Complete Plan of Care on your client In this third and final submission of your Course Project, you will be completing a comprehensive care plan. Include safet

Course Project Module 5

Course Project Module 5

Course Project Module 5

Patricia Z Babirye

Rasmussen College

Fundamentals Of Professional Nursing

Lisa Abbey

May 8th, 2022

Client and Background Information

The patient Initial is G.J., female, and 88 years old date of birth is 09/03/1947. She was admitted 0n 04/21/22. The patient is positive for E.coli and is currently-droplet lets the precaution. She is on the oxygen of 2.0 liters. She needs assistance with ambulation action, dressing, and transferring. She has an order for a compression device, and she should wear them daily and only take them off at night. The marital status of this Client is widowed and is current with no occupation as children providing care and support needs. The Client has 7daghters and 2sons. G.J is one of the 7daughters that visit her a lot and take care of her the most. She Speaks English and Latino. This patient is allergic to Heparin, dog dander, and Augmentin. And is Full code status. The Client has a surgical wound; it’s pink, dry, and about 1inch in size as per the assessment. She's Hispanic. (Acharya, Y., Badai 2018).

I met this Client at thriving of lisle, where I’m doing my clinical currently. This patient has lived at thriving of lisle for about 3weeks now. She used to work as a teacher at a driving school and trained school bus drivers. This patient is a female. Alert oriented. And she was widowed. She currently has Occupational and Physical Therapy, working with her 5days a week for an hour each day. She has had a right shoulder X-ray. Now, she is being monitored for Covid-19 symptoms. No blood pressure draw on the Right arm. No blood marks on the right arm. Needs 2people assistance to the bathroom and chair. She’s currently on 15medications, and her discharge from this facility which is a short-term facility has been planned already. She is presently taking metoprolol, Docusate sodium, Aspirin, Allopurinol, levothyroxine, and many other medications. The Client's chief complaint is wet compression fracture lumber region. This patient has had surgery done on her back. This patient has other diagnoses, i.e., Type two diabetes, stage 1 breast cancer, and hypertension. The following lab orders are CBC, CMP, creatinine, BUN, Glucose, PT/INR, Magnesium, and Phosphorous, one time a day (Acharya, Y., Badai 2018).

The biological and physiological assessment of the Client provides specific information. (Lambert, 2022). Including 64.0inches and 202lbs height and weight, BP= 113/65mmhg, Temperature: 97.5, and pulse: 63bpm. Similarly Respiration indicated: 18breaths per minutes, 0xygen saturation: 92%, pain: 0. With the new information tested, there are B.P.: 120/65mmhg, Temperature; 97.5, pulse;63bpm, respiration; 18breaths per minute, Oxygen saturation; 94%, pain;4, pulse; 60beats [per minute]. Thus, a change in pain level from 0 to 4 is critical in the decision for the Client's treatment and care interventions. And all the above, mentioned Vitals has been assessed by me and charted on the computer (Adane, K 2019).

Past medical and health history is critical to evidence-based analysis and treatment for quality outcomes in healthcare settings. According to a practical assessment of past health, history is vital to accurate and effective decisions in healthcare settings (Acharya et al., 2018). The Client's past medical history indicates knee replacement for both legs. The paid code status indicates a complete code with Heparin allergies, Augmentin, dog dander, etc. Treatment orders included dressing changes, blood sugar monitoring four times a day, and TEDs. Noteworthy, the Client's past medical history and present are critical in healthcare decision-making for effective and accurate outcomes in care provision (Adane, K 2019).

The Client's diet is regular texture, a Diabetic diet, and Thin consistency. She has Assistive Devices such as Tubes, Drains, and Ostomies, with notable old age movement and posture challenges. She needs assistance to the bathroom and has a walker and a wheelchair. The Client needs help with the wheelchair and toilet. The patient Feels dizzy when she stands up. Currently is on a few other medications like Xanax for anxiety. She has precautions for vitamin K. The Client uses an incentive spirometer to practice slow breathing exercises. The patient has an order for coumadin to prevent blood clots (Adane, K 2019).

Family history is critical in assessing notable causes and origin of the illness that are gene and inheritance-oriented for effective decisions. In the Client's case, there is a history of breast cancer, and hypertension, according to her patient chart. Clients accommodating past family health pertinent statuses such as lung disease, cancer, hypertension, diabetes, tuberculosis, arthritis, neurological disease, obesity, mental illness, and genetic disorders are critical for accurate decision-making and systematic diagnosis in the healthcare system. Thus, the Client's family's pertinent health status is crucial for correct decisions in this case. Accommodating clients' social and cultural values, beliefs, and attitudes on healthcare are essential and influential in healthcare settings (Acharya et al. 2018).

In the Client's case, the cultural background includes the Client's primary language, which is English. Thus, accommodating cultural and social features an effective for cultural competency in the case of management within a clinical setting (Adane, K 2019).

References

Acharya, Y., Badai, S., Vink, I., Ebisi, M., Arja, S., & Altahir, T. (2018). Descriptive Analysis of Patient History Based On Its Relevance. International Journal of Medical Science and Education, 5(4):479-482

Adane, K., Gizachew, M., & Kendie, S. (2019). The role of medical data inefficient patient care delivery: a review. Risk Management and Healthcare Policy, 2019:12 67–73

Vallerand, A.H (2020). Davis’s Drug Guide for Nurses (17th Edition). F.A. Davis

Company. https://amabassadorred.vital

Lambert, N. (2022). Nursing care plans in mental health. Mental Health Practice, 25(1).

Sanson, G., Vellone, E., Takao‐Lopes, C., Barrientos‐Trigo, S., Porcel‐Gálvez, A. M.,

Riegel, B., & D'Agostino, F. (2022). Filling a gap in standardized nursing terminology.

Development of a new nursing diagnosis proposal on heart failure self‐care. International

Journal of Nursing Knowledge, 33(1), 18-28.

PART TWO

This patient G.J s admitting medical diagnosis is a wedge compression fracture of the T7-T8 vertebra, subsequent encounter for fracture with routine healing. (Non-surgical) This patient had covid at the beginning of last year and she stayed in bed for a long time without ambulating later on developed a pain in her lower back that led to her being admitted thrive of Lisle. She has a history of wedge compression fracture of T9-T10 and history of COVID-19. which makes other problems even worse. (COVID.C Team 2020)

Dysphagia. Using my ABC which stands for Airway, Breathing, and Circulation I have chosen this as my first secondary diagnosis. Dysphagia is difficulty swallowing food or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage. This problem is due to his past surgical experience of T9-T10. Swallowing is a complex process and many disturbances in oropharyngeal and esophageal physiology including neurologic deficits, obstruction, fibrosis, structural damage, or congenital and developmental conditions can result in dysphagia. Breathing difficulties can sometimes affect the ability to swallow. Some causes of dysphagia are explained here. Dysphagia can be caused by immune system diseases such as polymyositis, age-related changes in swallow function and so many more. signs and symptoms include pain, unexpected weight loss, coughing, or choking on food or liquid. (Huvila. I & Erickson K,2020)

Chronic atrial fibrillation is the second secondary diagnosis for this patient. This is a type of heart arrhythmia that causes the top chamber of your heart, the atria to quiver and beat irregularly for an ongoing period. With this patient, it’s a chronic illness. This was evidenced by the client complaining of chest pain, fatigue, dizziness, and shortness of breath as evidenced by 4litres of oxygen that she was put on. Weakness and reduced ability to exercise. this patient went for physical therapy and asked the therapist to take her back to her room because she was already fatigued and weak to exercise. Atrial fibrillation is most common in an aging population. Treatments of A-fib may include medications, therapy to reset the heart rhythm, and catheter procedures to block faulty heart signals. This client is on calcium channel blocker and antiarrhythmic medications to treat this diagnosis.

Type-II Diabetes mellitus third secondary diagnosis. This one of the most common metabolic disorders are caused by a combination of two primary factors. Defective insulin secretion by pancreatic B cells and inability of insulin-sensitive tissues to respond appropriately to insulin. Insulin release and activity are essential processes for glucose homeostasis, the process that is involved in the synthesis and release of insulin. Type-II Diabetes mellitus risk factors include ethnicity, family, history, and genetic predisposition. Type-II Diabetes can be prevented by improving the main modifiable risk factors i.e. Obesity, low physical activity, and an unhealthy diet. Since Type-II Diabetes is most common in Hispanics, and Native Americans and this patient is Hispanic. this does correlate with what most studies say about ethnicity and Type-II Diabetes. (Cengiz. A & Yoder 2020)

Muscle weakness is my fourth secondary diagnosis. Related to musculoskeletal impairment, pain, and immobilization. The central component of muscle fatigue is generally described in terms of a reduction in the neural drive or nerve-based motor command to working muscles that results in a decline in the force output. It has been suggested that the reduced neural drive during exercise may be a protective mechanism to prevent organ failure if the work was continued at the same intensity. The exact mechanisms of central fatigue are unknown although there has been a great deal of interest in the role of serotonergic pathways. The patient is also associated with acute myasthenia gravis as the other condition. signs and symptoms of this diagnosis include difficulty rising from a chair and brushing hair. ( Dolonansky .M & Moore .S 2013)

Physical Assessment for this patient, I did neurological checks, and she was awake and Alert oriented times 4including person, place, time, and season. Verbalization was clear and appropriate. Cardiovascular checks S1 and S2 where present rhythms were irregular, peripheral pulses were palpable +2, no edema no numbness or tingling. Respiratory checks were labored, no cough or sputum, Lungs not clear patient has an incentive spirometer to use for deep breathing exercises. Gastrointestinal checks. The patient has a soft, non-distended abdomen with active bowel sounds times 4 quadrants. The last bowel movements were today morning, regular pattern. diet is a diabetic diet, thin consistency. Genitourinary checks. The bladder is non distended, urine is straw-like. musculoskeletal checks. passive range of motion exercises is being done i.e. flexion, extension, and rotation. extremities are weak most especially the lower legs and arms. the patient uses ortho devices i.e. wheelchair, and a walker. integumentary checks patient skin is warm, or dry. Wounds at the lower back. Safety patients call light is in reach, bed in a low position, side rails up times 2, and family at the bedside. The client’s current vital are Blood pressure 109/55, temperature 97.5, pulse 62bpm, weight 171lbs, oxygen saturation 97, Pain 7, Respiration 18breaths per minute.

Abnormal Laboratory & diagnostics Values of this patient include MCHC (red blood cells) 30.4 with a normal range of 32.0-36.0. Platelet count 143 with a normal range of 150-400 Platelet count measures the number of platelets in your blood. Protein 4.6 with a normal range of 5.6-8.2. Potassium 43.2with a normal range of 3.6-5.0. Carbon dioxide 32 with a normal range of 18-30.

NANDA diagnoses include Impaired swallowing evidenced by vomiting and regurgitation of gastric contents and vomiting. Decreased cardiac output evidenced by dysrhythmias and other problems. Acute pain is evidenced by a pain level of 7 and discomfort upon ambulation. Risk of falls evidenced by weakness in the lower left and right leg upon ambulation, orthostatic hypotension, and confusion.

References

Cengiz, A., & Yoder, L. H. (2020). Assessing nursing students’ perceptions of the

competencies: A systematic review of the literature with implications for Insulin

Use Worldviews on Evidence‐Based Nursing, 17(4), 275-282.

Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses (QSEN): The key is systems thinking about pathophysiology for muscle weakness OJIN: The Online Journal of Issues in Nursing, 18(3), 1-12.

Huvila, I., Enwald, H., Eriksson-Backa, K., Hirvonen, N., Nguyen, H., & Scandurra, I.(2019)

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