NSG245A Nursing Care Plan PDF

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NSG2 05 ACl i n i c a lRe a s on i n gWo r k s h e e t

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NSG 205A – Medical Surgical Nursing I Lab Clinical Reasoning Care-plan

Students Name: Taylor Rowley Date: 11/9/2020 Patient Initials: Age/Gender: Male Code Status: Full Allergies: Vicodin Surgery: Debridement decubitus ulcer with flap on right buttock I.

Admit Date: 11/6/2020 Room #: 313 Isolation: None

Synthesis of the Disease 1.

CHIEF COMPLAINT on admission? Refer to MD H&P and initial notes. (Chief complaint and medical diagnosis e.g. SOB secondary to Pneumonia)

Admission for surgical debridement decubitus ulcer with flap on right side of buttock. 2.

What is the current problem, signs and symptoms the patient is manifesting? Refer to the latest progress note. Provide a brief synthesis of the disease condition as it applies to your patient (cite reference).

Patient is post-op. Has an open wound on bilateral ankle. Possible pneumonia due to immobility post-op. II. Data Collection a. Personal/Demographic Data (e.g. age, gender, race/ethnicity) Patient is a 57-year-old Caucasian male. Patient is single and lives with his mother.

Clinical Significance Gives background information to the patient.

b. Past Medical History: (e.g. HTN, Diabetes, Asthma)

Clinical Significance

Paraplegic pt Colostomy Diabetic DVT Foley catheter High Cholesterol Obstructive Sleep Apnea Osteomyelitis Elbow injury – left arm

Patient is paraplegic – contributes to immobility complications after surgery. Foley catheter and colostomy always present. Patient is diabetic – contributes to slow healing

c. Socio/Economic History:(Family support, living situation, occupation) Patient has no job. Lives at home with his mother. Says he has support in family and friends.

d. Diagnostic Tests and

(Revised 2017)

Results

(Last revised: 2017/19.03)

Clinical Significance Patient has help – if anything were to happen, he would have help and support to take care of him.

Clinical Significance:

NSG2 05 ACl i n i c a lRe a s on i n gWo r k s h e e t

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Procedures Debridement decubitus ulcer with flap on right buttock

Patient got through surgery well. JP drain inserted at incision site. Surgery was successful.

e. RELEVANT Lab(s):

Normal range:

Glucose POCT

70-100

WBC

3.5-10.5

Hct

PLT

M: 38.8-50.0 F: 34.9-44.5 M: 13.5-17.5 F: 12.0-15.5 150-450

Na+

135-145

Cl

95-105

BUN

10-20

K+

3.5-5.9

Hgb

Patient had no issues during surgery – no signs or symptoms of infection.

Date/Result: ____________

Clinical Significance:

11/6/2020 217 mg/dL 11/6/2020 7.8

Glucose is High

11/6/2020 31.6 11/6/2020 10.3 11/6/2020 265 11/6/2020 135 11/6/2020 101

Hematocrit is low – indicating possible anemia

Normal range

Hemoglobin is low – indicating possible anemia Normal range Normal range Normal range

11/6/2020 10 11/6/2020 3.5

Normal range Normal range

III. Nursing Assessment: 1. Vital Signs Trend: Vital Signs: Date/Time: 11/6/2020 0730

Date/Time: 11/6/2020 1140

T: P: R: BP:

98.6 64 17 102/58

97.9 75 18 109/62

O2 sat:

99%

99%

2. Pain Pain Assessment Assessment Tool:

Time: 0730 1-10

Pain Level:

0

Location: N/A Quality of pain: N/A 3. Intake and Output:

(Revised 2017)

Time: 1140 1-10

Date/Time : 11/6/2020 1430 98.2 68 17 105/60 99%

Clinical Significance

Normal, within range. Normal, within range. Normal, within range. BP is on the hypotensive side – could be possible side effect from surgery. Normal, within range.

Time: 1430 1-10

Clinical Significance:

0

0

Pt. is paraplegic. No pain felt.

N/A N/A

N/A N/A

N/A N/A

(Last revised: 2017/19.03)

0 being no pain, 10 being the worst pain ever.

NSG2 05 ACl i n i c a lRe a s on i n gWo r k s h e e t

Intake Output I/O Balance 4.

Time: 0730 714.58 760 -45.4

Time: N/A -

3 Clinical Significance Patient is losing more than he is taking in.

Physical Examination: Date and Time of Assessment: 11/6/2020, 0800 GENERAL APPEARANCE: No isolation precautions. Patient is in good spirits and rests comfortable. No anxiety or uncertainty about condition. NEUROLOGICAL: AAOx4; Paraplegic – No feeling below waist. CARDIOVASCULAR: S1, S2 present – normal rate and rhythm. RESPIRATORY: No SOB, patient has crackles in lower lobes. Possible pneumonia. GASTROINTESTINAL/ABDOMEN: Colostomy bag – LBM 11/5/2020 BS present x4 quads. GENITOURINARY: Foley catheter, present on admission. Inserted on 10/29/2020 at 0930. MUSCULOSKELETAL/EXTREMITIES: Paraplegic – MORSE rating 55. Upper extremities good strength, no decreased muscle tone. INTEGUMENTARY: Open wound bilateral ankle. Right heel pressure ulcer pre-hospital stage IV. Patient has small skin tear on lower, left back from immobilization – happened during bed bath on 11/6/2020. Braden Score – 15. VTE risk level – HIGH.

IV. Patient Care 1.

Summary of treatment plan (Review Progress notes and H&P, outline problems identified by provider with corresponding treatment plan with interdisciplinary practice e.g. Infection: continue antibiotics and wound consult. Pain- continue analgesia per pain pharmacy service)

Continue to monitor JP drain in right buttock – monitor I&Os and for signs of infection. Encourage patient to participate in use of incentive spirometer and coughing exercises to prevent respiratory issues after surgery. Continue to care for wounds on lower extremities, dressing changes, etc. Administer medications as prescribed. Patient is on a consistent carb, no calorie level, diet. 2.

Current Medication List:

Medications Generic/Trade Name Dose/Route/Freque ncy Apixaban 5mg PO

(Revised 2017)

Classification and Mechanism of Action

Anticoagulant Acts as a selective, reversible site inhibitor

Side Effect and Adverse Reaction

Hemat: BLEEDING Misc: HYPERSENSITIVITY

(Last revised: 2017/19.03)

Nursing Considerations

Assess patient for symptoms of stroke, DVT, PE, bleeding, or peripheral

NSG2 05 ACl i n i c a lRe a s on i n gWo r k s h e e t BID

Ferrous sulfate 130mg PO Elixir Daily

of factor Xa, inhibiting both free and bound factor. Does not affect platelet aggregation directly, but does inhibit thrombininduced platelet aggregation. Decreases thrombin generation and thrombus development.

REACTIONS INCLUDING ANAPHYLAXIS * CAPITALS indicate life-threatening.

Antianemics Iron is essential for hemoglobin, myoglobin and enzymes, it is transported to organs where it becomes part of iron stores.

Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.

4 vascular disease periodically during therapy. Toxicity Overdose: Antidote is andexanet alfa. Effects persist for at least 24 hrs. after last dose. Oral activated charcoal decreases apixaban absorption, lowering plasma concentrations. Other agents and hemodialysis do not have a significant effect.

Black, tarry, or bloody stools. Fever. Very upset stomach or throwing up. Very bad belly pain. Throwing up blood or throw up that looks like coffee grounds.

May cause seizures, hypotension, constipation, epigastric pain, diarrhea, skin staining, anaphylaxis Assess nutritional status, bowel function Monitor hemoglobin, hematocrit, iron levels May cause elevated liver enzymes Take on an empty stomach to increase absorption/vitamin c helps with absorption Use z-track for IM injections

Lasix 40mg tablet daily

(Revised 2017)

Diuretic Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium. Effectiveness persists in impaired renal function.

CNS: blurred vision, dizziness, headache, vertigo. EENT: hearing loss, tinnitus. CV: hypotension. GI: anorexia, constipation, diarrhea, dry mouth, dyspepsia, nausea, pancreatitis, vomiting. GU: excessive urination. Derm: photosensitivity, pruritus, rash. Endo: hyperglycemia, hyperuricemia. F and E: dehydration, hypocalcemia, hypochloremia, hypoka lemia, hypomagnesemia, hyponatremi a, hypovolemia, metabolic alkalosis. Hemat: APLASTIC ANEMIA, AGRANULOCYTOSIS, hemolytic anemia, leukopenia, thrombocytopenia. MS: muscle cramps. Neuro: paresthesia.

(Last revised: 2017/19.03)

Implement fall-prevention strategies, especially in older adults or if patient exhibits sedation, dizziness, blurred vision, or other impairments that affect gait and balance (See Appendix E). Use caution during aerobic exercise, especially in hot environments. Increased sweating will cause fluid and electrolyte loss, and may exaggerate diuretic side effects (dizziness, muscle cramps, and so forth). To minimize orthostatic hypotension, patient should move slowly when assuming a more upright position.

NSG2 05 ACl i n i c a lRe a s on i n gWo r k s h e e t Misc: fever, increased BUN, nephrocalcinosis.

HumaLOG – sliding scale

Methenamine 1g PO BID

Vancomycin 1500mg IVPB Q12h

(Revised 2017)

5 Causes photosensitivity; use care if administering UV treatments. Implement aerobic exercise and endurance training programs to maintain optimal body weight, improve insulin sensitivity, and reduce the risk of macrovascular disease (heart attack, stroke) and microvascular problems (reduced blood flow to tissues and organs that causes poor wound healing, neuropathy, retinopathy, and nephropathy). Provide a source of oral glucose (fruit juice, glucose gels/tablets, etc.) to treat mild hypoglycemia. Call for emergency assistance if symptoms persist or in cases of severe hypoglycemia. Emergency treatment typically consists of IV glucose, glucagon, or epinephrine. Do not apply physical agents (heat, cold, electrotherapeutic modalities) or massage at or near the injection site; these interventions will alter insulin absorption from subcutaneous tissues.

Antidiabetics; Hormones Lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Other actions of insulin: inhibition of lipolysis and proteolysis, enhanced protein synthesis

Endo: HYPOGLYCEMIA. Local: lipodystrophy, pruritus, erythema, swelling. Misc.: ALLERGIC REACTIONS, INCLUDING ANAPHYLAXIS.

Antibiotic, Antiinfective Methenamine is hydrolyzed to formaldehyde and ammonia in acidic urine; formaldehyde has nonspecific bactericidal action

Integ: rash, pruritus, hypersensitivity reactions GI: N&V, upset stomach, stomatitis, GI disturbances, diarrhea, abdominal cramping, anorexia GU: hematuria, bladder irritation, dysuria, urinary frequency Hepatic: elevated AST, elevated ALT

Urine should be acidic (pH...