care plan oct 30_2010

Florida Community College of JacksonvilleNUR 1022C: Nursing Care Plan for TERM 1

(rev 02/25/08)

Student Date of Care: 10/30/2010 Code StatusFull

Client’s Initials Room # Age/Sex: 93 F Admit Date: 10/26/2010 Isolation Status Standard

Allergies NKDA Activity Level up w/ assistance Diet low cholesterol

Reason for Hospitalization Patient was eating breakfast @ asst. living facility when she dropped her fork and became unresponsive to voice. Patient then made sound that resembled slurred speech. Patient was transported to BMC -D ER. Were she then became responsive as if nothing had happened. Patient has no recollection of the event.Admitting Diagnosis Transient global amnesia, R/O TIA, SZTIA - transient ischemic shock, transient ischemic attack SZ - SeizuresOther Medical Diagnoses – Pressure ulcer on R heel, R arterial ankle, R knee, L lateral ankle, L lateral foot all unstaged. Dementia

Previous Surgery /Year: ( last 5 yrs)No known

Explanation of Admitting Diagnosis: (One-two sentences in own words about the pathophysiology; Then, 3-5 of the signs and symptoms of the medical disease process) Memory disorder seen in middle aged and elderly persons characterized by an episode of bewilderment and amnesia that lasts for several hours. The person is otherwise alert and intellectually active. 1. Patient was had sudden onset of memory loss that was verified by a witness. 2. Patient knew who she was and where she was after the incident3. Memory loss was not longer than 24 hours4. Patient had no signs indicating damage to a particular area of the brain such as limb paralysis, involuntary movement or impaired word recognitionVitals – temp. 98.3 HR 81 Res 19 BP 156/74 Pain (was not able to talk to patients but was told by ACP and RN that patient is in a lot of pain. Does not like for anyone to touch her)

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MEDICATIONS (List 10-15 of the meds to be given from 0730 -1200)

Generic Name (Trade Name)

Dose/ Route/

Time

Classification, Action, &

Indication for Client

Major Side Effects Nursing Implications Evaluation / Effectiveness/

Aspirin

(ASA)

Safe dose range: 300-325 mg/d, 81 mg may be effective

Actual dose: 81mg/PO/day

Classification- Func. Class: Nonopoid analgesic.NSAID,antipyretic,antiplatelet Chem. Class: Salicylate.

Action - Produce analgesia and reduce inflammation and fever by inhibiting the production of prostaglandins. Decreases platelet aggregation. Therapeutic Effects: Analgesia. Reduction of inflammation. Reduction of fever. Decreased incidence of transient ischemic attacks and MI.

Indication: mild to mod. Pain or fever including thromboletic disorders; transient ischemic

Thrombocytopenia, agranulocytosis, leucopenia, neutropenia,hemolytic anemia, seizures, GI bleeding, hepatitis,anaphylaxis, laryngeal edema, N/V, rash.

Crushed or whole; chewable tablets may be chewed.Do not crush enteric coated product.Take with food or milk to decrease gastric symp.; separate by 2 hr of enteric product

Relief of mild to moderate discomfort.

Increased ease of joint movement. May take 2–3 wk for maximum effectiveness.

Reduction of fever.

Prevention of transient ischemic attacks.

Prevention of MI.

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Dose/ Route/

Time




clopidogrel (Plavix)

Safe Dose: 300 mg initially, then 75 mg once daily; aspirin 75–325 mg once daily should be given concurrently.

Actual dose: 75 mg/PO/Daily

Classification: Antiplatelet agentsPlatelet aggregation inhibitors

Action: Inhibits platelet aggregation by irreversibly inhibiting the binding of ATP to platelet receptors. Therapeutic Effects: Decreased occurrence of atherosclerotic events in patients at risk

Indication Reduction of atherosclerotic events

Bleeding, neutropenia, thrombotic thrombocytic purpura

Assess for symptoms of stroke, PVD or MI periodically during therapy and for thrombotic thrombocytic purpura

Prevention of stroke, MI, and vascular death in patients at risk

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Dose/ Route/

Time




Bisacodyl

(Dulcolax 5mg tab)

Safe Dose: 5–15 mL/dose up to 4 times/day as liquid or 2.5–7.5 mL/dose up to 4 times/day as liquid concentrate mg/dose or 622–1244 mg/dose (2–4 tabs) up to 4 times/day.

Actual dose: 5mg/ PO/ q12 h/ PRN

Classification: Laxative, stimulant Action: acts directly on intestine by increasing motor activity

Indication: decrease constipation

Muscle weakness, nausea, vomiting, anorexia, cramps, tetany

Do not crush; monitor blood, urine electrolytes if used often; monitor cramping, rectal bleeding; give alone with water for better absorption; do not take w/ in 1 hr of antacids

Relief of gastric pain and irritation

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Dose/ Route/

Time




Tums

Calcium carbonate

Safe dose: Prevention of hypocalcemia, treatment of depletion, osteoporosis—1–2 g/day in 3–4 divided doses. Antacid—0.5–1.5 g as needed. Hyperphosphatemia in end-stage renal disease —1 g with each meal, increase to 4–7 g as needed.

Actual dose: 1000mg/PO/Daily

ClassificationT: mineral electrolyte replacements supplementsIndicationTreatment/prevention of heartburn

Arrhythmias, constipation Observe patient for signs of hypocalcemia )parasthesia, muscle twitching, cardiac arrhythmias)

Increase in serum calcium levels.

Decrease in the signs and symptoms of hypocalcemia.

Resolution of indigestion.

Control of hyperphosphatemia in patients with renal failure

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Dose/ Route/

Time




Calcium CarbonateSafe Dosage: Adult - 1–2 g/day in 3–4 divided doses. Antacid—0.5–1.5 g as needed. Hyperphosphatemia in end-stage renal disease —1 g with each meal, increase to 4–7 g as neededActual dose: 100mg PO Daily (Y)

C - mineral electrolyte replacements supplements

A - Replacement of calcium in deficiency states. Control of hyperphosphatemia in end-stage renal disease without promoting aluminum absorption

I - Treatment and prevention of hypocalcemia. Adjunct in the prevention of postmenopausal osteoporosis. Relief of acid indigestion or heartburn. Treatment of hyperphosphatemia in end-stage renal disease

Headache, tingling, arrhythmias, bradycardia, constipation, nausea, vomiting, calculi, hypercalciuria

doses with a full glass of water, except when using calcium carbonate as a phosphate binder in renal dialysis. Administer Administer calcium carbonate 1–1.5 hr after meals and at bedtime. Chewable tablets should be well chewed before swallowing. Dissolve effervescent tablets in glass of water. Follow oral on an empty stomach before meals to optimize effectiveness in patients with hyperphosphatemia

Increase in serum calcium levels

Decrease in the signs and symptoms of hypocalcemia

Resolution of indigestion

Control of hyperphosphatemia in patients with renal failure

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Dose/ Route/

Time




Tylenol Extra Strength1000mg q4h PRN (Y)

C

A

I

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Dose/ Route/

Time




Norvasc Safe dose: 5–10 mg once daily; antihypertensive in fragile or small patients or patients already receiving other antihypertensives—initiate at 2.5 mg/day, ↑ as required/tolerated (up to 10 mg/day) as an antihypertensive therapy with 2.5 mg/day in patients with hepatic insufficiency

Actual dose - . 5mg PO Daily (Y)

C - Therapeutic: antihypertensivesPharmacologic: calcium channel blockers

A - Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. Therapeutic Effects: Systemic vasodilation resulting in decreased blood pressure. Coronary vasodilation resulting in decreased frequency and severity of attacks of angina.

I -

CNS: headache, dizziness, fatigue. CV: peripheral

edema, angina, bradycardia, hypotension,

palpitations. GI: gingival hyperplasia,

nausea. Derm: flushing.

Monitor blood pressure and pulse before therapy, during dose titration, and periodically during therapy. Monitor ECG periodically during prolonged therapy.

Monitor intake and output ratios and daily weight. Assess for signs of CHF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention) .

Angina: Assess location, duration, intensity, and precipitating factors of patient’s anginal pain.

Lab Test Considerations: Total serum calcium concentrations are not affected by calcium channel blockers.

Decrease in blood pressure.

Decrease in frequency and severity of anginal attacks.

Decrease in need for nitrate therapy.

Increase in activity tolerance and sense of well-being.

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Dose/ Route/

Time




Colace Safe dose: 240 mg daily

Actual dose: 100mg PO Daily (Y)

C – T – Laxative P – Stool Softener A - Promotes incorporation of water into stool, resulting in softer fecal mass. May also promote electrolyte and water secretion into the colon. Softening and passing of stool I - PO: Prevention of constipation (in patients who should avoid straining, such as after MI or rectal surgery) Rectal: Used as enema to soften fecal impaction

throat irritation, mild cramps, rashes

This medication does not stimulate intestinal peristalsis. Administer with a full glass of water or juice. May be administered on an empty stomach for more rapid results. Oral solution may be diluted in milk or fruit juice to decrease bitter taste. Do not administer within 2 hr of other laxatives, especially mineral oil. May cause increased absorption

A soft, formed bowel movement, usually within 24–48 hr. Therapy may take 3–5 days for results. Rectal dose forms produce results within 2–15 min

Ferrous SulfateSafe Dose: 325mg PO/ BID

Actual Dose:

325mg TID PO Daily (Y)Iron

Classification: Therapeutic- anti- anemic. Pharmacologic- iron supplement

Action: Enters the bloodstream and is transported to the organs of the reticuloendothelial system

Indication: prevention/treatments of iron deficiency

Seizures; hypotension; nausea; constipation; dark stool; diarrhea; epigastric pain; skin staining; anaphylaxis

-Assess nutritional status and dietary history to determine possible cause of anemia and need for patient teaching-Monitor BP and heart rate-Assess for signs and symptoms of anaphylaxisMonitor hemoglobin, hematocrit

Increase in hemoglobin, improvement of iron deficiency and anemia

Hydralazine (Isosorbide dinitrite)

Safe Dose: 1 tablet 3 times daily, may be increased to 2 tablets 3 times dailyActual Dose: 25mg PO q8h

Classification: Therapeutic- vasodilators Pharmacologic- vasodilatorsnitrates

Action: BiDil is a fixed-dose combination of isosorbide dinitrate , a vasodilator with effects on both arteries and veins, and hydralazine , a predominantly arterial vasodilator

I: Management of heart failure in black patients

Tachycardia, Soduium retention, drug-induced lupus syndrome, dizziness, headache, hypotension

Dose may be titrated rapidly over 3-5 days, but may need to decrease if side

effects occur. May decrease to one-half tablet 3 times daily if intolerable side

effects occur. Titrate up as soon as side effects subside

Improved survival, increased time to

hospitalization and decreased symptoms

of heart failure in black patients


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Dose/ Route/

Time




LevothyroxineSafe dose: 50mcg as a single dose initially, usual maintenance dose 75mcg-125mcg daily.Actual dose: 37.5 mg PO Daily (Y)

C: Hormones, thyroid preparations

A: replacement of or supplementation to endogenous thyroid hormone. The principal effect is increasing metabolic rate. Promotes gluconeogenesis. Increases utilization and metabolization of glycogen stores.

I: thyroid supplementation in hypothyroidism. Treatment and suppression of euthyroid goiters and thyroid cancer.

Nervousness, headache, arrhythmias, cramps, hair loss, increased sweating, hyperthyroidism, heat intolerance

Assess apical pulse and blood pressure.

Assess for tachyarrhythmia’s and chest pain.

Monitor thyroid function.

Monitor blood and urine glucose in diabetics- may need to increase insulin or oral hyperglycemic dose.

Resolution of hypothyroidism and normalization of thyroid hormone levels.

MetoprololSafe Dose: 50mg/PO/BID

Actual Dose: 25mg PO BID

C – Anti-anginal, anti-hypertensive

A – Decreased blood pressure and heart rate. Decreased frequency of angina.

I – Hypertension

Fatigue, weakness, anxiety, depression, dizziness,

drowsiness, bronchospasm, bradycardia, CHF

Monitor blood pressure, ECG, and pulse frequently during dose adjustment and periodically during therapy.

Monitor I&O ratio and daily weights.

Assess routinely for signs of CHF (dyspnea, rales/crackles, weight gain, peripheral edema, JVD).

Decease in blood pressure.

Reduction in frequency of angina attacks.

Increase in activity tolerance.

Prevention of MI

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Dose/ Route/

Time




Ativan Safe Dose: 1 mg Q6 PRN IV

Actual Dose: 0.5mg

TID PRN

C - Therapeutic: analgesic adjuncts, antianxiety agents, sedative/hypnoticsPharmacologic: benzodiazepines

A - Depresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter. Therapeutic Effects: Sedation. Decreased anxiety. Decreased seizures.

I - Panic disorder, as an adjunct with acute mania or acute psychosis

CNS: dizziness, drowsiness, lethargy, hangover, headache, ataxia, slurred speech, forgetfulness, confusion, mental depression, rhythmic myoclonic jerking in pre-term infants, paradoxical excitation. EENT: blurred vision. Resp: respiratory depression. CV: rapid IV use only: Apnea, cardiac arrest, bradycardia, hypotension. GI: constipation, diarrhea, nausea, vomiting, weight gain (unusual). Derm: rashes. Misc: physical dependence, psychological dependence, tolerance

Conduct regular assessment of continued need for treatment.

Geri: Assess geriatric patients carefully for CNS reactions as they are more sensitive to these effects. Ass falls risk.

Anxiety: Assess degree and manifestations of anxiety and mental status (orientation, mood, behavior) prior to and periodically throughout therapy.

Prolonged high-dose therapy may lead to psychological or physical dependence. Restrict amount of drug available to patient.

Status Epilepticus: Assess location, duration, characteristics, and frequency of seizures. Institute seizure precautions.

Lab Test Considerations: Patients on high-dose therapy should receive routine evaluation of renal, hepatic, and hematologic function

Reduction of anxiety

Ondansetron (Zofran) Safe Dose: 4mg IV every 6 hours PRNActual Dose: 4mg q8h PRN

C - antiemetic, 5-HT3 antagonist

A - blocks the effects of serotonin at 5-HT3-receptor sites.

I - Prevention of nausea and vomiting

Headache, dizziness, drowsiness, constipation, diarrhea, extrapyramidal reactions

Assess the patient for nausea, vomiting, abdominal distention, and bowel sounds.

Assess the patient for extrapyramidal effects such as involuntary movements, facial grimacing, trembling of hands.

Check liver function test.

Prevention of nausea and vomiting.

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Dose/ Route/

Time




C

A

I

LAB/DIAGNOSTIC TESTSLab/Diagnostic Tests List Normal Values for your hospital below

Purpose of Test Date and ResultsAdmission Most Recent

Implications for abnormals (why do you think your patient had these abnormal values/what caused it for this patient )

WBC (4,500-10,000 uL)

assess WBC complete blood count (infection)

10, 000

RBC(4.6-6.0 mill/uL)

Monitor RBC count

Hgb(13.5- 18 g/dL)

Level of hemoglobin in RBC 9.3 Low due to anemia.

Hct(40-54 mL/dL)

Volume of RBC in blood (dehydration) 27.5 Low due to anemia. Was given 1 unit of packed red blood cells and fluids IV.

Platelets(150,000-400,000 uL)

Check platelet count

Glucose(70-110 mg/dL)

Glucose level to see if insulin is needed(hyper/hypoglycemia)

Na(135-145 mEq/L)

Monitor sodium levels (hyper/hyponatremia). Comparison of sodium levels to other electrolyte levels.

K(3.5-5.3 mEq/L)

Check Potassium level(hyper/hypokalemia)

Ca(4.5-5.5 mEq/L)

Check serum levels for hyper/hypocalcemia. Monitor calcium levels.

7.4 High due to patient taking Calcium suppliments

BUN(5-25 mg/dL)

Check renal disorder or dehydration associated with increased BUN levels

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Creatinine(0.5-1.5 mg/dL)

Diagnostic tool for renal dysfunction

PT/INR(2.0-3.0 INR)

Assess renal function 1.2 Low due to patient taking Coumadin prior to admittance

PTT(60-70 seconds)

Monitor heparin therapy and screen for clotting factor deficiencies

29.7 Low due to patient taking Coumadin prior to admittance

WBC (4,500-10,000 uL)

assess WBC complete blood count (infection)

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RBC(4.6-6.0 mill/uL)

Monitor RBC count

DIAGNOSTIC TESTS: X-rays, CT, MRI, US12 lead EKG, ABG, etc

Purpose of Test Date Results Implications for abnormals

X-rays Identify bone structure and tissue in the body

CT Screen for CAD; head, liver, and renal lesions; tumors; edema; abscesses; infections; metastatic diseases; vascular diseases; stroke; bone destruction

MRI Detect a CNS lesion, vascular problem, cardiac perfusion problem, injury, tumor, edema.

US

EKG Detect cardiac dysrhythmias. Identify electrolyte imbalance. Monitor ECG changes during stress/exercise tests and recovery phase after a myocardial infarction.

ABGDetect metabolic acidosis/alkalosis, or respiratory acidosis/alkalosis. Monitor blood gasses during an acute illness and evaluate need for medical intervention.

Nursing Diagnoses (PES Format)

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1. Acute confusion r/t dementia AEB confusion and client yelling at healthcare providers when trying to provide care.__________

2. Impaired skin integrity R/T physical immobilization AEB pressure ulcer on R heel, R arterial ankle, R knee, L lateral ankle, L lateral foot all unstaged_________

3. Risk for infection AEB numerous pressure ulcers

Nursing Diagnoses (PES Format): P=Client Problems E=Pathophysiology/ psychosocial S=Supportive Data for Nursing Diagnosis

1. ___________________________________________________________________________________________________________

Nursing Process

Nursing Diagnoses P=Client Problems (number in order of

priority)

E=Pathophysiology/psychosocial

S=Supportive Data for Nursing Diagnosis

You must include:1. Subjective2. Objective

Goals/Outcomes Client Centered, Stated in Behavioral Terms with Desired Outcomes

(Must be specific and measurable)

Nursing Orders & Interventions

Include at least 5 specific interventions per problem. Asterisk (*) those interventions you implemented.

Scientific Basis for Action/Rationale

Include source and page number for each intervention.

Client Responses/

Evaluation

BE SPECIFIC!

Acute confusion r/t dementia AEB confusion

an client yelling at

Patient was eating breakfast @ asst. living facility when she dropped

Goal: Patient will demonstrate restoration of cognitive status to

*1. Assess the client’s behavior and cognition systematically and

1. Rapid onset and fl uctuating course are hallmarks of delirium

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healthcare providers when trying to provide

care.

her fork and became unresponsive to voice. Patient then made sound that resembled slurred speech. Patient was transported to BMC -D ER. Where she then became responsive as if nothing had happened. Patient has no recollection of the event.

baseline

Outcome: Patient will be alert and be able to state place, time and persons.

Outcome: Patient will demonstrate appropriate cognitive behavior

continually throughout the day. (Ackley Ladwig. Nursing Diagnosis Handbook, 247.)

*2. Note results of all laboratory tests reporting abnormalities and follow-up with primary care physician. (Ackley Ladwig. Nursing Diagnosis Handbook, 248.)*3. Conduct a medication review..(Ackley Ladwig. Nursing Diagnosis Handbook, 248.)84. Assess for and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypoxia, hypo-tension, infection, changes in temperature, fluid and electrolyte imbalance, and use of medications with known cognitive and psychotropic side effects). (Ackley Ladwig. Nursing Diagnosis Handbook, 247.)*5. Modulate sensory exposure and establish a calm environment. (Ackley Ladwig. Nursing Diagnosis Handbook, 248.)

(Inouye, 2006). The CAM is sensitive, specifi c, reliable, and easy to use. Another tool to consider is the MMSE (Inouye, 2006).2. Laboratory results should be closely monitored and physiological support given as appropriate. (Ackley Ladwig. Nursing Diagnosis Handbook, 248.)3. Medication use is one of the most important modifiable factors that can cause or worsen delirium, especially the use of anticholinergics, benzodiazepines, and hypnotics (Inouye, 2006)4. Early attention to these risk factors may prevent delirium or shorten the length of the delirium episode (Inouye, 2006).5. Lights and noise can give rise to agitation, especially if misunderstood. Sensory overload or sensory deprivation can result in increased confusion Clients with a hyperactive form of

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delirium often have increased irritability and startle re-sponses and may be acutely sensitive to light and sound. Ackley Ladwig. Nursing Diagnosis Handbook, 248.)

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2.___________________________________________________________________________________________________________

Nursing Process


priority)










Client Responses/

Evaluation

BE SPECIFIC!

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3.___________________________________________________________________________________________________________

Nursing Process


priority)










Client Responses/

Evaluation

BE SPECIFIC!

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PHYSICAL ASSESSMENT Circle and describe appropriate responses. If abnormal, describe within this assessment form

GEN-ERAL

Vital Signs @ Start of your care: Temp Pulse Resp BP

Vital Signs @ End of your care: Temp Pulse Resp BP

Describe general appearance: (Physical appearance, Body structure, Mobility, Behavior)

Ht ________ Wt __________________ BMI_____________(Normal = 18.5-24.9)

BMI= weight (in pounds) divided by height (in inches)2 x 703

State of nutrition: Underweight____ Overweight____ Obese____ (>30)

PAIN Onset and duration:

Location (specify anatomical site):

Severity (use 0-10 pain scale):

Precipitating or aggravating factors:

Pain med given ? What med, dose, route? What time?

Effective? . No Yes (Describe how you can tell this)

NEURO

MENTAL STATUS

Oriented to: time, person, place. Describe behavior if disoriented:

Any: Numbness, tingling, vertigo, syncope, headache, tremors, seizures, memory loss, aphasia/verbal behaviors, inattentive, agitation. No Yes Circle term &describe): Cooperative: No Yes (describe): Level of sedation (Glascow Coma Scale): Best eye opening response?Best motor response?Best Verbal response?

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GEN-ERAL



SKIN or WOUND

Skin Temperature: warm, cool, dry, clammy,__________

Skin characteristics: edema, blanching, cyanosis, pallor, jaundice, hyperemia, ecchymosis, petechiae, bleeding, cuts, boils, decubiti, drainage, diaphoresis; rash, hematoma, nail changes. Skin turgor/ Pinch test findings: Describe hair color, condition & distribution:

Tattoos , piercings scars: Specific anatomical locations)

Wound Sites (Specific anatomical locations)

Dressings (Specific anatomical location , dressing composition, status):

Drains/Drainage (type and location):

EYES Vision loss, glasses, contact lens, excessive tearing, sty, exophthalmus, cataracts, artificial eye, ptosis, discharge (describe)______________________________________ other: _______________________________Test PERRLA ? No Yes Findings? Test 6 Cardinal Positions of Gaze? No Yes Findings?

NOSE Rhinitis, epistaxis, loss of sense of smell, sneezing , discharge, irritation, other:_____________________Septum midline: No Yes Nares patent: No Yes

EARS Deafness, hearing aid, discharge, tinnitus, other:_____________________Whisper Test? No Yes

MOUTH,THROAT & NECK

Dentures Bleeding gums, caries, implants, speech impediment, goiter, throat irritation, lesions; lips, gums, halitosis , Dysphagia, Dysphasia, Tracheostomy, Hoarseness

Able to speak, bite, chew, swallow, taste; If any No, describe______Lymph node enlargement? No Yes (where)

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GEN-ERAL



Uvula midline? Move anterior when says “ahh”? No Yes

Tongue thrust midline? No Yes

RESPIRATORY

Respirations: shallow, irregular, regular, irregular, other:____________ Nocturnal dyspnea, dyspnea on exertion, orthopnea unequal chest expansion, Tactile fremitus Cough: dry, wet, productive, nonproductive; hemoptysis, Lung sounds Anterior chest RIGHT Clear ___ Diminished _____; LEFT Clear ___ Diminished _____;Lung sounds Posterior chest RIGHT Clear ___ Diminished _____; LEFT Clear ___ Diminished _____; crackles ? _____ Where heard? _________ wheezes? _____ Where heard? _________

Oxygen _____L/min Device: (type)______________________ Pulse Ox _________%Incentive spirometer ______________ave._mL . Nebulizer ? _______ MDI? ______

CARDIO

VASCU LAR

Heart Rate: apical_____ Rhythm: regular____ irregular___

Pulse deficit (Apical_____ minus radial______) PD________

Pulse Pressure: (Systolic)________minus Diastolic ______= PP______________Peripheral pulses Present RIGHT : Popliteal? _________ Post Tibial______ Dorsalis Pedis?___________Peripheral pulses Present LEFT : Popliteal? _________ Post Tibial______ Dorsalis Pedis?___________ Edema: RIGHT pitting______ non-pitting_____ ; LEFT pitting______ non-pitting_____ Capillary refill_______ seconds; Lower extremity temp _________ and color: _________________

GAS

TRO-INTESTINAL

Nausea, vomiting, dysphagia, anorexia, polydipsia, heartburn, ascites, constipation, diarrhea, abdominal distention, flatulence, tarry stool, mucous stools, hemorrhoids, rectal bleeding, pain, incontinence, hernia, weight loss/gain

Date last B.M and characteristics: ___________________________________

% of diet eaten: ____________________food intolerance ________________

Bowel sounds present RLQ? ________ RUQ?________ LUQ? ________ LLQ? ______________NG tube_______ G tube_______ J tube_______ Ostomy_______

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GEN-ERAL



GENI

TO-URINARY

Urine:color____________, clear, cloudy, Foley, Suprapubic catheter, CBI, dysuria, polyuria, oliguria, hematuria, nocturia, incontinence, flank pain UTI, albuminuria, glucosuria, dribbling, hesitancy, frequency, burning, other (specify)______________________________________________

Intake: previous 24 hrs. _________ During care: PO/Tube ____________cc IV_____________cc

Output: previous 24 hrs. ________ During care:urine________________CC other`(specify) ______

MUS CULO-SKE LETAL

Joint pain, arthritis, gout, claudication, varicose veins, paralysis, contractures, deformities, amputations, unsteady gait. Describe ROM and strength in each extremity (0-5 scale):Head & Neck____; R arm_________; L arm_______; R leg__________; L leg____________

Describe activity tolerance:

Describe ability to ambulate/ gait:

IV/ INFUS ION & CATH ETERS

IV site(s) ____________________________ -__________________________________

IV type(s)_______________________Rate_____ ; _______________________________ Rate _____

IV needle gauge?______ Date inserted: __________ Site condition: ___________________________

Tubing change date: ______________ IV Site care given: No Yes

THERA PEUTICOr ASSISTIVE DEVICES

Walker, crutches, cane, trapeze, prosthesis, wheelchair, scooter, CPM,SCDs, TEDs, Heating pad, Ice pack, bed fall monitor, therapeutic bed, wound VACs, PCA pump, cooling/heating blanket,

Implants: ___________________________________________________

DOCUMENTATION (Your Nurses Notes defining care given)

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References

Ackley, B. J. & Ladwig, G. B. (2006). Nursing diagnosis handbook. 8th ed. St. Louis, MO: Mosby.

Deglin, J. & Vallerand, A. (2009). Davis’s drug guide for nurses. (11th ed.). Philadelphia: Davis.

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care plan oct 30_2010

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