Appendectomy Nursing Care Plan

Nursing Care Plan Med/Surg Student Name Demographics Room # 315 Gender Female Age 79 Code Status DNR Allergies none Day of Admission 10/12/19 Diet Soft diet Activity Ambulatory with walker Emergency Department Presentation/Chief Complaint On Admission Primary Diagnosis on Admission Weakness and lethargy after taking abx for 2 days for UTI. Pt has suprapubic catheter. Medical History GERD, a fib, bladder spasms, UTI, severe sepsis r/t ARF, metabolic acidosis, resistant to Cipro, ARF likely 2/2 dehydration, lost 20-30 lbs, chronic pain, L hydronephrosis Surgical History Appendectomy Admission summary (HPI) Verbatim Not obtained Primary problem on day of care (if different than diagnosis) Weakness and lethargy after taking abx for 2 days for UTI. Pt has suprapubic catheter. Vital Signs Time 0800 Temp 98 degrees F 97.7 degrees F 1107 P 75 bpm 77 bpm RR 20 rpm 18 rpm BP 125/65 mmHg 132/67 mmHg O2 sat 97% 100% O2 delivery method & flow rate. RA RA discharged 2 Pain 9/10 4/10 Pain location LUQ LUQ Intake Enteral  Oral  Tube Parenteral Other Total Output Urine Chest Tube NG Drains Other Total 720mL 600mL Relevant Provider Orders Listed in Priority for Day of Care (minimum of 3) Order Rationale switch from IV amiodarone 450mg Normal sinus rhythm for 24 hrs, getÝng discharged +dextrose 5% in H20 500mL to amiodarone 400mg PO discharge Pt feels less fatigued, has normal sinus rhythm for 24 hours, UTI is cleared Assessment Data Relevant Basic Conditioning Factors Primary Language: English Family System: lives with daughter Religion: none Socio-Cultural Factors: used to smoke, daughter smokes, alcohol use, no substance abuse Environmental Factors: fall risk, lives in Escondido Erikson’s Developmental Stage: integrity vs despair- pt is dissatisfied with medical problems but is overall happy with her life Patterns of Living at Home: daughter helps her with ADLs, daughter will remind her to walk with walker qh 3 Healthcare Insurance: Not obtained Ht/Wt/BMI Behavior HEENT Neurological Cardiovascular Respiratory GI GU Musculoskeletal Skin Pain IV Site Focused Assessment Not obtained cooperative, calm PERRLA, EOMI, oropharynx clear and moist, neck supple, no JVD, tenting, trachea midline without deviation AOx3, reflexes intact, facial symmetry, appropriate eye contact S1, S2, normal sinus rhythm, weak pulse, cap refill <3 sec, 125/65 mmHg, 75 bpm (0800), 132/67mmHg, 77 bpm (1107), radial pulses 2+ Lung fields clear to auscultation, no SOB, no labored breathing, 20 rpm, 97% RA (0800), 18rpm, 100% RA (1107) BSx4, soft abd, no organomegaly, no rigidity, no rebound, last BM 10/17 UTI, suprapubic catheter-600mL void, no distended bladder BLE pedal/ankle edema, generalized weakness, ambulatory /c walker Bruises on extremities, warm, pink, tenting, skin color appropriate to Caucasian ethnicity 9/10 LUQ Assess IV line R arm 20 gauge, assess urinalysis and WBC for evidence of infection, assess level of fatigue, assess cardiac rhythm on EKG Braden Risk Assessment Scale Description Sensory/Mental Moisture Activity Mobility Nutrition Friction/Shear Point s 4 4 3 3 3 2 No impairment Rarely moist Walks occasionally Slightly limited Adequate Potential problem Total & Risk 19 No risk History of falls Point s 0 Morse Fall Scale Description No Intervention for area of risk Assist with ambulation Assist with ambulation Encourage to eat more Sacral foam, bilateral heel foam, assist with movement in bed Intervention for area of risk 4 2nd diagnosis Ambulatory aid IV/saline lock 15 15 20 Yes Yes-walker Yes Gait/Transfer Mental status Total & Risk 20 0 70 Impaired Understands limitations High risk Pt is weak, stand-by assist Stand-by assist Make sure IV line is not tangled, move the pole when patient is ambulatory Walker, weak Stand-by assist with ambulation Orem Self-Care Requisites (Only the unmet and partially met needs) (FULL for 201/301) Universal self-care requisites (USCR) 1. Maintain balance between activity and rest. 2. Maintain balance between solitude and social interaction. Needs met, partially met, or unmet Met Explanation Partially met 3. Promotion of normalcy in function and development. Partially met Pt lives with daughter, had daughter with her in the hospital, does not have much social interaction other than daughter Pt is able to ambulate on her own, needs some assistance with ADLs Developmental self-care requisites (DSCR) 1. Maturational: changing needs associated with development. Needs met, partially met, or unmet Met Health deviation self-care requisites (HDSCR) 1. Awareness of care and pathologic conditions Needs met, partially met, or unmet Partially met Pt is ambulatory with walker Explanation Lives with daughter, daughter assists her when necessary, walks with walker Explanation Pt is aware of conditions however does not understand her chronic GERD, could use teaching Labs (Related To Current Medical Diagnosis With Attention To Trends And Abnormal) Lab Value Date WBC Normal Range 4.5-11.0 x 10^3mm3 Prior 5.9 x 10^3mm3 Day of Care 10/16/19 Trend Rationale and/or action for abnormal value 5 RBC Hgb Hct Platelets 4.7-6.1 x 10^6/mm3 13.5-17.5 g/dL 45-52% 150-450 x 10^3/mm3 2.51 x 10^6/mm3 7.7 g/dL Low ARF Low ARF 23.4% 196 x 10^3/mm3 Low ARF 135145mmol/ L 3.5-5.1 mmol/L 96106mEq/L 7-20mg/dL 0.61.2mg/dL <100mg/dL 140mmol/L High High ARF ARF Low ARF Low ARF ARF Neutrophil bands % Neutr/segs % PT PTT INR Chemistry Na K Cl BUN Cr Gluc ose Ca 910.5mg/dL 1.7-2.2 Mg Phosphate Albumin 3.4-5.4g/dL Total protein HgA1c 4-5.6% Liver/Pancreas ALT 7-56 units/L AST 10-40 units/L Ammonia Bilirubin <0.3mg/dL Amylase Lipase Cardiac Troponin BNP <125 pg/mL CK CRP 4.1mmol/L 106mEq/L 27mg/dL 1.9mg/dL 70mg/dL 7.1mg/dL 2.2 mg/dL 1.5g/dL 5.1% 10/13/19 66 units/L 10/13/19 high <6 units/L 10/13/19 low 0.3mg/dL 10/13/19 378 pg/mL 10/13/19 High A fib 6 Point of Care Testing Time Test Value Rationale and/or action for abnormal value N/A Misc. Laboratory and Diagnostic Tests Urine/fecal Urinalysis Fecal/Occult blood Date N/A N/A Results Microbiology Culture (stool) 10/13/19 Negative c.diff Diagnostic Test Chest x-ray EKG CT/MRI Renal ultrasound 10/12/19 L hydronephrosis 7 Medications Administration Record Scheduled Medication TIME DOSE/ ROUTE 81mg qPM PO Pharm or Thera. class Thera: antipyretics, nonopioid analgesics Pharm: salicylates REASON Analgesia, a fib, decreased risk of TIA and MI Major SIDE EFFECTS GI bleeding, anaphylaxis, epigastric distress, dyspepsia, tinnitus Aspirin 2100 Atorvastatin (Lipitor) 2100 40mg PO tab qday Famotidine (Pepcid) 1700 20mg PO tab AC qdinner Pantoprazol e (Protonix) 0800 40mg PO AC qBreakfast/D inner Thera: GERD, healing antiulcer esophagitis and agents duodenal ulcers Pharm: proton pump inhibitors Headache, nasopharyngitis, tiredness, NVD, c. diff associated diarrhea, hyperglycemia Piperacillin (Zosyn) 1600 3.375 g IVPB q12h Thera: antiinfectives Pharm: Seizures, c. diff associated diarrhea, serum sickness, anaphylaxis Thera: lipidlowering agent Pharm: hmg coa reductase inhibitors Thera: antiulcer agents Pharm: histamine h2 antagonists Lowering total and LDL cholesterol, reduces risk of MI and stroke, slows progression of atherosclerosis GERD treatment, decreased gastric acid UTI Rhabdomyolysis, abdominal cramps, constipation, heartburn, angioneurotic edema Arrhythmias, aplastic anemia, agranulocytosis, confusion Nursing Implications -Assess pain in terms of location, type, and intensity -Monitor hepatic function -Monitor onset of headache, tinnitus, hyperventilation, mental confusion, or agitation -Obtain a diet hx -Monitor liver function tests -If muscle tenderness develops, monitor CPK levels -Assess for abdominal pain and frank or occult blood in the stool -Assess for confusion -May cause increase in serum creatinine and serum transaminases -Monitor B12, Mg, liver function, renal function -Assess for abdominal or epigastric pain -May increase AST, ALT, bilirubin, and alkaline phosphatase -Assess for rash, edema, ulcerations, or inflamed eyes -Assess for anaphylaxis 8 Tazobactam (Zerbaxa) 1600 50 mL IVPB in NaCl Potassium 0800 PO TID packet Trazodone (Oleptro) 2100 300mg PO tab qbedtime Apixaban (Eliquis) 0800 2.5 mg tab PO bid Fentanyl (Duragesic) Last given 10/16 /19 1200) 25mcg/hr patch q72 hr extended spectrum penicillin Thera: antiinfectives Pharm: cephalosporin derivatives, beta lactamase inhibitors Thera: mineral and electrolyte replacements/ supplements UTI C. diff associated diarrhea, anaphylaxis, diarrhea Replacement, prevention of deficiency Arrythmias, abdominal pain, flatulence, confusion, restlessness Thera: antidepressan ts Antidepressant action Suicidal thoughts, confusion, drowsiness, hypotension, dry mouth Thera; anticoagulants Pharm: factor xa inhibitors Thera: opioid analgesics Pharm: opioid agonists Treatment and prevention of thromboembolic events Decreased pain, supplement in anesthesia Bleeding, anaphylaxis Apnea, facial itching, laryngospasm, arrhythmias, bradycardia -Monitor for diarrhea, fever, blood stools, or abdominal cramping -Assess for rash, laryngeal edema, wheezing, pruritus -Monitor bowel function -Obtain specimen for culture and sensitivity -Assess for infection -Assess for hypokalemia (fatigue, weakness, polydipsia, polyuria) -Assess for hyperkalemia (slow, irregular heartbeat, muscle weakness, paresthesia) -Assess for serotonin syndrome (hallucinations, mental changes, coma, agitation) -Assess for suicidal tendencies -Monitory pulse and blood pressure before and during therapy -Assess for symptoms of DVT, stroke, PVD -Monitor BP and respiratory rate -Assess fall risk and implement prevention strategies -Assess location, type, and 9 Amiodarone (Nexterone) PRN Medication N/A 1130 Freq 400mg PO Thera: antiarrhythmi cs DOSE/ ROUTE Pharm or Thera. class Suppression of arrhythmias REASON Pulmonary fibrosis, adult respiratory distress syndrome, HF, worsening of arrythmias, toxic epidermal necrolysis, fatigue, corneal microdeposits, hypotension Major SIDE EFFECTS intensity of pain -Monitor ECG during therapy -Assess for pulmonary toxicity (crackles/rales, decreased breath sounds, cough, dyspnea, fatigue) -Assess for neurotoxicity (muscle weakness, ataxia, numbness or tingling in fingers and toes) Nursing Implications (Vallerand, Sanoski, & Quiring, 2019) IV Fluids Amiodaron e (Nexterone ) Time 10/16/19 DOSE/ROUTE 450mg + dextrose 5% in H2O 500mL REASON Suppression of arrhythmias Major SIDE EFFECTS Pulmonary fibrosis, adult respiratory distress syndrome, HF, worsening of arrythmias, toxic epidermal necrolysis, fatigue, corneal microdeposits, hypotension Nursing Implications -Discontinued at 1130, switched to amiodarone 400mg PO -Monitor ECG during therapy -Assess for pulmonary toxicity (crackles/rales, decreased breath sounds, cough, dyspnea, fatigue) -Assess for neurotoxicity (muscle weakness, ataxia, numbness or tingling in fingers and toes) 10 Water and electrolytes and alkalizing agent Lactated ringers 0800 (Vallerand et al, 2019) 1000mL, 50mL/hr Abdominal pain, convulsions, cough, loss of appetite, nervousness, sweating, dyspnea -Monitor for fluid overload -Monitor for impaired renal function -Monitor heart rate and bp during therapy 11 Pathophysiology: Focus on Primary Diagnosis with explanation of effect of co-morbidities on patient recovery (paraphrase in your own words with a citation) (500 word count limit) A urinary tract infection (UTI) is an infection anywhere in the urinary tract. Lower urinary tract infections include urethritis, inflammation in the urethra, cystitis, inflammation in the bladder, and prostatitis, inflammation in the prostate. Upper urinary tract infections include pyelonephritis, inflammation in the kidneys, and glomerulonephritis, inflammation in the glomerulus. Pathogens move into the urethra due to irritation, trauma, urinary tract obstruction, small output or infrequent voiding, or sexual intercourse. Catheters are also a main cause of UTIs in the hospital setÝng. UTIs are caused by pathogens invading the host. The most common pathogen that causes UTIs are Escherichia Coli. An immunocompromised host is more susceptible to UTIs. UTIs are categorized as uncomplicated or complicated. Uncomplicated infections mean that there is no functional or anatomical abnormality in the urinary tract, and it usually occurs in an otherwise healthy individual. Complicated UTIs, on the other hand, are associated with obstruction, renal insufÏciency, and immunosuppression. Complicated UTIs take a longer treatment of antibiotics to clear. Comorbidities such as diabetes mellitus, chronic obstruction, immunosuppression, and nephrolithiasis can increase the likelihood of resistant pathogens and make treatment more complicated. The patient has a complicated UTI, because she as acute renal failure, making her infection more difÏcult to treat. She was brought in for weakness and lethargy after taking abx for 2 days for her UTI, which could be indicative of more serious complications. Testing showed her WBC had returned to normal range, indicating her treatment was working and the infection had cleared. If a UTI is not controlled, however, the infection can travel to the bloodstream and lead to severe sepsis (Ignatavicius & Workman, 2016). Critical Thinking 1. What is your patient’s primary diagnosis or problem for the day? Weakness and lethargy after taking abx for 2 days for UTI. 2. What are the important assessments to make? WBC, assess catheter, vital signs, suprapubic tenderness or flank pain, hydration status (skin turgor, I&O), changes in mental status, CVA tenderness, assess urine, bladder distension (Ignatavicius & Workman, 2016). 3. What could go wrong with your patient today? Urosepsis, urethritis, cystitis, pyelonephritis, glomerulonephritis, fever, tachycardia, tachypnea, dehydration, confusion, increased weakness and lethargy, urine abnormalities (foul odor, cloudiness, blood, sediment) (Ignatavicius & Workman, 2016). 4. How might you prevent/intervene with your patient if this occurs? 12 Increase fluid intake to maintain diluted urine, drink cranberry juice because it decreases the ability of the bacteria to adhere to the cells in the urinary tract, administer prescribed analgesics and antibiotics (Ignatavicius & Workman, 2016). 5. What orders might you expect the physician to order if this problem were to occur? Urinalysis to see WBC and RBC in urine, urine culture to see the type of bacteria and colonies in urine, pelvic ultrasound to see if there is an obstruction of urine out flow, cystoscopy to see abnormalities such as urethra strictures, bladder calculi, foreign bodies, and bladder diverticula, antibiotics to treat the infection, analgesics for pain (Ignatavicius & Workman, 2016). 13 Nursing Diagnosis: 3 NANDAs. NANDA Subjective / Objective Data and subjective 1. Fatigue r/t physiological condition secondary to urinary tract infection AEB pt has generalized weakness, and a hx of ARF and a fib, and pt states she feels weakness and fatigue after taking abx for 2 days for UTI Subjective: pt feels weakness and fatigue after taking abx for 2 days for UTI Objective: generalized Goal/Expected Outcome (appropriate and measurable) Nursing Interventions and Rationales 1. Patient will create a planned 1a. Review medications to exercise routine before determine if side effects discharge. could cause fatigue. The aging process changes the way an individual absorbs, metabolizes, and eliminates medications, leaving the geriatric client susceptible to medication side effects, and medication interactions that can cause fatigue, especially when multiple medications are prescribed (Rich & Nienaber, 2014, as cited in Ackley, Ladwig, & Makic, 2017). 1b. Create a planned exercise routine. Physical activity has been associated with better quality of life, including improved functioning in both physical and social realms (Fong et al, 2012, as cited in Ackley et al, 2017). 1c. Encourage client to keep Evaluation of Patient Response 1. Met: Client reports that she will walk across the hall and back with walker qh. Her daughter said that she helps encourage the client to move qh, which the client reports helps keep her accountable. 14 weakness, hx of ARF and a fib 2. a journal of activities that increase symptoms of fatigue, relieve symptoms of fatigue, and what activities the fatigue has an effect on. Clients who feel as if they have control over their fatigue and its impact on their lives have lower levels of fatigue (Primdahl et al, 2011, as cited in Ackley, et al, 2017). 1. Subjective: Objective: 3. Subjective: Objective: 1a. 1. 1b. 1c 1. 1a. 1. 1b. 1c 60 Point Final NCP: 3 NANDA; 1 goal/expected outcome for each; 3 interventions & rationales for each; 1 evaluation of patient response for the goal/expected outcome. Mimi NCP: Write to most important: 1 NANDA, 1 goal/expected outcome for each; 3 interventions & rationales for each; 1 evaluation of patient response for the goal/expected outcome.