Nursing care plan
Student Name Clinical Judgement Plan American Career College NURS117C Instructor Date 1 NURS117C – Advanced Medical Surgical Nursing Clinical Judgement Plan Clinical Site GEM Student Date of Care From 1.31.24 Admit Date 1.30.24 Isolation ■ N/A Room 13B ■ Home Initials Yes (Specify): SNF H.M Instructor Sub-Acute Homeless Other: Age 68 Sex M Code ■ Full F T. Walcott Unit Med-Surg Spoken Language Spanish DNR DNI Modified: Allergies NKA Chief Complaint/Reason for Hospitalization Abdominal pain, Vomiting x3 days, Fever, Malaise Perforated Appendicitis Admitting Medical Diagnosis A 68 year old female was brought into the emergency due to abdominal pain, vomiting, fever, and weakness. She History of Present Illness had been vomiting for the last 3 days. She pointed to her pain which was located in her umbilicus area, radiating to her right lower quadrant. She explained that her pain was getting worse each day. Medical History DM 2, HTN, ESRD Surgical History AV Fistula Smoking (Specify type): Social History Illicit drug use (Specify and list duration): Pack per day and duration, if applicable: Alcohol (Specify, type, duration, and amount per day): Socioeconomic/Cultural/Spiritual Patient is Hispanic, lives with her husband and son. She practices Catholicism. No history of drug or alcohol abuse. Orientation and Psychosocial Considerations/Concerns Erikson’s Developmental Stage Generativity VS. Stagnation: Generativity refers to making a positive impact and contributing to the world, such as through raising children, mentoring others, or engaging in meaningful work. Stagnation, on the other hand, represents feeling stuck and unproductive, lacking a sense of purpose. 2 Relevant Diagnostics and/or Lab Test Instructions: Cite all reference(s). Relevant Diagnostics and/or Lab Tests Normal Range Admission Current Lab Value Lab Value Clinical Judgement Plan Significance of Abnormal Lab Values Abdominal CT Diagnostic Interpretation/Findings Demonstration of right iliac fossa abscess or phlegmon in association with signs of appendiceal inflammation and appendicolith WBC 4.5-10 17,000 12,000 Patients WBC are elevated indicating infection and inflammation. Potassium 3.5-5 5.7 4.2 Patients potassium is elevated due to her ESRD. Her kidneys aren’t able to excrete excess fluids and electrolytes. Creatinine 0.6-1.2 5.9 3.8 Patients creatinine levels are elevated indicating impaired kidney function. Hemoglobin 12-16 10.1 12.5 Low hemoglobin can indicate that there is blood loss that is occuring. Hematocrit 37%-47% 32% 38% Low hematocrit levels indicate that there is a decrease in red blood cells. 3 Clinical Judgement Plan M.A.R. Instructions: List all scheduled medications and PRN medications administered. Cite reference(s) for each section. Medication Name Side Effects/Adverse Reactions Dose/Route/ Frequency Mechanism of Action Ondansetron 2 mg/IV/Q 4HR Helps reduce the signals that trigger nausea and vomiting Headache, constipatio n,fatigue, allergic reaction Nausea and Vomiting Reduces workload of the heart, reducing blood pressure Promotes glucose uptake by cells, lowering BS Headache, dizziness, fast heartbeat, hypotension Elevated BP Hydralazine 10 mg/ IV/ Q6 HRS PRN Insulin (Regular) Sliding scale/SQ/ PRN Dilaudid 1 mg/IV/ Q4 HRS PRN Binds primarily to the mu-opioid receptors in the brain, reducing pain Zosyn 3.375 GM/ IV/ Q 12 HRS Inhibits bacterial synthesis, treating bacterial infection Indication Nursing Considerations Push medication slowly, monitor vitals, monitor effectiveness Monitor BP, assess for hypotension , adverse effects Elevated Blood sugar Monitor blood sugar, assess for hypoglycemia Respiratory depression, nausea, headache,dizzi ness,sedation Severe Pain Assess pain, respirations, constipation, safety precautions N&V,Rash, allergic reactions ,GI upset Perforated appendix, inflammation Monitor for allergic reaction, LFTs,Labs Hypoglycemia Medical Management & Collaborative Plan Anticipated Transfer/Discharge Planning Patient Education Collaborate with surgery for drainage of abscess, contact nephrology for dialysis D/C home with home health for JP drain Teach patient about S/S of infection; Medication compliance 4 Clinical Judgement Plan Physical Assessment: This is YOUR assessment of the patient, should not be copied from the assigned nurse or EMR. Head-to-Toe Assessment Neurological A&O X4. Patient has been blind since 2014 from diabetic retinopathy. Decreased sensation in extremities to do diabetic neuropathy.Hearing intact. Clear speech. Cardiovascular Heart sounds regular. HR 88. Capillary refill >3 seconds in lower extremities. Edema +2 bilateral ankles, awaiting dialysis. Pulses present, faint. Respiratory Gastrointestinal Genitourinary Unable to assess continence status. Foley catheter inserted 1/30. 14 FR Foley Cath. 280 mL of clear,yellow urine in bag. 1200/0000 1600/0400 BP: 178/98. HR 99. T 97.5. RR 22. O2 97% 2L O2. BP: 136/72. HR 86. T 98.2. RR 18. O2 98% 2L O2. Unable to assess gait. Able to complete PROM exercises. Uses cane to ambulate, reported by patients husband. Integumentary Skin cool to touch, dry. No signs of any redness in bony prominences. 2 inch laceration in right lower quadrant for drain. Pallor. Lines/Drains JP drain inserted after abscess drainage. 50 mL of serosanginous fluid. Foley catheter 14 fr inserted on 1/30. IV replaced to right hand on 1/31. 22 gauge. VTE 0800/2000 Lung sounds clear bilaterally. Respirations 22. O2 @ 98% on 2 L O2. Patient has a JP drain in her right lower quadrant to collect drainage from abcsess/appendix. Client on clear liquids, hypoactive bowel sounds, last BM 1/29. Musculoskeletal/Mobility/Activity Vital Signs BP: 148/80. HR 88. T 98.3. RR 20. O2 98% 2L O2. IV Drips Medication Name Shift Start Dose VTE prophylaxis active. 5000 units/ 1 mL of Heparin Q 12 hours. 5 Shift End Dose Clinical Judgement Plan Observation Assessment Recognize Cues 1. 2. 3. Tachypneic. RR 22. Anxious, restless. Pain level 9/10. Grimacing. Gaurding. Edema +2 in lower extremities. Generalized weakness, fatigue. Pallor. Dizziness. Skin cool to the touch. Interpreting Analysis Prioritize Analyze Cues Hypotheses 1.Tachypnea caused by pain increasing respirations. 2. Anxiety, restlessness from pain. Planning Generate Solutions Responding Implement Take Action Maintain oxygenation Maintain O2 Elevate HOB levels. High Explain procedures fowlers. Patient teaching, and medications to patient and family communicate with patient. 1.+2 pitting edema 1. Decreased oxygen Report to Scheduled dialysis 2. Weight gain of 2 carrying capacity. Nephro Monitor intake and Elevate lbs since admission 2. Decreased output extremities date. perfusion. Monitor weight Report to MD 2 units of blood Promote rest 1. Weight gain, 1. Low Hemoglobin. administered Report Labs 2. Cool, pale skin. retaining fluids, to MD unable to excrete excess toxins. 2. Edematous 1.Tachypnea, compensating 2. Anxiety Reflecting: Evaluate 1. Tachynea, anxiousness,pain Goals were met. Respirations 18. Pain 4/10. 2. Edema +2 Goals not met. Awaiting dialysis. MD ordered Lasix 40 mg. 3. Weakness,pallor,dizziness Goals were met. 2 units of blood were administered. Hemoglobin 12.5, within range 6 References Brown, Di, and Helen Edwards. Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Australia, 201 7
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