Jill's Nursing Portfolio



NURSING CARE PLANseq Text_Box \* Arabic1Student Information:Name: Jill GarrettDate: September 18, 2015Course: Nursing 1220 – Health and Illness Concepts IInstructor: Rosa Colella-Melki, Robert Berry, Corrine Eiznhamer, and Melissa McGovern.Dates Assigned to Patient: September 14, 2015Patient Information:Demographic DataPatient Initials: T. G Age: 49Sex: MaleMarital Status _Married__________________________Religion: ___Catholic_________________________________Race: __White_________________________________ Country of Origin: __America____________________________Occupation _____Police Officer_______________________________________________________________________Admitting Diagnosis: __Sigmoid Diverticulitis_________________________________________________________Current Medical Diagnosis: ___Abdominal Pain_________________________________________________________Surgery & Date Done: Did not have surgery yet.____________________________________________________________Important Health InformationPast Health HistoryPrevious Illness/Hospitalizations (With Dates & Diagnoses)March 2014 – Hospitalized for diverticulitisJuly 2015 – Hospitalized for diverticulitisPrevious illnesses include: hypertension and hyperlipidemia: he did not have specific dates or times for these.Previous Surgery (With Dates & Complications)2 quadriceps repairs – right quad repair in 2014, left quad repair in 2013.Adenoidectomy - 2005Current Medications (Include PRN, OTC, & Herbal Use)(Complete attached medication list)Current Surgery or Other Treatments (ie; Chemotherapy, Radiation, Physical Therapy)He is talking with his doctor about surgery for his diverticulitis. The plan is a colon resection sometime in the next 6-8 weeks.Allergies and Reaction (Medication, Environmental, Food)He is allergic to mold extracts.I.TEXTBOOK FOUNDATIONSThorough Description of Medical Diagnosis (es) from Medical-Surgical TextbookClinical Manifestations or Problems That This Patient Presented WithAbdominal rebound tenderness, pain and cramps, abdominal distension. The patient may also have rectal bleeding and a high temperature.(Ignatavicius, 1285).Current Medical Diagnosis(es):Sigmoid mon Medical Interventions:Surgery such as a colon resection can be performed to correct the diverticulitis and help him to not come back to the hospital as often for colon related pain. The patient may or may not have a colostomy bag.(Ignatavicius, 1285).Common Nursing Interventions:We can instruct the patient to take medications as prescribed. This is because we want to induce clinical remission while avoiding toxic medications.We can encourage the patient to engage in usual diversional activities, hobbies, relaxation techniques, and psychosocial support systems as tolerated. We do this so the patient’s attention isn’t as focused on the pain as it is on what they are participating in. We can recommend necessary alterations in diet. Small frequent meals tend to be better tolerated and cause less GI distress. An increase in fiber reduces constipation and abdominal comfort for a patient with diverticular disease.Patients are managed on an ambulatory care basis if the symptoms are mild. Monitor the patient for any prolonged or increased fever, abdominal pain, or blood in the stool.The patient with moderate to severe diverticulitis may be hospitalized, especially if the patient is older. Manifestations suggesting the need for admission are a temperature higher than 101° F (38.3° C), persistent and severe abdominal pain for more than 3 days, and/or lower GI bleeding. (Ignatavicius 1285).Common Diagnostic Interventions with Description:Abdominal x-rays: can be done to look for fluid and air that may be causing perforation.CT scan: can be done to diagnose an abscess or thickening of the bowel related to diverticulitis.(Ignatavicius, 1285).TEXTBOOK FOUNDATIONS (Continued)Thorough Description of Surgical Intervention(s) from Medical-Surgical TextbookClinical Manifestations or Problems That This Patient Presented With Post-SurgicallyCurrent Surgical Intervention:(If patient did not have surgery, please identify a possible surgical intervention)The patient has been talking with his doctor about having a colon resection sometime in the next 6 to 8 weeks for his sigmoid diverticulitis.The nursing care for patients after an open colon resection for diverticulitis is the same as that for any patient who has undergone open abdominal surgery. The patient may have a drain in place at the abdominal incision site for several days. If a colostomy has been performed, the stoma may be covered with a petroleum gauze dressing because the colostomy does not drain for about 2 days, or a colostomy bag may be placed over the stoma. If the stoma is visible, monitor for color and integrity. The stoma should be pinkish to cherry red without retraction into the abdomen or prolapse.The patient may be NPO with an NGT until peristalsis returns if open surgery is performed. Clear liquids are then introduced; the diet is advanced to solids, depending on the return of peristalsis and bowel function. Patients who had laparoscopic surgery usually do not have an NGT. (Ignatavicius 1286).Post- Surgical Nursing Interventions for this Procedure:Give the patient an opportunity to express feelings about the ostomy if it was created. Discuss these feelings with the patient, reinforcing that anger and depression are normal responses. When he or she is physically able, encourage the patient to look at the stoma and touch the pouching system. Collaborate with the ostomy nurse to teach the patient how to self-manage ostomy care.First we start with a clear liquid diet, eventually advancing to solid foods. Teach the patient the importance of a good diet.(Ignatavicius 1286).Concurrent Medical Problems:The patient has hypertension, so he has been on Lisinopril. Hypertension is abnormally high blood pressure.My patient also has hyperlipidemia, so he has also been on Simvastatin. Hyperlipidemia is high cholesterol levels in the mon Nursing Interventions r/t Concurrent Medical Problems:Hypertension: We can encourage questions about hypertension and the treatments, involve the family in teaching about hypertension, instruct the patient to self-measure blood pressure, and plan the teaching in stages to prevent information overload.Hyperlipidemia: We can teach the patient about a healthier diet to improve cholesterol levels, we can also introduce them to a dietician to help them plan their diet.Reflection on Patient Interview DataCognitive-Perceptual Patterns:Piaget's stage of intellectual development (what it should be for this patient’s age): The Formal Operational Stage.State behaviors that indicate whether or not this level is attained: Patient speaks logically, can reason well, and understands abstract ideas.Ability to communicate and understand ideas: Patient understood everything I was saying, understood my purpose of the care plan project, communicated well, told a lot of stories, etc. We talked for a while.Appropriate verbal responses: The patient makes sense and speaks logically.Risks for injury related to mental status: None.IntegumentaryFactors predisposing patient to skin breakdown: If the patient is lying in bed for a certain about of time in the same position, then he is at risk for skin breakdown. The patient is getting up and ambulating to the bathroom independently & moves all of his limbs often. The patient has a Braden Scale score of 22.Thorax and LungsFactors affecting or interfering with breathing: The patient is on PRN hydromorphone (Dilaudid), so while he is taking this, it is important to monitor his respiration rate.MusculoskeletalRisks for injury (e.g. falls): The patient was placed on fall risk, but he is fairly steady.Interventions done to promote patient safety: The patient has been instructed to use the call light, sit to stand slowly, and ask for assistance when needed.Self-Perception-Self Concept PatternsHow does your patient relate to you and others? The patient has a family at home just like most people and I do. He communicates his feelings, and correctly responds to stimuli and can carry a conversation well.Role Relationship PatternsErikson's Developmental Task: Generativity vs. Stagnation. What is the developmental task for this age? Care.Describe normal behavior for this stage: Establishing career, settling in a relationship, begin families, and develop a sense of seeing ourselves as a part of the bigger picture.Describe behaviors that demonstrate the patient is at the level for this age. If not, explain: Patient has a five year old daughter, him and his wife worked out a plan to compensate for the child being home and going to school with their work patterns.Coping Stress Tolerance PatternsBehaviors that indicate how your patient copes with stressful situations: He said he’s a communicator, he lives to talk through these situations, his family helps him.Does your patient's emotional status affect his/her activity levels? Yes, being in a better mood helps him do his job better.Describe patient’s nonverbal communication: Body language included smiling and being calm and relaxed. The patient had an optimistic mood the entire interview/clinical.ASSESSMENT:Functional Health PatternsHealth Perception- Health Management PatternReason for Seeking Health Care (Patient's own words)The patient said he had abdominal pain, and he came to the ER at Elmhurst Memorial Hospital with a pain level of 7 or 8.Perception of HealthHow would describe your health prior to this hospitalization?He said “good other than diverticulitis.”Perception of IllnessEvents causing the hospitalization. When did your health problem or symptoms begin?He said he was on antibiotics, and then his pain got worse. The CT scan from this visit showed the disease progressing since his last visit in July.Describe the:Characteristics – Stabbing/piercing pain.Onset & Frequency – Quick, got worse quickly.Location – Abdomen.Duration & Recurrence – Has reoccurred several times, the duration varies.Severity – 6 as of now, very uncomfortable.Pattern (Aggravating & Alleviating factors) – walking makes it worse, laying down makes it better.Associated factors (what else happens?) – He just said that it is a random onset. Nothing specifically causes it; his visits have been sporadic and random.How has it affected your normal activities?It usually doesn’t affect him. But the pain was too persistent this time and he needed to come to the hospital again. This is why him and his doctor are talking about colon resection surgery.PATIENT DATA SHEETPatient Initials & Room # T.G, Rm 670 Age/Sex: 49, Male Admission Date: 9/13/2015 Allergies: Mold extracts. Admitting Diagnosis: Acute pain related to diverticulitis. Code Status: Full code.Other Medical Problems (PMH):Vital Signs: B/P: 131/77, HR: 73 bpm, RR: 18, Temp: 98.2, SPO2: 96%Surgeries (significant PSH): Adenoids, quadriceps repair. Significant Psychiatric History: N/A Current Pain Rating: A 1 or a 2, mild. GENERAL APPEARANCE:[x] male [ ] female DOB: 7/2/1966 Age: 49 Ethnicity: GermanOccupation: Police OfficerReligion: Catholic[x] awake [x] cheerful [ ] crying [ ] sleeping [ ] lethargic[x] calm [ ] agitated [ ] anxious [ ] combative []fearfulRESPIRATORYActivity-Exercise PatternRESPIRATIONS: Rate: 18, O2: Room Air, SPO2: 96%[x]reg [ ] even [ ] irreg [ ] labored [ ] uses accessory muscles [ ] coughBREATH SOUNDS: RIGHT: [x] clear [ ] crackles [ ] wheezes [ ] rhonchi[ ] decreased [ ] absentLeft: [x] clear [ ] crackles [ ] wheezes [ ] rhonchi[ ] decreased [ ] absentTHORAX: [x] even expansion [ ] uneven expansionSMOKING: [ ]cigarettes pk/day ____________ [ ] cigars [ ] marijuana [ ] cocaineSKIN Nutritional-Metabolic PatternBraden scale score: 22 [ ] risk skin breakdownCOLOR: [x] acyanotic [ ] pale [ ] ruddy [ ] jaundiced [ ] cyanoticTEMP: [x] warm/dry [ ] hot [ ] cool [ ]cold/clammy [ ]diaphoreticTURGOR: [x]<3 sec [ ] >3 secHAIR: [x] shiny [ ]dry/faking [ ]balding [ ] lesions [ ] liceNEUROLOGICALCognitive-Perceptual PatternORIENTATION: [x] person [x] place [x] time [ ] Disoriented: [ ] confused [ ] impaired memoryRESPONDS TO: [x] name [x] stimuli [ ] non-responsiveSPEECH: [x] clear [ ] garbled [ ] slurred [ ] aphasic[ ] inappropriate [ ] cannot follow conversationFACE: [x] symmetrical [ ] drooping [ ] droolingEYES: [x] PERRLA [ ] unequal [ ] drooping lid SIGHT: [ ] no correction [x] glasses [ ] contacts [ ] blindHEARING: [x] WNL [ ] HOH [ ] hearing aidHx: [ ] seizures [ ] CVA [ ] brain injury [ ] spinal injury [ ] otherGASTROINTESTINAL/NUTRITION Elimination Pattern & Nutritional-Metabolic PatternAPPEARANCE: [ ] flat [x] round [ ] obese [ ] soft [ ]gravidBOWEL SOUNDS: [x] active [ ] hypoactive [ ] hyperactive [ ] absentPALPATION:[ ] non-tender [x] tender (location): abdomen.[ ] mass (location) _____________LAST BM: 0825 [ ] incontinent [ ] stoma- _______[ ] constipation [ ] diarrhea [ ] mucous [ ] bloodDiet: Clear liquid diet [ ] impaired swallowing [ ] choking[ ] NG tube Color drainage______________[ ] Feeding tube[ ] tube feeding Type: ______________ Rate:_________MUSCULOSKELETALActivity-Exercise PatternGAIT: [x] steady [ ] unsteady [ ] non-ambulatoryACTIVITY: [x] up ad lib [ ] walker [ ] cane [ ] crutches [ ] wheelchairAssist: [x] x1 [ ] x2 [ ] lift [ ] bed boundHAND GRIPS: RIGHT: [x] strong [ ] weak [ ] flaccid [ ] contracturesLEFT: [x] strong [ ] weak [ ] flaccid[ ] contracturesROM: ARMS: [x] full [ ] weak [ ] flaccid [ ] contracturesLEGS: [x] full [ ] weak [ ] flaccid [ ]contractures [ ]TEDAMPUTATION: [ ] right [ ] left [ ] BKA [ ] AKA [ ] otherSPINE: [ ]kyphosis [ ] scoliosis [ ] osteoporosisOTHER: [ ] Cast location:___________ [ ] Traction_____________GENITOURINARY[x] Voids [ ] catheter [ ] stomaAPPEARANCE OF URINE:[x] clear [x] light yellow [ ] amber [ ] brown[ ]cloudy [ ] sediment [ ] red/wine [ ] clotsBLADDER: [x] soft [ ] firm/distended [ ] incontinentSexuality-Reproductive PatternFEMALES: LMP: _________ [ ] WNL [ ] dysmenorrhealBirth control:[ ] yes [ ] no [ ] BSE monthly[ ] menopause [ ] taking estrogenSEXUALITY: [x] sexually active [ ] safe sexMED HX: [ ] urinary retention [ ] BPH [ ] Frequent UTICARDIOVASCULARHEART SOUNDS: [x] normal S1-S2 [ ] Abnormal S3-S4 [ ] murmurPULSE: APICAL: [x] reg [ ] irreg [ ] strong [ ] faintRADIAL: [x]reg [ ] irreg [ ] strong [ ] faint [ ] nonpalpablePEDALIS: [x]reg [ ] irreg [ ] strong [ ] faint [ ] nonpalpableEXTREMITY COLOR & TEMP: [x] warm [ ] cool [ ] cold [ ] acyanotic [ ] cyanotic [ ]discolorEDEMA: [x] none [ ] generalized (anasarca)Site #1________________Site #2 ________________CAPILLARY REFILL: Fingers [x] brisk [ ] slow Toes: [x] brisk [ ] slowHx: [ ] Pacemaker [x] HTN [ ] CAD [ ] CHF [ ] PVD Other:_______PAIN ASSESSMENT: Cognitive-Perceptual PatternPRECIPITATING: Sigmoid diverticulitis.QUALITY: Stabbing, gradually worsening.REGION: Abdomen.SEVERITY 0-10/10: Now 1 or 2. At worst: 8, At best: 0.TIMING: Rapid onset.SAFETY:[ ] see nursing notes [ ] Fall risk PRECAUTIONS: [ ] side rails x_______ [ ] bed down [ ] call lightDISCHARGE/TEACHING: [x] see nursing notesNEEDS:Pt. recently admitted, nothing yet. I would say teaching about the PICC line or teaching about a better diet.TYPE OF LEARNER: [x] visual [ ] auditory [ ] kinestheticEducational level Bachelor’s, Family present: No.FLUID BALANCE Nutritional-Metabolic PatternINTAKE: [x] PO [x] IV: Solution: NaCl 0.9%Rate: 150 ml/hrSITE LOCATION: Right forearm [x] clean [x] patent [ ] redness [ ] swelling [ ]cool [ ] hot [ ] pain[ ] tubing change [ ] dressing changeMUCOUS MEMBRANES: [x] moist [ ]pink [ ]dry [ ]sticky [ ] coatedToday’s weight: 255 lbsYesterday’s wt: Only documented weight is 255 lbs.LAB VALUESBMP 138 / 4.1|105 / 29|7 (low) / 1.16 < 87 CBC 10.6 > 14.5 / 43.9 < 259PT/INR and PTT: N/AOtherInterviewHealth MaintenanceWhat do you do to keep healthy? (ie; screenings, annual physicals, breast or testicular self-exams)He sees the doctor regularily, works out on the treadmill walking sometimes, and he does regular yard work. Do you use any of the following:Tobacco: Cigarettes (ppd & # of yrs), pipes or cigars or Chewing tobacco? NoAlcohol (ie; beer, wine, hard liquor): Socially.Coffee, tea, cola: Coffee.Recreational drugs: None.Nutritional- Metabolic PatternNutritional StatusHave you had recent weight loss or gain (amount, time span, intentional or not): Nothing significant, he is not trying to lose any weight.Do you have diet restrictions and Diet prior to hospitalization: He watches his salt due to his hypertension.Problem with mastication: None.Own teeth/dentures? Own teeth.Describe your Appetite: Normal.Presence of abnormal thirst: None.Swallowing: Normal.Other factors interfering with nutrition: Diverticulitis, hypertension, & hyperlipidemia.Food and fluid preferences: No soda, likes all types of food but tries to watch his salt consumption. Cognitive-Perceptual PatternHave you had any recent changes in memory? No.Highest level education attained: Bachelor’s degree.What is the easiest way for you to learn new information? Visual learner.Would you like information about current tests or treatment? Not as of now, he already discussed with his nurse and doctor.Sensory StatusAny difficulty or changes in:Hearing (note any assistive devices): Hears normally, no assistive devices.Vision (note any assistive devices): Uses glasses. IntegumentDo you heal properly? Yes.Regulatory Mechanisms (Endocrine)Do you have Diabetes Mellitus or any other abnormal endocrine problem (thyroid problems)? No.Effects of diabetes or other abnormal endocrine function on health status or life style: N/A.Immune MechanismsPast or present allergies: Mold extracts, cat dander.Past or present sensitivities (drug, environmental, other agents): Same as above.Past or present factors creating an increased susceptibility to infection: Antibiotic therapy.Thorax & LungsDo you smoke? No.What and how much per day? N/A.Cardiac & Peripheral VascularHave you had any complaints of syncope, dizziness, palpitations: No.Have you had any complaints of SOB, orthopnea: No.Elimination PatternBowel EliminationWhen was your last bowel movement? Today at 0825.Frequency and characteristics of stools: Normal, formed, and brown.Do you use laxatives or enemas? (Frequency): Occasionally he uses Miralax. Does not need help having bowel movements usually.Bladder EliminationFrequency of voiding: Normally, he drinks water constantly throughout the day.What is the color of urine: Clear, pale yellow. Have you noticed odor of urine: None.Urinary incontinence: No.c/o dysuria, urgency, pain when voiding: None.Receiving renal dialysis therapy: None.Access: N/A.Activity-Exercise PatternDo you have sufficient energy for desired or required activities? Yes.Describe your exercise pattern, type and regularity: Works out by walking on the treadmill, participates in yard work frequently, and he is a police officer.MusculoskeletalAny complaints of new or increased stiffness, achiness, or weakness? No.Activity prescribed: Up with lib.What activity practiced: Walking, bathroom privileges, ROM exercises.Tolerance of activity: Tolerates activities well. Do you have any activity restrictions: No, after this hospital visit/surgery, he will have to heal for at least 4 weeks.Ability to perform ADL (hygiene, grooming, toileting, feeding, etc.): Independently performs ADLs.*If not independent, indicate which activities require assistance: N/A.*Do you have any difficulties? No.Ambulation: Independent.Transfers: Independent.Use of aids for mobility: None.Limitations in ROM: None.Sleep-Rest PatternWhat is your usual sleep pattern? 6-8 hours a night.Current sleep pattern? Gets less sleep in the hospital, a lot of people constantly waking him up.Do you feel rested after sleeping? Yes.Aids used to sleep/ sleep rituals (excluding meds): None, watches TV before bed sometimes.Factors interfering with rest and comfort: None other than being woken up in the hospital.c/o or signs of pain, discomfort and restlessness: None.Aids used to relieve pain (excluding meds): Sometimes Advil.Self-Perception – Self-Concept PatternHow would you describe yourself prior to this hospitalization? Healthy, active, and happy.Stated feelings about hospitalization: Hopeful that the surgery will resolve his diverticulitis issues so he does not have to keep coming back.Role-Relationship PatternEffect of patient's illness on family: Stressful more than anything else.Living arrangements (home alone, retirement home, extended care facility, etc.): House, a wife who works from home, and one 5-year-old daughter in kindergarten. Occupational HistoryCurrent work role: Police officer.Previous jobs held: Police officer for 25 years, little odd jobs when he was a teenager.Current employment status: Full time.Number of days missed due to illness: Half a day so far.Occupational Hazards/Potential Health Problems: Stress, infection, being injured in many different ways.Economic StatusSole provider/Financial concerns: None as of now, he and his family are financially stable.Sexuality-Reproductive Pattern FemaleNumber of pregnancies:__________Live births: __________Living children: _______________Number of grandchildren: _____________Family planning methods:Menstrual pattern:Menopause (age of onset and associated factors):Breast selfexamination routine:Frequency of pap smears: MaleLast testicular examination: Does not know.Testicular selfexamination routine: Not normally, but he has performed one before.Stated concerns about sexual performance, function, and sexuality: None. May have to take a break after surgery.Do you have any vaginal or penile discharge, pain: None.Coping-Stress Tolerance PatternWhat do you do to relieve stress? Try to relax, go for walks.Do you have someone to confide in available to you now? Yes, his wife and his twin brother.Have you experienced recent life changes? None besides a progression in his diverticulitis.How do you work out problems? He likes to be open and talk about things, does not beat around the bush.Verbal expressions of feelings (stated concerns, anxieties, and fears): He is worried if he will have enough time off at work for surgery and time to recover.Non-verbal expressions of feelings (facial expressions, body language, etc.): He is a very optimistic and cheerful munity ResourcesAvailable Community Resources (list a possible resource for your patient): A support group or even a class on nutrition at Elmhurst Memorial Hospital. Elmhurst has a lot of informational classes including those about: hypertension, nutrition, heart failure, etc. These can be found on the website.Value-Belief PatternOrientation (How closely does the patient adhere to traditional habits and values from his or her parents cultural system? What is the accepted behavior of the cultural group regarding expression of responses to illness and death?)He is very optimistic about his illness, and he keeps a strong mental state through all of this. His parents are the same way, and they taught him to be like this.Nutrition (Are there foods that are encouraged or discouraged from eating while ill?)Discouraged foods consist of foods high in sodium. He is encouraged to have a clear liquid diet.Family Relationships: (Are there key family members who need to be involved in health care decisions? Any family members present frequently, assist with ADL's?)Yes, his wife. They make financial decisions together. The patient is independent and he does not need assist.Health Habits (health practices or home treatment, traditional remedies)“Nothing he can think of”, exercises sometimes, watches salt in his diet.Religion (religious beliefs, sacred rites, religious restrictions)He is a Catholic and he practices this actively; i.e. Good Friday, etc.NURSING DIAGNOSES(Actual and High Risk Problems)(Include “related to” and “as manifested by” statements.)List Nursing Diagnoses from highest to lowest priority.Acute pain r/t inflammatory bowel disease aeb pain level of 8/10 with rebound tenderness.Stress syndrome r/t unpredictability of the experience aeb verbal expressions of anxiety.Blood pressure knowledge deficient r/t unfamiliarity with information resources aeb verbalizing inaccurate information.Imbalanced nutrition, more than body requirements, r/t poor dietary habits aeb weight 20% over ideal for height and frame.Risk for infection r/t immunosuppression. Medication Review by SystemDrugs ordered that may affect nutritional status:Simvastatin and Lisinopril.Drugs ordered that may affect mental status:Dilaudid and Acetaminophen.Drugs ordered that may affect body temperature:Zofran, Acetaminophen, and Zosyn.Drugs ordered that may affect the integument (skin, mucous membranes, hair & nails):Sodium Chloride 0.9%, Dilaudid, Acetaminophen, Acetaminophen, and Zosyn.Drugs ordered that may affect eyes, ears:Zofran.Drugs ordered that may affect endocrine function:Sodium Chloride 0.9% and Lisinopril.Drugs ordered that may affect the immune system:Lisinopril and Zosyn.Drugs ordered that may affect gas exchange:Sodium Chloride 0.9%, Lisinopril, Dilaudid, and Acetaminophen.Drugs ordered that may affect heart and circulation:Sodium Chloride 0.9%, Lisinopril, Zofran, and Dilaudid.Drugs ordered that may affect fecal elimination:Simvastatin, Zofran, Dilaudid, Acetaminophen, and Zosyn. Drugs ordered that may affect urine elimination:Lisinopril and Dilaudid.Drugs ordered that may affect mobility:Simvastatin, Lisinopril, and Dilaudid. Drugs ordered that may promote sleep, rest, or comfort:Dilaudid.Medications that may affect reproductive system or sexuality:N/A.Drugs ordered that may affect emotional status: Dilaudid and Acetaminophen.Medication SheetName, dose, routefrequency,classificationAction of drug and why ordered for this patientAdverse effectsPatient assessment,i.e. VS or lab valuesHow you will know thisdrug is effective forthis patientPatient teachingyou need to doSimvastatin tablet, 10 mg, PO, daily, antihyperlipidemic. It is a lipid lowering-agent. It increases the rate of removal of cholesterol from the body.Abdominal pain, constipation, nausea, headache, and an upper respiratory infection.Lipid panel, liver enzymes, and creatine.The lab values will be within normal range.Warn of side effects, immediately report jaundice, muscle weakness, and muscle pain. Avoid grapefruit juice. Consult doctor before taking another drug with this drug.Sodium Chloride 0.9%, 1000mL, IV, Q12H, Nutriceutical.A source of water and electrolyte. It is important in the regulation of osmolarity, acid-base balance, and the membrane potential of cells. Patient is on a clear liquid diet, needs fluid.Phlebitis, injection site extravasation, injection site reaction, and hypervolemia.Monitor serum electrolytes and acid-base balance. Also watch for fluid balance.The patient will be hydrated, electrolyte levels will be normal, and acid-base balance will be normal.Tell the nurse if the IV site hurts.Lisinopril tablet, 10 mg, PO, daily, ACE inhibitor (antihypertensive).Prevents the conversion of angiotensin I to angiotensin II, which is a potent vasoconstrictor. Patient has high blood pressure, needs to be on an ACE inhibitor.Chest pain, hypotension, syncope, dizziness, headache, and dry non-productive cough.We will take vital signs (blood pressure) frequently and before we administer the drug.Reduction in signs and symptoms of high blood pressure, decreased blood pressure.Move slowly from sitting to a standing position, report symptoms of cough. May cause nausea and vomiting.Zofran, 4 mg, IVP, injection, PRN Q6H, antiemetic.Prevents nausea and vomiting. Blocks receptors on the vagal nerve. Patient is taking this drug to reduce side effects of nausea and vomiting from other drugs.Constipation, diarrhea, xerostomia, increased liver enzymes, headache, and fever.Reduction in nausea and vomiting. EKG important in patients with electrolyte abnormalities or CHF.Patient will report no nausea or vomiting.Drink fluid to avoid constipation, report any reactions such as rash, breathing problems, lightheadedness, or syncope.Dilaudid, 1 mg, IVP, PRN Q6H, analgesic (opioid).Relieves pain exerting therapeutic effects. Patient is on this drug because of pain related to his sigmoid diverticulitis.Flushing, pruritis, constipation, vomiting, asthenia, headache, and somnolence.Monitor vital signs and watch for respiratory depression. Patient will report less pain than originally stated before receiving this medication.Avoid activities requiring mental alertness, drug may cause nausea and vomiting or dizziness and sedation, patient should report constipation, absence of pain relief, and respiratory depression.Tylenol, 650 mg, PO, PRN Q6H, analgesic.Pain reliever with anti-inflammatory properties. Relieves pain and reduces fever. Patient is on this drug as a more mild pain reliever due to his pain from sigmoid diverticulitis.Pruritis, constipation, nausea, vomiting, headache, agitation, and atelectasis.We should measure the patient’s temperature and their level of pain.Patient should state less pain, and signs and symptoms of fever should be diminished.Unsafe to take more than 4000mg of this drug in a 24 hour period. This drug may interact with other drugs. Should take this drug with a full glass of water and do not drink alcohol with this drug.Zosyn, pharmacy to dose, IVPB, PRN, antibiotic.An antibiotic effective in treating gram-positive and gram-negative aerobic and anaerobic microorganisms. The patient is on this for pre-surgery precautions, he will be getting a colon resection for his sigmoid diverticulitis.Pruritis, rash, constipation, diarrhea, nausea, oral candidiasis, headache, insomnia, and fever.We can do a CBC, measure his body temperature, infection improvement, electrolyte levels, and liver function.Patient’s infection will diminish.Report symptoms of bleeding, watery or bloody diarrhea. May cause constipation, nausea, vomiting, insomnia, headaches, and injection site reactions.Concept Map #1- Example325247036830“I don’t know how this fits”Recent widowKids live out of state? support system00“I don’t know how this fits”Recent widowKids live out of state? support system665734028575#4Key Problem:Knowledge deficit Data:Pt verbalizes confusion about diagnosis,new meds,diet, exercise routineSample Outcomes for care plan page:Pt will: maintain glucose within defined limits prior to discharge, follow 1800 ADA diet and verbalize understanding of ADA diet, administer insulin using appropriate techniqueInterventions:Assess glucose, monitor I/O, monitor appetite, provide education00#4Key Problem:Knowledge deficit Data:Pt verbalizes confusion about diagnosis,new meds,diet, exercise routineSample Outcomes for care plan page:Pt will: maintain glucose within defined limits prior to discharge, follow 1800 ADA diet and verbalize understanding of ADA diet, administer insulin using appropriate techniqueInterventions:Assess glucose, monitor I/O, monitor appetite, provide education-32067582550#3Key Problem:Impaired urinary elimination Data:Intake=2200 Output=1800Polyuria3+ glucose in urin 00#3Key Problem:Impaired urinary elimination Data:Intake=2200 Output=1800Polyuria3+ glucose in urin 390036543082-123190430821997954698534734540640Medical Problems (Pathophysiology)/Surgical Procedures:Newly diagnosed diabeticKey Assessments:S/S of hyper and hypo glycemia, good intake, I/O, glucose level, vitalsTests:00Medical Problems (Pathophysiology)/Surgical Procedures:Newly diagnosed diabeticKey Assessments:S/S of hyper and hypo glycemia, good intake, I/O, glucose level, vitalsTests:-31750095250#2Key Problem:Imbalanced nutrition, less thanAEB:Polydipsia, I/O imbalance,abnormal albumin level,weakness,lack of informationOutcomes:Interventions:00#2Key Problem:Imbalanced nutrition, less thanAEB:Polydipsia, I/O imbalance,abnormal albumin level,weakness,lack of informationOutcomes:Interventions:663511578740#1Key Problem: Acute anxietyAEB:Pt states “don’t know what I will do with diabetes, this is too overwhelming”Outcomes:Pt will appear relaxed and verbalize that anxiety is decreased, identify healthy ways to deal with anxiety, verbalize understanding of resources availableInterventions:Identify client’s perception of anxiety, monitor vitals, use empathy00#1Key Problem: Acute anxietyAEB:Pt states “don’t know what I will do with diabetes, this is too overwhelming”Outcomes:Pt will appear relaxed and verbalize that anxiety is decreased, identify healthy ways to deal with anxiety, verbalize understanding of resources availableInterventions:Identify client’s perception of anxiety, monitor vitals, use empathy389719018805-1263651841541211525400Past Medical HistoryRisk Factors00Past Medical HistoryRisk FactorsConcept Map #2337248566675“I am here for complaints of pain due to my sigmoid diverticulitis.”He is a Police Officer with a wife and one child. He is hoping to get his diverticulitis permanently by having a colon resection.00“I am here for complaints of pain due to my sigmoid diverticulitis.”He is a Police Officer with a wife and one child. He is hoping to get his diverticulitis permanently by having a colon resection.673036569850#4Key Problem: Acute painAEB: Patient stated he had a pain level of 8 on a scale of 10. Abdominal pain.Outcomes: Patient will verbalize decreased pain.Interventions: We can give patient medication and/or distract the patient with other activities or actions. This may take his mind off of it. 00#4Key Problem: Acute painAEB: Patient stated he had a pain level of 8 on a scale of 10. Abdominal pain.Outcomes: Patient will verbalize decreased pain.Interventions: We can give patient medication and/or distract the patient with other activities or actions. This may take his mind off of it. -10922069850#3Key Problem: Imbalanced nutrition, more than body requirements.AEB: Patient’s weight. He is overweight and does not exactly have the healthiest diet.Outcomes: Patient will establish a healthy diet pattern and exercise regularly. Patient will be at a healthy weight for his height and build.Interventions: Patient will eat healthy and come up with an exercise routine. 00#3Key Problem: Imbalanced nutrition, more than body requirements.AEB: Patient’s weight. He is overweight and does not exactly have the healthiest diet.Outcomes: Patient will establish a healthy diet pattern and exercise regularly. Patient will be at a healthy weight for his height and build.Interventions: Patient will eat healthy and come up with an exercise routine. 382992931750-123630317501997075117475018923048260Medical Problems (Pathophysiology)/Surgical Procedures:Patient has sigmoid diverticulitis. The patient has talked with his doctor about having a colon resection.Key Assessments:Pain assessment is very important, elimination patterns are also very important. Assessments of the patient’s diet is also important.Tests: An X-ray or a CT scan can be used to look for air, blocked matter, or swelling in the colon. Can be used to diagnose the diverticulitis and where it is.00Medical Problems (Pathophysiology)/Surgical Procedures:Patient has sigmoid diverticulitis. The patient has talked with his doctor about having a colon resection.Key Assessments:Pain assessment is very important, elimination patterns are also very important. Assessments of the patient’s diet is also important.Tests: An X-ray or a CT scan can be used to look for air, blocked matter, or swelling in the colon. Can be used to diagnose the diverticulitis and where it is.-107315-11430#2Key Problem: Hypertension AEB: Patient’s vital signs and past medical history.Outcomes: Patient will have decreased blood pressure. The medication will work therapeutically.Interventions: Have the patient handle stress with care and reduce salt intake in diet. 00#2Key Problem: Hypertension AEB: Patient’s vital signs and past medical history.Outcomes: Patient will have decreased blood pressure. The medication will work therapeutically.Interventions: Have the patient handle stress with care and reduce salt intake in diet. 672084037465#1Key Problem: Anxiety AEB: Pt. states “I don’t know if I can find enough time off from work to get this surgery done and recover properly.”Outcomes: Pt. will appear relaxed and and verbalize that the anxiety is taken care of. Maybe he would have talked to his boss by now, talked his decisions over with his wife, and/or talked to the doctor about any other concerns.Interventions: Identify patient’s concerns and perception of care, reduce aggravating factors, provide medication, etc. 00#1Key Problem: Anxiety AEB: Pt. states “I don’t know if I can find enough time off from work to get this surgery done and recover properly.”Outcomes: Pt. will appear relaxed and and verbalize that the anxiety is taken care of. Maybe he would have talked to his boss by now, talked his decisions over with his wife, and/or talked to the doctor about any other concerns.Interventions: Identify patient’s concerns and perception of care, reduce aggravating factors, provide medication, etc. -12954039370-4037965122555-3650615110490Past Medical HistoryHypertension and hyperlipidemia.Risk FactorsThe patient said hypertension runs in his family. Stress and sodium are also risk factors. Hyperlipidemia is from too much cholesterol intake, so it is important to watch his diet.00Past Medical HistoryHypertension and hyperlipidemia.Risk FactorsThe patient said hypertension runs in his family. Stress and sodium are also risk factors. Hyperlipidemia is from too much cholesterol intake, so it is important to watch his diet.NURSING CARE PLAN AND EVALUATION #1NURSING DIAGNOSISPATIENT GOAL ANDOUTCOME CRITERIANURSING INTERVENTIONRATIONALEEVALUATION(Actual patient response tointerventions while in your care) Diagnosis:Acute Pain Related to:Inflammatory bowel disease Manifested by:Pain level of 8/10 with rebound tenderness.Long-term Goal:Reduce signs and symptoms that are bothering the patient and preventing him from doing his job and being pain free.Expected Outcome Criteria:Patient will not complain of pain, the patient will go to work and be able to carry out his work duties and a normal at home life.1. Instruct patient to take medications as prescribed.2. Encourage patient to engage in usual activities, hobbies, relaxation techniques, and psychosocial support systems as tolerated.3. Recommend necessary alterations in diet.4. Constantly assess pain.5. Evaluate the patient’s perception of dietary impact on abdominal pain.6. Monitor changes in bowel habits (i.e. diarrhea).7. Try to encourage bed rest.8. Teach the patient about diagnostic tests.9. When administering medications, monitor the patient for adverse effects.10. If a colostomy is placed after surgery, teach the patient colostomy bag maintenance. 1. The goal is to induce clinical remission while avoiding toxic medications.2. Distraction heightens the patient’s concentration on non-painful stimuli to decrease awareness and experience and mental awareness to reduce the tension and pain.3. Small frequent meals may be better tolerated and cause less GI distress.4. Changes in pain may happen rather quickly and we always want to be sure we are on top of the comfort of the patient.5. Many patients with IBD cannot tolerate dairy products and may not tolerate many other foods.6. It is important to observe these just in case there is a problem that needs immediate attention.7. The patient stated his pain became worse when walking, and alleviated while laying down. With pain being a big concern, bed rest would be good for the patient.8. The more the patient knows about the disease and how it is diagnosed, the more comfortable they will be with the procedures and may lessen anxiety.9. We want to make sure the medication administration goes as planned, we do not want any unwanted effects to progress into something bad.10. It is important that we teach the patient about this because having a colostomy bag is a major life change. Being ignorant can create anxiety.Objective Data:The patient has co-existing medical conditions: hypertension and hyperlipidemia. The patient’s vital signs all seemed to be in normal range, especially for having hypertension. His blood pressure was 131/77, a little high, but within a good range. He is on an antibiotic as a pre surgery precaution. Subjective Data: The patient stated that when he came into the emergency room at the hospital his abdominal pain was an 8/10. Now he says it’s a 1 or a 2 because he is taking Dilaudid and acetaminophen. When I palpated his abdomen, there was rebound tenderness, reinforcing his sigmoid diverticulitis pain.Conclusion: Overall, his colon resection should resolve his sigmoid diverticulitis. That is the main goal he discussed with his doctor. If he takes the time off and heals properly, I anticipate a very positive outcome for him and this diagnosis.NURSING CARE PLAN AND EVALUATION #2NURSING DIAGNOSISPATIENT GOAL ANDOUTCOME CRITERIANURSING INTERVENTIONRATIONALEEVALUATION(Actual patient response tointerventions while in your care) DiagnosisStress Syndrome Related to:Unpredictability of the experience Manifested by:Verbal expressions of anxiety.Long-term Goal:Reduce stress related to sigmoid diverticulitis and it’s stress on his life and job experience.Expected Outcome Criteria:Patient will verbalize that he is not stressed, will appear to be less anxious about the outcome.1. Always include the patient in making decisions/plans about the procedure.2. Include significant others in discussions and decisions as appropriate.3. Avoid talking about unplanned or abrupt changes.4. Encourage expression of feelings.5.Use a calm reassuring approach.6. Seek to understand the patient’s perspective of the event.7. Arrange situations to encourage the patient’s autonomy.8. Allow family members to discuss their concerns and feelings related to the surgery and recovery.9. Teach the person the characteristics of normal anxiety/nervousness/anticipation.10. Discuss with the person and significant others the differences in patterns of adjustment.1. The patient’s attitude toward the plan will be less stressed when he participates in making important decisions.2. Decisions following acute stress can be detrimental for the person. Significant others are trusted individuals with whom the patient is familiar.3. This can disrupt feelings of safety and increase the risk for acute stress.4. Exploration of feelings assists in perceiving the situation more realistically assists with adaptability.5. Anxiety may be reduced in a calm environment.6. Demonstration of understanding is part of building trusting relationships.7. Autonomy reinforces self-worth and feelings of value.8. Family members may feel a broad variety of feelings and it is important for the patient to include them in conversations about this.9. Knowing what is normal can provide reassurance and decrease anxiety.10. The person and family members need to understand that people` adjust to change in different ways. Identification of differences assists in normalizing the patient’s feelings.Objective Data:The patient’s blood pressure was at a normallevel. Subjective Data:The patient verbalized many times when wewere talking that he was very stressed aboutfiguring out how many days he would haveto take off in consideration of the surgeryand recovery. His wife works from home,and his daughter goes to kindergarten. Hewill have to be out of work for quite sometime so until he talks to his boss about thesituation, he will continue to be stressed.Conclusion: Once the patient talks to hisboss and doctor and they figure everythingout, I believe his stress will be alleviated. It may seem hard right now and I observedhim and his wife arguing a bit about whatwas going to happen, which I’m sure didnot help, but once the surgery and time offare scheduled and worked out, I think it willalleviate his stress syndrome. Patient/Family Teaching PlanII. NURSING CARE PLAN AND EVALUATION(Continued)A.Assessment(Include additional data, not previously included, that supports the need for teaching for this patient/family)Basically, the patient and his family need to be informed about the procedure and the recovery. He needs to know what the outcome of the surgery will be, the risks, etc. They need to figure out the time away from work for the patient. Most importantly, they need to talk about how this will help him in the long runB.Nursing Diagnosis:Knowledge deficit related to the outcomes of the surgery.C.Patient/Family Goal and Outcome Criteria:1.Long-term Goal: To not come back to the hospital for anymore acute pain related to his sigmoid diverticulitis2.Expected Outcome Criteria: The patient will be able to return to his regular work duties and normal at home life. He will not return to the hospital for anymore acute pain related to his sigmoid diverticulitis. This problem will not cause him anymore stress.D.Plan 1.Content of Teaching (What are you going to teach): I would teach him to be more open with his doctor and nurses and tell them what is bothering him. I would also teach him to have a better diet related to his hypertension. He also needs to find a better way to deal with stress rather than sitting there worrying about the same thing. He should talk about how he feels.2.Strategies (How are you going to go about it): I would give him a support group or some classes (at Elmhurst Memorial Hospital). It is always good to have people you can relate to, and it might help him learn about having a healthier diet. Hypertension and nutrition classes are very common at many different hospitals.E.Intervention & Evaluation:What did you actually teach and what was the response of the patient/family:Content of Teaching (What are you going to teach): I would teach him to be more open with his doctor and nurses and tell them what is bothering him. I would also teach him to have a better diet related to his hypertension. He also needs to find a better way to deal with stress rather than sitting there worrying about the same thing. He should talk about how he feels.2.Strategies (How are you going to go about it): I would give him a support group or some classes (at Elmhurst Memorial Hospital). It is always good to have people you can relate to, and it might help him learn about having a healthier diet. Hypertension and nutrition classes are very common at many different hospitals.Discharge PlanII. NURSING CARE PLAN AND EVALUATION (continued)Overall Discharge TeachingBy the time of discharge the patient/family will be able to verbalize and/or demonstrate. 1. He will find a support group related to diverticulitis complications. 2. He will meet with a dietician to develop a healthier diet due to him being overweight and having hypertension. 3. He will talk to his boss about taking time off for the surgery and recovery, alleviating some stress. 4. He will learn to be more open with his feeling and about what is bothering him. 5. He will talk to his doctor about the risks of the surgery and the expected outcomes. 6. He will avoid having a high sodium diet.7. He will develop a regular exercise routine. 8. He will take the proper amount of time off work to heal correctly. 9. He will attempt to lose an x amount of weight by a certain date.10. He will prevent infection to him being immunosuppressed by breaking the chain of infection by washing his hands.References for Information in APA Format:Ignatavicius, D., & Workman, L. (n.d.). Medical-Surgical Nursing: Medical-Surgical Nursing: Patient-Centered Collaborative Care (7th ed.). Elsevier.Micromedex. (n.d.). Retrieved September 23, 2015, from ................
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