Vernon Russell Complete Care Plan PDF

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CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)

Right-Sided Stroke

DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) CBC- test blood cells’ count, check for other ther underlying conditions Chem panel- determine pt general health status Prothrombin time- blood to measure how long it takes for pt’s blood to clot

PATIENT INFORMATION Vernon Russell, Male DOB: 1/14/1965 (55y) Weight: 97.5kg Height: 178cm

Assess glucose before meals Carb evaluation Full body assessment, including assessment of extremities Pt education of care & diet Pt repositioning

ANTICIPATED PHYSICAL FINDING

poss skin bruising neuro changes: -disoriented, weakness increased b/p decreased sensation in extremities

vSim ISBAR ACTIVITY INTRODUCTION

STUDENT WORKSHEET RN An acute care unit, such as an emergency dept.

Your name, position (RN), unit you are working on

SITUATION

Vernon Russell, 55 YOM, Admitted with a stroke with mild left hemiplegia

Patient’s name, age, specific reason for visit

BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient

ASSESSMENT Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs

Right-sided stroke Adm on 10/04/20202 Orders: Vital signs and neuro checks ever 4hrs Assist pt to chair and bathroom NPO until after swallow study is complete Fall risk Assessment Bedside blood glucose 2x daily Labs: CBC, chem panel, prothrombin time Medication Orders: IV: normal saline 1000mL at 100 mL/hr Losartan 50mg orally 2x daily Aspirin 81mg orally daily Metformin 500mg orally 2x daily Chlorthalidone 25mg orally daily -review pt info., log, diagnostics, clinical observations, MAR & orders -hand hygiene and confirm PT using 2 identifiers -wear gloves while performing pt assessment -assess for pain, symptoms & allergies -examine skin for color, swelling, breakage, infection -assess mucous membranes -listen to pt’s lungs -listen to pt’s heart and also check for normal breathing -check radial pulse & pedal pulse -check temperature -take blood pressure -check IV site for redness, swelling, bleeding or drainage -check pupils for PERLA -check eye movement -check orientation: date, time, place -check for weakness on either side: hand grip, push against RN’s pal w/ feet, have pt smile, stick tongue out -position pt in a confortable position -administer medications -educate pt and family about: Activities, safety & fall risk Diet

Medication Risk of aspiration RECOMMENDATION Any orders or recommendations you may have for this patient

-smoking cessastion -continue ROM exercises -consult w/ speech therapist

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: IV: normal saline 1000mL at 100 mL/hr

CLASSIFICATION:

PROTOTYPE:

SAFE DOSE OR DOSE RANGE, SAFE ROUTE

Maximum dosage for adults: 1,000 mL/bolus of a 0.9% isotonic solution IV route

PURPOSE FOR TAKING THIS MEDICATION

PATIENT EDUCATION WHILE TAKING THIS MEDICATION Poss side effects include: Fluid retention High blood pressure IV site reactions Electrolyte imbalance

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Losartan 50mg orally 2x daily

CLASSIFICATION: antihypertensives

PROTOTYPE: angiotensin ll receptor antagonists

SAFE DOSE OR DOSE RANGE, SAFE ROUTE 25-100 mg/day as a single dose or 2 divided doses Oral route PURPOSE FOR TAKING THIS MEDICATION For hypertension

PATIENT EDUCATION WHILE TAKING THIS MEDICATION Ask pt of other medications currentl taking including OTC, vitamins and herbal remedies Instruct pt how to take daily and reason for taking it Inform pt of importance to continue medication even if feeling better Teach pt about dietary changes Caution pt of BP decreased as it may cause dizziness w/ sudden movements Teach pt how to take bp and report changes Instruct pt to report any facial swelling and/or diffictulty swallowing

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Aspiring 81mg orally 2x daily

CLASSIFICATION: antipyretics, nonopioid analgesics

PROTOTYPE: salicylates

SAFE DOSE OR DOSE RANGE, SAFE ROUTE As prescribed: 81mg 2x daily General info: Safe range for adults- no more than 200mg daily PURPOSE FOR TAKING THIS MEDICATION Decrease blood cot formation Moderate pain management Decrease inflammation

PATIENT EDUCATION WHILE TAKING THIS MEDICATION Take 2x daily (as instructed by prescriber) Instruct pt to make sure to have enough medication available Teach pt how to take BP and pulse and report any changes May cause drowsiness and dizziness, and therefore pt should not drive until medication reaction is known Monitor blood glucose Ask about any other medications pt is currently taking including OTC, vitamins and herbal remedies Reinforce the need to continue hypertension care and smoking cessation

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Metformin 500mg orally 2x daily

CLASSIFICATION: antidiabetics

PROTOTYPE: biguanides

SAFE DOSE OR DOSE RANGE, SAFE ROUTE As instructed by prescriber- 500mg 2x daily Orally General info for adult patients: 500mg up to 2000mg daily / not to exceed 2500mg PURPOSE FOR TAKING THIS MEDICATION Management of type 2 diabetes mellitus

PATIENT EDUCATION WHILE TAKING THIS MEDICATION Take at the same time every day, as directed Take missed doses as soon as possible Explain that it helps mange type 2 daibetes mellitus but not cure Teach and encourage pt to follow a proper diet and exervise regimen Teach pt of signs of hypo/hyperglycemia and what to do in an event Instruct of proper blood glucose and ketone testing Ask about any other medications pt is currently taking including OTC, vitamins and herbal remedies May cause unpleasant or metallic taste Emphasize importance of routine follow up Asvise pt to carry a form of sugar Advise pt to report diarrhea, nausea, vomiting and stomach pain or fullness

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Chlorthalidone 25mg orally daily

CLASSIFICATION: diuretics, antyhepertensives

PROTOTYPE: thiazide diuretics

SAFE DOSE OR DOSE RANGE, SAFE ROUTE As instructed by prescriber General information for adult pts: 12.5-100 mg/daily orally PURPOSE FOR TAKING THIS MEDICATION Management of mild to moderate hypertension

PATIENT EDUCATION WHILE TAKING THIS MEDICATION Take at the same time every day Take missed dose ASAP, but not at the same time as next dose, do not double dose Monitor weight biweekly Advise of hypotension, stand slowly to prevent dizziness Teach and encourage proper diet Continue taking medication even after feeling better Teach how to monitor BP Ask about any other medications pt is currently taking including OTC, vitamins and herbal remedies

Clinical Date: 10/04/2020 Initials:

Student Name: Diagnosis: right-sided stroke

HCP:

Assigned vSim: Vernon Russell Isolation: n/a

VR

IV Type: Normal saline

Fall Risk: Age: Length of Stay:

Consults: speech pathologis

55y M/F:

high

Location: intravenously

Allergies: none Transfer:

male

Fluid/Rate: 1000mL at 100 mL/hr

Code Status:

Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Pt was admitted to the hospital with right-sided stroke and mild left side hemiplegia

Health History/Comorbities (that relate to this hospitalization): Stroke Smoker Hypertension Coronary artery disease Diabetes mellitus type 2 Inactive life-style Shift Goals/ Patient Education Needs: 1. Assess pt and document findings and changes 2. lab work/tests 3. teach pt of proper care, diet and risks 4. Path to Discharge: Subacture rehab Education of general care for pt condition, diet, fall risk, aspiration risk, daily medication Physical/occupational therapy Speech therapy

Critical Labs:

Other Services:

CBC Chem panel Prothrombin time Consults Needed:

Clinical Path to Death or Injury:

Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1.

aspiration

2.

fall risk

3. bruising/bleeding

Management of Care: What needs to be done for this Patient Today?

Vital signs and neuro checks ever 4hrs Assist pt to chair and bathroom NPO until after swallow study is complete Fall risk Assessment Bedside blood glucose 2x daily Labs: CBC, chem panel, prothrombin time Administer prescribed medications

What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?)

Priorities for Managing the Patient’s Care Today 1. ensure pt comfort and pain management

1.

speech therapy evaluation

2.

check and monitor pt vitals and neuro status

2.

check for sided weakness

3.

teach pt of risks to prevent any injuries during stay, as well as after discharge

3.

full body assessment, check skin for bruising, bleeding, check for signs of disorientation/confusion, check for palor, slurred speech

4.

maintain communication with pt care team and keep them informed of pertinent pt info and changes.

List Complications may occur related to dx, procedure, comorbidities: 1.

fall/injury

2.

neuro changes

3.

aspiration/choke

What nursing or medical interventions may prevent the above Alert or complications?

1.

assist pt with transfer and ambulation. Education of fall risk

2.

assess to detect early onset

3.

teach of asirartion / follow facility protocols for PT placed on NPO status

4.

What aspects of the patient care can be Delegated and who can do it? Speech evaluation – speech therapist Blood glucose testing – hospital tech/phlebotomist ROM exercises – physical therapist Chem panel- hospital tech/phlebotomist Prothrombin time - hospital tech/phlebotomist

1. What priority problems did you identify? Difficulty swallowing- other than the causing a risk for aspiration, it’s also preventing pt from taking his medications which further prevents pt from getting better. Others include: Stroke Internal bleeding in the brain Diabetes Left side hemiplegia 2. Correlate the abnormal coagulation study results to Vernon's current treatment. They were abnormal in the sense that his stroke was caused by thrombosis which requires thrombolytic treatment, which is like a very strong blood thinner in order to destroy the obstructing blockage. 3. What resources are available to the interprofessional healthcare team to guide the care of Vernon Russell and /or any stroke patient? Every medical facility has stroke protocols in place to guide the responses of nurses and care providers. There are also speech therapists, which Mr. Vernon may need due to his difficulty swallowing; physical therapist to assist with his ROM exercises. 4. Discuss the rationale for Vernon being placed on NPO status. Due to the risk of choking and/or aspiration caused by the dysphagia. Aspiration is when food/liquid/meds go down the wrong pipe, which can lead to pneumonia. 5. How did you respond to Vernon's question related to why he needs someone to help him walk and what is your rationale for your response? Though he may feel capable of ambulating on his own, his left-sided weakness makes him vulnerable to falls and injuries which can be very dangerous for someone on thrombolytic treatment. 6. Utilizing Vernon's health history, identify factors that predisposed him to having a stroke. -smoking -poor diet and inactive lifestyle -predisposed to stroke -diabetes -coronary artery disease 7. Discuss why the referral for speech therapy is important in Vernon's care. To assist him with his current case of dysphagia, as well as to assess for further complications caused by the stroke, if any, such as impaired speech....