nursing care plan

NEW YORK UNIVERSITY

COLLEGE OF NURSING

NURSE-UN.1245 Leadership and Management in Nursing

NURSING CARE PLAN

STUDENT’S NAME: _______ CLINICAL INSTRUCTOR: _____________

DATE OF PATIENT CARE: ____9/23/2021__________________

DEMOGRAPHIC DATA:

Patient Assignment #: __29__Age: __55_ Gender: _Female_ Date of Admission __9/20/2021_ Advance Directives _CPR_________

(Indicate if DNR/DNI or Full Code)

HISTORY OF PRESENT ILLNESS:

REASON FOR SEEKING HEALTHCARE (“What brought you to the hospital?” – must include “What happened, where, when, how long PTA”):

Patient had severe pain at the back and decided to come to the emergency room with the husband and son. Chiefs complain was spinal stenosis in the Lumbar region. Neurologic claudication, lower back pain, and bilateral leg pain. Left leg worsening, right leg pain started 4 months ago. Bilateral buttock and lateral high thigh and dorsum of foot left worse than right with numbness and tingling.

ADMITTING MEDICAL DIAGNOSIS (DIAGNOSES): __Spinal stenosis, lumbar region without neurologic claudation. _

ALLERGIES: _______No Allergies_________________ REACTION: _________N/A___________

I. PAST MEDICAL HISTORY (Include date condition was diagnosed, if known):

Hyperlipidemia

Hypertension

Lower Back Pain (with left sided sciatica)

II. PAST PSYCHIATRIC HISTORY. N/A

         Describe & include history of treatment: N/A

Current Mood: [ ] Depressed   [  ] Anxious    [  ] Withdrawn

Communication: [X] Verbal [ ] Non-verbal [ ] Cues/behaviors (specify) _________________________________

Other: ____ ___________________________________ ______

III. PAST SURGICAL HISTORY (Include dates of surgery, if known):

Colonoscopy. 2018

Tubal Litigation

Lumbar Fusion. Bilateral ( Transforaminal lumbar interbody fusion spine single level open L4 – 5). 09/20/2021

IV. PSYCHOSOCIAL HISTORY:

Spiritual/ Cultural Assessment: Religion____Catholic___________ Cultural/ethnic background ___Hispanic______ Marital status_______Married__

Smoking: [ ] Yes (Specify # cigarettes/ packs per day ____) [ X ] No Smoking Cessation Teaching: [ ] Yes [ X ] No

Substance Abuse: [ ] Yes (Specify Substance ___________________________ Treatment ________________) [ X ] No history

V. VACCINE HISTORY:

Influenza Vaccination – [ ] Yes (Date: _______) [ X] No Pneumovax [ ] Yes (Date: _______) [ ]  No

If No, Specify Reason ___Patient is below 65_______ _

Other:

VI. LAB VALUES (Include Date of Results, Specific Value with Unit of Measure, & if High or Low) 09/21/2021: 3:10pm

Hemoglobin – 10.2 low Na – 138 BUN – 19 Albumin – N/A

Hematocrit – 29.9 low K – 4.1 Creatinine – 0.73 PT –N/A

WBC – 11.4 high CO2 – 23 Glucose – 133 INR –N/A

Platelets –258 CL – 104 Fingerstick – N/A PTT – N/A

VII. VITAL SIGNS and PAIN ASSESSMENT

BP __122/80_Apical HR (rate/ rhythm) ___regular_ Radial (rate/rhythm) ___regular__ RR __18___ Temp. _98.6 C_Pulse Oximetry _96 on room air.

Height ___5’1_______ Weight __166___ BMI__31.49_____Indicate if: [ X ] Normal [ ] Overweight [ ] Obese [ ] Underweight

Time	Location of Pain	Scale (Pre)	Interventions	Scale (Post)	Comments
8:30AM	Lower back around the incision site	5/10 on a scale of 10/10	Administered oxycodone 5mg	1/10	Patient felt so much better with 1/10 pain on incision site.

VIII. INTAKE & OUTPUT (During your shift – indicate amount in ml.):

INTAKE	OUTPUT
Type	Amount	Type	Amount
P.O. (water, juice, soup, meds)		URINE	1
INTRAVENOUS (IV)		OSTOMY
FEEDING		DRAINAGE	10CC
OTHER (specify)		OTHER (specify)
TOTAL		TOTAL

IX. PERIPHERAL & CENTRAL INTRAVENOUS LINES

Type ___22__Gauge_____ Date Inserted __09/21/2021___ Site ___Right hand____ Describe Site Appearance __Site was intact, clean and dry.

X. PHYSICAL ASSESSMENT / SYSTEMS REVIEW

1. Neurological System:

Subjective Data: __Patient was able to tell me everything about her admission and surgery. Also about place, person and time.__

LOC: [X ] Alert [ ] Confused [ ] Lethargic [ ] Restless [ ] Aphasic Orientation: [ X ] Time [ X ] Place [ X] Person

Pupils: [ X ] Equal [ ] Unequal [ ] Brisk [ ] Sluggish [ ] Nonreactive [ ] Irregular [ ] Opaque Aids: [ ] Glasses [ ] Hearing Aid

Other: _________________________________________________________________________________________ ____

Describe abnormal findings: ______________________________________________________________________________

2. Neuromuscular System:

Subjective Data__ Patient didn’t have walker before the surgery. Patient uses a walker now that will help prevent so much strain on incision sight. _______________________________________

Motor & Sensory Function: [ X ] Intact Weakness: [ ] Right [ ] Left Paralysis: [ ] Right [ ] Left

Gait: [ X ] Steady [ ] Unsteady Use of Assistive device: [ ] Cane [X ] Walker [ ] Wheelchair

Other: ____ ____________________________________________________________ _________________________

Describe abnormal findings: ___________________________________________________ __________________________

3. Cardiovascular:

Subjective Data: ____Patient has no chest pain and was breathing regular without accessory muscles___________________________________________________ _______________

[ ] Chest Pain (Describe) __________________________ [ ] Palpitations (Describe)

Peripheral Pulses (Specify 0 – 3+): Radial: [ X ] Right [ ] Left Brachial: [ ] Right [ X ] Left Femoral: [ X ] Right [ ] Left

Dorsalis Pedis: [ X ] Right [ ] Left Posterior Tibialis [ X ] Right [ ] Left

Other: _________________________________________________________________________________________ ____

Describe abnormal findings: ______________________________________________________________________________

4. Respiratory:

Subjective Data: ____Patient doesn’t smoke or use illicit drugs. Patient has no family history of pulmonary disease. Patient has no cough or shortness of breath.__________________________________________________________________

RR ___18______ Pattern: [ X ] Regular [ ] Irregular [ ] Use of accessory muscles

[ X ] Breath sounds clear, bilateral [ ] Rhonchi- right [ ] left [ ] Wheezing – right [ ] left [ ] [ ] Crackles – right [ ] left [ ]

[ ] O2 therapy (specify) __________________________ [ ] Cough – productive - No [ ] yes [ ] describe _______________

[ ] SOB at Rest [ ] SOB On Exertion Other: ______________________________________________________________

5. Gastrointestinal:

Subjective Data: ___Patient have free bowel movement and stool is soft. No constipation or irritable stomach.__________________________________________________________________

Abdomen: [ X ] Soft [ ] Firm [ ] Distended [ ] Tenderness [ ] Bowel sounds: [ X ] Present [ ] Diminished [ ] Absent

[ ] Nausea [ ] Vomiting _____________ [ ] Anorexia [ ] NGT to suction [ ] Last BM (Date) _09/23/2021_________ [ ] Constipation

[ ] Diarrhea # times________ Type of Stool ___________ Onset________ [ ] Ostomy (specify ______________________

Dental/Oral Health (describe) _______________________________________ NGT/OGT/PEG feeding _________________

Gastric Residuals (color/Amount) ___________________________Other: _________________________________________

6. Genitourinary:

Subjective Data: ______Patient is urine 2 times that morning. Patient has no catheter, and no incontinence_____________

Urine Color :_pale yellow______ Character_____________ [ ] Voiding [ ] Foley catheter – date inserted __________________

[ ] Incontinence [ ] Dysuria [ ] Hematuria [ ] Hemodialysis (frequency) _______________ Last Dialysis _______________

Dialysis Access: [ ] AV Shunt [ ] AV Graft [ ] Permacath/Cook’s Catheter Describe Site: ____________________________

Thrill: _____ Bruit: _______ Other: _______________________________________________________________________

7. Integumentary:

Subjective Data: __Patient skin is clear, warm and dry. Patient has no edema or pressure ulcer. ______________________

Skin quality: Temperature [X ] Cool [ ] Warm [ X ] Dry [ ] Moist [ ] Ecchymosis [ ] Hematoma [ ] Petechiae

[ ] Edema (indicate location) ____N/A____________ [ ] Rash [ ] Scar __N/A____________________________________________

[ ] Pressure ulcer site_____N/A________________________________________________________________________________

_______________________________________________________________________________________________________

Braden Scale Score ___22_ [ X] Operative wound (describe) __Wound is at the lower back and dressing was clean and dry with no drainage.________________________________________________

Other: __________________________________________________________________________________________________

Students need to submit a written summary of the following assessment tool findings and interpretation with the NCP.

(The NCP must be uploaded as ONE electronic Word document labeled with your last name & assignment name, e.g., Jones NCP):

1. Braden Scale

2. Fall Risk Assessment

3. Other Geriatric Assessment Tools (SPICE, KATZ etc.)

XI. MEDICATIONS (use another sheet or add rows to table if needed)

Medication (as ordered by M.D. /NP) – Classification – How does the medication work (Chemical action)? Cite references here & in reference list in APA format.	Reason For Taking Them? (Example: To treat Hypertension and CHF)	Side Effects, Contraindications and Lab Values to be monitored (Only specific, priority ones)	Patient and Family Teaching (Only specific instruction for that drug) Never write: Take as directed
Atorvastatin tablet 40mg P.O. Daily Classification : Antilipemic Chemical Action : Inhibits 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase	Treats and prevent stroke. This patient has a past medical history of hyperlipidemia so this will prevent angina and myocardial infarction	Side Effects : Headache, diarrhea, cold like symptoms. Contraindications : pregnancy and liver diseases, hypersensitivity to atorvastatin Lab Values : ATP, Serum cholesterol and triglyceride should be monitored.
Cyclobenzaprine Tablet 5mg, oral TID 3 times daily. Classification : Skeletal muscle relaxant Chemical Action : Act at the brain stem to reduce tonic somatic motor activity, influencing both gamma and alpha motor neurons leading to a reduction in muscle spasms.	Treat, prevent and improves muscle spasms, reduces local pain and tenderness, and increases range of motion in acute, painful musculoskeletal conditions.	Side Effects : Fatigue, Dizziness, Loss of strength and energy, Dry mouth, Constipation, Nausea Contraindications : Hyperthyroidism, Myocardial infarction (the acute recovery phase), Arrhythmias and heart failure. Lab Values :
Enoxaparin 40mg injection subcutaneous every 24hrs Classification : Anticoagulant Chemical Action : Binds to antithrombin III, a serine protease inhibitor, forming a complex that irreversibly inactivates factor Xa. inhibits coagulation factors Xa and IIa.	Treats thromboembolic disorder and prevent blood clots.	Side Effects : Bleeding. Contraindications : Allergy Lab Values : Monitor patient platelets. Don’t use this when platelet level is low.
Hydrochlorothiazide tablet 25mg oral daily Classification : Antihypertensive/ diuretic. Chemical Action : Acts on the distal convoluted tubules and inhibits the sodium chloride co-transporter system	To treat and control high blood pressure/ hypertension. Help control hyperlipidemia.	Side Effects : Constipation, Diarrhea, Dizziness, Fatigue, Stomach cramps and vomiting. Contraindications : Diabetes, high cholesterol, Lab Values : Sodium and potassium.
Oxycodone 10mg tablet oral PRN (pain 7-10). Oxycodone 5mg tablet oral PRN (pain level 4-6) Classification : Analgesic/opioid Chemical Action : Binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways, altering the perception of and response to pain; produces generalized CNS depression	To treat and control pain. After surgery patient will be in a lot of pain especially around the incision site.	Side Effects : Dizziness, nausea, headache and vomiting. Contraindications : Respiratory depression; hypercapnia; acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment. Lab Values

XII. NURSING CARE PLAN

Nursing Diagnosis (List 3-5 priority nursing diagnoses in order of priority.)	Short & Long Term Goals (Must complete for EACH priority nursing diagnosis listed. Goals should be SMART: specific, measurable, attainable, realistic, & time-framed.)	Interventions (Must complete in comprehensive manner for two highest priority nursing diagnoses. Include collaborative /interdisciplinary.)	Rationale (Evidenced based rationale for each intervention for two highest priority nursing diagnoses. Describe in your own words with references cited here & in reference list in APA format.)	Evaluation (How did/will you evaluate the effectiveness of planned interventions listed in previous column? HINT: Assess attainment of SMART goals.)
Acute pain related to physical injury as evidence by pain level of 8/10 on a 0-10 scale	Short Term: Long Term:
Impaired Physical mobility related to pain as evidence by walking with walker	Short Term: Long Term
Risk for Trauma	Short Term: Long Term
Risk for impaired skin intergrity	Short Term: Long Term
Risk for autonomic dysreflexia	Short Term: Long Term

XIII. DOCUMENTATION (Write a note in AIE format – Assessment, Intervention/Implementation, Evaluation)

Assessment

Intervention

Evaluation

XIV. NARRATIVE SUMMARY OF DISCHARGE PLANNING, TRANSITIONAL CARE NEEDS, & INTERPROFESSIONAL COLLABORATION

Discharge Planning & Transitional Care Needs (Include):

Support systems: Husband and children.

Care givers: Husband, Son and Daughter

Living arrangements: House

Teaching needs: Check site of incision for any sign of infection and drainage. Take pain medication as needed

Medication administration issues:

Outpatient services required: N/A

Interprofessional Collaboration (Include): N/A

Referrals /consultations

Follow up appointments: Appointment in the next 2 weeks at the orthopedic outpatient.10/07/2021

XV. REFERENCES

Use APA Format, 7th Edition.

Students need to submit a written summary of the following assessment tool findings and interpretation with the NCP.

(The NCP must be uploaded as ONE electronic Word document labeled with your last name & assignment name, e.g., Jones NCP):

1. Braden Scale

Patient had a surgery of …… She will be immobile for a while, so I did a Braden scale to check her risk for pressure ulcers. Patient has no impairment; she can respond to verbal commands (4). Patient skin is occasionally moist, that is her sheet will be changed once a day (3). Patient physical activities is she walks occasionally with a walker. She can walk for short distances due to pain (3). Patient has no limitations; she was able to make frequent changes in position without assistance (4). Patient nutritional/ diet, she eats every meal and never refuses a meal. Patient usually eat a total of 4 or more serving of meat or dairy food. Patient does not require supplement (4). Friction and shears, patient moves but requires minimum assistance. Maintain good position in chair or bed most of the time but occasionally slide down (2). This leads to a total of 20 that is patient is at a lower risk of getting pressure ulcer.

2. Fall Risk Assessment

3. Other Geriatric Assessment Tools (SPICE, KATZ etc.)

KATZ Assessment tool is used to determine how independent the patient it with her ADL’s. Patient Bathes by herself but will needs help in bathing only a single part of the body such as the genital area or areas around her surgery site (back) (1). Patient is able pick up her dress and get dress independently but needed help with slippers. (1). Patient was able to walk to the bathroom, take off clothes, sit and get up of toilet independently (1), Patient can move in and out of the bed without help (1). Patient can exercise racomplete self-control over urination and defecation (1). Patient feeds herself by getting the food from plate to his mouth without any help (1). Total is 6 therefore this makes the patient independent.

MINI-COG: Patient scored a 5. Patient is negative to dementia, this means patient is also alert and oriented to place, time, and person.

Brief Oral Health status: The patient score is 0, pat