nursing care plan

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Patient Assessment (NR 226 RUA)

STUDENT: ____________________________________ Date of Care: _01-27-20______________

Client Initials: ___V. J_______ Age: _____65_____ Gender: ___F_______

Resuscitation Status ____Full Code_____ Allergies______NKA________________

Reason for Admission: ____Long _Term Care______________________________________________

Medical Diagnoses_ HTN, Peripheral Vascular Disease Unspecified, Hemiplegia and Hemiparesis following Cerebral Infarction Generalized Muscle Weakness, ____________________________________________________________________________________

________________________________________________________________________________________________________

Surgeries/Procedures and Dates: ____________________________________________________________________________

Past medical history________________________________________________________________________________________

________________________________________________________________________________________________________

Current Orders:

Diet No Added Salt (NAS), Regular texture, (Thin) consistency, for Heart Healthy Diet; Low Fat, Low Cholesterol related to Essential (Primary)Hypertension__________________________ Activity________________________________

Intake ___________________ Output_________________ Accu Cheks______________________________

Vital signs_______________________________________________________________________________________________

Drsg changes/wound care_No wounds, no dressing changes____________________________________________________

Foley__None_________________________ NG/G-tube/PEG?PEJ_______None____________________________________

IV ___None__________________________________________ Reason for IV_____None_____________________________

Other orders:

______________________________________________________________________________________________________

Most recent Imaging Findings: (CXR? CT? MRI?)

Type of Imaging (X-Ray, CT, MRI, etc)	Body Area Imaged	Reason for testing and results of test

Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?)

Date	Lab Test	Results	Norms	Comments

Other recent, significant procedures or tests (EKG, etc)

Date	Test	Reason for testing and results of test

Review of pathophysiology:

You may copy and paste these tables onto the next sheet if you have more medications

Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Acetaminophen Tablet (Tylenol)	325-650mg	In patients hypersensitive to this drug. Stevens-Johnson syndrome, Acute Renal Failure Pts
Pharmacotherapeutic Class	Dosage Ordered	Adverse Reactions
Analgesics	Give 650mg	Fatigue, insomnia, nausea, vomiting, diarrhea, rash muscle spasm
Why is patient receiving this med? (Can list related diagnosis, symptom, or need)	Route and Frequency	Nursing Considerations and Teaching
Pt taking this med as needed for generalized pain	PO every 6 hours as needed	Many OTC and prescription products contain acetaminophen, be aware when calculating total daily dosage. Contact MD if s/s of liver damage occur.

Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Atorvastatin Calcium Tablet (Lipitor)	10 – 80 mg	In patients with active liver disease, Renal failure caused by Rhabdomyolysis, acute myopathy
Pharmacotherapeutic Class	Dosage Ordered	Adverse Reactions
Antilipemic/HMG-CoA reductase	40mg	Insomnia, nasopharyngitis, myalgia, extremity pain, muscle pain
Why is patient receiving this med? (Can list related diagnosis, symptom, or need)	Route and Frequency	Nursing Considerations and Teaching
Pt has high cholesterol levels	Give 1 tablet PO one time a day	Pt should follow standard cholesterol-lowering diet before and during therapy. Obtain baseline LFT and lipid levels and during therapy and 6 -12 weeks after treatment started

Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Hydralazine HCL Tablet	10-100mg	With pts hypersensitive to the drug, with CAD or Mitral Valvular Rheumatic Heart disease.
Pharmacotherapeutic Class	Dosage Ordered	Adverse Reactions
Antihypertensive	10 mg as needed	Palpitations, tachycardia, orthostatic hypotension, edema, flushing
Why is patient receiving this med? (Can list related diagnosis, symptom, or need)	Route and Frequency	Nursing Considerations and Teaching
Pt is hypertensive	PO, give 1 tablet one time a day every 6 hours as needed for Per vital Sign Parameter related to Essential (Primary) Hypertension for SBP>180, DBP>105	Monitor BP, pulse rate, and body weight frequently, Elderly pts may be more sensitive to low blood pressure effects

Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Lisinopril (Zestril)	Tablet 2.5-40mg	Pt with history of angioedema, hypersensitive to ACE inhibitor,
Pharmacotherapeutic Class	Dosage Ordered	Adverse Reactions
Antihypertensive/ACE inhibitor	40mg	Dizziness, headache, nasal congestion, dyspepsia, impotence, orthostatic hypotension, hypotension
Why is patient receiving this med? (Can list related diagnosis, symptom, or need)	Route and Frequency	Nursing Considerations and Teaching
Pt is hypertensive	PO, give 1 tablet one time a day every 6 hours as needed for Per vital Sign Parameter related to Essential (Primary) Hypertension for SBP>180, DBP>105	Monitor BP frequently, monitor glucose, electrolyte, and lipid levels during therapy, discontinue use if jaundice and elevated liver enzyme levels occur. Monitor for angioedema of face, tongue or larynx

Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Famotidine Tablet (Pepcid)	Tablet 10-40mg	Hypersensitive to drug or its derivative, QT-interval prolongation and torsades de pointes
Pharmacotherapeutic Class	Dosage Ordered	Adverse Reactions
Antiulcer/H2-receptor antagonists	20mg	Headache, dizziness, irritability, constipation, diarrhea, vomiting
Why is patient receiving this med? (Can list related diagnosis, symptom, or need)	Route and Frequency	Nursing Considerations and Teaching
Pt has GERD	PO, give 1 tablet one time a day for heartburn	Monitor pt for abdominal pain, assess for blood in stool, monitor pt with renal dysfunction for QT-interval prolongation

Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Plavix Tablet (Clopidogrel Bisulfate)	Tablet 75-300mg	History of sensitivity to the drug, inn pts with hematologic reaction and intercranial hemorrhage
Pharmacotherapeutic Class	Dosage Ordered	Adverse Reactions
Antiplatelet/Platelet aggregation inhibitors	75 mg	Confusion, abdominal pain, epistaxis, ulcers, myalgia, Stevens-Johnson syndrome
Why is patient receiving this med? (Can list related diagnosis, symptom, or need)	Route and Frequency	Nursing Considerations and Teaching
Pt has peripheral vascular disease	PO, give 1 tablet one time a day for CVA	Teach pt to avoid grapefruit juice and drug may be given without food. Advise pt that bleeding may take longer than usual to stop and to stop any activities where trauma or bleeding may occur. Notify MD if bruising or bleeding occurs.

Medications

Routine Findings

Patient Variations/Abnormals

Skin –

Head and neck –

Respiratory –

Cardiovascular

Abdomen –

Bowel continence? Last BM? Bowel Plan?

Neurological

Musculoskeletal - .

Genitourinary -

Urinary continence? Toileting plan?

Nursing Diagnosis #1: Imbalanced Nutrition more than body requirements Related to (RT): intake of nutrients that exceeds metabolic needs As evident by (AEB): body weight (30% over ideal for height)
Planning/Desired Outcome(s): Pt will progressively lose weight/ pt will lose at least 1 pound per week until a goal of 4 pounds per month is reached Pt will eat healthy meals with fruits for snacks each day/ pt will consume 1500kcal/day Pt will show no sign of excess weight / Physical assessment findings and lab values will be within normal ranges
Implementation/Nursing intervention(s):	Rationale	Evaluation/Patient Response
Nurse will coordinate care with PCP, Dietitian, PT and family	Coordination of nutritional care helps for a more successful outcome
Individulaized food and menue according to pt’s preferences	Pt will be encouraged to eat by incorporating her food preferences





Nursing Diagnosis #2: Related to (RT): As evident by (AEB):
Planning/Desired Outcome(s):
Implementation/Nursing intervention(s):	Rationale	Evaluation/Patient Response







Nursing Diagnosis #3: Related to (RT): As evident by (AEB):
Planning/Desired Outcome(s):
Implementation/Nursing intervention(s):	Rationale	Evaluation/Patient Response

Medical Diagnoses:

Key Assessments:

Problem#_________

ND:

AEB

Problem#_________

ND:

AEB

Problem#_________

ND:

AEB

Problem#_________

ND:

AEB

Problem#_________

ND:

AEB

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