NUR2115 Module 10 Comprehensive Plan of Care Assignment

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…

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