NURSING CARE PREPARATION



NURSING 111 CARE PREPARATIONStudent Name: Stephanie Perkins Date of Care: 2/12/15Unit/Room Number: PSU 377Age: 81Gender: MaleErikson’s Developmental Level: Integrity vs DespairDate of Admission: 2/11/15Ethnic/Cultural Preferences: WhiteAllergies: NKACode Status: DNRPrimary Diagnosis: Acute respiratory failureCo-morbidities: Hx of CVA, dyspnea, COPD pneumoniaDischarge Plan (add day of clinical):Integrated Pathophysiology (what is going on with your patient at the cellular level for the health condition, no more than three pages in length, including reference page)Fluid builds up in the alveoli sacs of the lungs which then causes a decrease of oxygen in the blood as evidenced by dyspnea. COPD correlates with this as it’s a chronic condition of fluid in the lungs which also causes dyspnea.Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any assessment/elaboration should be made on the assessment sheet):Diet (Type): Regular, vegetarian, mechanical softIV (Fluid type, rate, access type): FS Sodium Chloride 0.9% 999 mL/hour over 1 H statI&O (MD order/Nursing Order/Frequency): noCBG (Yes/No, frequency): noFall Risk/Safety Precautions (Yes/No): Activity (What is ordered): Up for meals, up ad lib minimum 4 times dailyWound Care (Yes/No):Oxygen (Yes/No, Delivery method, how much): Yes 2-4 L/min NCDrains (Yes/No, Type):Last BM: will assess day of clinicalOther Tubes:ASSESSMENTS(Include Subjective & Objective Data)Integumentary:Color appropriate for race, c/d/I, turgor present no wounds or lesions.Head and Neck:Normocephalic, nontender Ear/Nose/Throat:No drainage, nares patent, oral mucosa pink and intact. Mouth and tongue dry.Thorax/Lungs:Expiratory and inspiratory wheezes and rhonchi throughout lower lobes Cardiac:S1S2 heard but diminished. PP weak and easily obstructed no edema cap refill less than 3 secMusculoskeletal: Grips equal bilaterally extremities strength equal bilaterallyGenitourinary:Urine yellow no sediment or odor output 75 ccGastrointestinal:Abdomen soft and nontender bowel sounds hypoactive in all 4QNeurological: A/O x 3 PERRLAOther (Include vital signs, weight): BP 128/60 P 87 O2 100 Pain 0/10 RR 20CURRENT MEDICATIONSList ALL regularly scheduled and prn medications scheduled on your client.(Due morning of clinical)Generic & Trade NameClassificationDose/Route/Rate if IVOnset/PeakIntended Action/Therapeutic use. Why is this client taking med?Adverse reactions (1 major side effect)Nursing Implications for this client. (No more than one)Saline Flush (Sodium Chloride Flush)0600Maintenance Fluid 10 mln/aIV patency IrritationAssess IV siteAlbuterol/Ipratrop (Duoneb)0800 1200 Bronchodilator3 ml neb QID5-15 min/0.5-2hDecrease airway resistance Worsening of breathing problemsCPV assessment before and after treatment to determine effectiveness Aspirin EC (Acetylsalicylic Acid)0900Nonnarcotic Analgesic81 mg 1 tab PO dailyUnknown/15 min-2 hPain relief of low to moderate intensityThrombocytopeniaAssess labsCalcium Carb/Vit D (Caltrate/ Vit D)0900Fluid and electrolyte replacement solution1 tab PO dailyUnknown/unknownCalcium supplementConstipationAbdominal AssessmentChlorhexidine (Peridex)0900Germicidal mouthwash0.12% oral rinse 15 ml mucosal BIDUnknown/unknownReduces bacteria in mouthSevere irritation and chemical burnsAssess oral mucosa Enoxaparin (Levenox)0900Anticoagulant 40 mg=0.4 ml SC dailyUnknown/ 3 hAntithrombotic agenthemorrhageAssess labsMupirocin (Bactroban)0900Antibiotic2% Ointment Nasal BID Not systemically absorbed Rid of nasal bacteriaBurningAssess for burningParoxetine (Paxil)0900Antidepressant 20 mg= 1 tab PO Daily2 wk/ 5-8 hTreat depressionWorsening depressionAssess efficacy Prenatal Vitamin w/ Iron0900multivitamin1 mg PO daily-mealVitamin deficiency/supplementconstipationAssess abdomenVitamin D 2000 unit0900Vitamin2 tab PO dailyHelps to absorb calcium and phosphorusnoneAcetaminophen (Tylenol)Nonnarcotic Analgesic2 tab PO q4h prn minor pain/HAUnknown/ 0.5-2 hRelieve painAcute renal failure in acute poisoningAssess labsAlbuterol HFA (Ventolin HFA)Bronchodilator 2 puff q 4 h prn wheezing/ SOB5-15 min/0.5-2hDecrease airway resistance Worsening of breathing problemsCPV assessment before and after treatment to determine effectiveness Albuterol neb sol (Ventolin Proventil)Bronchodilator 3 ml neb q2h prn SOB5-15 min/0.5-2hDecrease airway resistance Worsening of breathing problemsCPV assessment before and after treatment to determine effectiveness Nicotine Transdermal patchSmoking deterrent1 patch prn nicotine cravingsUnknown/ 8-9 hReduce withdrawal symptoms of smokingLocalized edemaSkin assessmentOndansetron (Zofran INJ)Antiemetic 2 ml IV q4h prn nausea vomiting Unknonw/ 1-1.5 hPrevents n/vDiarrhea Assess stoolsDIAGNOSTIC TESTINGInclude pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays, CT, MRI, U/S, etc.]NOTE: Adult values indicated. If client is newborn or elder, normal value range may be different.DateLab Test Normal ValuesPatient Values/Date of careInterpretation as related to Pathophysiology –cite reference & pg #2/11Sodium 135 – 145 mEq/L 140Potassium 3.5 – 5.0 mEq/L4.7Chloride 97-107 mEq/L108Renal failure not being able to excrete chlorideCo2 23-29 mEq/L24Glucose 75 – 110 mg/dL97BUN 8-21 mg/dL32Renal failure not being able to excrete waste productCreatinine 0.5 – 1.2 mg/dL1.73Severe renal impairmentUric Acid Plasma 4.4-7.6 mg/dLn/aCalcium 8.2-10.2 mg/dL9.2Phosphorus 2.5-4.5 mg/dLn/aTotal Bilirubin 0.3-1.2 mg/dL0.6Total Protein 6.0-8.0 gm/dL8.3dehydrationAlbumin 3.4-4.8gm/dL3.7Cholesterol <200-240 mg/dLn/aAlk Phos 25-142 IU/L97SGOT or AST 10 – 48 IU/L26LDH 70-185 IU/Ln/aCPK 38-174 IU/Ln/aWBC 4.5 – 11.09.8RBC male: 4.7-5.14 x 10 female: 4.2-4.87 x 103.82Hemolytic anemiaHGB male: 12.6-17.4 g/dL female: 11.7-16.1 g/dL11.6Hemolytic anemia HCT male: 43-49% female: 38-44%35.2Decrease in number or RBCMCV 85-95 fL92MCH 28 – 32 Pg 30.4MCHC 33-35 g/dL33.0RDW 11.6-14.8%14.2Platelet 150-450189DIAGNOSTIC TESTINGDateUANormal RangeResultsInterpretation as related to Pathophysiology –cite reference & pg #Color/AppearancepHSpec GravityProteinGlucoseKetonesBloodDateOther(PT, PTT, INR, ABG’s, Cultures, etc)Normal RangeResultsInterpretation as related to Pathophysiology –cite reference & pg #++++++DateRadiologyResultsInterpretation as related to Pathophysiology –cite reference & pg #X-RaysScansEKG-12 leadTelemetryDAR NURSING PROGRESS NOTEInclude the same note that was written in the client record for the priority nursing diagnostic statement. Include the date/time/signature.2/12/15 1230Patient up in wheelchair. Lung sounds diminished, inspiratory and expiratory wheezing. Rhonchi and crackles present. Assisted in ordering lunch and in feeding. During feeding pt coughed after every bite. Inquired about denture use and pt stated “they’re too expensive”. Called for speech therapy consult for a swallow study which lead to diet change of mechanical soft and thick liquids with thin liquids between meals. Left pt with call light in reach, brakes on, O2 at 3 L-------------------------------------------------------------------------Stephanie Perkins SNPATIENT CARE PLANPatient Information: Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by (AEB).Problem #1 Impaired gas exchange r/t lung disease AEB dyspneaDesired Outcome: Patient will not experience s/s of dyspnea at rest during shiftNursing InterventionsClient Response to InterventionAssess CVP q 2 h1. Inspiratory and Expiratory wheezing and rhonchi with cracklesEncourage use of incentive spirometer q1h2. Able to get to 750Educate proper use of inhalers every administration 3. n/a RT did all nebulizer treatmentsEvaluation (evaluate goal & interventions, what worked/what didn’t, what would you adapt if needed): This pts lung sounds were absolutely horrendous. He was able to use the incentive spirometer a few times and I educated him on how to use it correctly. I did leave it on the bedside table as well to serve as a visual reminder. I think these interventions worked well minus the inhaler/neb treatments since RT did all of those. I hope that throughout his stay the other RNs and CNAs do similar interventions to help him get better.Problem #2 Risk for Aspiration r/t swallowing difficulties AEB coughing during meal time.Desired Outcome: Patient will not show s/s of aspiration during meal time (i.e. coughing, gagging, etc.) Nursing InterventionsClient Response to InterventionAssess lungs before and after meal time1. Lung sounds unchanged before and after meal, however lots of food in back of throat after swallowingAssess for s/s of aspiration during meal time2. Coughed during and after mealtime Consult for swallowing evaluation 3. Diet was changed to mechanical soft and thickened liquids with thin liquids between mealsEvaluation (evaluate goal & interventions, what worked/what didn’t, what would you adapt if needed): Assessing the lungs before meals helped establish a baseline so if there was an aspiration I had something to look back on. He did cough during the mealtime so that’s why I had speech therapy evaluate his swallowing. During the evaluation it was discovered that he’s a silent aspirator so his diet was changed to prevent aspiration pneumonia. In all I think these interventions worked well to help him in the future.Problem #3 Activity intolerance r/t lung disease AEB dyspnea Desired Outcome: Patient will walk at least 50 feet 4 times during shiftNursing InterventionsClient Response to InterventionAssess extent to which pt is able to move around in room at beginning of shift1. Pt weak, able to transfer from bed to wheelchair with 1 person assistEncourage patient to walk 50 feet 4 times during shift2. Unable to walk d/t weaknessEducate patient about controlled breathing during activity3. O2 stats raised during deep breathing exercises Evaluation (evaluate goal & interventions, what worked/what didn’t, what would you adapt if needed): Besides the walking the other interventions worked. This pt had tried to adjust himself in bed and in doing so his O2 stats dropped significantly from 92 to 85. The deep breathing exercises helped bring his O2 stats back up to 92. ................
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