NUR2115 Module 10 Comprehensive Plan of Care Assignment
In this third and final submission of your Course Project, you will be completing a comprehensive care plan. This written assignment should include the following: Comprehensive Plan of Care Develop a comprehensive plan of care/treatment with short and long term goals and include safety needs, special considerations regarding personal needs, cultural/spiritual implications, and needed health restoration, maintenance, and promotion.
Patient education: (Example: medication, safety, possible complications associated with the patient).Complete in a narrative format exactly how you would educate the patient.Include at least 7 narrated sentences.
Outcome: Caring:
Identify one example from your clinical day in which you observed, participated in or provided some aspect of caring for the provision of psychosocial and/or cultural diversity needs.
Evidence-based Practice (EBP): Summarize one article published within the last 3 years that you could use to improve the care you provide to this patient. Utilize learning resources available through Rasmussen Online library. Include APA citation in reference list.
References
Clinical Site/ Unit: TCU
Patient Initials: S.D
Gender: Female
Age: 71
Weight: 287lbs
Height: 64.0
Baseline vitals (from the patient chart)
Date: 02/07/19; B/P: 127/52; Pulse: 85 bpm; RR: 16 bpm; T/mode: 98 (Tympanic)
Pulse ox: 98.0%
Vital Signs Assessment (Taken by me)
B/P: 143/58; HR: 72 bpm; RR: 19 bpm; T: 97; SpO2: 94%
Allergies: Amlodipine, Meperidine, Nitroglycerin, Polyethylene Glycol, Simvastatin, NSAIDs, Penicillin, Sulfa Antibodies
Code Status: Full code
Social Health: Husband of 44 years; Daughter (EMT); Son (EMT Firefighter)
Marital Status: Married
Cultural Background: Caucasian
Primary Language: English
Past Medical/ Surgery History: Had depression in the past and is treated for it.
Family Health History: Mental health problem, had depression in the past
Diet: Consistent carbohydrate diet, Regular Texture texture, Thin Liquid consistency
Special Instructions: Preferences for taking medications – water with ice, ice tea
Activity/Assistive Devices: No assistive devices required
Treatment Orders: Not required
Tubes/ Drains/ Ostomies: No Tubes/ Drains/ Ostomies required
Interdisciplinary Cares (OT/ PT/ ST) and frequency: No interdisciplinary cares noted
Dressings/ Wounds: (type & location): No Dressing/ Wounds noted
ASSESSMENT SUMMARY
Body System Subjective: Patient’s Health History Objective: My assessment findings
Pain Level (pain scale 0-10/ location): Patient reports pain of 6.5 out of 10 (leaning forward) and 3 out of 10 (still sitting) Pain rating: 0-10:
Characteristic: Temporal
Onset: When leaning forward
Location: Right shoulder
Description (dull, aching,
sharp): Sharp pain
Exacerbating factors factor(s): Comes and go.
Relieving factor(s): Pain medications (oxyCODONE)
Orientation:
Head/Eyes/ Ears/ Nose/ Throat (HEENT): Patient reports no trauma to the head. Does not experience any headache.
Patient reports no problem with vision, no eye pain, no glasses or contact lenses, no history of an ocular problem, no blurring, no blind spot.
Patient reports no ear pain, no history of ear infections, no ear discharge, and no hearing loss.
Patient reports nose is always clogged. Patient reports no experience of headaches and trauma to the head.
Orientation (person, place, time and situation): Patient alert and oriented X 4. Had four (4) brain surgery to stop trimmers.
Speech (clear/appropriate): Speech is clear
PERL (pupils equal and reactive to light): Pupils are equal and reactive to light. Had a cataract surgery.
Ears (clean/dry): No lesions, no drainage, CN8 intact, no hearing aids
Nose (clean/dry/intact): Symmetrical no deformities, no lesions, mucosa and turbinate are pink, moist, no exudates, no septal deviation, no perforations.
Throat (pink, moist): Thrush on her tongue from a fungal infection, has sore on the mouth (lip), oral mucosa is pink and moist, and the patient has good dentition. Good symmetrical movement. The pharynx is normal in appearance without tonsillar or exudates. No adenopathy is noted. CNS I-XII (All intact).
Musculoskeletal: Patient reports arthritis in fingers but does not have rheumatoid arthritis
MAE (moves lower extremities very well, and left upper extremity
Weakness: Right shoulder
Assist (transfers/ambulation): Stand by assist with all transfers and ambulation.
Assistive device (walker, cane): no use of any assistive devices (walker or cane).
Respiratory: Patient reports no cough, no shortness of breath, no chest pain, no smoking history, no history of respiratory infections, and no environmental exposure. Respirations: 19 bpm
Rate: Regular
Lung sounds: quick deep on inspiration and quick shallow on expiration
Cough: No cough noted
SOB: no shortness of breath
Cardiac: Patient reports no chest tightness, no recent fatigue. AP (apical pulse): 72 bpm
Rate (regular): Is regular.
Chest pain: No chest pain
Peripheral pulses: Brachial, Carotid, Radial, Dorsal Pedis
Edema: Lower extremities – 4+ pitting edema
Capillary refill: Less than 3 seconds
Integument: Patient reports no leg pain, no leg cramps Skin ( moist, intact): Skin is moist and intact, not dehydrated, warm to touch
Color (pink, pale, cyanotic): Skin is pink
Wound(s): 2-3 inches red bruise on left foot from blister.
Dressing(s): No dressings on any part of body.
Gastrointestinal (GI): Patient reports no bowel problems. Patient reports having a bowel a day before. Bowel sounds (x4): Bowel sounds regular and present in all 4 quadrant.
Nausea/vomiting: no nausea or vomiting
Pain/tenderness with palpation: No pain on palpation
Last BM: 2 bowel movements a day ago (02/06/19)
Continent: Continent of bowels
Genitourinary (GU); Patient reports no problem with voiding. Patient reports voiding 8-10 times a day Frequency of urination (q2h, q4h, foley): 8-10 times a day. Approximately q2h.
Color: Pale yellow
Dysuria (frequency, burning):
No pain or burning sensation
Continent: Continent
Endocrine; Patient reports no abnormal growth, no endocrine disease or disorders, no abnormal temperature Diabetic/ Blood sugar: 193.0
Diet: Consistent carbohydrate diet, Regular Texture texture, Thin Liquid consistency
Appetite (%): 75%
Psychosocial/ Spiritual: Patient reports associating with Native American Spirituality and is Buddhist. Patient reports having a strong family support. Good spirits/ Pleasant: Very active and good spirit
Sad/ Tearful/ Anxious: She is not sad, tearful or anxious
What is resident main concern during their stay? To walk 3-4 times a day to get lower extremities working.
Main concern after they discharge? To be able to go back to work and go about normal business.
Medication Data Sheet
Drug Name Trade and generic name, dose, route& frequency Drug Classification Expected action and indication for use Medical Diagnosis
Side Effects and Adverse Reactions Nursing Administration special instructions and assessments Client Education Evaluation of medication effectiveness, e.g., Pin Scale
Acetaminophen (Tylenol) Tablet 500 mg. Give 2 tablets by mouth orally 3 times a day. No more than 4000 mg in 24 hours, also a PRN dose of 1000 mg. It is used to treat mild to moderate pain. For pain experiencing in Right shoulder. Side effects: Nausea, stomach pain, loss of appetite, itching, rash, headache, dark urine.
Adverse reaction: Difficulty breathing or swallowing, swelling of the face, lips, throat or tongue. Hives, severe itching
Assess the history of pain.
Demonstration of relieving of pain on the pain scale 0-10
Vitamin D3 (Cholecalciferol) tablet 5000 units. Give one pill by mouth two times a day.
Treatment or prevention of vitamin D deficiency. For Closed Fracture off the head of the right humerus Side Effects: Kidney stones, confusion, disorientation, muscle weakness, frequent urination, nausea, vomiting, constipation.
Adverse Effects: Extremely large doses can cause toxicity. I am assessing patient carefully for evidence of hypocalcemia, assessing for symptoms of vitamin deficiency before and periodically.
Normalization of serum calcium and parathyroid hormone levels.
Resolution of prevention of vitamin D deficiency.
Gabapentin (Neurontin) Capsule 300 mg. Give 300 mg by mouth two times daily. Neuropathic pain, diabetic peripheral neuropathy. For neuropathic pain Side effects: sleepiness, dizziness, fatigue, clumsiness while walking, weight gain, tremor
Adverse effects: Skin rash, unusual bruising, swollen glands, muscle aches. Assess the location, characteristics, and intensity of pain periodically during therapy.
Decreased intensity of neuropathic pain.
Wellbutrin (buPROPion HCL, ER) SR Tablet Extended Release. Every 12 hours 200 mg.
Give 1 tablet by mouth two times a day. Treatment of depression. The patient is taking for depression and has a history of depression. Side Effects: dry mouth, sore throat, nausea, vomiting, flushing, headache, abdominal pain.
Adverse Effects: mood or behavior changes, anxiety, depression, panic attack. Assess mental status and mood changes, inform health care provider if the patient demonstrates a significant increase in signs of depression.
Increased sense of well-being, renewed interest of surroundings.
Protonix (Pantoprazole Sodium) Tablets Delayed-Release 40 mg.
Give 1 mg tablet by mouth two times a day. Erosive esophagitis associated with GERD. Maintenance of healing of erosive esophagitis. The patient is taking this medication for GERD. Side Effects: headache, nausea, vomiting, diarrhea, stomach or abdominal pain, gas, dizziness.
Adverse Effects: Facial edema, hyperglycemia, photosensitivity
I am assessing patient routinely for epigastric or abdominal pain.
Decreased in abdominal pain, heartburn, gastric irritation and bleeding in patients with GERD.
Nursing Diagnosis Expected Outcomes (S.M.A.R.T) Specific, measurable, attainable, realistic, & time oriented (ID a future time or date for reassessment/ evaluation Nursing Interventions
#1
Acute pain
R.T.
Movement of bone fragments, edema, and injury to the soft tissue
A.M.B.
Reports of pain The patient will verbalize relief of pain.
Short-term goal: Patient verbalizes minimized or controlled feeling of pain.
Long-term goal: Patient is free of pain on surgical site.
Maintain immobilization of affected part by means of bed rest, cast, splint, traction.
#2
Impaired Physical Mobility
R.T.
Neuromuscular skeletal impairment; pain/discomfort; restrictive therapies (limb immobilization)
A.M.B.
Reluctance to attempt movement; limited ROM The patient maintain position of function.
Short-term goal: After 4 days of nursing intervention, the patient will be able to demonstrate techniques and behaviors that enables resumptions of activities.
Long-term goal: After 4 days of nursing intervention, the patient will be able to maintain or increase strength and functions of affected body part.
Instruct patient or assist with active and passive ROM exercises of affected and unaffected extremities.
#3
Skin/Tissue Integrity, impaired: actual/risk for
R.T.
Physical immobilization
A.M.B.
Reports of itching, pain, numbness, pressure in affected/surrounding area The patient verbalize relief of discomfort.
Short-term goal: After 6-8 hours of nursing intervention the patient will have reduced risk of further impairment of skin integrity.
Long-term goal: After 3-4 days of nursing intervention the patient will be able to reduce risk of infections.
Assess position of splint ring of traction device.
Which of your diagnoses are Priority using Maslow’s Hierarchy of Needs: Impaired Physical Mobility according to Maslow’s Hierarchy of Needs, physiologic needs should satisfy first, so that the patient should satisfy this to satisfy her physiologic needs.
Evaluation: Were any of your short term expected outcomes met during your shift? None of the short-term expectations were met during my shift.
How might you revise your care plan next time to achieve at least one outcome during your shift? I plan on improving my care plan next time by monitoring my patients’ recovery process keenly and offering effective ways to have my patient be able to decrease edema and promotes venous return.
Medical Diagnosis
1. The patient diagnosed with an Unspecified Displaced Fracture of Surgical Neck of Right Humerus the pieces of bone at the fracture site are separated and shifted out of position. This type of fracture typically requires surgery. Proximal humerus fractures are diagnosed by a thorough physical examination and diagnostic imaging (Stanley, n.d.).
2. Humerus fractures are caused by direct harm to the arm shoulder. About 20% of humerus fractures are displaced and mostly occur in baseball games. Such type of fracture requires a more intrusive treatment like surgery
3. A subsequent encounter is experienced when an active treatment of the patient’s injury has been offered, and the patient is now receiving routine care for the injury in the healing process (Deter, 2006). An example is medical ex-rays to monitor the healing process of the fracture
4. Asthma is an inflammatory disease of the airway demonstrated by various recurring symptoms and bronchospasm. Common symptoms of asthma include; coughing, wheezing, short breaths, and chest tightness.
5. A major depressive disorder is a mental disorder demonstrated by two weeks or more of low mood. It is accompanied by loss of interest in several things, low self-esteem, pain with no clear cause and low energy. Patients with depression often hear or see things that are unseen by other people. They affect patients negatively as some end up committing suicide (Deter, 2006).
LAB RESULTS
DATE LAB TEST NORMAL VALUE CLIENT VALUE SIGNIFICANCE OF ABNORMAL LAB VALUE
01/27/19 Sodium
135-145 mmol/L 134 (L) The significance of abnormal sodium lab value is hyponatremia.
01/27/19 BUN/Creatinine Ratio
10-20 mg/DI 27 (H) This mean the patient may not be getting enough blood flow to their kidneys, and could have conditions such as congestive heart failure, dehydration, or gastrointestinal bleeding.
01/27/19 Hemoglobin
12.0-16.0 g/DI 7.8 (L) This mean that there is a nutritional deficiencies such as iron, folate or B12 deficiency.
01/27/19 ALK Phosphate 50-136 IU/L 144 (H)
Elevated ALK Phosphate is most commonly caused by liver disease or bone disorders.
01/27/19 RBC 4.00-5.20 mil/cu mm 2.95 (L)
This could signify trauma in the patient.
Diagnostic Tests
Tests Results Significance
US Venous Upper Extremity Right Indication: Right Humerus Fracture The right arm veins are negative of DVT It enables the nurse to know where exactly the fracture happened and the intensity of the fracture to administer proper medication.
EKG 12- Lead Interpretation: Artifact, Sinus rhythm, right Atrial enlargement, Abnormal ECQ It directs the nurse on the exact medication to use.
References
Deter, L. L. (2006). Basic medication administration skills. Australia: Thomson Delmar Learning.
Stanley, L. (n.d.). Moving Forward: Physical Therapy Brings Motion to Life. https://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=937e6560-3300-4bdc-9285-16d9cb759554
