Stan Checketts Nursing Care Plan PDF

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Stan checketts nursing care plan...

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Nursing Diagnosis Care Plan Client Initials: SC

Age: 52

Sex: Male

Diagnosis: Rule out bowel obstruction Nursing Plan of Care

Assessment

Planning

Implementation

Circle all that apply QSEN #1: Patient Centered Care QSEN #2: Evidence Based Practice QSEN #3: Quality Improvement QSEN #4: Safety

Expected Outcomes must be realistic, specific, measurable, and include a time frame (SHIFT LONG)

Nursing Actions must be independent, collaborative, and individualized. Scientific rationale must be included.

Address: Cognitive, Affective, and psychomotor goals (if applicable)

*Each goal is to have a corresponding nursing action*.

Nursing Diagnosis (NANDA): Risk for decreased cardiac output

Short term (2) goals to include a time frame (SHIFT LONG)

1. Administer IV fluids as prescribed and monitor blood pressure, heart rate, and lung sounds. Rationale: With acute fluid loss, severe hypovolemia could occur and one of the compensatory mechanisms of the body when the blood pressure is low is to increase heart rate. If fluids are given too fast the heart won't be able to pump efficiently, leading the fluid to reside in the lungs.

Related to: (etiological factors) inadequate food and fluid intake, alteration in heart rate, decreased oxygenation.

1. Within the next two hours the patient will verbalize a decreased or absent feeling of “dizziness”.

As Evidenced by: (defining characteristics)

decreased urine output, weakness, fatigue, dry mucous membranes, hypotension, increased pulse rate Subjective behavior/information: Pt states he feels weak.

2. Within the next hour pulse oximetry is within an acceptable range and the patient is not exhibiting any signs of respiratory distress within the next 2 weeks.

2. Provide oxygen. Maintain bedrest or encourage adequate rest and provide assistance with care and desired activities. Rationale: Administering oxygen will increase SpO2 levels. Bed rest will reduce oxygen consumption and

Evaluation Expected Outcomes indicate if met, or not. If outcomes are not met, explain the needed changes to the plan of care.

Met

Met

Patient mentions he feels “dizzy” and feels like he is going to vomit .

Objective behavior/information: dry mucous membranes, decreased skin turgor, tachycardia, increased pulse, low blood pressure, low SpO2 level: 90%.. Vitals: BP 110/79 mmHg, RR 28, HR 128, Oral temp 99F, SpO2 90% at room air Labs: WBC 17, Hgb 20:, Hct: 60, Platelet count: 340. Sodium: 150, Potassium: 3.7, Chloride: 108, BUN: 42, Creatinine: 1.9

cardiac workload. Long term (2) goals at discharge to include a time frame. 1. After 8 hours the patient will exhibit warm skin, good skin turgor, pink mucous membranes and appropriate capillary refill time. 2. The patient will show lab results shifting to a more acceptable range by the end of the shift.

1. Assess the client’s skin color, temperature, moisture, mucous membranes, and nail beds. Rationale: Pallor reflects vasoconstriction or anemia, which is common in acute kidney injury. Cyanosis is a late sign of cardiac failure and a long capillary refill time and decreased skin turgor is associated with hypovolemic state. 2. Monitor patient’s lab values: BUN, creatinine, electrolytes. Rationale: Creatinine is indicative of renal failure. BUN is indicative of hydration status and electrolytes such as calcium and potassium can affect cardiac rate and rhythm.

Not met, night sift nurse should continue to assess skin.

Met

Client Initials: SC

Age: 52

Sex:

Male

Diagnosis: Rule out small bowel obstruction

Nursing Plan of Care Assessment

Planning

Implementation

Circle all that apply QSEN #1: Patient Centered Care QSEN #2: Evidence Based Practice QSEN #3: Quality Improvement QSEN #4: Safety

Expected Outcomes must be realistic, specific, measurable, and include a time frame (SHIFT LONG)

Nursing Actions must be independent, collaborative, and individualized. Scientific rationale must be included.

Address: Cognitive, Affective, and psychomotor goals (if applicable)

*Each goal is to have a corresponding nursing action*.

Nursing Diagnosis (NANDA): Fatigue

Short term (2) goals to include a time frame (SHIFT LONG)

1. Administer antiemetic as prescribed. Rationale: If the patient is feeling nauseated or feels the need to vomit that decreases his level of energy and will not want to engage in any sort of participation or engagement activities. He’ll also present with an altered mood.

Related to: (etiological factors) diet restriction (NPO) and repetitive vomiting. As Evidenced by: (defining

1. Within the next 2 hours the patient will report decreased or absent feelings of dizziness and nausea.

characteristics)

Patient feeling weak and dizzy. Subjective behavior/information: Patient states he feels weak and dizzy.

Objective behavior/information: hypotension, hyperactive bowel sounds, low SpO2 levels. Vitals: BP 110/79 mmHg, RR

2. Within the next 2 hours the patient will show no signs of dehydration.

2. Administer appropriate IV fluids to maintain fluid and electrolyte balance. Rationale: Symptoms of low fluid status include fatigue. Also, if the patient is dehydrated it’s more than likely that his electrolyte levels are out of balance. So, dealing with the causative factor in this case hydration status will help alleviate symptoms of fatigue, dizziness, and vomiting.

Evaluation Expected Outcomes indicate if met, or not. If outcomes are not met, explain the needed changes to the plan of care.

Met

Met

28, HR 128, Oral temp 99F, SpO2 90% at room air Labs: WBC 17, Hgb 20:, Hct: 60, Platelet count: 340. Sodium: 150, Potassium: 3.7, Chloride: 108, BUN: 42, Creatinine: 1.9

Long term (2) goals at discharge to include a time frame. 1. The patient will show lab values shifting to a more acceptable range by the end of discharge.

1. Monitor lab values. Rationale: The patient has high sodium, chloride, and BUN levels which is indicative of dehydration. Creatinine is indicative of kidney function. So over the next few days once we’ve implemented the nursing interventions and the patient has undergone surgery we want to continue to monitor lab values. 2. Encourage bed rest.

2. By discharge the patient will verbalize an improved sense of energy.

Met

Rationale: Patient will be undergoing surgery for small bowel obstruction so, we want the patient’s energy to be used towards healing.

Not met. Patient had to undergo many procedures today and adequate rest was not provided. Before and after surgical procedure rest will be provided to the patient.

Client Initials: SC

Age: 52

Sex:

Male

Diagnosis: Rule out small bowel obstruction

Nursing Plan of Care Assessment

Planning

Implementation

Circle all that apply QSEN #1: Patient Centered Care QSEN #2: Evidence Based Practice QSEN #3: Quality Improvement QSEN #4: Safety

Expected Outcomes must be realistic, specific, measurable, and include a time frame (SHIFT LONG)

Nursing Actions must be independent, collaborative, and individualized. Scientific rationale must be included.

Address: Cognitive, Affective, and psychomotor goals (if applicable)

*Each goal is to have a corresponding nursing action*.

Nursing Diagnosis (NANDA): Knowledge Deficit

Short term (2) goals to include a time frame (SHIFT LONG)

Related to: (etiological factors) Surgical procedure of small bowel obstruction

1. Before the surgical procedure the patient will review anatomy, physiology, and implications.

As Evidenced by: (defining characteristics)

unfamiliarity with the disease process, and lack of interest. Subjective behavior/information: When educating the patient about his condition and the need for surgery he replied “ok”.

Objective behavior/information:

2. Assess the patient’s individual learning needs in the next hour.

1. Provide resource information regarding the procedure or call the surgeon to answer/ clarify any questions that the patient is asking. Rationale: Provides a knowledge base for which the patient can make better informed decisions for himself and allow for clarification of any misunderstood instructions.

2. Ascertain the patient’s education level and learning style and note any barriers to learning the information.

Rationale: understanding the patient’s

Evaluation Expected Outcomes indicate if met, or not. If outcomes are not met, explain the needed changes to the plan of care.

Not met: I educated the patient briefly on his status after going in for the abdominal series x-ray, but the surgeon still needs to come in and explain and or clarify concerns and questions the patient might have.

Not met:

Constant verbalization of pain

needs and what helps them better grasp the information being taught is more beneficial to them then just giving the patient a pamphlet.

Vitals: BP 110/79 mmHg, RR 28, HR 128, Oral temp 99F, SpO2 90% at room air Labs: WBC 17, Hgb 20:, Hct: 60, Platelet count: 340. Sodium: 150, Potassium: 3.7, Chloride: 108, BUN: 42, Creatinine: 1.9

Long term (2) goals at discharge to include a time frame. 1. Before discharge the patient will initiate the proper indications of the treatment regimen.

2. By discharge the patient will demonstrate how to care for his wound.

1. Teach the patient proper care maintenance after surgery such as diet changes: frequent small meals, adequate fluid intake, avoiding alcohol, beer, and wine. Rationale: Bowel movement will change after surgery because of medications being given (opioids) so encouraging the patient to drink lots of fluids and eat small yet frequent meals will help the healing process and symptoms such as constipation.

Not met: have not thoroughly explained what the surgery entails and recovery process.

2. Teach the patient and family proper wound care such as washing hands frequently, watching for signs of infection, having doctor take out the stitches or staples, taking care of wound dressing.

Not met: Patient will be undergoing surgery soon once he is out of surgery and before discharge it is important to teach the patient how to take care of wound from the surgical procedure.

Rationale: Helps prevent infection.

Sources: Lippincott Advisor for Education found through the Point

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span. F.A. Davis....