NURS 101L Marvin Hayes Nursing Care Plan PDF

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Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L

Student Julie Pineda Instructor Professor Sylvain Patient Initial

Date Course Unit/ Room#

MH

Surgical Unit 0800

Code Status Allergies N/A Temp (C/F Site) 99˚F

DOB Height/Weight

Pulse (Site) 95

Respiration 18

History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with Evidence Based Citations History of Present Illness: Rectal adenocarcinoma (Vsim for Nursing, Marvin Hayes) Chief complaint: Experienced weight loss, increasing fatigue, and narrowing stools with blood (Vsim for Nursing, Marvin Hayes). Medical Diagnosis: Colorectal Cancer (Vsim for Nursing, Marvin Hayes).

Pulse Ox (O2 Sat) 95

Blood Pressure 132/86

10/13/2019 NURS 101L 10/03/1977 178cm/75kg

Pain Scale 1-10 1

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations Skin: The client’s skin is uniform in color, unblemished and no presence of any foul odor. He has a good skin turgor and skin’s temperature is within normal limit. Noticeable incision in the perineal area related to recent surgery. Hair: The patient has no hair on his head and has a variable amount of body hair. There are also no signs of infection and infestation observed. Nails: The client has nails on all phalanges and has the shape of convex curve. It is smooth and is intact with the epidermis. When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds. Head: The head of the client is rounded; normocephalic and symmetrical. Skull: There are no nodules or masses and depressions when palpated. Face: The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses. Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned and showed equal movement when asked to raise

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Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L

and lower eyebrows. Eyes The pupils of the eyes are black and equal in size. The iris is flat and round. PERRLA (pupils equally round respond to light accommodation), illuminated and non-illuminated pupils constricts. Ears and Hearing Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles are aligned with the outer canthus of eye. When palpating for the texture, the auricles are mobile, firm and not tender. The pinna recoils when folded. During the assessment of Watch tick test, the client was able to hear ticking in both ears. Nose and Sinus Nose: The nose appeared symmetric, straight and uniform in color. There was no presence of discharge or flaring. When lightly palpated, there were no tenderness and lesions Mouth: The lips of the client are uniformly pink; moist, symmetric and have a smooth texture. Teeth and Gums: There are no discoloration of the enamels, no retraction of gums, pinkish in color of gums. The buccal mucosa of the client appeared as pink; moist, soft, glistening and with elastic texture. Neck: The neck muscles are equal in size. The client showed coordinated, smooth head movement with no discomfort. The lymph nodes of the client are not palpable. The trachea is placed in the midline of the neck. Thorax, Lungs, and Abdomen Lungs / Chest: The chest wall is intact with no tenderness and masses. There’s a full and symmetric expansion and manifested quiet, rhythmic and effortless respirations.

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Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L

The spine is vertically aligned. The right and left shoulders and hips are of the same height. Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no presence of heaves or lifts. Abdomen: The abdomen of the client has an unblemished skin and is uniform in color. The abdomen has a symmetric contour. There were symmetric movements caused associated with client’s respiration. Patient has a colostomy bag on the RUQ of the abdomen. When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds. Extremities The extremities are symmetrical in size and length. Muscles: The muscles are not palpable with the absence of tremors. They are normally firm and showed smooth, coordinated movements. Bones: There were no presence of tenderness and swelling. Joints: There were no swelling, tenderness and joints move smoothly. Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges), include dates and rationales supported with Evidence Based Citations

Test

Norms

WBC

11

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On admission 10

Current value 8.9

Test

Norms

Sodium

136

On admission 140

Current value 138

Past Medical & Surgical History, Pathophysiology of medical diagnoses (include dates, if not found state so) Supported with Evidence Based Citations Underwent a laparoscopic abdominal perineal resection with a

Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L

Hemoglobin Hematocrit Platelets PT INR aPTT HA1c BNP

11 33 200 N/A N/A N/A N/A N/A

11.5 34 180 12 N/A 30 N/A N/A

11.8 35 212 N/A N/A N/A N/A N/A

Potassium Calcium BUN Creatinine Magnesium Blood Glucose Urinalysis Culturesblood/sputum

4.1 N/A 15 0.9 N/A 108 N/A N/A

4.5 N/A 12 0.8 N/A 90 N/A N/A

4.4 N/A 12 0.8 N/A 88 N/A N/A

permanent sigmoid colostomy 3 days ago for rectal cancer(Vsim for Nursing, Marvin Hayes).. Colorectal Cancer start as a growth on the inner lining of the colon or rectum. These growths are called polyps. Some types of polyps can change into cancer over time (What Is Colorectal Cancer?: How Does Colorectal Cancer Start?).

Erikson’s Developmental Stage with Rationale And supported by Evidence Based Citations

Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations Generativity vs. Stagnation. Mr. Hayes is currently in his middle age where White 43 year old Chrisrtian male (Vsim for Nursing, Marvin Hayes) he is trying to make his mark on the world (2019). A concern: body image issue, physchological concerns due to colostomy (2019). Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each (“At Risk for…” nursing dx)



Risk for infection related to colostomy

o Maintain strict aseptic technique for dressing changes. o Monitor white blood cell count. o Assess immunication status and history. 

Risk for postoperative complications o Assess for any bleedings.

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Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale supported with Evidence Based Citations Gastroenterologist consult for bowel studies (2019). Dietician must be consulted to progress from clear liquid to advancing normal diet (2019). Case management consult placed to have a HHC visit home to assess patient (2019). Surgeon to follow up with patient before discharge and upon any complication related to surgery (2019).

Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L

o o

Assess presence or degree of insicion. Evaluate the scar tissue.

Diagnostic Label

Priority Nursing Diagnosis (at least 2) Written in three part statement Risk for infection related to colostomy

Anxiety related to recent weight loss and increasing fatigue

Related to

ePlanning (outcome/goal) Measureable goal during your shif (at least 1 per Nursing diagnosis) Patients WBC count will remain WNL. Patient will not have a high temperature during shift. Patient will state having no anxiety or manageable levels of anxiety throughout shift.

Contributing Factors

Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) Intiate specific precautions for suspected agents.

Allow patient to talk about anxious feelings and examine anxiety Provoking situations if they are identifiable.

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As evidenced by

Rationale Each must be supported with Evidence Based Citations

Covid19, MRSA, etc. Requiring specific PPE usage to prevent further spreading/complications (2019). Discussing the patients anxiety can help the patient perceive the situation realistically (2019).

Signs and Symptoms

Evaluation Goal Met, Partially Met, or Not Met & Explanation

Evaluation goal met

Evaluation goal met

Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L

MEDICATION LIST Medications (with APA citations) Omeprazole (2020)

proton pump inhibitors (PPI)

PO

Daily at 0900

Dose (& range) If out of range, why? 40mg

Enoxaparin (2020)

Anticoagulant

SQ

Daily at 0900

40mg

Hydrocodone/ Acetaminophe (2020)

Anticoagulant

PO

PRN

10/325mg

Class/Purpose

Route

Frequency

Common side effects headache abdominal pain diarrhea Nausea Diarrhea anemia confusion Nausea vomiting constipation lightheadedness dizziness

Nursing considerations specific to this patient Avoid alcohol an foods that cause irritation Monitor for bleeding

Monitor for orthostatic hypotension

References:

Vsim for Nursing Marvin Hayes. (n.d.). Retrieved October 13, 2020, from https://thepoint.lww.com/Book/Show/592700?focus=vs Taylor, C., Lynn, P., & Bartlett, J. L. (2019). Fundamentals of Nursing (9th ed.). New york, NY: Wolters Kluwer. Jones, & Bartlett. (2020). Nurse's Drug Handbook. Burlington, MA: Jones & Bartlett Learning.

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Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L

What Is Colorectal Cancer?: How Does Colorectal Cancer Start? (n.d.). Retrieved October 20, 2020, from https://www.cancer.org/cancer/colon-rectal-cancer/about/what-is-colorectal-cancer.html

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