Nursing Care Plan - class assignment PDF

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Appendix A care Plan Student Name: Paulette Darbey CLIENT DEMOGRAPHIC INFORMATION Client Initials: DOB: 1965 Age: 64 years K. B Date (s) cared for: 13th March 2021

Wt: N/A

Allergies: No history of any allergies

Section I: PHYSIOLOGICAL ASSESSMENT & NURSING DIAGNOSES MEDICAL HISTORY: Reason for admission: High blood pressure with symptoms such as headache and dizziness Medical history: Positive history of hyperlipidemia, not current on any medication, no history of food or drug allergies Current medical Problems: High blood pressure, hyperlipidemia, deficient in knowledge Surgeries/Procedures: None PATHOPHYSIOLOGY Current medical Diagnoses/problems Hypertension/high blood pressure

How this relates to this patient The patient has elevated blood pressure which impairs blood supply to the brain leading to dizziness. As well, increased in blood pressure results in headache that the patient presents with

RELEVANT LABORATORY FINDINGS Date of Test Test Name Patient’s lab Findings

Normal range

03/13/2021

3.5-10.5 x 109/L

03/13/2021

03/13/2021

Complete blood count (WBC) Basic metabolic panel (creatinine) Lipid panel (total cholesterol)

RELEVANT LABORATORY FINDINGS VITAL SIGNS Temperature 98.9F Heart rate 88bpm Respiratory rate 18bpm

0.9-1.3 mg/dL

below 200 (5.18 mmol/L)

How does the value related to this patient? (Analyze trend) Patient’s hypertension

Blood pressure SaO2 Pain/Scale used

178/90mmHg 95% in room air N/A

REVIEW OF SYSTEMS NEUROLOGICAL CARDIOVASCULAR PULMONARY GASTROINTESTINAL GENITOURINARY/REPRODUCTIVE MUSCULOSKELETAL INTEGUMENTARY

The patient has headache and dizziness but no convulsions No palpitation, no chest pain, no dyspnea on exertion No cough, no chest pain, no difficulty in breathing No diarrhea, no vomiting, no nausea, no abdominal pain No dysuria, no hematuria, no urinary incontinence, no urgency No joint pain, no muscle pain No rashes, no area of hyperpigmentation of hypopigmentation

SECTION II: DEVELOPMENT & PSYCHOSOCIAL ASSESSMENT DEVELOPMENTAL ASSESSMENT Expected developmental milestones Nutrition Elimination Gross Motor Fine motor Language Cognitive development Self-Concept Roles and Relationships Coping and Resiliency

Actual Stage of Development (How does this patient compare to expected milestones) N/A N/A N/A N/A N/A N/A N/A N/A N/A

FAMILY ASSESSMENT The patient lives alone. The wife died two years ago following Road Traffic Accident. He has two sons and one daughter. The one son and the daughter regularly visits on a weekend. The younger son lives nearby and therefore frequently visits. He reports good relationship with the children. SECTION III: NURSING PROCESS: Problem 1: High blood pressure Risk factors: High lipid levels in blood, genetics, and history of smoking for 20 pack years.

General Goal: To reduce and maintain blood pressure within the normal ranges Nursing Strategies/Interventions Administration of anti-hypertensive drugs as directed by the physician Monitoring and recording of blood pressure Monitoring the response to medication to control blood pressure Reducing the level of activity Educating the patient on importance of compliance to medication

Patient Responses The patient should be compliant to taking medication and develop a self-initiative of taking the medication The patient should be compliant to the nursing interventions The patient should be compliant to medication The patient should engage in activity to the level least to cause symptoms The patient should demonstrate understanding during educative session with the nurses and physicians

Problem 2: Hyperlipidemia Risk factors: Diet, genetics, General Goal: To reduce the lipid levels to normal range and maintain it as low as possible in order to reduce the risk of further complication Nursing Strategies/Interventions Administration of the anti-lipidemia drugs as prescribed by the physicians Regularly checking the lipid levels in the blood Assist the patient in developing a health nutrition plan Monitoring for any potential complication associated with elevated lipid levels

Patient Responses The patient should accept the medication as directed by the physician Compliance to the interventional procedure The patient should strictly follow the stipulated nutritional plan The patient should report any new symptoms that develops to the nurses

Problem 3: Deficient in knowledge Risk factors: lack of ability to recall/knowledge, information misinterpretation, cognitive limitation and denial of the diagnosis General Goal: To improve the knowledge and understanding of his condition in order to improve on compliance and adherence to medication Nursing Strategies/Interventions Educate the patient on the important information about their health status and assess for proper understanding Assisting the patient in identifying and

Patient Responses The patient should demonstrate understanding on the health status The patient should be willing to engage in

managing the risk factors that could worsen his condition Discuss with the patient on the necessity of eliminating smoking and assist the patient in formulating the plan to quit smoking Help the patient in developing a simple and convenient plan for taking medication to ensure compliance

activity to identify the potential risk factors. The patient should be ready to quit smoking

The patient should demonstrate compliance to the plan of taking medication as per stipulated simple plan

Document ALL regularly scheduled medications given during the clinical shift, attach additional sheet if necessary Medication list Medication: Trade/Generic (reference page # in parenthesis) Classification/Action

1 Intravenous labetalol

2 3 Nifedipine Artovastat in

Beta blockers

Calcium channel blocker High blood pressure Dosage: 10-30mg Route: Oral Frequency : 8 hourly Safe Dose:180 mg daily AC CF PC

Indication for THIS patient

High blood pressure

Physician’s order

Dosage: 2mg/min Route: IV Frequency: Continuous Safe Dose: 200mg/day AC CF PC

Nursing Implications/Administrat ion instructions

Assess for compliance, monitor intake output ratio Blood pressure Arrhythmias , bradycardia, pulmonary

Labs/parameter Major Side Effects

4

5

Dosage: Route: Frequency : Safe Dose: AC CF PC

Dosage: Route: Frequency : Safe Dose: AC CF PC

Statin

hyperlipid emia

Monitor ECG periodicall y

Dosage:10 -20mg Route: oral Frequency : 24 hourly Safe Dose:40m g AC CF PC Monitor liver function tests

Blood pressure Headache, arrhythmi as, cough, Steven

Lipid profile Rhabdom yolysis, diarrhea, rashes,

edema Patient/Family teaching

Notify healthcare provider in case of difficulty in breathing, wheezing, dizziness and unusual bleeding

Johnson Syndrome The patient should be advised to change position slowly

hypersensi tivity Complian ce

PRN MEDICATIONS (ADMINISTERED IN LAST 24 HOURS) Drug/Drug Class Target Dose, Route, Why Ordered Dose/Range for Frequency for this patient your patient Aspirin

75mg

P.O, PRN

CONTINUOUS INFUSIONS Infusion Name Target Dose/Range for your patient I.V Normal saline

125mL/hr

Myocardial infarction

Why Ordered for this patient It is essential to increase intravascular volume in the patient

Priority Assessments & Interventions for this patient Monitor ECG

Priority Assessments & Interventions for this patient Regular monitoring of the urine output to assess the fluid input output

What are the relationships between the pathophysiology, psychosocial assessment, medications, labs, and treatments? (You may draw a concept map – relationships between above items must be clear and detailed) Hyperlipidemia results in atheroma formation which narrows the vessels and predisposes to atherosclerosis. If it affect the coronary vessels, myocardial infarction may ensue. Lipid profile help in determination of the hyperlipidemia. Statins such as atorvastatin helps lower the lipid levels in blood alongside nutritional intervention thus reducing chances of complication. Hypertension is determined by measuring blood pressure which is higher than the normal range. Anti-hypertensive particularly labetalol given intravenously help to rapidly reduce blood pressure. They work by reducing the heart rate and thus reducing the blood pressure.

Nifedipine reduces blood pressure by reducing the cardiac output through blocking the calcium channels in the heart as well as causes vasodilation thus reducing the peripheral resistance SECTION V: ADDITIONAL INFORMATION DISCHARGE PLANNING: (What goals must be met before pt is discharged): COMMUNITY/TEACHING RESOURCES The goal before discharge is to ensure blood pressure is well controlled. As well the patient should demonstrate proper understanding of the condition in order to promote compliance. The patient is discharged on anti-hypertensive particularly nifedipine to be taken every day alongside atorvastatin to control the lipid level. The patient is educated to ensure compliance to medication and integrate nutritional interventions and exercise to manage hypertension and hyperlipidemia. The follow up visit is scheduled for the patient to assess the health status and need for nay intervention....