Nursing Care Plan

NURSING CARE PLAN

Nursing Assessment:
Ms. F.E. is a 20yr. old female who was involved in a motor vehicle accident (M.V.A.), and was admitted on 04.03.12 to the surgical unit with Spinal injuries, Polytrauma and fractured right humerus. She started complaining of severe abdominal pains, one week after assessment by Doctor, she was scheduled for emergency laparotomy with ?diagnosis Perforated Hallow Viscus. Following surgery patient was diagnosed with Fecal Peritonitis and was transferred to the Intensive Care Unit (I.C.U.), because her condition became critical. On 16.03.12, patient was scheduled for another laparotomy, for abdominal toileting and colostomy. Two chest tubes drains were left insitu in a paracolic area. Patient has nasogastric tube insitu for continuous drainage. Foley’s catheter is insitu on continuous drainage. IV fluids DNS 166mls/hr in progress via left hand.
Patient is conscious, but is maintained on mechanical ventilator and attached to cardiac monitor.
On 17.03.12 patient was extubated, but remained on continuous humidified O2 at 10L/min via facemask.

Physical Examination
T- 39.3 OC Skin: pale and moist
P- 150 bpm Pupils: 2/2
R- 15 bpm Reaction- RTL
B/P- 107/43 mmHg RBS- 101mg/dl
Midline abdominal incision, sutures dry and intact diagnostic Data
X-ray- chest, pelvic and spine
MRI
Electrolytes
Direct Bilirubin
Albumin
BUN Creatinine
DAY ONE 16-03-12: Patient is still intubated but is conscious and oriented

aSSESSMENT
Nursing Diagnosis
Outcome IDENTIFICATION/ Planning
Intervention
Evaluation
Subjective Data:
Patient indicated using her hands to signal that she in pain.

Objective Data:
Patient’s blood pressure increased,
Pulse rate increased. Patient’s facial expression showed that she’s in discomfort.
Alteration in comfort: Pain related to trauma manifested by patient moaning and expressing discomfort and increased pulse and blood pressure
Patient will experienced relief of pain as evidenced by:
- expressing relief using hand signs

- a change in the pulse and blood pressure ( within normal range)

- patient will be able to rest comfortable without discomfort

1. A comprehensive assessment of the patient’s pain was made which includes: location, severity on a scale of 1-10, duration, quality and precipitating factors of pain.

2. Reduce or eliminate factors that precipitate or increase the patient’s pain experience (e.g. fear, fatigue and lack of knowledge).

3. Patient was positioned properly to reduce discomfort caused by pain.

4. Simple relaxation therapies were used (e.g. music therapy, peaceful imaging and massage) before, after and if possible during certain procedures; before pain occurs or increases; and along with other pain relief measures.

5. Ms. F.E. was provided with optimal pain relief with prescribed analgesic.

6. Patient’s response to nursing interventions were documented.

The outcomes were partially met. The patient expressed pain and discomfort by showing hand signs or signals when she’s starting to experience pain during a procedure. Ms. F.E. uses her fingers to show if the pain is a 2 or 7 (on a scale of 1-10) before the administration of analgesics and 30 mins. following administration.
Ms. F.E. is willing to try relaxing techniques; however because of the workload in I.C.U. this is not always done.

ASSESSMENT
Nursing Diagnosis
Outcome IDENTIFICATION/ Planning
Intervention
Evaluation
Subjective Data:
Patient indicates that she’s uncomfortable and would like to be tidied.

Objective Data:
Patient’s facial expression showed signs of discomfort.

Self-care Deficit:
Bathing and Hygiene related to Polytrauma, fractured humerus, spinal cord injury and post operative wound as manifested by limited range of motion
Patient will:
1. Be able to assist in their self care.

2. Be able to express herself through signs and lip movements

3. Feel clean, tidy and refreshed.

4. Be able to rest comfortable to promote a faster recovery.

1. Requisites for self care needs were gathered, (soap, towels, a comb and clean gown, spatula, glycerin). The water temperature was tested by nurse (luke warm) and patient, by dipping her hands in the water.

2. Privacy was provided for hygiene care to promote client comfort and likeliness of assisting in hygiene care.

3. Patient was allowed to assist in her self-care, by using her uninjured hand to wipe her face.

4. Patient indicates what she wants done first through hand signs and lip movement.

5. Mouth care was done using a spatula and glycerin, to minimize injury while patient is intubated.

6. Bed bathing and changing of linens were done, while stabilizing patient’s hips and back to prevent further injury.

7. Encourage the client, who is reluctant to accept help, to express her feelings by writing them out on paper to communicate them with the healthcare team so that we may provide her emotional support as well as education in identifying her needs.
The outcomes were met as best they could.
Patient was anxious to have self care needs met, because of the inability to do so for herself, she felt very uncomfortable.
Ms. F.E. tried to assist in her care, but could not do much due to limited range of motion and pain. Patient did her best to communicate what she wanted done and was successful in using signs and lip movement to express herself.

ASSESSMENT
Nursing Diagnosis
Outcome IDENTIFICATION/ Planning
Intervention
Evaluation
Subjective Data:
Patient indicated that she’s not feeling well, through lip movement and hand signals

Objective Data:
Dry mucous membranes
Poor skin turgor
Weak peripheral pulses
V/S taken as follows:
BP – 80/45 mmHg
P – 145 bpm
R – 32bpm
T – 38oC

Fluid Volume Deficit related to Fluid shifts from extracellular, intravascular, and interstitial compartments into peritoneal space as manifested by, tachycardia, hypotension and decreased urinary output.
Patient will:
1. Show improved fluid balance as evidenced by adequate urinary output (50ml/hr).

2. Have stable vitals, (within acceptable range).
1. Monitor vital signs; note the presence of hypotension, tachycardia, tachypnea, fever. (record hourly vitals)

2. Maintain adequate intake and output. Include measured and estimated losses such as gastric suctioned, drains and dressings.
(measure and chart hourly input and output)

3. Measure urine specific gravity.

4. Observed skin and mucus membrane for dryness and turger. Note peripheral and sacral oedema.

5. Monitor laboratory studies: Hgb/Hct, electrolytes, protein, albumin, BUN, and Creatinine (Cr).

6. Administer plasma, blood, fluids, electrolytes, and diuretics, as indicated.

7. Maintain NPO status with nasogastric tube.
The outcomes were partially met. Patient showed improved signs of hydrations. Patient’s mucus membranes are pink and moist.
Patient’s urinary output increased to at least 50mls per hour.
Vitals improved, but not significantly. Blood pressure increased from 80/45 mmHg to 95/60mmHg and pulse rate decreased from 145bpm to 128bpm, respiration decreased from 32 bpm to 24bpm.

DAY TWO 17-03-12: Patient was extubated and placed on continuous humidified oxygen, she in conscious and oriented

ASSESSMENT
Nursing Diagnosis
Outcome IDENTIFICATION/ PLANNING
Intervention
Evaluation
Subjective Data:
Patient said that she’s feeling cold and sweaty.

Objective Data:
Patient’s skin is flushed and very warm to touch

Restlessness

Vital signs taken as follows: T: 39 oC
P: 102 bpm
R: 22 bpm
BP: 100/60 mmHg

Alteration in body temperature related to infection manifested by a temperature of 39oC.
Patient’s core temperature will be
Within normal range
(36-37 oC) within the 8 hours shift.

1. Patient’s temperature was assessed every hour.

2. Patient’s heart rate and rhythm were monitored.

3. Patient’s fluid intake and output were monitored and recorded.

4. Patient was tepid sponge to keep body cool.

5. Antipyretic medications such as; panadol 1g, were administered orally.

6. Patient’s vitals were remeasured. Patient’s temperature decreased to 37.6 oC.

7. Bed linens were changed and patient was made comfortable and leave to rest.
The outcomes were met.
Within the 8 hrs. shift,
The patient was able to maintain core temperature within normal range. The temperature decreased from 39oC to 37.6 oC.

ASSESSMENT
Nursing Diagnosis
Outcome IDENTIFICATION/ PLANNING
Intervention
Evaluation
Objective Data:
Some parts on the patient skin appeared red especially the patient’s back. During tidying the areas noted was tender and patient showed discomfort while cleansing those areas.

Risk for impaired skin integrity related to prolong lying in one position manifested by redness and irritation
The client will maintain tissue integrity as evidenced by: absence of redness and irritation no skin breakdown.

1. Patient’s skin was assessed, especially the bony prominences and dependent areas, for pallor, redness, and breakdown.

2. The affected areas were massaged to increase circulation in those areas.

3. Patient was assisted to turn at least every 4 hours using the log-roll method prevent further injury to the spine.

4. Patient was positioned properly; using pressure-reducing or pressure-relieving devices (e.g. pillows, foam cushions)

5. Powder was applied to potential areas for breakdown, such as under breast, neck, back and axillae to keep the areas dry and free from tissue breakdown.

6. Patient’s skin was kept cleaned and was thoroughly dried after bathing, paying special attention to skin folds and opposing skin surfaces (e.g. axillae, perineum, beneath breasts).

7. Patient’s bed linens were changed after every bed bathing, and were kept dry and wrinkled free to prevent shear force or friction.

Patient’s goals were partially met.
Patient was turned after every bed bathing and on every shift to decrease potential for skin breakdown, while using the log-roll method. This is to prevent further injury to the spine.

ASSESSMENT
Nursing Diagnosis
Outcome IDENTIFICATION/ PLANNING
Intervention
Evaluation

Subjected Data:
Patietn complained anxiousness about a procedure to be done on the ward. Pateint said that she is nervous and would like to know what the procedure is about

Objective Data:
Pain appears nervous, restless.

Anxiety related to knowledge about procedure/surgery manifested by restlessness, inability to cope
The patient will demonstrate a decrease in anxiety as evidence by:

A reduction in restlessness, emotional, and/or inability to cope with anxiety.

Verbalization of relief of anxiety.

Discuss effective coping mechanisms for dealing with anxiety.

Patient was assisted to reduce the present level of anxiety by:

Providing reassurance and comfort.
Staying with person.
Not making demands
Speaking slowly and calmly.
Attending to physical symptoms.

Patient was given clear, concise explanations regarding impending procedures.

Focus was made on present situation.

Patient’s past coping strategies were identified and reinforced

The advantages and disadvantages of existing coping methods were discussed with the patient.

Strategies for handling anxiety such as relaxation techniques (music therapy) were discussed with the patient.

The outcomes were partially met. The patient was trying her best to cope giving the situations, but because of her vulnerability at this point and after having three previous surgeries, she is still nervous and worried about what will happen after the next operation. That is, will things improve or get worse for her.