Care Plan 2

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PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET Student Name:Richard Boateng Week: Dates of Care: Patient Initials B.A

Sex Female

Age 78

Room 1514/01

Admitting Date 07/15/21

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital? Patient present with irregular heart rate.

Attending physician/Treatment team: Hakim S.Ibrahim

Consults:

Present Diagnosis: (Why patient is currently in the hospital) Aterial fibrillation with RVR (SMC-HCC)

ER Management: (if applicable)

Allergies: Patient has no Allergies

Code Status: Full code

Isolation: (type and reason) No isolation

Admission Height: 5’’6

Admission Weight: 156 pounds/12 ounce

Arm Band Location (colors & reasons) Clear and+

Communication needs: (verbal, nonverbal, barriers, languages) English, verbal Past Medical History: (pertinent & how managed) PMH: stage iv squamous cell lung cancer on ipi/nivo, DM2, HLD , CAD MI (2003)

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Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome) Bilateral redness on both legs (edema) and difficulty in breathing (pneumonia). Tests/Treatments/Interventions impacting clinical day’s care (include current orders) Chest Xray OT and Pt

Assessments and interventions: (Include all pertinent data) Vital signs: (2 sets per day) Time 0948 T 97.8 P 83 R 18 B/P 117/69

Time 1640 T 96.7F P 88

GI: Diet: General Swallow precautions: Takes patient a long time to shallow pills Tube feedings:N/A NG / G tube:N/A Blood Glucose: (time & date)N/A Last bowel movement: (time & date) In the Morning Pertinent Labs/Test: Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

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R 18 B/P 11050

Respiratory: 02 modalities: Nasal cannula 02 Saturation:99% Suction: Resp Rx’s: Trach: Chest Tubes: CT chest w/o contrast Pertinent Labs/Test: Assessments/Interventions: (Lung sounds, cough, sputum, SOB) Regular cough

Neurosensory: Neuro checks: Alert & Orientated:x4 Follows commands: Yes Speech Comprehensible: Yes Pertinent Labs/Test: Assessments/Interventions: Elevated legs to reduce edema (LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)

Cardiovascular: Telemetry:76 Pacemaker/IAD: DVT Prevention: Daily Weights: Pertinent Labs/Test: Assessments/Interventions: (peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)

Musculoskeletal: Activity: Walk with Assist walker Traction: Casts/Slings: Pertinent Labs/Test: Assessments/Interventions: (strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps

Renal: Catheter (indwelling/external): CBI: Dialysis: A/V access: Pertinent Labs/Test: Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)

Skin: Braden Score: Pertinent Labs/Test: Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)

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Pain: Pain score: 8 Assessments/Interventions: Morphine (scale used, location, duration, intensity, character, exacerbation, relief, interventions) General body patient

Vascular Access: (IV site) Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance) IV site, pump tubing Check Arm bands/HUGS O2 settings

Gyn: Gravida/Para: LMP: Last Pap: Breast exam: Pertinent Labs/Test Assessment/Interventions: (bleeding, discharge)

Post-operative /procedural: Assessments/Interventions: (immediate post procedure care)

Safety: Call light: Yes Bed Rails: Yes Bed alarms: Fall risk: Assistive Devices: Walker Sitter use: Restraints (type, duration & reason): Assessment/Interventions (modifications to room, environment, Patient)

Advance Directives/Ethical considerations: DPOA: Hospice:

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

Results Normal Lab Values

Significance to your patient

WBC 12.4 11.5 RBC HGB 12.9 10.5 HCT 12.8 10.5 MCV MCH MCHC Platelets RDW MPV PT 21.9 16.0 INR 1.8 1.3 APTT Glucose BUN 10 13 Creatinine 0.45 0.49 Sodium Potassium Cloride Calcium T Protein Albumin SGOT SGPT Alk Phos 85 68 Magnesium Amylase Lipase CPK LDH Cholestrol CK CK-MB Troponin I

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Myoglobin LDI Urinalysis Color Character Spec. Grav. pH Protein Glucose Acetone Bilirubin Blood Nitr Urobili RBC WBC Epithelium Urine Culture

Chest X-ray MRI CT Scan Others test:

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

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

Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:

Current overall plan of care: (A short statement that summarizes the anticipated plan of care)

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Discharge plans and needs: Teaching needs:(Disease process, medications, safety, style, barriers) Ditiazem 10 mg(Cardizem ) 100gm/hr Sodium chloride 100ml 1V infusion Allopurinol 300 oral Apixaban 5mg Potassium Chloride 20 0ral

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Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this particular 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, pathophysical 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 pertaining to diagnosis of patient. Write a summary about the article.

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List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide 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)

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Medications Classification Dose Route Freq Purpose/Mechanism of

Action Significant Side Effects / Adverse Reactions

Nursing Implications

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Medications Classification Dose Route Freq Purpose/Mechanism of

Action Significant Side Effects / Adverse Reactions

Nursing Implications

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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

timed, 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 new evaluation

date/time is set)

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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

timed, 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 new evaluation

date/time is set)