Comprehensive Plan of Care

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Question Description

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

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Running Head: HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS Health History, Assessment, and Nursing Diagnosis Alfreda T. Sambolah Rasmussen College Author Note This paper is being submitted on February 27, 2019, for Cathy Meadows’ NU211/NUR2115 Section P1 Fundamentals of Professional Nursing 2019 Winter Quarter. 1 HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS 2 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) HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS 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 3 HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS 4 ASSESSMENT SUMMARY Body System Pain Level (pain scale 0-10/ location): Subjective: Patient’s Health History Patient reports pain of 6.5 out of 10 (leaning forward) and 3 out of 10 (still sitting) Objective: My assessment findings 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. Orientation: Head/Eyes/ Ears/ Nose/ Throat (HEENT): Relieving factor(s): Pain medications (oxyCODONE) Patient reports no trauma to Orientation (person, place, the head. Does not experience time and situation): Patient any headache. alert and oriented X 4. Had four (4) brain surgery to stop Patient reports no problem trimmers. with vision, no eye pain, no glasses or contact lenses, no Speech (clear/appropriate): history of an ocular problem, Speech is clear no blurring, no blind spot. PERL (pupils equal and Patient reports no ear pain, no reactive to light): Pupils are history of ear infections, no equal and reactive to light. ear discharge, and no hearing Had a cataract surgery. loss. HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS Patient reports nose is always clogged. Patient reports no experience of headaches and trauma to the head. 5 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. Musculoskeletal: Patient reports arthritis in fingers but does not have rheumatoid arthritis 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 IXII (All intact). MAE (moves lower extremities very well, and left upper extremity Weakness: Right shoulder Assist (transfers/ambulation): Stand by assist with all transfers and ambulation. Respiratory: Patient reports no cough, no shortness of breath, no chest pain, no smoking history, no history of respiratory infections, and no environmental exposure. Assistive device (walker, cane): no use of any assistive devices (walker or cane). Respirations: 19 bpm Rate: Regular Lung sounds: quick deep on inspiration and quick shallow on expiration Cough: No cough noted HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS Cardiac: Patient reports no chest tightness, no recent fatigue. 6 SOB: no shortness of breath 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 Integument: Capillary refill: Less than 3 seconds Patient reports no leg pain, no Skin ( moist, intact): Skin is leg cramps 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. Gastrointestinal (GI): Patient reports no bowel problems. Patient reports having a bowel a day before. Dressing(s): No dressings on any part of body. 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 HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS Genitourinary (GU); Patient reports no problem with voiding. Patient reports voiding 8-10 times a day 7 Frequency of urination (q2h, q4h, foley): 8-10 times a day. Approximately q2h. Color: Pale yellow Dysuria (frequency, burning): No pain or burning sensation Endocrine; Psychosocial/ Spiritual: Patient reports no abnormal growth, no endocrine disease or disorders, no abnormal temperature Patient reports associating with Native American Spirituality and is Buddhist. Patient reports having a strong family support. Continent: Continent Diabetic/ Blood sugar: 193.0 Diet: Consistent carbohydrate diet, Regular Texture texture, Thin Liquid consistency Appetite (%): 75% 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. HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS 8 Medication Data Sheet Drug Name Trade and generic name, dose, route& frequency 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. Vitamin D3 (Cholecalciferol) tablet 5000 units. Give one pill by mouth two times a day. Drug Classification Expected action and indication for use It is used to treat mild to moderate pain. Medical Diagnosis Side Effects and Adverse Reactions Nursing Administration special instructions and assessments For pain experiencing in Right shoulder. Side effects: Assess the Nausea, history of pain. 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 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, I am assessing patient carefully for evidence of hypocalcemia, assessing for symptoms of Client Education Evaluation of medication effectiveness, e.g., Pin Scale Demonstration of relieving of pain on the pain scale 010 Normalization of serum calcium and parathyroid hormone levels. HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS Gabapentin (Neurontin) Capsule 300 mg. Give 300 mg by mouth two times daily. Neuropathic pain, diabetic peripheral neuropathy. For 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. Protonix (Pantoprazole Sodium) Tablets Erosive esophagitis associated with GERD. The patient is taking this medication for GERD. 9 frequent urination, nausea, vomiting, constipation. Adverse Effects: Extremely large doses can cause toxicity. Side effects: sleepiness, dizziness, fatigue, clumsiness while walking, weight gain, tremor Adverse effects: Skin rash, unusual bruising, swollen glands, muscle aches. Side Effects: dry mouth, sore throat, nausea, vomiting, flushing, headache, abdominal pain. Adverse Effects: mood or behavior changes, anxiety, depression, panic attack. vitamin deficiency before and periodically. Resolution of prevention of vitamin D deficiency. Assess the location, characteristics, and intensity of pain periodically during therapy. Decreased intensity of neuropathic pain. Assess mental status and mood changes, inform health care provider if the patient demonstrates a significant increase in signs of depression. Increased sense of wellbeing, renewed interest of surroundings. Side Effects: headache, nausea, vomiting, I am assessing patient routinely for Decreased in abdominal pain, heartburn, HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS Delayed-Release 40 mg. Give 1 mg tablet by mouth two times a day. Maintenance of healing of erosive esophagitis. Nursing Diagnosis #1 Acute pain diarrhea, epigastric or stomach or abdominal pain. abdominal pain, gas, dizziness. Adverse Effects: Facial edema, hyperglycemia, photosensitivity Expected Outcomes (S.M.A.R.T) Specific, measurable, attainable, realistic, & time oriented (ID a future time or date for reassessment/ evaluation The patient will verbalize relief of pain. Short-term goal: Patient verbalizes minimized or Movement of bone fragments, controlled feeling of pain. edema, and injury to the soft tissue Long-term goal: Patient is free of pain on surgical site. R.T. 10 gastric irritation and bleeding in patients with GERD. Nursing Interventions Maintain immobilization of affected part by means of bed rest, cast, splint, traction. A.M.B. Reports of pain #2 Impaired Physical Mobility R.T. Neuromuscular skeletal impairment; pain/discomfort; restrictive therapies (limb immobilization) The patient maintain position of function. Short-term goal: After 4 days of nursing intervention, the patient will be able to demonstrate techniques and behaviors that enables resumptions of activities. A.M.B. Reluctance to attempt movement; limited ROM Long-term goal: After 4 days of nursing intervention, the patient will be able to maintain or increase strength Instruct patient or assist with active and passive ROM exercises of affected and unaffected extremities. HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS #3 Skin/Tissue Integrity, impaired: actual/risk for R.T. Physical immobilization A.M.B. Reports of itching, pain, numbness, pressure in affected/surrounding area 11 and functions of affected body part. The patient verbalize relief of discomfort. Short-term goal: After 6-8 hours of nursing intervention the patient will have reduced risk of further impairment of skin integrity. Assess position of splint ring of traction device. Long-term goal: After 3-4 days of nursing intervention the patient will be able to reduce risk of infections. Which of your diagnoses are Priority using Maslow’s Hierarchy of Needs: Impaired Physical Mobility according to Maslow’s Hierarchy of Needs, physiologic needs should satisfy first, so that the patient should satisfy this to satisfy her physiologic needs. Evaluation: Were any of your short term expected outcomes met during your shift? None of the short-term expectations were met during my shift. How might you revise your care plan next time to achieve at least one outcome during your shift? I plan on improving my care plan next time by monitoring my patients’ recovery process keenly and offering effective ways to have my patient be able to decrease edema and promotes venous return. HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS 12 Medical Diagnosis 1. The patient diagnosed with an Unspecified Displaced Fracture of Surgical Neck of Right Humerus the pieces of bone at the fracture site are separated and shifted out of position. This type of fracture typically requires surgery. Proximal humerus fractures are diagnosed by a thorough physical examination and diagnostic imaging (Stanley, n.d.). 2. Humerus fractures are caused by direct harm to the arm shoulder. About 20% of humerus fractures are displaced and mostly occur in baseball games. Such type of fracture requires a more intrusive treatment like surgery 3. A subsequent encounter is experienced when an active treatment of the patient's injury has been offered, and the patient is now receiving routine care for the injury in the healing process (Deter, 2006). An example is medical ex-rays to monitor the healing process of the fracture 4. Asthma is an inflammatory disease of the airway demonstrated by various recurring symptoms and bronchospasm. Common symptoms of asthma include; coughing, wheezing, short breaths, and chest tightness. 5. A major depressive disorder is a mental disorder demonstrated by two weeks or more of low mood. It is accompanied by loss of interest in several things, low self-esteem, pain with no clear cause and low energy. Patients with depression often hear or see things that are unseen by other people. They affect patients negatively as some end up committing suicide (Deter, 2006). LAB RESULTS DATE LAB TEST NORMAL VALUE CLIENT VALUE SIGNIFICANCE OF HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS 01/27/19 Sodium 135-145 mmol/L 134 (L) 01/27/19 BUN/Creatinine Ratio 10-20 mg/DI 27 (H) 01/27/19 Hemoglobin 12.0-16.0 g/DI 7.8 (L) 01/27/19 ALK Phosphate 50-136 IU/L 144 (H) 01/27/19 RBC 4.00-5.20 mil/cu mm 2.95 (L) 13 ABNORMAL LAB VALUE The significance of abnormal sodium lab value is hyponatremia. This mean the patient may not be getting enough blood flow to their kidneys, and could have conditions such as congestive heart failure, dehydration, or gastrointestinal bleeding. This mean that there is a nutritional deficiencies such as iron, folate or B12 deficiency. Elevated ALK Phosphate is most commonly caused by liver disease or bone disorders. This could signify trauma in the patient. Diagnostic Tests Tests Results Significance HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS US Venous Upper Extremity Right Indication: Right Humerus Fracture The right arm veins are negative of DVT EKG 12- Lead Interpretation: Artifact, Sinus rhythm, right Atrial enlargement, Abnormal ECQ 14 It enables the nurse to know where exactly the fracture happened and the intensity of the fracture to administer proper medication. It directs the nurse on the exact medication to use. References Deter, L. L. (2006). Basic medication administration skills. Australia: Thomson Delmar Learning. Stanley, L. (n.d.). Moving Forward: Physical Therapy Brings Motion to Life. https://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=937e6560 -3300-4bdc-9285-16d9cb759554 ...
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School: Rice University

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Patient education
The patient has several complications including diabetes mellitus, depression which may
lead to mental health problems, and poor diet. I would advise the patient to maintain a healthy
leaving whereby they maintain healthy feelings, diet and maintain a healthy body. The patient
should maintain a constant exercising schedule which may help with maintaining healthy body
weight and assist in getting rid of the depression. The patient should also attend psychological
sessions which would also assist with the depression. The patient has a poor diet which may be
as a result of the depression and the main cause of poor health. The pat...

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Anonymous
Good stuff. Would use again.

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