Will someone be able to write my complex nursing care plan for me?

GENERAL PATIENT INFORMATION

HEALTH HISTORY

Age: 84 Race: Caucasian Sex: Male MS: Divorced

Chronic or Previous Health Problems (include date of onset if known):

-Arthritis

-COPD

-Lung dz

-Hypercholesterolemia

-HTN

-Cancer

-Multiple myeloma

-Muscle Cramps

-Thyroid

___________________________________________________

History of current symptoms: Denied any other pain or complications besides his arm

Diet: Healthy Heart,

Height: 172.72 cm

Weight: 86.18kg

Code Status: Full Resuscitation

Activity Ordered: Activity as tolerated

Religion: No preference

Economic Status: Medicare

Activity Possible: Bed rest. Activity as tolerated

Perception of Health/Reason for Admission (pt’s own words):

Nutrition: □ PEG Tube PO

“I broke my arm”

Elimination: □ Foley □ Ostomy—Type: Void

I & O schedule:

Admitting Medical Diagnosis:

Syncope, Hypotension, ARI

Wounds/ Wound Care:

No wound care

Previous Surgeries (include date):

-Left heart cardiac 8/11/15

-Coronary arteriography using two caths 8/11/15

-Biopsy of bone marrow 4/16/15

-Eye

-Hernia

-HIp replacement,

-Knee

-Shoulder replacement

-Thyroid

Respiratory: No supplemental O2

□ O2 @ ______ L/min via _________________________

□ Incentive Spirometer every ___________

□ Respiratory Treatments:

-Documented: Albuterol (Albuterol 90 mcg/inh inhalation) - 2 puffs, INH, BID, PRN SOB or wheezing

-Documented: Fluticasone-salmeterol - 1 puff, INH, BID # 60 EA

-Fluticasone-salmeterol (Advair Diskus 250 mcg-50 mg inhalation powder) - 1 puff, Inh-oral disk, INH, BID, Routine

• Ventilator Settings_________________________

Date of Admission: 2/12/17

Surgical Procedures: No surgeries since admission

Date:

Home Medications:

-Aspirin (Aspirin EC 81 mg) = 1 tab(s), oral daily

-Prochlorperazine (Compazine) = 1 tab, oral q 6hr

-Multivitamin with mineralys (PreserVision oral capsule) = 1 cap, oral, BID, presersivion with Lutein

-Fluticasone - Salmeterol - 1 puff, INH, BID, #60 EA

-Calcium-Vitamin D (Calcium 500 + D oral tablet, chewable) - 1 tab chewed BID

-Multivitamin - 1 tab, oral, daily

-Acetaminophen-hydrocodone (Norco 5mg/325mg) - 1 tab, oral, q4hr, PRN for pain

-Omega-3 polyunsaturated fatty acids (omega - 3 polyunsaturated fatty acids 1000 mg oral capsule) - 1,000 mg = 1 cap, oral, once a day (bedtime) #60 cap

-Potassium chloride - 10 mEq, oral daily

-Memantine (Namenda) - 10mg = 1 tab, oral, BID #60 tabs

-Cetirizine (Cetirizine 10 mg oral tab) = 10 mg = 1 tab, oral daily #30 tabs

-Cyanocobalamin (Vita B12 100 mcg oral tablet) - 100 mcg = 1 tab, oral, daily #30 tab

-Levothyroxine (levothyroxine 112 mcg (0.112 mcg) oral tablet) - 112 mcg = 1 tab, oral daily # tab

-Polyethylene glycol 3350 (MiraLax) - 17 gm 1 packet, oral, daily

-Ropinirole (Ropinirole 2 mg oral tablet) - 2 mg = 1 tablet, oral, once a day #270 tab

-Albuterol (Albuterol 90 mcg/inh inhalation) - 2 puffs, INH, BID, PRN SOB or wheezing

-Omeprazole (Prilosec 20 mg oral delayed releases capsule) - 20 mg = 1 cap, oral, daily

-Isosorbide mononitrate - 30 mg, oral, qAM, 0 refill

-Allupurinol (allupurinol 300 mg oral tab) - 300 mg = 1 tab, oral, daily #30 days

-Ferrous sulfate (ferrous sulfate 325 mg (65 mg elemental iron) oral tab) - 1 tab, once a day #270 tabs

-Lisinopril (Lisinopril 10 mg oral tab) - 40 mg, oral daily #30tabs

-Cholecalciferol (Vitamin D3 400 intl units oral tabs)- 400 int unit = 1 tab(s), oral, daily

-Carbamide peroxide otic (Debrox 6.5% otic soln)-5 drops, otic, BID, # 15 mL

-Donepezil (Donepezil 5 mg oral tab) 5mg = 1 tab, oral once a day at bedtime #30 tabs

-Ondansetron (Zofran 8 g oral tab) - 8 mg = 1 tab, oral, q6hr, PRN N/V #9 tabs

-Amlodipine (Amlodipine 10 mg oral tab) - oral daily

□ Accuchecks: □ ac & hs □ sliding scale insulin: No accuchecks/sliding scale

Allergies (include symptoms): Bactrim and Codeine

IV: (includes site change date) LAC site due to be changed 02/16/17

Multidisciplinary: Physician, Nurse, RT

Patient Classification:

Class II. INtermediate care, moderately ill, both pt and nurse participate in care

Priority Dx #1:

R/f injury r/t altered LOC secondary to inadequate cerebral blood flow; increased peripheral resistance; increased concentration of lipids in the blood

Priority Dx #2:

Ineffective airway clearance r/t increased production of tenacious secretions and retained secretions

Priority Dx #3:

Chronic pain r/t to destruction of tissues/bone; degeneration of joint

VS q4 hours

Assess for s/s of ineffective airway clearance (ex: abnormal breath sounds; rapid, shallow respirations; dyspnea; cough)

Assess VS q 4 hours (including pain on a 0-10 scale)

Monitor BP and pulse

Improve airway patency (encourage hydration 2 to 3 L/day)

If pain present, administer acetaminophen-hydrocodone (Norco 5mg/325 mg) - 1 tab,oral, q4hr, PRN for pain

Check O2 Sat

Promote bed rest (the pt should assume a comfortable position to promote rest and breathing ex: Semi-Fowler’s position position)

Instruct pt to frequently change positions

Check capillary refill

Turn pt q 2 hours as ordered to enhance secretion clearance and pulmonary ventilation and perfusion

Encourage the use of relaxation techniques including breathing control and guided imagery

Keep bed in low position with side rails up when pt is in bed

Instruct and assist pt to deep breathe and cough or “Huff” every 1-2 hours

Give ice-cold compress if needed to relieve the pain and swelling during the acute period of arthritis

Keep needed items within reach

Administer albuterol (albuterol 90 mcg/inh inhalation aerosol) - 180 mcg = 2 puffs, inH -oral, INH, BID, PRN for SOB or wheezing

Encourage pt to ask for assistance whenever needed

Administer fluticasone-salmeterol (Advair Diskus 250 mcg-50 mg, inhalation powder) - 1 puff, inh-oral disk, INH, BID, Routine

Instruct and assist pt to rise and change positions slowly

Instruct pt to wear nonskid socks

Diagnosis

Diagnosis

Diagnosis

Interventions

Interventions

Interventions

Diagnosis

Diagnosis

Diagnosis

Interventions

Interventions

Interventions

Diagnosis

Diagnosis

Diagnosis

Interventions

Interventions

Interventions

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Influenza virus Vaccine (Flu Vaccine)

Immunization

0.5 mL, syringe

IM

As directed

At risk for infections

could have allergic rxn if allergic to egg protein

Nursing Implications and Interactions: and during administration. Assess previous immunization hx and hx of hypersensitivity

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Fluticasone-Salmeterol (Advair Diskus powder pgs 1105, 347

Corticosteroid - Bronchodilator

250 mcg - 50 mg

Oral, inhalation

1 puff, BID

Hx of COPD and lung dz and has ARI. Bronchodilates

SE: headache

AE: asthma-related death

Nursing Implications and Interactions: Assess lung sounds, pulse and BP before administering. Drug interactions: MAO inhibitors and tricyclic antidepressants, CYP3A4

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Acetaminophen-hydrocodone (Norco 5 mg / 325 mg)

Davis Drug Guide pg 651

Opiod agonists/nonopioid analgesic combinations

5mg/325 mg

oral

q4hr, PRN for pain

Therapeutic: decreases in severity of moderate pain. Suppression of the cough reflex

SE: confusion, dizziness, sedation, hypotension, constipation, dyspepsia, nausea

Nursing Implications and Interactions: Drug interactions: MAO inhibitors, CYP3A4 inhibitors, alcohol, antihistamines, sedative/hypnotics, kava-kava, valerian, skullcap, chamomile

Implications: Assess BP, pulse and respirations before and periodically during administration

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Acetaminophen Davis Drug Guide pg 97

Antipyretics, nonopioid analgesics

1,000 mg

oral

2 tabs

Antipyretics, analgesia

AE: hepatotoxicity; acute generalized exanthema

Nursing Implications and Interactions: Drug interactions: warfarin, alcohol, isoniazid, rifampin, rifabutin, phenytoin, barbiturates and carbamazepine

Implications: assess overall health status and alcohol usage before administering acetaminophen. Assess type and location of pain

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Memantine (Namenda) Davis Drug Guid pg 800-801

Anti-alzheimer’s agent

10 mg

oral

BID

Displaying cognitive decline. Decreased symptoms of dementia/cognitive decline.

Dizziness, fatigue, h/a, sedation, HTN, rash, diarrhea, wt gain, urinary frequency, anemia

Nursing Implications and Interactions: Drug interactions: carbonic anhydrase inhibitors, sodium bicarbonate

Implications: Assess cognitive function (memory, attention, reasoning, language, ability to perform simple tasks)

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Cetrizine (Zyrtec) Davis Drug Guide pg 300 - 301

Allergy, cold and cough remedies, antihistamines

10 mg

oral

daily

ARI. Decreased symptoms of histamine excess (sneezing, rhinorrhea, ocular tearing and redness, pruiritus)

CNS: dizziness, drowsiness

Nursing Implications and Interactions: Drug interactions: alcohol, opioid analgesics, sedative/hypnotics

Implications: Assess allergy sx, assess lung sounds and character of bronchial secretions

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Methylprednisolone (Medrol) 353

Intermediate-acting corticosteroids

100 mg = 1.6 mL

injection, IV

As directed

suppression of inflammation and modication of the normal immune response

SE: depression, euphoria, hypertension, anorexia, nausea, acnes, decrease wound healing, ecchymoses, fragility, hirsutism, petechiae, adrenal suppression, muscle wasting, osteoporosis, cushingoid appearnace

AE: peptic ulceration, thromboembolism

Nursing Implications and Interactions: Drug interaction: thiazide and loop diuretics or amphotericin B, digoxin, PHenytoin, phenobarbital and rifampin, NSAID, fluoroquinolones, Antacids, ketoconazole, itraconazole

Implications: Assess for adrenal insufficiency

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Diphendramine Davis Drug Guide pg 431

Allergy, Cold and cough remedies, antihistamines, antitussive

12.5 mg = 0.75 mL,

IV injection

1 dose as directed

ARI. Decreased symptoms of histamine excess (sneezing, rhinorrhea, nasal and ocular pruirtus, ocular tearing and redness, urticaria). Suppression of cough

SE: drowsiness, anorexia, dry mouth

Nursing Implications and Interactions: Drug interactions: antihistamines, alcohol, opioid analgesics, sedative/hypnotics, tricyclic antidepressants, quinidine, MAO inhibitor

Implication: Assess frequency and nature of cough, lung sounds, and amount and type of sputum produced

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Levothyroxine (Synthroid) Davis Drug Guide pg 757

Thyoid

125 mcg

oral

daily

Thyroid supplementation in hypothyroidism. Therapeutic: replacement in hypothyroidism to restore normal hormonal balance

Can cause angina pectoris, arrhythmias, tachycardia, abdominal cramps

Nursing Implications and Interactions: Drug interactions: warfarin, insulin, oral hypoglycemic agents, estrogen

Implications: assess apical pulse and BP prior to and periodically during therapy. ASsess for tachyarrhythmias and chest pain

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Albuterol pg 116 Davis Drug Guide

Bronchodilator

180 mcg = 2 puffs

oral inhalation

Inh, BID, PRN for SOB or wheezing

ARI. Hx of COPD. Bronchodilation

SE: nervousness, restlessness, tremor, chest pain, palpitations

AE: Paradoxical bronchospasm

Nursing Implications and Interactions: Drug interactions: adrenergic agents, MAO inhibitors, Beta blockers, digoxin, tricyclic antidepressants, potassium-losing diuretics

Implications: Observe for paradoxical bronchospasm (wheezing)

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Ropinirole (Requip) Davis Drug Guide pg 1099

Dompamine agonists

2 mg

oral

once a day

Decreased tremore and rigidity in Parkinson’s dz. Decreased leg restlessness.

SE: dizziness, syncope

AE: sleep attacks

Nursing Implications and Interactions: drug interactions: p450 CYP1A2,, estrogen, phenothiazines, butyrophenones, thioxanthenes or metoclopramide

Implications: Assess pt for drowsiness and sleep attacks. ASsess pt for concomittant medications that have sedating effects or may increase serum ropinirole levels

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Bortezomib (Velcade) Davis Drug Guide pg 229

Proteasome inhibitors

2.2 mg = 0.88 mL

Subq

Death of rapidly replicating cells, particulary malignant ones

SE: fatigue, malaise, weakness, hypotension, anorexia, constipation, diarrhea, nausea, vomiting, anemia, neutropenia, thrombocytopenia, peripheral neuropathy, fever

AE: progressive multifocal leukoencephalopahty, reversible posterior leukoencephalopathy syndrome, liver failure, bleeding

Nursing Implications and Interactions: Drug interactions: antivirals, amiodarone, nitrofuratoin, isoniazid

Implications: Monitor for s/s of RPLS (h/a , seizure, lethargy, confusion, blindness). HTN. Assess for any new s/s that may be suggestive of PML

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Famotidine (Pepcid) Davis Drug Guide 637

Anti-ulcer agent

20 mg = 50 mL

IV soln

200 mL/hr, infuse over 15 min

Pt on bedrest. Healing and prevention of ulcers. DEcreased sx of gastroesophageal reflux. Decreased secretion of gastric acid.

SE: confusion

AE: arrhythmias, agranulocytosis, aplastic anemia

Nursing Implications and Interactions: Drug interactions: Benzodiazepines, chlordiazepoxide, diazepam, beta blockers, caffeine, CCB, carbamazepine, cyclosporine, dofetilide, lidocaine, metronidazole, mexiletine, nefazodone

Implications: Assess for epigastric or abdominal pain and frank or occult blood in teh stool, emesis or gastric aspirate. Monitor CBC with differential periodically during therapy

Medication generic/trade

Classification/

mechanism of action

Dose

Route

Frequency

Why the patient is taking this medication

Side Effects

Enoxaparin (Lovenox) Davis Drug Guide pg 634

Anticoagulants

Antithrombotics

30 mg = 0.3 mL

Sub q injection

daily

Prevention of clots

Common SE: anemia

AE: bleeding

Nursing Implications and Interactions: Drug interactions: warfarin, aspirin, NSAIDs, dpyridamole, clopidogrel, ticlopidine, eptifibatide, tirofiban and thrombolytics

Lab Studies

Date

Normal Values

Patient Values

Reason for Abnormal in YOUR patient (with reference)

__

CBC WNL X

RBC

RBC

2/12/17

2/13/17

4.7-6.1

4.7-6.1

(L) 3.62

(L) 3.13

Multiple Myeloma. Pagana pg 442

Multiple Myeloma. Pagana pg 442

Hgb

Hgb

2/12/17

2/13/17

14-18

14-18

(L) 11.9

(L) 10.1

Multiple Myeloma. Pagana pg 284

Multiple Myeloma. Pagana pg 284

Hct

Hct

2/12/17

2/13/17

42-52%

42-52%

(L) 35.9

(L) 30.6

Multiple Myeloma. Pagana pg 280

Multiple Myeloma. Pagana pg 280

MCH

MCH

2/12/17

2/13/17

27-31

27-31

(H) 33

(H) 32

Elevated lipid levels. Pagana pg 445

Elevated lipid levels. Pagana pg 445

RDW

RDW

2/12/17

2/13/17

11-14.5%

11-14.5

(H) 16.0

(H) 16.0

Elevated lipid levels. Pagana pg 445

Elevated lipid levels. Pagana pg 445

MPV

MPV

2/12/17

2/13/17

7.4-10.4

7.4-10.4

(L) 6.8

(L) 6.8

Cancer chemo substance. Pagana pg 408

Cancer chemo substance. Pagana pg 408

Mono Abs

2/12/17

100-700

(H) 0.60

Drug therapy.: prednisone. Pagana 532

Lymph Auto

2/13/17

20-40

(L) 20.1

Drug therapy. Pagana pg 530-532

Cardiac testing WNL except

Total CK

Total CK

Total CK

CK MB

CK MB

CK MB

2/12/17

2/13/17

2/13/17

2/12/17

2/13/17

2/13/17

55-170

55-170

55-170

0%

0%

0%

Normal 77

Normal 59

Normal 67

Normal 3.50

Normal 2.60

Normal 2.90

Normal

Normal

Normal

Normal

Normal

Normal

Troponin

Troponin

Troponin

Myoglobin

Myoglobin

Myoglobin

2/12/17

2/13/17

2/13/17

2/12/17

2/13/17

2/13/17

< 0.1- 0.03ng/mL

<0.1 - 0.03 ng/mL

< 0.1 - 0.03 ng/mL

< 90%

< 90%

< 90%

(L) < 0.02

(L) < 0.02

(L) < 0.02

Normal 102

Normal 64

Normal 56

According to Pagana, normal

According to Pagana, normal

According to Pagana, normal

Normal

Normal

Normal

ABG’s WNL except

No ABG’s

Coagulation study: No coagulation study

Blood C/S:

Negative

U/A

2/12/17

Color

Spec gravity

UA BI

Rlt

Urobilogen

Blood

Glu

Ketones

Protein

Nitrate

Leuk Est

Yellow

< = 1.005

Neg

6.0

0.2 Eu/dL

Neg

Neg

Ketones

Neg

Neg

Neg

Lab Studies

Date

Normal Values

Patient Values

Reason for Abnormal in YOUR patient (with reference)

Chemistry WNL except

Sodium

2/12/17

136 - 145

(L) 133.0

Pagana pg 466 - 467 Deficient dietary intake

BUN

BUN

2/12/17

2/13/17

10-20

10-20

(H) 37

(H) 30

Pagana pg 511 dehydration

Pagana pg 511 Dehydration

Creatinine

Creatinine

2/12/117

2/13/17

0.5-1.2

0.5-1.2

(H) 1.86

(H) 1.73

Pagana pg 191 Dehydration

Pagana pg 191 Dehydration

GFR African American

GFR African American

2/12/17

2/13/17

87-107

87-107

(L) 42

(L) 46

Pagana pg 193 Dehydration

Pagana pg 193 Dehydration

GFR Non African American

GFR Non African American

2/12/17

2/13/17

87-107

87-107

(L) 35

(L) 38

Pagana pg 193 Dehydration

Pagana pg 193 Dehydration

Calcium

2/13/17

9.0 - 10.5

(L) 7.9

Pagana 138 Drug therapy (Albuterol)

Glucose Level

2/12/17

70-100

(H) 124

Pagana pg 256 Corticosteroids

Diagnostic Testing, EKG’s, etc.

Date

Interpretation

XR Chest 1 View Portable

2/12/17

Stable exam; no acute process

CT Head

2/12/17

1) Cerebral atrophy & evidence of mild chronic microvascular ischemia, which appear to be stable

2) NO acute intracranial abnormality

3) Small amount of fluid inferior in the L mastoid air cells, which may be related to mastoid effusion clinical correlation is necessary to include mastoiditis

U/S Carotid Duplex Comp Bil

2/13/16

NO significant stenosis identified

CARDIOVASCULAR

ENDOCRINE

GENITOURINARY

MUSCULOSKELETAL

RESPIRATORY

INTEGUMENTARY

REPRODUCTIVE

Patient’s General Appearance

Growth and Development

Patient’s Age: _______

GASTROINTESTINAL

Usual Sleep Pattern

Assessment of How Each Developmental Task is Met or Unmet and Summary of resolution

SENSORINEURAL

Activities to Promote Health

_____________________________________

Activities needed to improve health

NURSING DIAGNOSIS, GOALS AND OUTCOME CRITERIA

5 points

Diagnosis:

R/f injury r/t altered LOC secondary to inadequate cerebral blood flow; increased peripheral resistance; increased concentration of lipids in the blood

Goal: TPW not become injured AEB no new bruises, broken bones or bleeding

Outcome:

NURSING INTERVENTIONS

Individualized and Applicable in order of priority

10 points

PATHOPHYSIOLOGY to support Nursing Diagnosis and Intervention

(must paraphrase and reference)

15 points

EVALUATION OF INTERVENTIONS AND ACHIEVEMENT OF GOALS

10 points

NURSING DIAGNOSIS, GOALS AND OUTCOME CRITERIA

5 points

Ineffective airway clearance r/t increased production of tenacious secretions and retained secretions

NURSING INTERVENTIONS

Individualized and Applicable in order of priority

10 points

PATHOPHYSIOLOGY to support Nursing Diagnosis and Intervention

(must paraphrase and reference)

15 points

EVALUATION OF INTERVENTIONS AND ACHIEVEMENT OF GOALS

10 points

NURSING DIAGNOSIS, GOALS AND OUTCOME CRITERIA

5 points

Chronic pain r/t to destruction of tissues/bone; degeneration of joint

NURSING INTERVENTIONS

Individualized and Applicable in order of priority

10 points

PATHOPHYSIOLOGY to support Nursing Diagnosis and Intervention

(must paraphrase and reference)

15 points

EVALUATION OF INTERVENTIONS AND ACHIEVEMENT OF GOALS

10 points