Nur 412: Case Study Plan Of Care
NUR 412
PLAN OF CARE
Nursing Problem
Interventions (Minimum of 3)
(with rationales)
Evaluation
Problem statement: Aspiration precaution.
Related to: Feeding/trach
As manifested by: PEG tube and tracheostomy
Expected Outcome: Pt. will not experience any aspiration episodes while in the hospital.
Problem statement: Risk for infection
Related to: Foley cath
As manifested by: erosion to urethral site
Expected Outcome: Pt. will not have infection while in the hospital
..HOB elevated 35 degrees.(gravity will help keep food down)
..Check residual. (Tells if the medication/food is being passed.
..Hold feed for care and turning. (laying the pt. flat changes gravity and the stomach content ability to aspirate) …show more content…
..Monitor WBC. (rise in WBC may indicate infection and early intervention can be taken)
..Apply Bacitracin ointment as order (Bacitracin is used as a prophylactic to prevent infection at site)
..Keep site clean and dry. (Wet and dirty areas can be a reservoir for bacterial growth)
Pt. did not experience any episode of aspiration.
Pt.
did not experience any infection while in the hospital.
NUR 412
WEEKLY PATIENT ASSESSMENT GUIDE (include your head to toe physical assessment in addition to information obtained from patient and medical record)
Neurological status/ sensory status/ pain/ orientation/ teaching learning readiness/ communication style
Pt. is alert but not oriented. Pt. is does not respond to verbal response but respond to tactile stimuli. Pt. is nonverbal and cannot express pain level, communication is difficult.
Oxygenation level/ respiratory assessment/ aspiration risk
Pt. o2 level is 100%, pt. has tracheostomy. Pt. appears to have difficulty breathing as evidenced by thick mucus production and rhoni noted bilaterally Pt. has high aspiration risk due to feeding/trach.
Cardiac Rhythm /Circulation & pulses/ IV’s/ fluid volume …show more content…
status
Pt.
is on cardiac monitor, B/P=138/48 and pulse 86. Pulses noted to be 2+. RRR, no gallops, no present edema
Abdominal assessment Nutrition/ oral health, dentures/ weight & BMI/ diet amt consumed/emesis
BS present in all 4 quadrants, pt. is on diabetic diet, wt. 68.6kg. PEG tube, clean and intact. There is no evidence of emesis and pt. is tolerating tube feeding well, on 18hrs isosource.
Elimination/ continence/ urine & stool color, amt, odor/ drains output color, odor
Urine output: 300 light yellow and clear, no odor unusual via Foley cath, bowel movement x2. No drains noted.
Mobility/ Activity
Exercise
Pt. is immobile and cannot participate in active nor passive ROM without assistance
Skin/Wound care/ Dressings/Protection/ Safety
Pt. has a stage two sacral ulcer and a healing stage two ulcer on left ankle. Duaderm is intact and no sign of drainage noted.
Psychosocial/spiritual/ growth & development level/ sleep- wake pattern
Pt. is non-verbal- cannot assist psychosocial or spiritual, sleep wake pattern details.
Client Data Sheet (Weekly)
NUR 412
PHARMACOLOGICAL RECORD (Weekly)
Medications:
Generic/Brand Name
Dose
Route
Frequency
Reason this client receiving med
Assessment of response to med
Toprol XL
25mg
PEG
Q10am
Treat
hypertension
No adverse reaction noted
Atrovent HFA
1 PUF
Inhalation
Q6h
Assist with breathing
No adverse reaction noted
Ferrous sulfate
300mg
PEG
Q8h
Treat anemia
No adverse reaction noted
Folic acid
1mg
PEG
Q10am
Treat anemia
No adverse reaction noted
Zinc sulfate
220mg
PEG
Q12h
Treat zinc deficiency
No adverse reaction noted
Carafate
1gm
PEG
Q8h
Prevent ulcers
No adverse reaction noted
Colace
100mg
PEG
Q8h
Relieve constipation
No adverse reaction noted
Bacitracin ointment
1 apl
Affected area
Q12h
Prevent infection on urethral erosion
No adverse reaction noted
Ascorbic acid
250mg
PEG
10A-10P
Decrease severity of colds
No adverse reaction noted
Multivitamin-mineral
1 tab
PEG
Q10am
Vitamin therapy
No adverse reaction noted
Pantoprazole
40mg
PEG
Q10am
Prevent ulcers
No adverse reaction noted
Baclofen
10mg
PEG
10-2-6/daily
Muscle relaxant
No adverse reaction noted
Senna
8.8mg
PEG
Q11pm
Treat constipation
No adverse reaction noted
Water
250mg
PEG
6A-2-10P
Prevent dehydration
No adverse reaction noted
Heparin sodium
5000u
Subq
Q8H
Prophylaxis to prevent DVT
No adverse reaction noted
Levothyroxine sodium
112 mcg
PEG
Q6am
For hypothyroidism
No adverse reaction noted
PLAN OF CARE
Nursing Problem
Interventions (Minimum of 3)
(with rationales)
Evaluation
Problem statement: Aspiration precaution.
Related to: Feeding/trach
As manifested by: PEG tube and tracheostomy
Expected Outcome: Pt. will not experience any aspiration episodes while in the hospital.
Problem statement: Risk for infection
Related to: Foley cath
As manifested by: erosion to urethral site
Expected Outcome: Pt. will not have infection while in the hospital
..HOB elevated 35 degrees.(gravity will help keep food down)
..Check residual. (Tells if the medication/food is being passed.
..Hold feed for care and turning. (laying the pt. flat changes gravity and the stomach content ability to aspirate) …show more content…
..Monitor WBC. (rise in WBC may indicate infection and early intervention can be taken)
..Apply Bacitracin ointment as order (Bacitracin is used as a prophylactic to prevent infection at site)
..Keep site clean and dry. (Wet and dirty areas can be a reservoir for bacterial growth)
Pt. did not experience any episode of aspiration.
Pt.
did not experience any infection while in the hospital.
NUR 412
WEEKLY PATIENT ASSESSMENT GUIDE (include your head to toe physical assessment in addition to information obtained from patient and medical record)
Neurological status/ sensory status/ pain/ orientation/ teaching learning readiness/ communication style
Pt. is alert but not oriented. Pt. is does not respond to verbal response but respond to tactile stimuli. Pt. is nonverbal and cannot express pain level, communication is difficult.
Oxygenation level/ respiratory assessment/ aspiration risk
Pt. o2 level is 100%, pt. has tracheostomy. Pt. appears to have difficulty breathing as evidenced by thick mucus production and rhoni noted bilaterally Pt. has high aspiration risk due to feeding/trach.
Cardiac Rhythm /Circulation & pulses/ IV’s/ fluid volume …show more content…
status
Pt.
is on cardiac monitor, B/P=138/48 and pulse 86. Pulses noted to be 2+. RRR, no gallops, no present edema
Abdominal assessment Nutrition/ oral health, dentures/ weight & BMI/ diet amt consumed/emesis
BS present in all 4 quadrants, pt. is on diabetic diet, wt. 68.6kg. PEG tube, clean and intact. There is no evidence of emesis and pt. is tolerating tube feeding well, on 18hrs isosource.
Elimination/ continence/ urine & stool color, amt, odor/ drains output color, odor
Urine output: 300 light yellow and clear, no odor unusual via Foley cath, bowel movement x2. No drains noted.
Mobility/ Activity
Exercise
Pt. is immobile and cannot participate in active nor passive ROM without assistance
Skin/Wound care/ Dressings/Protection/ Safety
Pt. has a stage two sacral ulcer and a healing stage two ulcer on left ankle. Duaderm is intact and no sign of drainage noted.
Psychosocial/spiritual/ growth & development level/ sleep- wake pattern
Pt. is non-verbal- cannot assist psychosocial or spiritual, sleep wake pattern details.
Client Data Sheet (Weekly)
NUR 412
PHARMACOLOGICAL RECORD (Weekly)
Medications:
Generic/Brand Name
Dose
Route
Frequency
Reason this client receiving med
Assessment of response to med
Toprol XL
25mg
PEG
Q10am
Treat
hypertension
No adverse reaction noted
Atrovent HFA
1 PUF
Inhalation
Q6h
Assist with breathing
No adverse reaction noted
Ferrous sulfate
300mg
PEG
Q8h
Treat anemia
No adverse reaction noted
Folic acid
1mg
PEG
Q10am
Treat anemia
No adverse reaction noted
Zinc sulfate
220mg
PEG
Q12h
Treat zinc deficiency
No adverse reaction noted
Carafate
1gm
PEG
Q8h
Prevent ulcers
No adverse reaction noted
Colace
100mg
PEG
Q8h
Relieve constipation
No adverse reaction noted
Bacitracin ointment
1 apl
Affected area
Q12h
Prevent infection on urethral erosion
No adverse reaction noted
Ascorbic acid
250mg
PEG
10A-10P
Decrease severity of colds
No adverse reaction noted
Multivitamin-mineral
1 tab
PEG
Q10am
Vitamin therapy
No adverse reaction noted
Pantoprazole
40mg
PEG
Q10am
Prevent ulcers
No adverse reaction noted
Baclofen
10mg
PEG
10-2-6/daily
Muscle relaxant
No adverse reaction noted
Senna
8.8mg
PEG
Q11pm
Treat constipation
No adverse reaction noted
Water
250mg
PEG
6A-2-10P
Prevent dehydration
No adverse reaction noted
Heparin sodium
5000u
Subq
Q8H
Prophylaxis to prevent DVT
No adverse reaction noted
Levothyroxine sodium
112 mcg
PEG
Q6am
For hypothyroidism
No adverse reaction noted