroughly

comfort to

explain the need

patient.

for interventions. 4. Encourage family

3. Helps establish a trusting

to stay by patient

relationship

side to help

between the

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reduce anxiety

nurse and patient

and promote

(Phelps et al.,

relaxation.

2018). 4. If the patient has the support of his loved ones nearby it promotes relaxation which reduces the demand for oxygen (Phelps et al., 2018).

MEDICATION LIST Medications (with APA citations) trazadone

Class/Purpose

Therapeutic/ antidepressant

Route

PO

Frequency

Mechanism of action / Onset of action

Common side effects

1, 50mg tablet PRN

Alters the effects of

Drowsiness,

Nursing considerations specific to this patient Increases digoxin

at bedtime

serotonin in the

confusion,

or phenytoin

CNS (Deglan &

hypotension, dry

serum levels.

Vallerand, 2009).

mouth, slurred speech (Deglan &

Increased depression with

Vallerand, 2009).

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CNS depression (Deglan & Vallerand, 2009). bupropion

1, 150 mg tablet

Decreases neural

Agitation,

Increase of

orally twice a day

uptake of

headache,

adverse reactions

Pharmacologic:

dopamine in

insomnia, dry

when used with

aminoketones

CNS(Deglan &

mouth, nausea

Vallerand, 2009).

(Deglan &

Therapeutic/

PO

Antidepressant

amatadine, levodopa, or MAO

Vallerand, 2009).

inhibitors (Deglan & Vallerand, 2009).

naproxen

1 500mg tablet PRN

Inhibits

Dizziness,

Increased risk of

nonopioid

twice daily with

prostaglandin

drowsiness,

bleeding with

analgesics,

food. Do not take

synthesis.

headache,

anticoagulants,

nonsteroidal anti-

for more than 2

Decreased pain,

constipation,

inflammatory

weeks per month to

reduction of fever.

diarrhea, and

agent, antipyretics.

reduce risk of

Suppression of

sweating (Deglan &

kidney & stomach

inflammation

Vallerand, 2009).

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