Care Diagnosis

Student Name: Q. A

Week: 2

Dates of Care: 09/01/2020

Patient Initials

M.C

Sex

F

Age

73

Room

5026

Admitting Date

9/19/2020

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

Pelvic Pain. Patient had increasing pelvic pain, UTI, Dysuria.

Attending physician/Treatment team:

M.D

Consults:

Oncology

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

Increased Pelvic Pain

Hyponatremia

Intractable abdominal pain

ER Management: (if applicable)

N.A

Allergies:

Bisphosphonates

Tomatoes

Code Status:

Full Code

Isolation: (type and reason)

N.A

Admission Height:

165.1cm ( 5’r’’

Admission Weight:

62.5kg (137lb 11oz)

Arm Band Location (colors & reasons)

N.A

Communication needs: (verbal, nonverbal, barriers, languages) (Osborn pages 258 - 262)

Past Medical History: (pertinent & how managed)(Osborn Chapter 9)

Dental Crowns Present

Diabetes Mellitus (HCC)

Hx of presenting hazard to health

Hyperlipidemia

Hypertension

Uterine cancer (HCC)

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

Glucose level 22 (Increase 9/24)

Genitourinary – Positive for dysuria, pelvic pain, and vaginal bleeding

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

GFR MORD – 57

Anion Gap - 5

Co2 – 33

Chloride -96

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

GI:

Diet: General

Swallow precautions: N.A

Tube feedings: N. A

NG / G tube: N. A

Blood Glucose: (time & date) 9/24

Last bowel movement: (time & date) 9/24

Pertinent Labs/Test:

Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

Soft on palpation, soft stool, no distention and no straining while having a BM. Patient has a good appetite, no nausea and vomiting.

Respiratory:

02 modalities: N/A

02 Saturation: 95

Suction:

Resp Rx’s:

Trach: N/A

Chest Tubes:

Pertinent Labs/Test:

Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

Lungs and breath sounds were clear bilaterally. No SOB or sputum production noted upon assessment.

Neurosensory:

Neuro checks:

Alert & Orientated: X4

Follows commands: Yes

Speech Comprehensible:Yes

Pertinent Labs/Test: N/A

Assessments/Interventions:

(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)

No numbness or tingling and patient is able to ambulate without assist.

Cardiovascular:

Telemetry: Sinus

Pacemaker/IAD: Non

DVT Prevention: Non

Daily Weights: N/A

Pertinent Labs/Test:

Assessments/Interventions:

(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)

Normal rate, regular rhythm and normal heart sounds. No bruits, edema or discomfort noted

Musculoskeletal:

Activity:

Traction:

Casts/Slings:

Pertinent Labs/Test:

Assessments/Interventions:

(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps Osborn et al., 2010, p. 1796)

Normal Range of motion

Renal:

Catheter (indwelling/external): No

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)

Pain:

Pain score: 1/10

Assessments/Interventions:

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)(Osborn, et al., 2010, p. 339)

Vascular Access: (IV site)

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change)

Port A catheter 04/24/19 Right Chest

Peripheral IV 09/24/2020 Forearm

Gyn:

Gravida/Para:

LMP: Not stated

Last Pap: Not Stated

Breast exam: Not stated

Pertinent Labs/Test Not stated

Assessment/Interventions: (bleeding, discharge)

Post-operative /procedural:

Assessments/Interventions:

(immediate post procedure care)

Patient will follow up with IR for pelvic mass.

Safety:

Call light: Yes

Bed Rails: Yes

Bed alarms: Yes

Fall risk: Yes

Assistive Devices: Yes

Sitter use: No

Restraints (type, duration & reason): N/A

Assessment/Interventions (modifications to room & environment)

Advance Directives/Ethical considerations:

DPOA:N/A

Hospice: N/A

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) (Osborn Chapter 9)

Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) (Osborn Chapter 13) What stage of development evident with patient:

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

Discharge plans and needs:

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

Priority

Nursing Diagnosis

Related to

As Evidence By

Rationale (reason for priority)

1

2

3

4

5

6

7

8

9

10

Medications

Classification

Dose

Route

Freq

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Hydralazine (Apresoline)

Hydrocodone (Norco)

Morphine Injection 2mg

Ondansetron

Acetaminophen

Amlodipine

Atorvastatin

Enalapril

Gabapentin (Neurontin)

Metropolol

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome (objective, expected or desired outcomes or evaluation parameters)

Interventions/

Implementations

Evaluation

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome (objective, expected or desired outcomes or evaluation parameters)

Interventions/

Implementations

Evaluation

Assessment as evident by (AEB), or data collection relative to the nursing diagnosis

Patient Goal(s)

Outcome (objective, expected or desired outcomes or evaluation parameters

Interventions/

Implementations

Evaluation

Assessment supports the nursing diagnosis above. The assessment should reflect the “defining characteristics” that are expected to be present for that diagnosis to be appropriately utilized.

Review Chapter 7 in Osborn for the elements of assessment that should be contemplated.

Types of data: subjective & objective

Sources of data

Nursing health history

Physical examination

Diagnostic data

“A statement of purpose describes the aim of nursing care” (Osborn et. al., p. 113)

Refer to Chapter 7 in Osborn for review of nursing diagnosis (may have more than one outcome for each nursing diagnosis)

May be short or long term assists in the ongoing evaluation of the patient’s progress to achieving the goal.

Should be acceptable by the patient and the nurse, realistic, specific and measurable (Osborn, et al., 2010)

Stated realistic behavioral terms that can be observed, measured and relevant to the identified nursing diagnosis.

Intervention – the planned nursing actions that are likely to achieve the desired outcomes (Osborn, et al., 2010).

Implementation – the carrying out of the planned nursing interventions (Osborn, et al., 2010)

Interventions should reflect on going assessment and activities that will assist in achieving the goal/outcomes.

Interventions should reflect indendent nursing practice as well as collaborative practice.

Interventions should reflect the needs of this specific patient not a generic listing of possible interventions.

Interventions should include specific like schedules, food choices, frequency, etc….

Focuses on change and compares the changes with the outcomes (Osborn et al., 2010).

Essentially this is a reassessment of the patient and the responses as to the interventions implemented.

Compare actual patient behaviors with expected behaviors.

Give reasons why or why not each outcome has been met.

Consider the effectiveness of the nursing intervention, time elements.