Care Plan Template NSG 1705: Student Resuscitation Status Full Code
SLCC Nursing Program
Nursing Care Plan Template NSG 1705
Student Resuscitation status full code
Age 1/28/1988 Gender male Surgery Date & Type Unit 4th floor
Weight and Height 61kg 67cm Primary Language English Date 2/26/2012
Admitting Diagnosis & Date 10/30/2012 shortness of breath and fever Religion no spiritual needs Culture American
Admission History: (This should be a summary in the student’s own words of why the client came to the hospital now. Include a list of the client’s allergies, other medical problems. Do not just copy down the physician’s history and physical.)
This patient was admitted for shortness of breath, fever and chills. He has a history of cystic fibrosis, with secondary diabetes. …show more content…
He has had several hospitalizations in the past year. He was last admitted/discharged on Sept 15, and was continuing his treatment at home until his symptoms of being short of breath, fever and chills got a lot worse. He also reported increased sputum production.
His past medical history consists of cystic fibrosis, diabetes secondary to cystic fibrosis, SVC thrombosis status post thromboplasty and allergic bronchopulmonary aspergillosis
He currently works as a delivery driver for jimmy johns
Allergies:nizatidine, imipenem, and cayston
Home Meds: azithromyocin, pulmozyme, tobramycin, pancrelipase, acidophilous, multivitamin, calcium citrate, vitamin E nexium, albuterol, novolog, posaconazole, lantus, prednisone and clindamycin
Pathophysiology: (This should be a summary in the student’s own words of the client’s main medical problem.
For example, if the client was admitted for altered mental status or weakness the student needs to peruse the medical chart and discover what medical diagnosis caused these symptoms. Pathophysiology should be on a cellular level and a source should be sited.)
This patient has cystic fibrosis. cystic fibrosis is an inherited chronic disease that affects the lungs and digestive system it is usually caused by a defective gene and its protein product cause the body to produce unusually thick, sticky mucus that clogs the lungs and leads to life threatening lung infections and obstructs the pancreas and stops natural enzymes from helping the body break down and absorb food. The mutated gene is the protein cystic fibrosis transmembrane conductance regulator (CFTR). This gene is required to regulate the components of sweat, digestive juices, and mucus. Although most people without CF have two working copies of the CFTR gene, only one is needed to prevent cystic fibrosis. CF develops when neither gene works normally and therefore has autosomal recessive …show more content…
inheritance.
Some of the signs and symptoms of cystic fibrosis are very salty-tasting skin; persistent coughing, at times with phlegm; frequent lung infections; wheezing or shortness of breath; poor growth/weight gain in spite of a good appetite; and frequent greasy, bulky stools or difficulty in bowel movements.
Common for patients with cystic fibrosis may include antibiotics for infections of the airways, chest physical therapy, exercise, oxygen, and lung transplants.
ref www.cff.org/AboutCF
Laboratory data and all diagnostic tests (include x-rays, EKGs, cultures, ultrasound etc):
Test
Normal Range
Client Result Rationale for abnormal & significant normals in this client
CHEMISTRY PANEL sodium 136-144
138
Normal due to adequate hydration
Potassium
3.3-5.0
3.2
Low due to CF
Chloride
98-107
105
Normal due to adequate hydration
Carbon Dioxide
20-29
24
Normal would this be significant because he is receiving so many breathing treatments?
Anion Gap
8-14
9
Normal
Urea Nitrogen
9-22
4
Due to malnutrition, due to decreased appetite from CF
Creatinine, Serum or Plasma
0.66-1.25
0.81
Normal
Glucose Level
64-128
58
Low, due to malnutrition based off of him doing carb counting for insulin requirements
Medications:
Drug/dosage/route/
Classification/Action at
Reason for use in this client
Nursing Considerations pertinent to this client schedule cellular level
Ancef (cefazolin) 1 gm q 12 hr. IV at 0600 and 1800
Antibiotic-1st Generation Cephalosporin/disrupts bacterial cell wall so increased oncotic pressure lysis bacterial cell
UTI- E Coli infection
This client is elderly and has borderline kidney function so maintaining strict I&O, monitor BUN & Cr- if drawn. Caution client to refrain from drinking alcohol for 72 Hrs after med d/c’d. Monitor for allergy albuterol 2.5mg NEB solution QID
Therapeutic: bronchodilators controls symptoms of asthma and COPD.
Action: Relaxation of airway smooth muscle with subsequent bronchodilation bronchodialation Assess lung sounds, pulse and BP before administration and during peak of med.
Monitor sputum amount, color, and character produced.
Observe for paradoxical bronchospasm (wheezing). If condition occurs withhold med and notify physician. azithromyocin 250mg, PO, TAB Q day
inhibits protein synthesis at level 508 bacterial adults
Due to CF assess pt for dizziness, seizures, drowsiness or fatigue assess pt for any kind of infection at beginning and throughout therapy assess pt for any kinds of anaphylaxis calcium citrate
950mg, PO, TAB, QDAY
Maintains cell membrane and capillary permeability. Acts as an activator in the transmission of nerve impulses and contrction of muscles.
Calcium supplement replacement
Assess pt for s/s of hypercalcemia(muscle twitching, larygospasms, colic and cardiac arrhythmias.)
Monitor vs. could cause vasodilatation
Assess phosphate levels and make sure they are staying within a normal range. dornase alfa (Pulmozyme)
2.5mg NEB, solution, QDAY
Hydrolyzes extracellular DNA, decreasing mucous viscosity cystic fibrosis
Monitor pt breathing
Monitor for signs and symptoms of URI
Do not mix in nebulizer fluticasone nasal
2 spray, NASAL, spray Qday
1 Spray Nasal BID
Corticosteroid-(allergies)
1. Monitor degree of nasal stuffiness, amount and color of nasal discharge, and frequency of sneezing.
2. Monitor for CNS effects (dizziness, headache).
3. Monitor for GI effects (dry mouth, esophageal candidiasis, nausea, vomiting). fluticasone-salmeterol (Advair Diskus)
1 puff, inhale, powder, BID
Potent, locally acting anti-inflammatory and immune modifier. Therapeutic effects: decreased frequency and severity of asthma attacks. Improves asthma symptoms.
Increase lung expansion
Monitor respiratory status and lung sounds.
Notify physician if sore throat or sore mouth occurs.
Monitor for withdrawal symptoms (joint or muscular pain, lassitude, and depression) during withdrawal from oral corticosteroids. insulin glargine (Lantus)
20 units SQ, INJ, Qday
binds to receptors on sensitive cells. enhances peripheral glucose uptake and utilization and inhibits hepatic gluconeogenisis blood glucose
1. check bs periodically throughout the shift
2. check dose with another RN before administration
3. check for signs of hypoglycemia insulin lispro
1 unit, SQ, solution, TIDw/meals
1unit per 15g cho each meal
Lower blood glucose by stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. diabetes 1. check bs periodically throughout the shift
2. carefully count carbs so the right amount is being given
3. check for signs of hypoglycemia levofloxacin 750mg, PO, TAB, Q24hr
Inhibits bacterial DNA synthesis by inhibiting DNA gyrase
Cystic fibrosis do not give antacid products containing aluminum and magnesium or dairy products two hours before or two hours after levofloxacin administration
Don’t get it confused with levothyroxine
Assess pt for s/s of infection, making sure symptoms are getting better not worse
Encourage fluids to 1500-2000ml to prevent crystaluria
Assess pt for dizziness and drowsiness lortadine (Claritin)
10mg, PO, TAB, QDay
Antihistamine
Relief of symptoms of allergies
Maintain fluid intake of 1500-2000 mL/day to decrease viscosity of secretions.
May cause false negative result on allergy sin testing.
May cause dizziness or drowsiness. multivitamin 1 tablet PO, QDay
Therapeutic: nutritional
Action: used to supplement vitamins not consumed through diet.
Used for nutritional supplement
Monitor patient for Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue).
Do not take this medication with milk, other dairy products, calcium supplements, or antacids that contain calcium, it may make it difficult for your body to absorb some of the vitamins.
Inform patient of possible side effects such as: unpleasant taste, or upset stomach. omeprozole 20mg, PO, CAP, BID
Antiulcer agent/
Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH
Management of heartburn
Administer before meals.
Educate the patient that this medication is not for instant relief of heartburn. It is a maintenance drug.
Assess patient for blood in the stool or emesis.
Assess patient routinely for epigastric or abdominal pain.
pancrelipase, (Creon 24) 5 cap PO TID with meals
Contains lipolytic, amylolytic, and proteolytic acitivity. Increased digestion of fats, carbohydrates, and proteins in the GI tract
Cystic fibrosis
Administer right before or with meals or snacks
If pt cannot swallow whole pills, they can break apart the capsules and sprinkle onto food
Make sure pt is getting enough fats when taking this medicine, and give with plenty of water
Posaconazole (Noxafil)
400mg, PO, suspension, BID
Blocks ergosterol synthesis, a major component of fungal plasma membrane antifungus take with a full meal monitor for n/v check herbal meds for contraindications tobramycin (tobramycin injectable for cystic fibrosis)
500mg, IV Q24hr
Inhibits protein synthesis in bacteria at level of 30S ribosome
Cystic fibrosis
Assess for infection, or sputum getting worse, before and throughout therapy
Evaluate eighth cranial nerve function by audiometry before and throughout therapy for hearing loss
Monitor I & O and daily weight to assess hydration status and renal function vitamin E
200units, PO, Cap, QDay
Prevents the oxidation of other substances. Protects RBC membranes against hemolysis
Supplement
Administer with food or meals
Assess pt for signs and symptoms of vitamin E deficiency
Assess pt for signs and symptoms of overdose
prn meds
acetaminophen
325mg PO, TAB Q4hr prn pain/fever nonopoid analgesic pain/fever assess pain/fever, noting presence of diaphoresis, tachycardia, and malaise assess pain type, location and intensity prior to and after administrating monitor other medications, do not exceed 4000mg per day loratadine (Claritin)
10mg, PO, TAB, Qday prn as patient
Antihistamine
Relief of symptoms of allergies as patients condition necessitates
Maintain fluid intake of 1500-2000 mL/day to decrease viscosity of secretions.
May cause false negative result on allergy sin testing.
May cause dizziness or drowsiness. condition necessitates
ondansetron
4mg, PO, TAB, Q8hr, prn n/v
Blocks the effects of serotonin at 5-HT3 – receptor sites located in the vagal nerve terminals and the chemoreceptor trigger zone in the CNS. Therapeutic effects: decreases severity of nausea and vomiting following chemotherapy or surgery.
Prn Nausea/Vomiting
Assess patient for nausea and vomiting,
Assess patient for abdominal distention, and bowel sounds prior to and following administration.
Monitor patients for extrapyramidal effects (involuntary movements, facial grimacing, rigidity, shuffling walk, trembling hands) periodically throughout
therapy.
pseudoephedrine (Sudafed)
60mg PO, TAB, Q6hr prn congestion
Stimulates alpha and beta adrenergic receptors, produces vasoconstriction in the respiratory tract mucosa prn congestion
Assess pt. for congestion
Monitor bp during therapy
Assess lung sounds and character of bronchial secretions
Increases fluids
Nursing Diagnosis
Goals
Interventions
Rationale
Evaluation
Actual problems must contain:
1. Problem
2. Related to: (this is what caused the problem. Can’t be a medical diagnosis)
3. As evidenced by (this is from your assessment data).
Potential problems:
4. Problem
5. Related to
Short term: NSG 1705 defines this as what will happen on your shift
Long term: NSG 1705 defines this as what will happen after your shift
Goals must be realistic, achievable and measurable.
This is what this client/family will do.
The client will…
**Need one long & one
Low-level interventions expected at NSG 1355, but NOT at 1705 and above. For instance hand washing, use sterile technique & use universal precautions should not appear
This is what the nurse will do to assist this client to accomplish the goal.
The nurse will …
**Need 2 per goal**
Explanation of the interventions based on the individual client’s needs. NOT the generic client. Tell how the intervention will help this client accomplish the goal.
Tell what tool you will use to know whether or not the goal was met, what would you look for?
How will you know whether each goal was met?
NSG 1705 students cannot actually evaluate whether the goal was met because the care plan has not yet been implemented.
**Need 3** short** Inadequate nutrition, less than body requirements, as evidenced by him not eating secondary to cystic fibrosis
Short term: pt will take all necessary meds and eat a full lunch on 11/05/2012
Long term: pt will eat whenever he is hungry and have adequate nutrition as evidenced by his chemistry panel with no significant abnormals before discharge
1. pt will have lunch delivered with his meds
2. lunch will be brought in when pt is awake
1. pt will have plenty of snacks and food to eat in his room so that if he is hungry he will have something to eat
2. pt will have meals delivered whenever he is hungry, and is awake
1. because he has CF his body doesn’t process the nutrients as well as they should, some of his meds help with the digestion
2 if he is awake he is more likely to eat lunch
1 having things readily available for him to eat, makes it so if he is hungry he has something to eat
2 if he is awake, he is more likely to eat his meals
Short term: pt took at necessary meds, and at lunch on 11/05/2012
Long term: pt had adequate nutrition as evidenced by chemistry panel with no significant abnormals, before discharge
Fatigue related to not getting good rest as evidenced by patient verbalizing it, secondary to cystic fibrosis
Short term: pt will get 2-4 hours of rest on my shift on 11/05/2012
Long term: pt will feel rested and on her way to getting better by discharge
1.nurse will provide a quiet and comforting environment for the pt
2. nurse will coordinate all the care so that pt will all care will be done at the same time, or as close to the same time
1. nurse will leave pt alone if she is sleeping unless medically necessary
2. nurse will help keep pt as comfortable as possible
1. by providing a comforting and quiet place will make it easier for pt to sleep
2. by coordinating care it leaves more time that the pt is left alone to get as much rest as possible
1. waking up a patient to see if they need something is unnecessary if they are resting peacefully. Still check up on them, but don’t bother them
2. keeping the patient comfortable will help the patient relax and be able to get better rest
Short term: pt stated she got 3 hours of rest on my shift on 11/05/2012
Long term: pt stated she felt rested by discharge impaired gas exchange related to decreased lung function as evidenced by him being short of breath and coughing
short term: pt will keep his sats above 90% during my shift on 11/05/2012
Long term: pt will keep his sats above 90% without added oxygen by discharge
1. nurse to check on the pt every 2 hours to make sure O2 is on
2. nurse to make sure mask or nasal canula is as comfortable as possible and stays on
1. nurse will give meds on time to
2 nurse will take pt on walks around the hospital
1. if mask stays on then pt won’t be short of breath
2. if mask is comfortable, pt is less likely to take mask off
1 giving meds on time is important for the mucous build up to break down
2 being active will help decrease the mucous build up, which will help him breath better short term: pt kept his stats above 90% during my shift on 11/05/2012
long term: pt kept his stats above 90% on room air by discharge.
Nursing Care Plan Template NSG 1705
Student Resuscitation status full code
Age 1/28/1988 Gender male Surgery Date & Type Unit 4th floor
Weight and Height 61kg 67cm Primary Language English Date 2/26/2012
Admitting Diagnosis & Date 10/30/2012 shortness of breath and fever Religion no spiritual needs Culture American
Admission History: (This should be a summary in the student’s own words of why the client came to the hospital now. Include a list of the client’s allergies, other medical problems. Do not just copy down the physician’s history and physical.)
This patient was admitted for shortness of breath, fever and chills. He has a history of cystic fibrosis, with secondary diabetes. …show more content…
He has had several hospitalizations in the past year. He was last admitted/discharged on Sept 15, and was continuing his treatment at home until his symptoms of being short of breath, fever and chills got a lot worse. He also reported increased sputum production.
His past medical history consists of cystic fibrosis, diabetes secondary to cystic fibrosis, SVC thrombosis status post thromboplasty and allergic bronchopulmonary aspergillosis
He currently works as a delivery driver for jimmy johns
Allergies:nizatidine, imipenem, and cayston
Home Meds: azithromyocin, pulmozyme, tobramycin, pancrelipase, acidophilous, multivitamin, calcium citrate, vitamin E nexium, albuterol, novolog, posaconazole, lantus, prednisone and clindamycin
Pathophysiology: (This should be a summary in the student’s own words of the client’s main medical problem.
For example, if the client was admitted for altered mental status or weakness the student needs to peruse the medical chart and discover what medical diagnosis caused these symptoms. Pathophysiology should be on a cellular level and a source should be sited.)
This patient has cystic fibrosis. cystic fibrosis is an inherited chronic disease that affects the lungs and digestive system it is usually caused by a defective gene and its protein product cause the body to produce unusually thick, sticky mucus that clogs the lungs and leads to life threatening lung infections and obstructs the pancreas and stops natural enzymes from helping the body break down and absorb food. The mutated gene is the protein cystic fibrosis transmembrane conductance regulator (CFTR). This gene is required to regulate the components of sweat, digestive juices, and mucus. Although most people without CF have two working copies of the CFTR gene, only one is needed to prevent cystic fibrosis. CF develops when neither gene works normally and therefore has autosomal recessive …show more content…
inheritance.
Some of the signs and symptoms of cystic fibrosis are very salty-tasting skin; persistent coughing, at times with phlegm; frequent lung infections; wheezing or shortness of breath; poor growth/weight gain in spite of a good appetite; and frequent greasy, bulky stools or difficulty in bowel movements.
Common for patients with cystic fibrosis may include antibiotics for infections of the airways, chest physical therapy, exercise, oxygen, and lung transplants.
ref www.cff.org/AboutCF
Laboratory data and all diagnostic tests (include x-rays, EKGs, cultures, ultrasound etc):
Test
Normal Range
Client Result Rationale for abnormal & significant normals in this client
CHEMISTRY PANEL sodium 136-144
138
Normal due to adequate hydration
Potassium
3.3-5.0
3.2
Low due to CF
Chloride
98-107
105
Normal due to adequate hydration
Carbon Dioxide
20-29
24
Normal would this be significant because he is receiving so many breathing treatments?
Anion Gap
8-14
9
Normal
Urea Nitrogen
9-22
4
Due to malnutrition, due to decreased appetite from CF
Creatinine, Serum or Plasma
0.66-1.25
0.81
Normal
Glucose Level
64-128
58
Low, due to malnutrition based off of him doing carb counting for insulin requirements
Medications:
Drug/dosage/route/
Classification/Action at
Reason for use in this client
Nursing Considerations pertinent to this client schedule cellular level
Ancef (cefazolin) 1 gm q 12 hr. IV at 0600 and 1800
Antibiotic-1st Generation Cephalosporin/disrupts bacterial cell wall so increased oncotic pressure lysis bacterial cell
UTI- E Coli infection
This client is elderly and has borderline kidney function so maintaining strict I&O, monitor BUN & Cr- if drawn. Caution client to refrain from drinking alcohol for 72 Hrs after med d/c’d. Monitor for allergy albuterol 2.5mg NEB solution QID
Therapeutic: bronchodilators controls symptoms of asthma and COPD.
Action: Relaxation of airway smooth muscle with subsequent bronchodilation bronchodialation Assess lung sounds, pulse and BP before administration and during peak of med.
Monitor sputum amount, color, and character produced.
Observe for paradoxical bronchospasm (wheezing). If condition occurs withhold med and notify physician. azithromyocin 250mg, PO, TAB Q day
inhibits protein synthesis at level 508 bacterial adults
Due to CF assess pt for dizziness, seizures, drowsiness or fatigue assess pt for any kind of infection at beginning and throughout therapy assess pt for any kinds of anaphylaxis calcium citrate
950mg, PO, TAB, QDAY
Maintains cell membrane and capillary permeability. Acts as an activator in the transmission of nerve impulses and contrction of muscles.
Calcium supplement replacement
Assess pt for s/s of hypercalcemia(muscle twitching, larygospasms, colic and cardiac arrhythmias.)
Monitor vs. could cause vasodilatation
Assess phosphate levels and make sure they are staying within a normal range. dornase alfa (Pulmozyme)
2.5mg NEB, solution, QDAY
Hydrolyzes extracellular DNA, decreasing mucous viscosity cystic fibrosis
Monitor pt breathing
Monitor for signs and symptoms of URI
Do not mix in nebulizer fluticasone nasal
2 spray, NASAL, spray Qday
1 Spray Nasal BID
Corticosteroid-(allergies)
1. Monitor degree of nasal stuffiness, amount and color of nasal discharge, and frequency of sneezing.
2. Monitor for CNS effects (dizziness, headache).
3. Monitor for GI effects (dry mouth, esophageal candidiasis, nausea, vomiting). fluticasone-salmeterol (Advair Diskus)
1 puff, inhale, powder, BID
Potent, locally acting anti-inflammatory and immune modifier. Therapeutic effects: decreased frequency and severity of asthma attacks. Improves asthma symptoms.
Increase lung expansion
Monitor respiratory status and lung sounds.
Notify physician if sore throat or sore mouth occurs.
Monitor for withdrawal symptoms (joint or muscular pain, lassitude, and depression) during withdrawal from oral corticosteroids. insulin glargine (Lantus)
20 units SQ, INJ, Qday
binds to receptors on sensitive cells. enhances peripheral glucose uptake and utilization and inhibits hepatic gluconeogenisis blood glucose
1. check bs periodically throughout the shift
2. check dose with another RN before administration
3. check for signs of hypoglycemia insulin lispro
1 unit, SQ, solution, TIDw/meals
1unit per 15g cho each meal
Lower blood glucose by stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. diabetes 1. check bs periodically throughout the shift
2. carefully count carbs so the right amount is being given
3. check for signs of hypoglycemia levofloxacin 750mg, PO, TAB, Q24hr
Inhibits bacterial DNA synthesis by inhibiting DNA gyrase
Cystic fibrosis do not give antacid products containing aluminum and magnesium or dairy products two hours before or two hours after levofloxacin administration
Don’t get it confused with levothyroxine
Assess pt for s/s of infection, making sure symptoms are getting better not worse
Encourage fluids to 1500-2000ml to prevent crystaluria
Assess pt for dizziness and drowsiness lortadine (Claritin)
10mg, PO, TAB, QDay
Antihistamine
Relief of symptoms of allergies
Maintain fluid intake of 1500-2000 mL/day to decrease viscosity of secretions.
May cause false negative result on allergy sin testing.
May cause dizziness or drowsiness. multivitamin 1 tablet PO, QDay
Therapeutic: nutritional
Action: used to supplement vitamins not consumed through diet.
Used for nutritional supplement
Monitor patient for Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue).
Do not take this medication with milk, other dairy products, calcium supplements, or antacids that contain calcium, it may make it difficult for your body to absorb some of the vitamins.
Inform patient of possible side effects such as: unpleasant taste, or upset stomach. omeprozole 20mg, PO, CAP, BID
Antiulcer agent/
Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH
Management of heartburn
Administer before meals.
Educate the patient that this medication is not for instant relief of heartburn. It is a maintenance drug.
Assess patient for blood in the stool or emesis.
Assess patient routinely for epigastric or abdominal pain.
pancrelipase, (Creon 24) 5 cap PO TID with meals
Contains lipolytic, amylolytic, and proteolytic acitivity. Increased digestion of fats, carbohydrates, and proteins in the GI tract
Cystic fibrosis
Administer right before or with meals or snacks
If pt cannot swallow whole pills, they can break apart the capsules and sprinkle onto food
Make sure pt is getting enough fats when taking this medicine, and give with plenty of water
Posaconazole (Noxafil)
400mg, PO, suspension, BID
Blocks ergosterol synthesis, a major component of fungal plasma membrane antifungus take with a full meal monitor for n/v check herbal meds for contraindications tobramycin (tobramycin injectable for cystic fibrosis)
500mg, IV Q24hr
Inhibits protein synthesis in bacteria at level of 30S ribosome
Cystic fibrosis
Assess for infection, or sputum getting worse, before and throughout therapy
Evaluate eighth cranial nerve function by audiometry before and throughout therapy for hearing loss
Monitor I & O and daily weight to assess hydration status and renal function vitamin E
200units, PO, Cap, QDay
Prevents the oxidation of other substances. Protects RBC membranes against hemolysis
Supplement
Administer with food or meals
Assess pt for signs and symptoms of vitamin E deficiency
Assess pt for signs and symptoms of overdose
prn meds
acetaminophen
325mg PO, TAB Q4hr prn pain/fever nonopoid analgesic pain/fever assess pain/fever, noting presence of diaphoresis, tachycardia, and malaise assess pain type, location and intensity prior to and after administrating monitor other medications, do not exceed 4000mg per day loratadine (Claritin)
10mg, PO, TAB, Qday prn as patient
Antihistamine
Relief of symptoms of allergies as patients condition necessitates
Maintain fluid intake of 1500-2000 mL/day to decrease viscosity of secretions.
May cause false negative result on allergy sin testing.
May cause dizziness or drowsiness. condition necessitates
ondansetron
4mg, PO, TAB, Q8hr, prn n/v
Blocks the effects of serotonin at 5-HT3 – receptor sites located in the vagal nerve terminals and the chemoreceptor trigger zone in the CNS. Therapeutic effects: decreases severity of nausea and vomiting following chemotherapy or surgery.
Prn Nausea/Vomiting
Assess patient for nausea and vomiting,
Assess patient for abdominal distention, and bowel sounds prior to and following administration.
Monitor patients for extrapyramidal effects (involuntary movements, facial grimacing, rigidity, shuffling walk, trembling hands) periodically throughout
therapy.
pseudoephedrine (Sudafed)
60mg PO, TAB, Q6hr prn congestion
Stimulates alpha and beta adrenergic receptors, produces vasoconstriction in the respiratory tract mucosa prn congestion
Assess pt. for congestion
Monitor bp during therapy
Assess lung sounds and character of bronchial secretions
Increases fluids
Nursing Diagnosis
Goals
Interventions
Rationale
Evaluation
Actual problems must contain:
1. Problem
2. Related to: (this is what caused the problem. Can’t be a medical diagnosis)
3. As evidenced by (this is from your assessment data).
Potential problems:
4. Problem
5. Related to
Short term: NSG 1705 defines this as what will happen on your shift
Long term: NSG 1705 defines this as what will happen after your shift
Goals must be realistic, achievable and measurable.
This is what this client/family will do.
The client will…
**Need one long & one
Low-level interventions expected at NSG 1355, but NOT at 1705 and above. For instance hand washing, use sterile technique & use universal precautions should not appear
This is what the nurse will do to assist this client to accomplish the goal.
The nurse will …
**Need 2 per goal**
Explanation of the interventions based on the individual client’s needs. NOT the generic client. Tell how the intervention will help this client accomplish the goal.
Tell what tool you will use to know whether or not the goal was met, what would you look for?
How will you know whether each goal was met?
NSG 1705 students cannot actually evaluate whether the goal was met because the care plan has not yet been implemented.
**Need 3** short** Inadequate nutrition, less than body requirements, as evidenced by him not eating secondary to cystic fibrosis
Short term: pt will take all necessary meds and eat a full lunch on 11/05/2012
Long term: pt will eat whenever he is hungry and have adequate nutrition as evidenced by his chemistry panel with no significant abnormals before discharge
1. pt will have lunch delivered with his meds
2. lunch will be brought in when pt is awake
1. pt will have plenty of snacks and food to eat in his room so that if he is hungry he will have something to eat
2. pt will have meals delivered whenever he is hungry, and is awake
1. because he has CF his body doesn’t process the nutrients as well as they should, some of his meds help with the digestion
2 if he is awake he is more likely to eat lunch
1 having things readily available for him to eat, makes it so if he is hungry he has something to eat
2 if he is awake, he is more likely to eat his meals
Short term: pt took at necessary meds, and at lunch on 11/05/2012
Long term: pt had adequate nutrition as evidenced by chemistry panel with no significant abnormals, before discharge
Fatigue related to not getting good rest as evidenced by patient verbalizing it, secondary to cystic fibrosis
Short term: pt will get 2-4 hours of rest on my shift on 11/05/2012
Long term: pt will feel rested and on her way to getting better by discharge
1.nurse will provide a quiet and comforting environment for the pt
2. nurse will coordinate all the care so that pt will all care will be done at the same time, or as close to the same time
1. nurse will leave pt alone if she is sleeping unless medically necessary
2. nurse will help keep pt as comfortable as possible
1. by providing a comforting and quiet place will make it easier for pt to sleep
2. by coordinating care it leaves more time that the pt is left alone to get as much rest as possible
1. waking up a patient to see if they need something is unnecessary if they are resting peacefully. Still check up on them, but don’t bother them
2. keeping the patient comfortable will help the patient relax and be able to get better rest
Short term: pt stated she got 3 hours of rest on my shift on 11/05/2012
Long term: pt stated she felt rested by discharge impaired gas exchange related to decreased lung function as evidenced by him being short of breath and coughing
short term: pt will keep his sats above 90% during my shift on 11/05/2012
Long term: pt will keep his sats above 90% without added oxygen by discharge
1. nurse to check on the pt every 2 hours to make sure O2 is on
2. nurse to make sure mask or nasal canula is as comfortable as possible and stays on
1. nurse will give meds on time to
2 nurse will take pt on walks around the hospital
1. if mask stays on then pt won’t be short of breath
2. if mask is comfortable, pt is less likely to take mask off
1 giving meds on time is important for the mucous build up to break down
2 being active will help decrease the mucous build up, which will help him breath better short term: pt kept his stats above 90% during my shift on 11/05/2012
long term: pt kept his stats above 90% on room air by discharge.