N101L final care plan - n/a PDF

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NURSING CARE PLAN

Student Instructor Patient

Iris Chavez 206

DOB

Full Code

Height/Weight

Room#

Code Status Allergies Temp (C/F Site) 91.8 F Orally

Date Course

Unit/

PC

Initial

Professor Sanchez

10/16/20 N101L 01/23/64 Height: 162.56 cm Weight: 70kg (154 lbs.)

NKA Pulse (Site) 77 beats per minute

Respiration 16 breaths per

(RA)

minute

Pulse Ox (O2 Sat) 97% ( at room air)

Blood Pressure 145/82 ( Left arm,

Pain Scale 1-10 0-10 on Numeric

digital automatic

Scale

monitor) History of Present Illness including Admission Diagnosis &

Physical Assessment Findings including presenting signs and

Chief Complaint (normal & abnormal) supported with

symptoms supported with Evidence Based Citations

Evidence Based Citations Chief complaint:

Physical Assessment findings

Had a recent stroke

Signs: Client is alert and orientated x4; patient is able to hear at

History of present Illness:

normal voice and does not wear hearing aids. PERRLA was not



56-year-old female with a history of cerebral infarction

with right sided weakness. 

shown as patient was not able to open left eye due to impair vision. Right eye had a 2-3 mm showing no signs of redness or

Patient was transferred from Ballard View Hospital to

discharge. Head had no bumps, masses, or skin breakdown.

Arlington Gardens Care Center after her recent episode

Patient hair was intact and equally distributed. No evidence of

of a stroke.

jugular vein distention (JVD) on the neck bilaterally indicating

Admission Diagnosis:

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interrupting venous return and protruding veins. There was no

NURSING CARE PLAN



Patient was admitted to the facility by medical transport

goiter in the thyroid showing swelling or enlargement of the

with hypertension, Type 2 DM, spastic hemiplegia

neck (Sommers, 2019). Upon palpating the neck there was no

affecting right dominant side, and muscle weakness

palpable lymph nodes. Carotid arteries are palpable and equal

developing difficulty walking.

rhythmic 2+. No drainage in both ears and upon palpating there

Spastic hemiplegia:

was no tenderness or pain. Face was equally symmetrical with

Spastic hemiplegia is when one side of the body is paralysis with

no signs of facial drooping and skin was dry, warm, and intact.

involuntary motor control, stiffness, and spasms. This occurs

Mouth had shown an unspecific reason for white coating on the

when there has been damage to the nerves, brain, or spinal cord

top of the tongue with no signs of halitosis, although patient was

and can be usually seen after a brain injury such as a stroke,

able to swallow and move tongue. Skin was normal to their

cerebral palsy, or any traumatic injury affecting the brain and

ethnicity although on the chest region on the left side showed a

nerves. One with spastic hemiplegia can experience mobility

skin discoloration appearing to be a scar. Heart sounds were

impairments as it relates to motor deficits (Banasik &

clear and lung sounds were clear anterior as well as posterior in

Copstead,2019).

all lung fields. When listening to the lungs there was no highpitched sound of popping sounds meaning sputum in the airway. Neither wheezing implicating constricted airways from swelling or secretions or rhonchi. If rhonchi were present during auscultating there would be coarse snoring sounds (Taylor et al., 2019). On the abdomen in all four quadrants during auscultation bowel sounds were active with no bumps in either quadrants. On the left lower quadrant there was scarring, and patient had a recent bowel movement on 09/24/20 Thursday. Patient range of motion is limited in the arms cannot extend left arm and only

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NURSING CARE PLAN

able to move right arm. Grip is strong unilaterally in left arm. No signs of clubbing and capillary refills were brisk 1+. Nail beds were pink. Coccyx showed no signs of skin breakdown or ulcers. The lower extremities are strong bilaterally although patient does use assisted devices such as a wheelchair. The heels were dry and callous. No evidence of deep vein thrombosis specifying patient has a blood clot (thrombus) in the lower extremities. Lower extremities were not warm, no signs or redness, or swelling (Banasik & Copstead,2019).

Symptoms: Patient had no pain during the assessment, on the left lower quadrant on patient abdomen she states, “hot water had burn on her stomach”. Patient feels safe in the facility and states she has depression but is not currently wanting to hurt herself.

Relevant Diagnostic Procedures/Results & Pertinent Lab

Past Medical & Surgical History,

tests/ Values (with normal ranges),

Pathophysiology of medical diagnoses

include dates and rationales supported with Evidence Based

(include dates, if not found state so)

Citations

Supported with Evidence Based Citations

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NURSING CARE PLAN

Medical Hx:

Diagnostics Procedures: Magnetic resonance imaging (MRI)



Major depressive disorder, date of diagnosis: 06/10/2016

Results: MRI of the brain had shown a subacute infarct involving



Hypertension (HTN), date of diagnosis:03/23/2001

the left temporal lobe, left occipital lobe, and the left basal



of degrading blood products.

Type 2 Diabetes Mellitus (DM), date of diagnosis: 05/25/2015

ganglia, infarct in the left occipital. Left side does show evidence 

Diabetic neuropathy, date of diagnosis: 09/5/2019

Date test taken: 08/20/20

Surgical Hx:

Lab test rationale:

N/A

The Magnetic resonance imaging (MRI) uses superconducting

Psychosocial Hx:

magnetic and radiofrequency to examine the body organs in

Tobacco substance use

different dimensions. This procedure is noninvasive and could be

Family Hx:

used to detect injuries or abnormalities in the brain, kidneys,



Diabetes

tendons, ligaments, and view the heart structures (Banasik &



Heart disease

Copstead,2019). According to the results above the patient had



Mother and Father are not deceased.

an MRI conducted following her recent stroke showing

Pathophysiology of Medical Diagnosis

degrading blood products in the brain and disturbed blood supply

Major depressive disorder (MDD): MDD is a mental illness

in the left temporal lobe including other locations which is more

where there are alterations in the brain function that develops

visually in the left side of the brain.

from inherited genetics. The cognitive section of the brain

Complete Blood Count (CBC)

portrays negative experiences bringing down the person to view

Results:

everything with a negative bias standpoint. MDD includes the

CBC White blood cell

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RESULTS 9.4

NORMAL RANGE 5000-10,000

person's emotions, feelings, and memories turning them into negative information. With this disorder, the neurotransmission is

NURSING CARE PLAN

Red blood cell Hemoglobin

4.5

cells/mm^3 4.2-6.2 million

13.6

cells/mm^3 Females: 12-16 g/dL

Hematocrit

Platelet Count

34.6

299

Males: 13-18 g/dL Females: 37%-

dysregulated with impaired functioning of the hippocampal, prefrontal cortex, and the hypothalamus-pituitary-adrenal (HPA) system. The person central nervous system (CNS) will have decreased levels of serotonin which is found to be the neurotransmitter that creates happiness and soothes our moods. Also their melatonin hormones can fluctuate by either reducing or

47%

increasing amounts making the person have disturbed sleep

Males: 42%-52% 150-400 billion

because of the cardician rhythms being out of equilibrium. There

cells/L

Brain-derived neurotrophic factor (BNF) are decreasing causing

have been findings when stress hormones are increasing the

Date test taken: 08/28/20

the hippocampal cells to become decreasing in size relating to the

Lab test rationale:

decreased neurotransmission in this area (Banasik &

A complete blood count (CBC) is a laboratory diagnostics test to

Copstead,2019).

examine the values and components that are compacted in a red blood cell (RBC). Based on the results it can tell us if the patient

Hypertension (HTN): Hypertension is when the blood pressure of

has develop either an infection, disease, or some type of cancer

a person is high and their systolic being 130mmHg or greater

based on their abnormal values. RBC’s are formerly known as

including their diastolic being greater than 80mmhg. HTN

erythrocytes that are responsible for delivering oxygen to the

develops with other types of disease and can be form when

tissues and eliminating carbon dioxide from the tissues. The

consuming large amounts of sodium, alcohol consumption, or use

RBC plays a huge role in our body functions and without them

of tobacco. The person total peripheral resistance will be

the body will have inadequate oxygen supply for our organs to

increased as well as their afterload which then develops in HTN.

work properly. If the patient has a decrease RBC count they will

During HTN the heart has to increase their load of pumping to

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NURSING CARE PLAN

become anemic where there is not enough blood circulating in

keep up with the rising blood pressure. For example, cardiac

their body. The hemoglobin is a protein inside of the RBC that

output which increases the person heart rate and stroke volume

allows oxygen to be transported throughout the body composed

along with the contractility of the heart cells. With this condition

of oxyhemoglobin and carboxyhemoglobin (Banasik &

its often associated with some underlaying factor such as a

Copstead,2019). In addition, white blood cells (WBC) also

cardiovascular disease, kidney dieses, or vascular disease

known as leukocytes serve the human body to fight infections off

(Banasik & Copstead,2019). The underlying reason for HTN

which is aided in our immune function. The WBC’s consist of

ranges from genetics, environmental hazards, or as previously

lymphocyte, neutrophils, eosinophils, basophils, and monocytes

mention an underlying disease or illness. The renin-angiotensin-

each having their own specific roles when it comes to fighting an

aldosterone system (RAAS) has an effect on how HTN develops

infection. Our platelet is used for stopping bleedings and forming

with the formation of angiotensin being converted to angiotensin I

clots to damaged tissue sites which is used by hemostasis

from an enzyme from the kidneys called renin allowing this

(Banasik & Copstead,2019). When our platelet counts are

conversion to occur. Once angiotensin I has developed the

decreased the person would develop thrombocytopenia and if

angiotensin-converting enzyme transforms angiotensin I into

they are increased thrombocytosis will form. When examining

angiotensin II. Now once in this stage the RAAS can go into two

the hematocrit values it is a measure of the total blood volume of

categories such as vasoconstriction which ends at the development

an RBC. If hematocrit results are increase the patient can

of a bloop pressure being increased and the release of aldosterone

develop hypovolemia where there is low fluid volume which if it

who then retains sodium and water to increase the blood volume

comes to serve patient can go into hypovolemia shock (Banasik

and blood pressure (Banasik & Copstead,2019).

& Copstead,2019). An example of when a decrease hematocrit can occur is when the patient receives the wrong blood

Type 2 Diabetes Mellitus (T2DM): Type 2 Diabetes Mellitus is

compatibly leading them into hemolytic anemia destroying their

contributed to the lack of insulin being delivered across the tissues

erythrocytes. Based on the patient results above their values are

and beta cells impairments from the pancreas resulting in the

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NURSING CARE PLAN

in all normal range. This test was ordered because the patient

failure of glucose homeostasis. Glycogen functions that are

had a stroke which interruptus the blood supply to the brain

regulated from the sympathetic systems are increased and the

which can reveal if it is associated with a type of blood disease,

GLP-1 and GIP are reduced GLP-1 and GIP are needed to

cancer, or infection.

promote insulin production while glucose is active to allow the

Comprehensive Metabolic Panel (CMP)

beta cells to grow in numerous amounts to be able to secrete

Results:

insulin throughout the body (Banasik & Copstead,2019). T2DM

CMP Sodium Potassium Chloride Glucose Blood Urea

Results 135 (low) 4.7 100 149 (high) 18

Normal Range 136-145 mEq/L 3.5-5 mEq/L 100-106 mEq/L 100-125 mg/dL 10-20 mg/dL

is also associated with hyperglycemia that produces high amounts

Nitrogen (BUN) Creatinine Calcium

1.1 8

0.6-1.2 mg/dL 9-10.5 mg/dL

underlying cause of diabetes mellitus is poorly controlled. This

Carbon Dioxide

25

20-35 mEq/L

underlying diabetic disease more commonly in diabetes mellitus

SGPT (ALT)

30

5-35 u/mL

due to peripheral nerve damage and changes in the central nervous

SGOT (AST)

27

5-40u/mL

system that contributed to metabolic and vascular insufficiency.

Bilirubin

0.5

0.3-1.1 mg/dL

Usually the person can experience loss of sensory sensation

Albumin

4

3.5-5.5 g/dL

followed by numbness and tingling. Diabetic neuropathy is a

Proteins

5

6-8 g/dL

microvascular complication as it disrupts the platelets inability to

of sugar in the blood because the body is not producing insulin or withstanding it.

Diabetic Neuropathy: Diabetic Neuropathy develops because the

illness is commonly associated with the person having an

Date test taken: 08/28/20

work because hyperglycemia inhibits it. During the initial stage of

Lab test rationale: A Comprehensive Metabolic Panel (CMP)

diabetic neuropathy the glomerulus flow rate is increased then

measures many components by taking a sample of a person’s

turning into to hyperfiltration meaning the rate of the blood being

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NURSING CARE PLAN

blood to analyze the human body electrolytes, kidneys, and livers

filtered is high. When hyperfiltration keeps on occurring the

to determine if they are in within the normal range. Sodium,

glomerulus starts to thicken and get harden while the capillaries

potassium, calcium, and chloride are our electrolytes that are

are getting blocked and leaking (Banasik & Copstead,2019).

minerals that keep our body balanced by strengthen our muscles

Without proper care of diabetes neuropathy in the lower

and contracting them. They also maintain our fluid balance,

extremities it can lead into ulcers then turning into gangrene

regulate our blood pressure, and hormone production (ATI

meaning necrotic tissue which then results in amputation.

Nursing, 2016). If either of these electrolytes are imbalanced, the body will react. For instance, if sodium was low (hyponatremia) it means we have an excess of water and losing amounts of sodium. The person will experience muscle weakness, hypotension, vomiting, abdominal cramping, or tachycardia. There are numerous reasons why this could occur, and it can range from excessive gastrointestinal losses where our electrolytes are most stored to cirrhosis or hyperglycemia. On the other hand if the person would consume too much sodium it would result in hypernatremia where they will show signs and symptoms of hyperthermia, muscle twitching, or edema because the blood has too much sodium causing hypertonicity (ATI Nursing, 2016). The BUN and creatine values measures renal functions and cane determine if one is dehydrated or overhydrated. Creatine levels reflects the glomerulus filtration rate (GFR) which is responsible for filtering out the blood in the

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kidneys while BUN determines how much urea is being metabolism. If someone is dehydrated significantly their creatine and BUN will be elevated and if they were overhydrated it will be vice versa such as a decreased result (ATI Nursing, 2016). In addition, ALT, AST, bilirubin, and albumin test the liver functions and glucose measures the sugar in the blood for diabetes. Based on the results above the patient has high amounts of glucose in their blood which can relate to their diagnosis of T2DM and their low sedum results indicating they have hyponatremia during the date of the test was taken.

Erikson’s Developmental Stage with Rationale

Socioeconomic/Cultural/Spiritual Orientation

And supported by Evidence Based Citations

& Psychosocial Considerations/Concerns (3) supported with

Erikson Theory is the different stages of life through

Evidence Based Citations Socioeconomic: Patient is unemployed and lives with her sisters

development while each person progression to different

in Riverside, CA.

categories of coping based on their age. Also with what their

Cultural: African American and celebrates American holidays.

tasks should be based on their stage he relives how the person

Spirit...