Care Plan

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PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET

Student Name:

Week: 6

Dates of Care: 3/06/21

Patient Initials

E.J

Sex

Age

years old

Room

Admitting Date

3/04/2021

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Diarrhea, abdominal pain

Attending physician/Treatment team:

Ahmad Alwakkaf, MD

Brandon M O'Malley, MD

Natalie, Nurse

Louie Chua, Physical therapist

Consults: gastroenterologist

Respiration therapist

Present Diagnosis: (Why patient is currently in the hospital)

Acute colitis

ER Management: (if applicable)

The patient was rushed to ER due to frequent loose, watery stools and belly pain.

Allergies:

Pork, beef, erythromycin

Code Status:

Full

Isolation: (type and reason)

None. Not contagious on proximity

Admission Height:

175.3cm

Admission Weight:

55.8kg

Arm Band Location (colors & reasons)

Right hand. White

Communication needs: (verbal, nonverbal, barriers, languages)

1. Explain the importance of each medication administered.

2. Inform the patient of likely side effects of medications.

3. The patient's preferred language is English.

Past Medical History: (pertinent & how managed)

1. Bloody diarrhea- fluid administration, antidiarrheic meds

2. Seizures- anti-epileptic meds

3. Infectious colitis- antibiotics administration

Significant Events during this hospitalization but not during this clinical time: (include the date, event, and outcome)

1. Lactic acid once on 3/06/2021

2. C. dif. Screening on 3/05/2021

Tests/Treatments/Interventions impacting clinical day’s care (include current orders)

1. Vital signs every 4 hours

2. Intake and output every shift.

3. Maintain sequential compression device.

4. Height and weight once daily

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

3/06/2021

Time

1440

2026

99℉ (Auxiliary)

98.9℉ (Auxiliary)

76 beats/min(monitor)

81 beats/min(monitor)

19beats/min(monitor)

B/P

90/53 mmHg (right arm)

100/59 mmHg (right arm)

3/06/2021

Time

1812

2034

97.9℉ (Auxiliary)

98.2℉ (Auxiliary)

66 beats/min(monitor)

76 beats/min(monitor)

18 beats/min(monitor)

17 beats/min(monitor)

B/P

101/64 mmHg (right arm)

114/72 mmHg (right arm)

GI:

Diet: Clear liquid

Swallow precautions: for solids

Tube feedings: none

NG / G tube: none

Blood Glucose: (time & date)- 170mg/dL. 10am. 3/06/2021.

Last bowel movement: (time & date)- 5pm. 3/06/20.

Pertinent Labs/Test: None

Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting) I did a 5min assessment on this patient, however, I also noticed that his stool was brown and soft inconsistency. The patient did not report feeling nauseous or wanting to vomit.

Respiratory: 16 breath/min

02 modalities: room air

02 Saturation: 95%

Suction: none

Resp Rx’s: none

Trachodont

Chest Tubes: none

Pertinent Labs/Test: none

Assessments/Interventions: (Lung sounds, cough, sputum, SOB)- clear lungs sounds, no SOB.

Neurosensory: Alert x4

Neuro checks: Yes

Alert & Orientated: alert and oriented x4

Follows commands: yes.

Speech Comprehensible: yes

Pertinent Labs/Test: none

Assessments/Interventions:

(LOC, pupils, Glasgow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)- good LOC, dilated pupils, no dizziness, or headaches

Cardiovascular:

Telemetry: none

Pacemaker/IAD: none

DVT Prevention: none

Daily Weights: 55.8kg

Pertinent Labs/Test:

Assessments/Interventions:

(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)- radial pulse; +2, strong and normal rhythm/

Musculoskeletal:

Activity: Limited

Traction: none

Casts/Slings: none

Pertinent Labs/Test: none

Assessments/Interventions:

(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps – good muscle strength, good ROM, the pain of 7 out of 10, no fractures or amputation. The patient was able to hold my two-finger and pushed down against resistance.

Renal:

Catheter (indwelling/external): none

CBI: none

Dialysis: none

A/V access: none

Pertinent Labs/Test: none

Assessments/Interventions: (location, bruit, thrill) (urine-quality, burning with urination, hematuria, incontinent, continent, I & O)- good urination.

Skin:

Braden Score: 14

Pertinent Labs/Test:

Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toenails, wounds, drains, bed type)- intact skin, poor skin turgor, finer, and nails fine.

Pain:

Pain score: 7

Assessments/Interventions:

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)- scale of 0 to 10 for pain. O being the lowest pain and 10 the highest.

Vascular Access: (IV site)

Assessments/Interventions: (include the type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)- 20ml/kg isotonic sodium chloride. 0.9%. IV site has assessed no phlebitis, redness, or skin breakdown. An IV catheter was not due for a change. The skin was intact.

Gyn:

Gravida/Para: none

LMP: none

Last Pap: none

Breast exam: none

Pertinent Labs/Test: none

Assessment/Interventions: (bleeding, discharge): none

Post-operative /procedural:

Assessments/Interventions:

(immediate post-procedure care)- no surgery is done.

Safety:

Call light: was given to the patient aftercare.

Bed Rails: one side was taken up.

Bed alarms: none

Fall risk: Not at for fall.

Assistive Devices: none

Sitter use: none

Restraints (type, duration & reason): none

Assessment/Interventions (modifications to room, environment, Patient): none

Advance Directives/Ethical considerations:

DPOA: none

Hospice: none

Pertinent Data (Labs, X-rays, Etc.)

Results

Normal Lab Values

Significance to your patient

WBC

12.9

4.0 - 11.0

RBC

4.19

4.34 – 5.60

HGB

16.1

13.0 – 17.0

HCT

39.2

38.6 – 49.2

MCV

94.6

80.0 - 100.0

MCH

31.6

26.0 – 34.8

MCHC

33.4

32.5 – 35.8

Platelets

374.7

150 – 450

RDW

11.9 – 15.9

MPV

8.8

6.8 – 10.2

INR

APTT

Glucose

70 – 99

BUN

7-20

Creatinine

0.54

0.59 – 1.04

Sodium

137

135 - 145

Potassium

3.7

3.5 - 5

Chloride

Calcium

T Protein

Albumin

SGOT

SGPT

Alk Phos

Magnesium

Amylase

Lipase

115

11-82

CPK

LDH

Cholesterol

CK-MB

Troponin I

Myoglobin

LDI

Urinalysis

Color

yellow

Character

Spec. Grav.

Protein

6.8

Glucose

150

90 -120mg/dl

Acetone

Bilirubin

Blood

Nitro

Urobili

RBC

WBC

Epithelium

Urine Culture

Chest X-ray

MRI

CT Scan

Others test:

Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary caregiver, substance abuse, maternal/infant bonding, family dynamics)

No mental illness.

Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions)

No religious, or cultural preference

Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorists) What stage of development evident with the patient: fully alert, a little bit is withdrawn from the society.

The current overall plan of care: (A short statement that summarizes the anticipated plan of care)- includes control of diarrhea and promoting optimal bowel function; minimize or prevent complications; promote optimal nutrition and provide information about the disease process and treatment needs to the patient.

Discharge plans and needs: The patient should be discharged on the 6th of March 2021. According to her medical record, a follow-up appointment was made to reevaluate her progress after a month. The patient will have her belongings well accounted for by the time of discharge.

Teaching needs:(disease process, medications, safety, style, barriers)

The patient will be educated on the disease process.

The patient will be taught to identify and restrict foods and fluids that precipitate diarrhea (vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, milk products).

Provide written educational materials on various aspects of pain control to improve client understanding of pain and pain-related interventions.

Explain lifestyle changes that will help relieve pain.

Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering etiology, epidemiology, pathophysiology mechanism, manifestations, and treatment (medical and surgical). Also, note the complications that may occur with these treatments and the patient’s overall prognosis. Include appropriate references and use APA format.

ADH II: attach a research article about the diagnosis of a patient. Write a summary of the article.

· ETIOLOGY: infection, for example, caused by bacteria like C. difficile, viruses, and parasites; inflammatory bowel disease like Crohn's disease and ulcerative colitis; ischemic colitis caused by decreased blood supply; microscopic colitis (lymphocytic/collagenous); allergic reactions.

EPIDEMIOLOGY: The prevalence is lower in developing countries. In Asian populations, for example, the prevalence ranges from 5.3 to 63.6 per 100000 people, whereas in North America, it ranges from 37.5 to 238 per 100000 people. In addition to the gradient between its occurrence in West and Asian countries, it has been noted that in Europe, although there are exceptions, there is also a geographical gradient for the incidence of IBD, with higher rates in the north and a lower frequency in the south. (Florin TH, 2004).

PATHOPHYSIOLOGY: Inflammation in ulcerative colitis involves the rectum in 95% of patients and extends proximally in a continuous pattern. The disease may affect the entire colorectum (termed pancolitis) or only be limited to the rectum (termed proctitis). Some patients may develop limited terminal ileal involvement (backwash ileitis) that can be challenging to differentiate from Crohn's disease. (Jessurun, 2017).

MANIFESTATION AND TREATMENT: A combination of history, assessment of endoscopic and radiological appearances, histology, and microbiology is needed to diagnose colitis. The cardinal symptoms of ulcerative colitis are bloody diarrhea, urgency, tenesmus (straining at stool).

Mild distal colitis, in which rectal bleeding may be absent, can mimic irritable bowel syndrome. Colicky lower abdominal pain may occur, but severe pain is usually limited to severe colitis.

Stool cultures should be performed (particularly for Clostridium difficile toxin) even in patients with a relapse of known ulcerative colitis. 4 The presence of bloody diarrhea for more than three weeks should alert the doctor to the possibility of inflammatory bowel disease, and endoscopy should be performed. Treatment includes- Sulfasalazine, Corticosteroids, thiopurines amongst others. (Cohen RD, 2000).

ADH II:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1539087/

Above is a link to the article on the diagnosis of acute colitis. It shows what causes acute colitis, who gets it, how to identify it- using cardinal symptoms such as bloody diarrhea, urgency, tenesmus. It also explains other extraintestinal manifestations.

REFERENCES

· Florin TH, Pandeya N, Radford-Smith GL. Epidemiology of appendicectomy in primary sclerosing cholangitis and ulcerative colitis: its influence on the clinical behavior of these diseases. Gut. 2004; 53:973–979.

· Jessurun J. The Differential Diagnosis of Acute Colitis: Clues to a Specific Diagnosis. Surg Pathol Clin. 2017 Dec;10(4):863-885

· Cohen RD, Woseth DM, Thisted RA, Hanauer SB. A meta-analysis and overview of the literature on treatment options for left-sided ulcerative colitis and ulcerative proctitis. Am J Gastroenterol 2000;95: 1263-76

List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide a rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis.

Priority	Nursing Diagnosis	Related to	As Evidence By	Rationale (reason for priority)
1	Diarrhea	Inflammation of the colon	Watery stool	Relates to circulation. Urgent to prevent hypovolemic shock
2	Acute pain	Inflammation of colon	Abdominal pain of a 7 out of 10	Pain should be taken care of to make the patient cooperative
3	Risk for deficient fluid volume	Inadequate water intake	Dry mucous membrane	This should be taken care of to prevent deficient fluid volume
4	Fear	Learned response to a threat	Past medical history of infectious colitis	A psychosocial diagnosis should be taken care of as soon as stability is established.
5	Lack of readiness to learn.	frequent hospitalizations	Refusal to listen to teachings	This should be addressed so the patient can learn how to manage their health

Medications	Classification	Dose	Route	Freq	Purpose/Mechanism of Action	Significant Side Effects / Adverse Reactions	Nursing Implications
1) Aspirin	NSAID	81mg	oral	Once-daily	1.Pain relief 2. Anti-inflammation 3. Blocks PG synthesis	1.Upset stomach. 2. Stomach ulcers 3. Swelling of skin tissues.	1. Monitor potassium levels daily 2. Assess the patient for signs of bleeding daily.
2) Atorvastatin	Statins (HMG – CoA reductase inhibitors)	20mg	oral	Once-daily	1.Prevent cardiovascular disease. 2. Treatment of dyslipidemia 3. Inhibits HMG-CoA	1. Liver problems 2. Diabetes	1.Monitor liver enzymes daily 2. Monitor blood glucose level daily
3. Diltiazem	Calcium channel blocker	30mg	oral	Once-daily	1. Treat high blood pressure. 2. Treat angina. 3. Inhibits calcium ions inflow into smooth muscle	1.Hypotension 2. Bradycardia 3. Dizziness	1. Monitor blood pressure before therapy 2. Monitor ECG continuously
4. Hydromorphone	Opioid analgesics	1mg	IV	PRN Q4H	1.Treat severe pain. 2. Anesthesia 3. Acts on the opioid mu receptor	1. Respiratory depression 2. Dizziness 3. Constipation	1. Monitor respiratory rate daily. 2. Encourage the patient to sit on the bed for a while before getting up.
5.Levetiracetam	Anticonvulsant	500mg	oral	BID	1.Treat epilepsy 2. Treat tonic-colonic seizures 3. Binds synaptic vesicle protein in the brain to moderate synaptic neurotransmitter release.	1.Psychosis 2. Suicide 3. Anaphylaxis	1.Monitor the patient for abnormal behaviors. 2. Educate the patient on expected side effects. 3. Encourage the patient to speak with loved ones often.
6). Paroxetine	SSRIs/ Antidepressants	10mg	oral	QAM	1.Treat depression 2. Treat panic disorder 3. Treat PTSD	1. Suicide 2. Dysfunction 3. Headaches	1.Monitor for worsening of depression. 2. Monitor for headaches

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Statement of purpose for the patient to achieve

Patient Outcome (Should be measurable, attainable, realistic, and time, all criteria should be present and specific to the patient Dx.)

(Must have at least two short term outcomes and two long term outcomes)

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation. (Was the outcome met, partially met, or not met and why? And is the plan of care revised or continued and a new evaluation date/time is set)

1. Diarrhea r/t gastrointestinal disorders as evidenced by a discharge of watery stools.

2.Acute pain r/t inflammation of the colon as evidenced by abdominal pain of 7 out of 10 on a scale of 0 to 10.

A patient will defecate formed soft stool every 1 to 2 days.

The patient will describe pain at a level of 3 or less on a rating of 0 to 10 at the time of discharge.

1). The patient will defecate formed soft stool every 1 to 2 days.

2). Diarrhea will stop within 24 hours.

1). The patient will be relieved of pain and attain a desirable pain level of 3 or less on a scale of 0 to 10 by the time of discharge.

2). The patient will describe non-pharmacological methods to relieve pain by the time of discharge.

1)i. Monitor pattern of defecation to notice daily changes.

ii. inspect, auscultate, and palpate the abdomen to observe improvements daily.

2)i. Assess for feeding and medication history to inciting factors daily.

ii. Monitor food and fluid intake to prevent worsened conditions daily.

1)i. Conduct and document a comprehensive pain assessment daily to observe improvements daily.

ii. Ask the client to describe prior experiences with pain to identify factors that show the client’s description of pain evidenced by anxiety daily.

2)i. Give a warm bath daily to reduce pain.

ii. Teach patient non-pharmacological methods to relieve pain daily.

Goals are met.

PAGE

Care Plan

Medications

Classification

Dose

Route

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Patient Outcome (Should be measurable, attainable, realistic, and time, all criteria should be present and specific to the patient Dx.)

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation. (Was the outcome met, partially met, or not met and why? And is the plan of care revised or continued and a new evaluation date/time is set)