LEARN MORE...

Access Millions of academic & study documents

N 402 University of Louisville Care Plan & Clinical Worksheet

Content type
User Generated
Subject
Nursing
School
University of Louisville
Type
Worksheet
Showing Page:
1/6
University of Louisville School of Nursing
N402 Clinical Worksheet
Client Initials: Student: Date of Care:
Demographic Information
Health History
Care Prescriptions
Age: Gender: Race:
Chronic conditions & previous health problems:
•Parkinson’s Disease •Anemia
•Hypertension •Stroke
•Pneumonia. •Chronic kidney disease
•Colon Cancer •Hypothyroidism
Nutrition
Type of diet: Regular Diet
NPO
Tube Feeds: Type _________Rate ________
G tube NG tube
Aspiration risk Thickened liquids: Type __________
Code Status:
Weight: Height: BMI:
Reason for Admission [patient’s own
words]:
“Parkinson’s has made life hard”
Unexpected events/complications during stay:
•UTI-Urinary tract infection
•Constipation
Activity: Independent × Assist Dependent
× Ad lib BR only Chair Ambulate Bed Rest
× Assistance of 1 person
Assistive devices:
Gait belt mechanical lift walker cane
× Other: Wheelchair
Previous surgeries:
•colectomy
Medical Diagnosis [medical terms]:
• Hypertension
• Hypothyroidism
• Chronic kidney disease
Nursing Diagnoses
•Impaired physical activity
Related to: cognitive impairment, limited strength,
musculoskeletal impairment.
Evidenced by: Decreased muscle control/strength,
limited range of motion.
•Constipation
Related to: neurogenic disease, sedentary lifestyle,
endocrine disorder
Evidenced by: straining while trying to stool,
infrequent passage of stool. Decreased bowel sounds.
•Impaired verbal communication
Related to: stroke, lack of stimuli.
Evidenced by: Difficulty vocalizing words, difficulty
maintaining conversation, inability to recall familiar
words.
•Ineffective coping
Related to: uncertainty, confusion
Evidenced by: change in communication patterns,
inability to meet basic needs.
•Risk for injury
Related to: Impaired balance, impaired physical
mobility, diminished mental status
Evidenced by: no evidence
Elimination: × Continent Incontinent
×Voiding Foley catheter I & O
Enema Colostomy Other:
Skin Care:
×Intact skin Moisture barrier: __________
Other: ________ Turn & position w/ skin care q. 2 hrs.
Wound Care: Dressing/drain Drsg. Change/treatment
Location & Type: N/A
Date of admission:
Pulmonary care:
O2 ___ L/min via N/C mask ×O
2
Sat: 100%
Incentive Spirometer q ___ hrs.
MDI inhaler Mini-neb Med. albuterol atrovent
Other
Allergies:
Penicillin (drug allergy)
Other notes:
N/A
Glucometer: ac & hs × other: N/A
sliding scale insulin

Sign up to view the full document!

lock_open Sign Up
Showing Page:
2/6
Medications (scheduled & prn)
Class & Action
Major Side Effects
Nursing Implications
Patient Education
Vitamin, Fat Soluble. Promotes intestinal
absorption of dietary calcium.
Heart arrhythmias,
confusion, constipation,
vomiting. High blood
pressure.
-Monitor serum calcium through lab
work.
-Assess for cardiac arrhythmias.
-Advise patient to take medication as
directed.
-Review diet modifications with patient.
Therapeutic: antihypertensive
Pharmacologic: angiotensin II receptor
agonists.
Blocks the vasoconstrictor and aldosterone-
secreting effects of angiotensin II at
receptor sites
Dizziness, fatigue,
hypoglycemia, chest
pain, insomnia,
headache, abdominal
pain.
-Assess blood pressure.
-Assess for angioedema.
-Monitor renal function.
-Use of alcohol, standing for a long time,
and exercising may increase orthostatic
hypotension.
-Caution patient to avoid salt substitutes.
-Take the medication as directed.
Therapeutic: antiparkinson agent
Pharmacologic: Dopamine agonist.
Levodopa is converted to dopamine in the
CNS, where it serves as a neurotransmitter.
Provides relief of tremors and rigidity in
Parkinson’s syndrome.
Involuntary movements,
hallucinations,
hepatotoxicity,
hemolytic anemia,
anorexia, leukopenia.
-Assess parkinsonian symptoms.
-monitor renal & hepatic function.
-Monitor for toxicity/overdose.
-Eat high protein meals to reduce gastric
irritation.
-May cause sleepiness, dizziness or
drowsiness,
-Monitor for skin lesions/changes.
-Instruct patient to take medication as
directed.
Therapeutic: hormones
Pharmacologic: Thyroid Preparations
Replacement. / supplementation to
endogenous thyroid hormones. Principal
effect is increasing metabolic rate of body
tissues to restore normal hormone balance.
Angina pectoris,
arrhythmias,
tachycardia,
hyperthyroidism, weight
loss, headache.
-Assess apical pulse & BP.
-monitor thyroid-stimulating
hormone serum levels.
-monitor for tachyarrhythmias &
chest pain.
-Instruct patient to take medication as
directed.
-emphasize importance of follow up
exams to monitor therapeutic effect.
-notify healthcare provider if you
experience chest pain, diarrhea, increased
pulse rate, weight loss.
Therapeutic: antihypertensives
Pharmacologic: beta blockers
Blocks stimulation of beta
1
and beta
2
-
adrenergic receptor sites. Works to
decrease heart rate and lower blood
pressure.
Arrhythmias,
bradycardia, pulmonary
edema, bronchospasm,
orthostatic hypotension,
peripheral
vasoconstriction.
-Monitor BP and pulse.
-Monitor intake & output, daily
weight for weight gain.
-Assess for orthostatic hypotension.
-Assess for fluid overload, fatigue,
weight gain. Peripheral edema
-Teach patient how to check pulse & BP.
Hold dose if pulse is <50bpm
-Medication may cause
drowsiness/dizziness.
-Take medication as directed.
Therapeutic: nonsteroidal anti-
inflammatory agent
Pharmacologic: nonopioid analgesics
Inhibits prostaglandin synthesis, decreased
pain & inflammation associated with
osteoarthritis.
Edema, GI bleeding,
elevated liver enzymes,
anemia, diarrhea,
dyspnea, nausea.
-Assess for rhinitis & asthma
hypersensitivity reaction.
-Evaluate BUN, serum creatinine,
CBC & liver function labs.
-Assess pain & range of motion.
-Caution patient to avoid alcohol
consumption with medications.
-Instruct patient to take medication as
directed.
-Meloxicam may increase risk for heart
attack & stroke.

Sign up to view the full document!

lock_open Sign Up
Showing Page:
3/6

Sign up to view the full document!

lock_open Sign Up
End of Preview - Want to read all 6 pages?
Access Now
Unformatted Attachment Preview
University of Louisville School of Nursing N402 Clinical Worksheet Client Initials: Demographic Information Age: Gender: Race: Code Status: Weight: Height: BMI: Reason for Admission [patient’s own words]: “Parkinson’s has made life hard” Medical Diagnosis [medical terms]: • Hypertension • Hypothyroidism • Chronic kidney disease Date of admission: Allergies: Penicillin (drug allergy) Other notes: N/A Student: Date of Care: Health History Chronic conditions & previous health problems: •Parkinson’s Disease •Anemia •Hypertension •Stroke •Pneumonia. •Chronic kidney disease •Colon Cancer •Hypothyroidism Unexpected events/complications during stay: •UTI-Urinary tract infection •Constipation Previous surgeries: •colectomy Nursing Diagnoses •Impaired physical activity Related to: cognitive impairment, limited strength, musculoskeletal impairment. Evidenced by: Decreased muscle control/strength, limited range of motion. •Constipation Related to: neurogenic disease, sedentary lifestyle, endocrine disorder Evidenced by: straining while trying to stool, infrequent passage of stool. Decreased bowel sounds. •Impaired verbal communication Related to: stroke, lack of stimuli. Evidenced by: Difficulty vocalizing words, difficulty maintaining conversation, inability to recall familiar words. •Ineffective coping Related to: uncertainty, confusion Evidenced by: change in communication patterns, inability to meet basic needs. •Risk for inju ...
Purchase document to see full attachment
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.
Studypool
4.7
Indeed
4.5
Sitejabber
4.4

Similar Documents

What theory or model would you choose to apply to the program planning?
A community coalition hires you to assist with their community health smoking cessation program. What theory or model woul...
Getting Started with Meditation & Improve Your Overall Health Discussion
How would you as a healthcare provider utilize meditation to improve your overall health? Dan Harris (2017) talks about th...
Medical Nutrition Therapy Reference Pages
1. look at the rubric that I uploaded, and I already gave you the sample for the reference page, but different diseases sh...
Discussion
Explain research, statistical methods, and specific tools used in quality measurement and improvement (e.g., flowcharts, c...
Eastlake High School Natural High Presentation
What is a Natural High? Natural High.org Rock Band USA National Team Goalie MLS Colorado Rapids Goalie Fashion ...
need an answer to the post below
In Home Health we do comprehensive head to toe assessments on every admit and reassessment. We see most geriatric patients...
Communicable Disease Health Education Tool
The communicable disease health education tool focuses on Malaria. Malaria is common in the tropical regions of the world,...
Personal Statement For Family Nurse Practitioner Application1
Xavier University is one of the reputable institutions of higher education. One of the attractive factors is the Jesuit id...
Saudi Arabian Rural Healthcare System1
Saudi Arabia uses a national healthcare system in which the provision of care is done by the use of different government a...