nursing holistic + care plan + meds + labs

HOLISTIC ASSESSMENT PAGE 1

Client Initials MW Admit Date 1/21/09 Date of Care 1/29/09-1/30/09 F Age 84 Marital Status S

Diagnosis weakness, dyspnea, plural effusion, sinus bradycardia, CHF

Operation/Procedure (include date) thorocentisis (1/23/09),

Advance Directives (what type): no

Reason for admission(chief complaint) SOB

Significant History/Other pertinent information pneumonia (right lower lobe, 3 weeks PTA) , HTN, myocardial infarction, CHF, stent placement, dysrhythmias, lipidemia, diabetes mellitus, right lower lung lobe mass (nonmalignant),

Report Data: (information obtained from RN, morning report, clarification of information obtained from clinical instructor) Activity/Risk for Fall: up with assist, at risk for falls

Allergies: NKA

Vital signs(frequency): TID

Code Status: full code

Diet: Cardiac/ ADA 1800/ soft

IV/Saline lock: SL right hand

Telemetry: yes (sinus bradycardia)

I/O (last void; last bowel movement): BRP , slight urine incontinence, urine yellow, clear; last BM 1/29. monitor I/O.

Oxygen: RA

Drains/Wounds: puncture wound, right middle upper back, skin intact, open to air; stage II DU, coccyx, Allevyn wound dressing and skin barrier cream applied 1/30/09 930; rt upper arm, ecchymotic.

Procedures/specimens/medications: meds: 800, 900, 1200.

Isolation: Contact precautions, hx MRSA (bronchial wash) 1/2/09.

Scheduled Therapies/Other: PT

Plan of Care:1. Obtain report from RN.2. Review chart and MAR.3. Introduce self to Pt. and complete assessment4. Up-to-date pt on plan of care for the day5. Assist with AM care6. administer meds7. Ambulate8. gather holistic information9. report off to RN at end of clinical

What are the client’s top priorities regarding his or her own care for today?-assessment/ meds-diuresis-ambulation, OOB for meals-AM care

MEDICATIONS

:NAME

TIME DUE

INDICATION FOR RECEIVING MEDICATION

NURSING CONSIDERATIONS

ASSESSMENT RESULTS PRIOR TO

LAB RESULTS TO MONITOR PRIOR TO ADMINISTRATION

ADVERSE REACTIONS/SIDE EFFECTS TO ASSESS PRIOR TO


DOSAGE

ROUTE

ADMINISTRATION ADMINSTRATION

Pantoprazole

(Protonix)

40mg (1 tablet)

PO

900 To suppress gastric

secretions

No nausea, no vomiting, no

diarrhea, no constipation. No

epigastric or abd pain. No

bloody stools or emesis. No

headache.

-may inc glucose, uric acid, and

lipid levels

-may inc/dec liver function

BG:134

BUN:41 (elevated)

Creatinine: 1.9 (elevated)

CNS: anxiety, dizziness, headache,

insomnia. CV: chest pain, peripheral

edema. EENT: rhinitis, sinusitis. GI: abd

pain, constipation, diarrhea, dyspepsia,

flatulence, gastroenteritis, GI disorder,

nausea, vomiting. GU: rectal disorder,

urinary frequency, UTI. METAB:

hyperglycemia, hyperlipidemia.

MUSCSKEL: arthralgia, back pain,

hypertonia, neck pain. RESP: bronchitis,

dyspnea, inc cough, upper resp tract

infection. INTEG: rash. Flulike

symptoms, infections.

Insulin Regular

(Novalin R vial)

5 units

SubQ injection

800

1200

Antidiabetic Injection site: no bleeding, no

pain, no severe ecchymosis.

Blood glucose 830: 134

Urine ketones: wnl

-may dec magnesium, and

potassium levels

METAB: hyperglycemia, hypoglycemia.

RESP: dyspnea, inc cough, reduced

pulmonary function, resp tract infection.

INTEG: itching, rash, redness, stinging,

swelling, urticaria, warmth at injection

site. OTHER: anaphylaxis,

hypersensitivity reactions, rash.

Insulin Regular

(Novalin R vial)

Sliding Scale

SubQ injection

BG<150 0 units

151-199 2 units

200-249 4 units

250-299 6 units

300-349 8 units

>350 notify MD

Aspirin

(Ecotrin 81 mg)

81mg (1 tablet)

PO

900 Antiplatelet,

antipyretic

No GI bleed/distress, nausea,

occult bleeding, vomiting.

-may inc liver enzymes, BUN,

serum creatinine, s. K, and may

prolong bleeding times.

-may dec WBC and platelet count.

BUN and creatinine elevated.

EENT: hearing loss, tinnitus GI:

dyspepsia, GI bleeding, GI distress,

nausea, occult bleeding, vomiting. GU:

transient renal insufficiency HEMO:

prolonged bleeding time,


Plt count low (consistently

decreasing).

thrombocytopenia. METAB: HEPAT:

hepatitis. INTEG: bruising, rash,

urticaria. OTHER: angioedema,

hypersensitivity reactions (anaphylaxis,

asthma) Reye syndrome.

Magnesium

Oxide (Mag-Ox

400mg)

400mg (1 tablet)

PO

900 Mg replacement No abd pain, no diarrhea, no

nausea.

-may inc mag levels GI: abd pain, diarrhea, nausea METAB:

hypermagnesemia (hypotension, n/v,

depressed reflexes, resp depression,

coma)

Spironolactone

(Aldactone)

25mg PO

900 Anti-HTN (diuretic) BP: 142/58 P: 69

No v/d/n/c.

No edema.

Monitor I/O

Wt

-may inc BUN, creatinine, K

-may dec Na

-may dec granulocyte count

-may falsely inc digoxin level

Na:137

K:4.6

Cl:100

Ca:8.1 (Low)

PT: 11.3

INR:1.08

BUN:41 (elevated)


CNS: ataxia, confusion, drowsiness,

headache, lethargy. GI: cramping,

diarrhea, gastric bleeding, gastric

ulceration, vomiting. GU: impotence,

menstrual disturbances. HEMO:

agranuloctosis. METAB: dehydration,

hyperkalemia, hyponatremia, mild

acidosis. INTEG: erythematous rash,

urticaria OTHER: anaphylaxis,

angioedema, breast soreness, drug fever,

gynecomastia.

Ramipril

(Altace)

2.5mg PO

900 Anti-HTN (ACE

inhibitor)

No cough.

No n/v/d/c.

No headaches, lightheadedness.

No chest pain, no edema.

No abd pain.

-may inc BUN, creatinine, bilirubin,

liver enzyme, glucose, K.

-may dec hgb and hct

K: 4.6

Na:137

Ast:

Alt:

BG: 134

Hgb:10.6 (low)

Hct: 33.2

CNS: amnesia, anxiety, asthenia,

depression, dizziness, fatigue, headache,

insomnia, syncope, lightheadedness,

malaise, nervousness, neuropathy,

seizures, tremors, vertigo . CV: angina,

arrhythmias, chest pain, edema, MI,

orthostatic hypotension, palpitations .

EENT: epistaxis, tinnitus. GI: abd pain,

anorexia, constipation, diarrhea, dry

mouth, dyspepsia, gastroenteritis, nausea,

vomiting. METAB: hyperkalemia,


weight gain. MUSCSKEL: arthritis,

myalgia. RESP: dry persistent, tickling,

nonproductive cough. dyspnea. INTEG:

dermatitis, inc diaphoresis, pruritis, rash.

OTHER: andioedema.

Bumetanide

(Bumex)

1mg PO

900 Anti-HTN (diuretic) No dizziness, no headache.

I/O balanced.

BP:142/58

P: 69

Lung sounds (rt. post. Lower

lobe diminished)

No peripheral edema


BUN: 41 (elevated)

BG: 134

K: 4.6

Mg:

Na:137

Ca: 8.3 (low)

Plt count: 86 (low)

CNS: dizziness, headache . CV: ECG

changes, orthostatic hypotension, volume

depleteion and dehydration . EENT:

transient deafness GI: nausea GU: freq

urination, nocturia, oliguria, polyuria,

renal failure HEMO: thrombocytopenia

METAB: asymptomatic hyperuricemia,

fluid and electrolyte imbalance, dilutional,

hyponatremia/hypocalcemia/

hypomagnesemia, hyperglycemia,

hypokalemia, impaired glucose tolerance.

MUSCSKEL: muscle pain and

tenderness. INTEG: rash

Metoprolol

tartrate

(Lopressor

50mg)

50mg PO

900 Anti-HTN (beta

blocker)

BP: 142/ 58

P: 69

CNS: dizziness, fatigue, fever, lethargy .

CV: AV block, bradycardia, heart failure,

hypotension, peripheral vascular disease.

GI: diarrhea, nausea, vomiting.

MUSCSKEL: arthralgia. RESP:

bronchospasms, dyspnea. INTEG: rash

Diagnostic and/or Laboratory Test

NormalValues

Client’s Results Clinical Significance:


On-Admission

Current Reason this being monitored for this client.

What nursing interventions and clinical decisions are essential for this client’s care as a result of their diagnostic and/or laboratory tests?

HEMATOLOGY

WBC 4.5-11.0

K/mm3

10.2 12.9 Evaluation of pt with infection,

neoplasm, allergy or

immunosuppression. Pt was

recently hospitalized for

pneumonia.

Keep skin clean to avoid infections, cover open wounds, avoid

aspiration pneumonia,

RBC 3.90-5.20

L M/uL

3.78 3.85 Pt admitted SOB Monitor O2 sats.

HBG 11.2-15.0

g/dL

10.2 10.6 Used as a rapid indirect

measurement of the red blood cell

count.

HCT 32.8-44.7

L %

32.7 33.2 Used as a rapid indirect

measurement of the red blood cell

count.

PLATELETS 125-400

K/mm3

115 86

aPTT/PTT 33.8

PT 11.3

INR 1.08

SED RATE

BLOOD CHEMISTYRY

POTASSIUM 3.5-5.1

mmol/L

4.2 Electrolyte is very important in the

function of the heart and is part of

routine evaluations for pt on

diuretics or heart medications

Proper dietary intake

SODIUM 136-145

mmol/L

137 Routinely performed. Used to

evaluate and monitor fluid and

electrolyte balance and therapy.

Monitor I/O for fluid balance

MAGNESIUM

CALCIUM 8.5-10.1

mg/dL

8.3 To monitor Ca in relation to serum

albumin levels. Also electrolyte

Increase weight bearing activity. Supplements.


imbalances are dangerous to the

functioning of the heart

PHOSPHORUS 2.5-4.9

Mg/dL

4.0

CHLORIDE 98-107

mmol/L

101 100 In correlation with other

electrolytes, Cl gives indication of

acid-base balance and hydration

status.

Monitor I/O

BUN 7-23 mg/dL 41 Indirect and rough measurement of

renal function and glomerular

filtration rate.

Adequate protein intake, monitor I/O to avoid overhydration

CREATININE 0.6-1.0

mg/dL

2.0 Used to diagnose impaired renal

function

BUN/CREATININ RATIO 7-23 24

TOTAL BILIRUBIN <1.0 mg/dL To evaluate liver function

TOTAL PROTEIN 6.4-8.2 g/dL 6.4 Increase intake of protein to aid in tissue reconstruction and wound

healing

ALBUMIN 3.4-5.0 g/dL 2.3 To evaluate for hepatic

malfunction and nutrition

GLOBULIN 1.4-4.8 g/dL To evaluate for liver malfunction

ALBUMIN/

GLOBULIN RATIO

1.0-1.9 g/dL To distinguish between certain

diseases of kidneys and liver

TOTAL ALK PHOSPHATE 50-136 U/L

CO2 21-32

mmol/L

To assist in evaluating the pH

status of the pt and to assist in

evaluation of electrolytes.

Decreased levels can be

contributed to medications

administered.

GLUCOSE 70-99

mg/dL

134 In evaluation of diabetic pt. Blood

glucose levels rise as a response to

stress and several types of

Monitor intake, ambulate.


medications.

SERUM LIPIDS

CHOLESTEROL

TRIGLYCERIDES

LDL’S

HDL’S

LIVER ENZYMES

ALT 30-65 U/L Used to identify hepatocellular

disease of liver.

AST 15-37 U/L Used to identify pt with suspected

coronary artery occlusive disease

or suspected hepatocellular

disease.

CARDIAC MARKERS

TROPONIN <0.4 Cardiac enzyme which is measured

for evidence of cardiac muscle

injury.

MYOGLOBIN

CK-MB

Diagnostic and/or Laboratory Test

NormalValues

Client’s Results Clinical Significance:

On-Admission

Current Reason this is being monitored for this client.

What nursing interventions and clinical decisions are essential for this client’s care as a result of their diagnostic and/or laboratory tests?

BLOOD GASES

Ph

PCO2

PO2

HCO3

URINALYSIS

COLOR Yellow Yellow

GLUCOSE Absent

KETONE Absent

BLOOD Absent


PH 4.6-8.0 5.0

PROTEIN 0-8

Mg/dL

15

UROBILINOGEN

RBC <2 9

WBC 0-4 66 Infection. Increase fluids.

URINE OSMOLARITY

SPECIFIC GRAVITY

OTHERS

CXR No

pneumothorax

Lung US Large left

pleural

effusion that

is 3cm below

skin surface.

Small rt

pleural

effusion.

Lung biopsy Nonmalignant

cells

Abd US No evidence

of renal

stenosis.

Mildly inc

contical

echogeniaty.

Suggestive of

renal

parenchymal

disease.

Gallstones.


NEUMAN’S VARIABLES OF ASSESSMENT (Plan of Care based on the Nursing Process)

I. PSYCHOLOGICAL VARIABLES A. Interpersonal Communication Style

Pt is quiet and very friendly, open about medical and personal history.

B. Emotional status/Anxiety level

Coping, current outlook is good, pt is looking forward being discharged. Pt is worried about the

health status of her younger sister who is also hospitalized after a stroke. She has been keeping in tough

with her and are planning to being discharge together soon. Pt has slight anxiety and irritation because

she is not able to move about the same way she did before the previous admission in January.

C. Stress/concerns related to hospitalization

Pt’s concern is that she is unable to do self-care because she is weak, she is also concerned that

after her discharge home she will have to stay alone overnight and she might fall with no help around.

She does not want to go to an assisted living home but doesn’t not feel safe going home without the help

of her sister, who will most likely not being discharged as soon as she is to be.

D. Defense/coping mechanisms

Pt expresses her feeling by talking to her family. She has realistic views of her health and her

future and responds eagerly when discussing the importance of sitting in the chair for meals and

throughout the day.

II. SOCIOCULTURAL VARIABLES A. Living Arrangements/Dwelling

Pt lives alone but recently, before her hospitalization, her sister has been staying with her. They

live together in an apartment with easy access to the living quarters. She does not have to walk up stairs, she

uses the elevator. Upon discharge, pt will be going back to live back at her apartment with her sister as they

have previously been living together. She has a son visits her at home frequently throughout the week. Patient

feels comfortable with this living arrangement as long as someone spends the night with her.

B. Occupation/Retired/Student

Pt is retired.

C. Support Systems

Pt is very independent. Just recently she has been relying on her sister more often. Her family is

her support system. He is available to the patient throughout the day even during working hours. I did not

observe any domestic violence behavior cues. I did not inquire about other support systems available to the

patient.

D. Educational Status

n/a – specifics did not come up in conversation. I felt that the patient was very willing to learn

how to maintain her health.


E. Ethnic Heritage, Cultural Beliefs (other than spiritual), Customs and Health Practices

n/a – did not come up in conversation

F. Use of Complementary/Alternative Modalities of Treatment

n/a – did not come up in conversation

III.DEVELOPMENTAL VARIABLES (Erikson’s Stage)

A. Age 84

B. Life Stage Older Adult

C. Task Sense of Integrity vs. Despair

Has your assigned client achieved previous life stage tasks and is currently showing evidence of

mastering current life stage task? Explain.

Yes, pt is open about her life and her life experiences. She believes her life was lived to its

potential. She has a health self-esteem, she discusses her son as her great accomplishment for being a caring

child that has taken her in to care for her.

Age related risks

Depression, deprived nutrition and fluid intake, decreased activity and exercise, alcohol abuse, Self-concept and self-image changes, change in roles and relationships, personal loss, coping strategies.

IV. SPIRITUAL VARIABLES (Religious Affiliation/Activities/Use of Belief System as a Source of Hope

and Support)

Pt is a catholic who attends church weekly. She prays often. She states her prayers give her hope.

Chart states that pt received spiritual support on 11/2/08.

V. PHYSIOLOGIC VARIABLES

A. Neurological

1. Mental Status

a. LOC: alert

b. Orientation: alert to time, place, person and situation


c. Memory(short/long): no recent and remote memory deficits. Pt has no trouble recalling what she

was doing yesterday. Pt recalls clearly that she has met me yesterday also. Pt can recall

memories of when she was younger and where is lived.

d. Judgment: Pt is acting in a logical and rational manner. She is calm and cooperative. She calls

for assistance before getting up to go to the bathroom.

2. Appearance/Behavior

Pt is wearing a hospital gown with visibly good personal hygiene. Pt is weak related to her

condition. Pt is properly expressing her emotion in relation to her developmental stage. She is

cooperative and interested in our conversation. She maintains a calm manner and does not express

any feeling of anger.

3. Ability to communicate

Pt communicates clearly, does not have any noticeable speech deficits and is can be clearly

understood by the receiving party during a conversation. She maintains good eye contact and does

not speak off on tangents. Pt uses glasses. She speaks English.

4. Neurosensorya. Vision: History of cataract removal. Eye movements are symmetrical and no amblyopia

present. Eyebrows, eyelids, and lashes intact. Pt requires glasses.

b. Hearing: Patient responds to normal speaking volume and tone. Patient does not wear hearing

aids. No discharge or excessive cerumen in ears, skin of ears intact, pink, and warm.

5. Interventions: Fall precautions, up with assistance; assistance with ADLs. Make sure patient is

wearing glasses while communicating with others or as needed.

B. Musculoskeletal1. Gait/Ambulation: Patient ambulates with a rolling walker . Patient is ambulating safely when

walking with someone at her side to prevent falls, needs assistance of one. Gait is slightly leaning

forward, steady, slow, small steps. No shuffling gait present. No significant weakness on either side

of body. Patient has all four limbs, no prosthetic limbs.


2. Alignment/Posture: Patient is slightly stooped over while walking (mainly curvature of upper spine

and neck), able to maintain proper alignment while sitting in bed, chair or walking. Patient does not

lean toward right or left side while sitting up in bed or during ambulation.

3. Immobilizing/Assistive Devices: Patient uses a rolling walker. Two side rails are up while patient is

in bed and table is positioned in front of patient wile she is sitting in chair.

4. Motor Strength (moves all extremities)a. Symmetry: patient is moving all extremities symmetrically when prompted. Patient can move all

ten fingers and toes.

b. Strength: Lower and upper extremities are equally strong

c. Range of Motion: all active.

5. Neurovascular integrity of extremities (CMS): Upper extremities and lower extremities skin equally slightly pale, warm and dry. Capillary refill of both upper and lower extremities 2-3 sec. Upper peripheral pulses palpable and equally strong, in lower extremities peripheral pulses not palpable. Patient senses light touch to extremities. No numbness, tingling or pain in any extremities.

6. Interventions: ; physical therapy to ambulate; activity every two hours ( up from bed and ambulate),

up to chair for meals; assistance with ADLs. Bed mobility: moderate assist; Transfers: minimum

assistance to stand; Gait: contact-guard assistance; Device: rolling walker; Activity with nursing: out

of bed for meals and as tolerated; Ambulate in hallway.

C. Respiratory Integrity

1. Respiration (rate, rhythm, and depth): unlabored breathing, regular rhythm, regular rate 18

breaths/minute. Eupnea. Nasal flaring absent. Pursed lips absent while breathing. Patient breathing

comfortable while sleeping, sitting up in bed, sitting in chair. While walking patient increases

breaths per minute to about 20, once activity decreased, breathing rate returns to normal at 18 in less

than 5 minutes. No audible breathing sounds.

2. Lung sounds : clear except in right lower posterior lobe diminished. Pleural effusion.

3. Cough- patient is not coughing


4. Sputum (color and amount)-patient is not expectorating any sputum

5. Assistive Respiratory Treatments/Interventions: Oxygen protocol initiated as needed: per nasal

canula 2-4L LPM – currently patient 94% on room air, no supplemental O2 need.

D. Cardiovascular Integrity 1. Vital signs

a. Peripheral pulses (rate, rhythm, quality): right arm 69 bpm; regular, strong peripheral pulse

rhythm. In lower extremities, pulse non-palpable. Patient admitted with sinus bradycardia with

symptoms and placed on remote telemetry.

b. Apical pulse: 70 bpm. Regular and strong. No murmurs. PMI located in the left 4th or 5th

intercostal space just medial to the midclavicular line.

c. BP: 142/58 right arm (0800 1/29/09). Pt currently medicated for hypertension.

d. Temperature: 97.9 degrees F, oral.

e. Pulse oximetry: 94% on RA.

2. Color and warmth: Patients body is equally slightly pale and warm.

3. Capillary refill: 2-3 sec in both upper and both lower extremities.

4. Edema (peripheral): no peripheral edema present.

5. Interventions: Remote telemetry.

E. Gastrointestinal

1. Weight, Height, BMI, Nutritional State : Ht: 5ft 6in; Wt: 132 lbs. BMI: 21.3 (healthy range) frail

stature.

2. Note condition of mouth/teeth/gums and overall oral hygiene: Remaining teeth intact, inner mouth

moist and pink. No scabbing, skin abrasion or lesion in mouth.

3. Mucous membranes (moist/dry): mouth moist.

4. Capillary Blood Glucose: 134 (800 1/30/09)


5. Diet: Cardiac, ADA 1800, soft. Patient needs additional nutrients, currently in process of

assessments and changes.

6. Ability to Feed Self, Chew/Swallow: Pt does not needs set up of meal trays, able to feed self.

7. Appetite: good appetite, breakfast 11/5/08: 80% 180cc.

8. Abdomen (LOOK, LISTEN, FEEL): bowel sounds present in all four quadrants: normoactive, no

distention or abdomen, abdomen soft without pain; not tender.

9. Stool and Usual Bowel Characteristics, last BM (any changes in patterns): stools soft brown,

decreased in frequency while institutionalized. Patient has full control over bowels. No unusual

characteristics.

10. Perianal area/Rectal conditions: rectal area clean, no fissures, redness or external hemorrhoids, Stage

II DU on coccyx. Allyven wound dressing applied. Perineal area slight redness and irritation, inner

groin, Nystatin powder applied.

11. Intake/Output: intake by mouth. Output: BM with no unusual characteristics.

12. Interventions: monitor intake and output, encourage to eat during meals. Maximum assist with

bathing.

F. Genitourinary

1. Mode of elimination: Bathroom, walking and clean up with assist

2. Any changes in voiding pattern (pain/burning/frequency): no pain or burning while voiding, no

feelings of urgency, increased frequency or incomplete bladder emptying; slight incontinence

reported by pt, pt wears Depends at home.

3. Characteristics of urine: yellow, clear.

4. Intake/Output: breakfast 200cc. Output: 0800 1/30/09 – 300cc, slightly cloudy, yellow.

5. Interventions: monitor I/Os. Frequent perineal care to maintain genitalia clean and dry. Keep

dressing clean and intact, change dressing.

G. Integumentary (Skin)


1. General condition (color, turgor, rashes, moisture, bruises): skin pinkish white (pt is Caucasian) and

warm, no erythema, no jaundice, . Skin turgor is slightly elastic. No rashes on body. Skin is dry to

touch, no diaphoresis, slight dryness or flakiness. Ecchymosis on rt upper lateral arm.

2. Check bony prominences/protective aids: DU stage II on coccyx, wound dressing applied.

3. Wound/Incisions/Dressing: coccyx pressure ulcer as noted above.

4. Interventions: moisturize skin with lotion to preserve elasticity and to aid in the prevent tears, dry

skin well after bathing in skin to skin contact areas (genitalia, underarms, neck, under breasts and

abdomen). Protective dressings to coccyx, elevate heels on pillow to avoid heel contact with bed to

prevent possible skin breakdown. Measure and document all wounds and abrasion daily. Activity

every 2 hrs while awake to promote circulation and skin integrity. Nutritional consult requested

regarding skin integrity issues.

VI. Discharge Planning Assessment

A. Anticipated date of discharge: patient is to be d/c home within couple of days. Date of potential

discharge was not acquired from pt.

B. Self care needs: mod assist with dressing and bathing.

C. Educational needs/Health Promotion: discuss all of discharge planning and patient education with son

who will be helping care for pt.

D. Barriers to learning: diminished and slowed motor skills due to weakness.

E. Equipment/environmental needs: rolling walker . Potentially a type of monitoring/emergency calling

device to call for help when home alone.

F. Resources for discharge: nurse to follow up with doctor

Plan upon discharge: move back to own apartment with sister.

VI. Neuman Wheel


Based on the holistic variables of the individual (physiological, psychological, sociocultural, developmental and spiritual) chart on the Neuman Wheel to depict the priority of needs based on your assessment of the client. Give reasons for depicted priorities.

Pt is a 84 yo female. Admitted with SOB. Dx plural effusion, weakness, sinus bradycardia, dyspnea. Pt is a catholic who prays and attends church regularly. She has a son who she relies on mostly for emergencies. She lives alone in an apartment building which her sister also lives in. She is worried about her sister’s current medical condition and her ability to be potentially d/c soon. She states she is independent and able to complete her ADL independently with min assistance although she is quite weak and does need additional help. She relies on her family and friends for support and does not belong to any community groups.

Complete the following regarding your assigned client:

1. Explain the pathophysiology as it relates to your client’s medical diagnosis.

Transudative plural effusion is caused by some combination of increased hydrostatic pressure and decreased plasma oncotic pressure. Heart failure is the most common cause, followed by cirrhosis with ascites and hypoalbuminemia, usually from the nephrotic syndrome.

Sociocultural

Developmental

Physiological

Spiritual

Psychological


2. What are the most important assessments (including lab values) for your client today?

Auscultate and percuss lungs for abnormalities, BP, pulse, asses for dyspnea and tachypnea,

3. What complications may occur? What could go wrong?

Large effusions could lead to respiratory failure.

4. What health promotion interventions and/or activities are essential to optimize your assigned client’s wellness potential or condition?

Coughing and deep breathing exercises, ambulation, proper nutrition, frequent assessment to observe pt breathing pattern, oxygen sat, for evidence of improvement or deterioration.

5. Identify three pertinent actual or potential NANDA nursing diagnoses and list in order of priority.

Ineffective breathing pattern related to collection of fluid in pleural space. Impaired gas exchange related to right lower lung lobe mass.


Medication Administration: Nursing Process Focus**

Classification/Prototype: proton pump inhibitor

Generic Name: Pantoprazole sodium Trade Name: Protonix, Protonix IV

Assessment* Indication(s) for client receiving

this medicationHeartburn symptoms, increased stomach acid formation r/t stress of being

institutionalized Route and dosage for this client 40mg PO Therapeutic dosage ranges: 40mg

PO Required assessments prior to

administration with results of assessments

Required: asses underlying condition; asses pt for complaints of epigastric or abd pain and for bleeding

Results of: no abd pain, no n/v. no bloody stools or emesis.

Baseline data to consider prior to administration

Serum lipid enzyme levels, liver function test.

Allergies nka

Reason(s) to hold medication Abd pain, bloody stools or emesis, headache, pain, chest pain, peripheral edema, c/d,n/v, uti, dyspnea, increased cough, rash.

Reason(s) to notify M.D. Bloody stools or emesis, abd pain,n/v

Any contraindications to the administration of this medication?

In pt hypersensitive to the drug

Drug-Drug or Drug-Herbal/Food that may interact with this medication

Ampicillin esters, iron salts, ketoconazole, St.John’s wort, food delays absorption

Diagnosis* Identify actual/potential Nursing

Diagnosis for the client receiving this medication

Risk for imbalanced fluid volume related to drug-induced adverse reactions.

Planning: Client Goals and Expected Outcomes* Identify expected outcomes

related to the administration of this medication

Pt maintains adequate hydration throughout therapy.

Implementation*Nursing Interventions and Administration Alerts-can be given without regards to food. -monitor fluid intake

Client/Family Education-instruct pt take exactly as prescribed and at approx the same time every day. –drug can be taken with or without food. –table is to be swallowed whole. –instruct to report abd pain, or signs of bleeding, such as tarry stools. – not to drink etoh, eat food or take drugs that can cause gastric irritation.

Evaluation (effectiveness of interventions, therapeutic effects, and adverse/side effects)* Expected therapeutic effects

achievedDecrease gastric secretions

Any occurrence of adverse/side effects

Abd pain, constipation, diarrhea, nausea, vomiting, urinary frequency, inc cough, rash.

Need for further client/family education

As above


Any additional documentation required in the client’s chart besides the MAR? If so, where in the client’s chart would this data be documented? Allergies and diet.

**Adams, M. P., Holland, L. N. and Bostwick, P. M. (2008). Pharmacology for nurses: A pathophysiologic approach (2nd ed.). New Jersey: Pearson Prentice Hall.

nursing holistic + care plan + meds + labs

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