NURSING CARE PLAN Date 11/20/2018 Student Course Nurse 101L Instructor Unit/ Room# Patient Initial F.N DOB 1938 Height/Weight 125Lbs/ 62” Code Status Final EDC/Current Gestational Age: Allergies Penicillin and Cashews Temp (C/F Site) 99 Pulse (Site) 116 Respiration 24 History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with evidence based citations Chief Complaint (if possible, use patients words): HPI (PQRST of chief complaint, along with other pertinent pregnant complications [if any]): ___ y.o. at ___ week’s gestation, arrives to the hospital with prior noted chief complaint. Admit Dx: Pulse Ox (O2 Sat) 92% Blood Pressure 130/80 Pain Scale 1-10 9/10 Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations. If on postpartum, BUBBLE-HE for maternal assessment and if on antepartum/intrapartum, the following apply: fundal height, CV/Thorax, perineum, SVE, and fetal heart rate Category. NURSING CARE PLAN Relevant Diagnostic Procedures/ Results & Pertinent Lab tests/ Values (with normal ranges), include dates and rationales supported with Evidence Based Citations Past Medical and Surgical History, Pathophysiology of Medical Diagnoses (include dates, if not found state so) Supported with Evidence Based Citations Pertinent Labs Current CBC: Medical Hx: GBS: OB Hx: Prenatal Panel: Surgical Hx: PIH panel (if applicable): Family Hx: Relevant Diagnostic Procedures Ultrasound (latest): Erikson’s Developmental Stage (with Rationale). Provide examples of how client meets/doesn’t meet chosen stage (supported by Evidence Based Citations). Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns, (3) to include the following Social Determinants of Health ❋Economic Stability ❋ Education ❋Social and Community Context ❋ Health and Health Care ❋ Neighborhood and Built Environment supported with Evidence Based Citations NURSING CARE PLAN Socioeconomic Cultural: Spiritual: Three psychosocial concerns, based on above assessments: 1. 2. 3. Potential Health Deviations: aka Risk Diagnoses (AT LEAST TWO) Include THREE independent nursing interventions for each (RISK FOR XXX, AS EVIDENCED BY XXX) Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale Supported with Evidence Based Citations NURSING CARE PLAN Priority Nursing Diagnosis (at least 2) Written in three-part statement *Risk Diagnoses NEVER go in this section. Planning (outcome/goal) Measureable goal during your shift (at least 1 per Nursing Diagnosis) *Think SMART GOAL* Prioritized Independent and collaborative nursing interventions; include further assessment, Intervention and teaching (at least 4 per goal) Rationale Each must be supported with Evidence Based Citations Evaluation Goal Met, Partially Met, or Not Met & Explanation NURSING CARE PLAN MEDICATION LIST Medications (with APA citations) Class/ Purpose Route Frequency Dose (& range) If out of range, why? Mechanism of action Onset of action Common side effects Nursing considerations specific to this patient Updated FII17-NCC References FUNDS N101L SUMMER 2017 FUNDAMENTALS SCENARIO for CAREPLAN PATIENT INFORMATION: Ms. Florence Nightingale, African-American 80 year-old female who is alert and oriented x 4. She presents here to Utopia Hospital via AMR due to an un-witnessed fall at home. She currently lives alone fully independent with her 3 cats. She has two sons (both live out of state) and one daughter who lives two doors down from her mother’s home. She is an active woman who attends church every Sunday, watches her 3 grandchildren every Tuesday and Thursday after school, and plays bridge with the “red hat ladies” on Wednesday evenings at the YMCA. She is widowed as of three years ago and was married for 60 years. She is a retired professor of Nursing and states, “I am enjoying retirement very much – staying active is important to me”. She ambulates with a walker in the house and out. PATIENT HISTORY: HTN, CHF, Atrial Fibrillation, COPD, GERD, DVT in 2013 for which she was hospitalized at Utopia. She quit smoking 3 years ago. She was a one-pack-a-day smoker for 50 years. She does not consume alcohol or take illicit drugs. Ms. Nightingale is DNR. Patient is allergic to penicillin and cashews. HISTORY OF PRESENT ILLNESS: Ms. Nightingale has been admitted to Utopia Hospital via AMR for an un-witnessed fall at home. She states, “I tripped over my cat and fell on my left side”. She called her daughter who proceeded to call 9-1-1. Ms. Nightingale states, “I did not lose consciousness”. Vital signs upon arrival to the ER were: BP 130/80, P 116, RR 24, O2 sat 92% room air, T 99 degrees F, Wt 125 pounds, Ht 62”. Lower left lobe crackles on auscultation. She complains of pain 9/10 in her left hip and left thigh. She has a visible bruise measuring approximately 3 x 3” on her lateral left thigh with no skin breakdown or open wound. She presents with bilateral lower extremity edema with 2+ pitting. She states that it is normal for her to have swelling in her ankles. She complains of difficulty urinating and has been getting up at night to urinate. She states that she is “mildly” incontinent and has been wearing pads. She has a 20-guage IV catheter in her right AC infusing 0.9% NS at 25 mls/hr TKO. No signs of redness, edema, or infection. ORDERS: She has been placed on 2 L O2 NC bringing her oxygen saturation rate to 97%. Patient is NPO for pending surgery. Bed-rest and non-weight-bearing status ordered. Respiratory Therapy order PRN. Morphine 2 mg/ml IVP q2 hours PRN for pain PATIENT HOME MEDICATIONS: warfarin 4 mg PO q day, metformin 1000 mg PO q day, furosemide 20 mg PO qday, metoprolol 100 mg PO qday, ibuprofen 400 mg PO qday PRN, Tums 12+ PO qday PRN DIAGNOSTICS: 1/1/16, 0800, X-ray findings consistent with left accetabular hip fracture; additionally full complete fracture of left femur. Labs: 1/1/16 0900, Glucose Finger Stick = 310, WBC 12,000, HGB 13, HCT 55%, RBC 4.0, PLTS 300,000, NA+ 150, K+ 3.1, CL- 106, BUN 30, CREATININE 1.6, HgbA1c 8.2 %, INR 2.5, PT 12 NOTE TO STUDENTS: • This is an opportunity to ‘think like a nurse’ – the care plan is a process and a way that we deliver quality healthcare. • Only one ‘dot com’ reference; the rest should be books (Potter & Perry) and/or nursing journal articles. • Please do not copy content from above ‘word for word’ • APA formatting to include title page and reference page • In-text citations • No Wiki, WebMD, Taber’s, or dictionary
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