NURSING CARE PLAN TEMPLATE Student Date Instructor Course Unit/ Room# Patient Initial DOB Height/Weight 160 cm /60 Kg Code Status full code Allergies Ibuprofen Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10 101F 110 BPM 32 BPM 88% ORA 90/55 - History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with Evidence Based Citations Chief Complaint shortness of breath at rest, wet cough with thick yellow sputum x 2 days, temperature of 101.5F orally x 1 day, fatigue, lethargy, and new onset confusion. HPI • • Respiratory –shortness of breath, wet cough with thick yellow sputum. Normal: Clear to auscultation bilaterally. Central Nervous System - fever, confusion, lethargy Normal : awake alert oriented x4 (Carol Lynn Cox, 2019) Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations Normal • Head and Neck - WDL : Nonicteric sclerae, PERRLA, EOMI. Oropharynx clear. Moist mucous membranes. Conjunctivae appear well perfused. • Gastrointestinal - WDL - Normal active bowl sound • Urogenital - WDL - Condition of skin ,Distribution and any unusual characteristics of pubic hair, Swelling, Discharge, circumcised or not, size of scrotum • Musculoskeletal - WDL - assess all 4 extremities to determine muscle strength. • Psychiatric - WDL • Social – WDL - Clothing and hygiene, Level of consciousness, Body size, Posture Abnormal • Vital sign - Temp 101, Pulse:110BPM, RR32BPM, pulse Ox 88% BP 90/55 - Normal range :Temp 98.6, pulse 60-100 respirations 12-20, blood pressure 120/70 room air pulse ox 95%-100% • Respiratory –struggling to breath, right lower lung sounds diminished on auscultation, consistent cough with loose yellow thick secretions, Plus Ox-88% ORA- Abnormal breath sounds heard when listening to the chest. Adventitious sounds may include crackles or rales, rhonchi or wheezes, or pleural friction rubs. Normal: Clear to auscultation bilaterally. • Cardiovascular – weak upper and lower extremity pulses - Normal: S1& S2 regular rhythm , The chest should expand equally on both sides with normal breathing. • Central Nervous System - confusion-, fever - Normal : awake alert oriented x4 • Endocrine- WDL - lethargy, fatigue • Integumentary - pale - Normal: Skin should be smooth, unbroken, uniform color, warm, and resilient, Turgor (Carol Lynn Cox, 2019) NURSING CARE PLAN TEMPLATE Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges), include dates and rationales supported with Evidence Based Citations Past Medical & Surgical History, Pathophysiology of medical diagnoses (include dates, if not found state so) Supported with Evidence Based Citations NURSING CARE PLAN TEMPLATE Pertinent Labs Sputum culture: gram negative bacilli in clusters - Collection is often necessary to determine theetiology of disease, type of organisms, and sensitivity to antibi-otics. Serial sputum studies may be necessary to determine response to treatment (Doenges, Moorhouse, & Murr, 2014) Blood culture: no growth (Normal) - Determines presence of infection. (Doenges, Moorhouse, & Murr, 2014) CXR: white opacities in right lower lung- Evaluates organs and structures within the chest.Confirms the diagnosis of pneumonia; Normal: no evidence of cardiac and plural disease (Doenges, Moorhouse, & Murr, 2014) PMH Stroke - In medicine, a loss of blood flow to part of the brain, which damages brain tissue. gastroesophageal reflux disease (GERD): Information on the gastroesophageal reflux condition. Covers what it is, how it occurs, common treatments, and self-care advice. Hypertension - High blood pressure : Blood pressure is the pressure of blood pushing against the walls of your arteries. Arteries carry blood from your heart to other parts of your body. hypothyroidism - Hypothyroidism is the most common type of thyroid disorder. It means your thyroid gland is not active enough. This tiny gland is found in the front of your neck. Its job is to make thyroid hormone. If the gland is underactive, it may not make enough thyroid hormone. Thyroid hormones control how your body uses energy. They affect almost every organ in your body. When your thyroid doesn’t make enough of these hormones, parts of your body slow down. recurrent pneumonia - Pneumonia is an infection of one or both of the lungs caused by bacteria, viruses, or fungi. It is a serious infection in which the air sacs fill with pus and other liquid. MI - heart attack (myocardial infarction) happens when one or more areas of the heart muscle don't get enough oxygen. This happens when blood flow to the heart muscle is blocked. CBC: WBC 15K per microliter of blood - Battery of screening tests that typically includes hemoglobin (Hgb); hematocrit (Hct); red blood cell (RBC) count, morphology, indices, and distribution width index; platelet count and size; white blood cell (WBC)count and differential. Provides baseline data about the hemato-logic system and yields information related to oxygen-carryingcapacity and infection. Normal range: 4,500 to 10,000 cells/mcL (Doenges, Moorhouse, & Murr, 2014) PSH CMP: K 3.2meq/L- A comprehensive metabolic panel is a group of blood tests. They provide an overall picture of your body's chemical balance and metabolism. Metabolism refers to all the physical and chemical processes in the body that use energy.Normal range: 3.7 to 5.2 mEq/L (3.70 to 5.20 mmol/L) (Doenges, Moorhouse, & Murr, 2014) ABG (arterial blood gas): ph 7.1 and PCO2 50-Measure oxygen and carbondioxide levels to rule out hypoxemia or hypercapnia. Normal range: Arterial blood pH: 7.38 to 7.42 PCO2: 35-45. (Doenges, Moorhouse, & Murr, 2014) Myocardial infarction with CABG(coronary artery bypass graft) pacemaker - Coronary artery bypass graft surgery (CABG) is a procedure used to treat coronary artery disease. Coronary artery disease (CAD) is the narrowing of the coronary arteries – the blood vessels that supply oxygen and nutrients to the heart muscle. CAD is caused by a build-up of fatty material within the walls of the arteries. This build-up narrows the inside of the arteries, limiting the supply of oxygen-rich blood to the heart muscle. right hip replacement - Hip replacement (total hip arthroplasty) is surgery to replace a worn-out or damaged hip joint. The surgeon replaces the old joint with an artificial joint (prosthesis). This surgery may be a choice after a hip fracture or for severe pain because of arthritis. NURSING CARE PLAN TEMPLATE Erikson’s Developmental Stage with Rationale And supported by Evidence Based Citations Generativityvs. Stagnation Generativity versus stagnation is the seventh of eight stages of Erik Erikson's theory of psychosocial development. Erikson’s belief that generativity was associated with late adulthood was also supported in the same study, for those in the middle adult group scored highest on generativity. Erikson expanded this concept to include “grand generativity,” meaning that individuals engage in leadership and creative roles that create and promote growth for more than those in their immediate family or circle of friends and associates. Grand generativity focuses on humankind. (Julie Smart, 2011) This patient fits to this stage because he feels helpless and not very productive as his daughter does most of the work in the house. He enjoys cooking and tries to help out with the meals as much as his body can tolerate. Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations Patient is living with his daughter . He is currently working on publishing his next book and is able to write from home. Patient is Budhism. Three psychological concerns, based on above assessment: 1- Depression, a type of mood disorder, is the most prevalent mental health problem among older adults. It is associated with distress and suffering 2- anxiety 3-loneliness older adults with medical problems such as heart disease have higher rates of depression than those who are medically well. Conversely, untreated depression in an older person with heart disease negatively affects the outcome of the disease. Even mild depression lowers immunity and may compromise a 2 person's ability to fight infections and cancers. (Rook & Thuras & Lewis ,1990) NURSING CARE PLAN TEMPLATE Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each (“At Risk for…” nursing dx) At risk for : risk for deficient Fluid Volume Excessive losses through normal routes AED fever, mouth breathing, hyporventilation (Doenges, Moorhouse, & Murr, 2014) risk for imbalanced Nutrition: less than body requirements Biological factors—increased metabolic needs AEB fever, infectious process (Doenges, Moorhouse, & Murr, 2014) Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale supported with Evidence Based Citations Identify type First Consult: pulmonologist: A doctor who has special training in diagnosing and treating diseases of the lungs. Also called pulmonary specialist. Second Consult: cardiologist: A doctor who has special training to diagnose and treat diseases of the heart and blood vessels. Third Consult: neurologist: A doctor who has special training in diagnosing and treating disorders of the nervous system. NURSING CARE PLAN TEMPLATE Diagnostic Label Priority Nursing Diagnosis (at least 2) Written in three part statement Related to Planning (outcome/goal) Measureable goal during your shift (at least 1 per Nursing diagnosis) Contributing Factors Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) As evidenced by Rationale Each must be supported with Evidence Based Citations Signs and Symptoms Evaluation Goal Met, Partially Met, or Not Met & Explanation NURSING CARE PLAN TEMPLATE Impaired Gas Exchange related to hypoxia as evidence by shortness of breath, O2 saturation of 88%, and abnormal ABGS. (Doenges, Moorhouse, & Murr, 2014) Pt oxygen saturation will be 90-100% throughout hospitalization.-Pt respiratory rate will be 12-20 breaths per minute throughout hospitalization (Doenges, Moorhouse, & Murr, 2014) 1-Assess respiratory rate, depth, and ease. 2-Observe color of skin, mucous membranes, and nailbeds, noting presence of peripheral cyanosis (nailbeds) or centralcyanosis (circumoral). 3-Assess mental status. 4-Monitor heart rate and rhythm. (Doenges, Moorhouse, & Murr, 2014) Not met: in process 1-Manifestations of respiratory distress are dependent on, andindicative of, the degree of lung involvement and underly-ing general health status. 2-Cyanosis of nailbeds may represent vasoconstriction or thebody’s response to fever or chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth(“warm membranes”) is indicative of systemic hypoxemia. 3-Restlessness, irritation, confusion, and somnolence may reﬂecthypoxemia or decreased cerebral oxygenation. 4-Tachycardia is usually present as a result of fever and dehydration, but may represent a response to hypoxemia (Doenges, Moorhouse, & Murr, 2014) NURSING CARE PLAN TEMPLATE Ineffective Airway Clearance related to thick yellow sputum, as evidenced by rapid respirations, diminished breath sounds and thick yellow sputum (Doenges, Moorhouse, & Murr, 2014) Airway Patency as evidenced by not compromised Respiratory rate Moves sputum out of airway No adventitious breath sounds throughout hospitalization (Doenges, Moorhouse, & Murr, 2014) 1- Assess rate and depth of respirations and chest movement.Monitor for signs of respiratory failure, for example,cyanosis and severe tachypnea. 2-Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds, such as cracklesand wheezes. 3-Elevate head of bed; change position frequently. 4- Assist client with frequent deep-breathing exercises. Demonstrate and help client, as needed; learn to performactivity, such as splinting chest and effective coughing whilein upright position. (Doenges, Moorhouse, & Murr, 2014) MEDICATION LIST 1-Tachypnea, shallow respirations, and asymmetric chest move-ment are frequently present because of discomfort of mov-ing chest wall or fluid in lung. When pneumonia is severe,the client may require endotracheal intubation and mechan-ical ventilation to keep airways clear. 2-Decreased airflow occurs in areas consolidated with fluid.Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, andwheezes are heard on inspiration and expiration in responseto fluid accumulation, thick secretions, and airway spasm orobstruction. 3-Keeping the head elevated lowers diaphragm, promoting chestexpansion, aeration of lung segments, and mobilization andexpectoration of secretions to keep the airway clear. 4-Deep breathing facilitates maximum expansion of the lungs andsmaller airways. Coughing is a natural self-cleaning mecha-nism, assisting the cilia to maintain patent airways. Splintingreduces chest discomfort, and an upright position favorsdeeper, more forceful cough effort. Note:Cough associatedwith pneumonias may last days, weeks, or even months. (Doenges, Moorhouse, & Murr, 2014) Not met: in process NURSING CARE PLAN TEMPLATE Medications (with APA citations Class/Purpose Route Frequency Dose (& range) If out of range, why? Mechanism of action Onset of action Common side effects Nursing considerations specific to this patient IVF NS 20meq KCl at 50ml/hr Crystalloids IVF Continuous 50 ml/hr Essential in physiologic processes Arrhythmias Bleeding Diarrhea Dyspepsia Hyperkalemia Nausea Rash Vomiting Fluid over load Monitor K Levofloxacin Fluoroquinolone s IVPB Q 12 H 500mg L-stereoisomer of parent compound oﬂoxacin; D-isomer form is inactive Inhibits DNA gyrase activity, which in turn promotes breakage of DNA strands Good monotherapy with extended coverage against Pseudomonas spp, as well as excellent activity against pneumococcus Nausea (7%) Headache (6%) Diarrhea (5%) Insomnia (4%) Constipation (3%) Dizziness (3%) Dyspepsia (2%) Rash (2%) Vomiting (2%) Chest pain (1%) Dyspnea (1%) Edema (1%) Fatigue (1%) Injection-site reaction (1%) Moniliasis (1%) Pain (1%) Pruritus (1%) Vaginitis (1%) Monitor Allergy reaction Constipation Dizziness Chest pain Dyspnea Fatigue NURSING CARE PLAN TEMPLATE Albuterol Short-acting beta Inhale agonusts Q 6H 2.5mg (3ml) Albuterol: Beta2adrenergic bronchodilator Ipratropium: Anticholinergic (parasympatholytic) agent; inhibits vagally mediated reﬂexes by antagonizing acetylcholine action; prevents increase in intracellular calcium concentration caused by interaction of acetylcholine with muscarinic receptors on bronchial smooth muscle Angina Arrhythmia Arthralgia Dizziness Dry mouth Dyspepsia Dysphonia Edema Fatigue Hypertension Insomnia Nervousness Palpitation Paresthesia Tachycardia Tremor Vomiting Arrhythmia Dizziness Fatigue Hypertension Tachycardia NURSING CARE PLAN TEMPLATE Lasix Loop diuretic IVP twice daily 20mg Loop diuretic; inhibits reabsorption of sodium and chloride ions at proximal and distal renal tubules and loop of Henle; by interfering with chloride-binding cotransport system, causes increases in water, calcium, magnesium, sodium, and chloride Hyperuricemia (40%) Hypokalemia (14-60%) Dehydration Monitor kidney function Hypokalemia NURSING CARE PLAN TEMPLATE Tylenol Analgesic PO Q4H PRN 650 mg for temp > 100F and mild pain rated 1-5/10. Codeine: Opioid agonist; analgesia; blocks pain impulse generation and inhibits ascending pain pathways, thus altering the perception and response to pain; inhibits cough by acting centrally in the medulla; causes CNS depression Acetaminophen: Nonopioid, nonsalicylate analgesic; may work peripherally to block pain impulse generation; acts on hypothalamus to produce antipyresis Constipation Drowsiness Hypotension Tachycardia or bradycardia Confusion Dizziness False feeling of well being Headache Lightheadedness Malaise Paradoxical CNS stimulation Restlessness Rash Urticaria Anorexia Nausea Vomiting Xerostomia Ureteral spasm Decreased urination Increased LFTs Burning at injection site Weakness Blurred vision Dyspnea Histamine release Monitor liver function Constipation Drowsiness Hypotension Tachycardia or bradycardia Confusion Dizziness Dyspnea NURSING CARE PLAN TEMPLATE Levothyroxine Thyroid disorders PO daily in the morning before food 50 mcg Synthetic T4; thyroid hormone increases basal metabolic rate, increases utilization and mobilization of glycogen stores, promotes gluconeogenesis; involved in growth development and stimulates protein synthesis Angina pectoris Arthralgia Congestive heart failure Flushing Increased pulse Myocardial infarction Palpitations Arrhythmias Cramps Diarrhea Nervousness Anxiety Choking sensation Emotional lability Headache Heat intolerance Insomnia Myasthenia Pseudomotor cerebri Alopecia Weight loss Infertility Dyspnea Fever Tachycardia Tremor Decreased bone mineral density Avoid undertreatment or overtreatment, which may result in adverse effects Hypertension Tachycardia CHF NURSING CARE PLAN TEMPLATE Plavix Antiplatelets Po Daily 75 mg Inhibitor of adenosine diphosphate (ADP)induced pathway for platelet aggregation Severe neutropenia Thrombotic thrombocytope nic purpura Acute liver failure Aplastic anemia Hypotension Hepatitis Myalgia Eczema Erythema Agranulocytosi s Monitor bleeding Protonix PPI PO daily before food 20 mg PPI; binds to H+/ K+-exchanging ATPase (proton pump) in gastric parietal cells, resulting in blockage of acid secretion Angioedema Atrophic gastritis Anterior ischemic optic neuropathy Hepatocellular damage leading to hepatic failure Interstitial nephritis Pancreatitis Pancytopenia Rhabdomyolysis Risk of anaphylaxis Stevens-Johnson syndrome Fatal toxic epidermal necrolysis Erythema multiforme Rebond GERD NURSING CARE PLAN TEMPLATE Oxycodon Opioid ( narcotic) PO PRN for pain Q6H 5mg Narcotic agonistanalgesic of opiate receptors; inhibits ascending pain pathways, thus altering response to pain; produces analgesia, respiratory depression, and sedation Agitation Angina pectoris Anticholinergic effects (dry mouth, palpitation, tachycardia) Bradycardia Cardiac arrest Coma Constipation Dizziness Dysphoria Euphoria Faintness Mental clouding/ depression Myocardial infarction Nausea Nervousness Pruritus, urticaria QT-interval prolongation Respiratory arrest Respiratory/circulatory depression Restlessness Sedation Seizures Severe cardiac arrhythmias Shock ST-segment elevation Sweating, ﬂushing, warmness of face/ neck/upper thorax Syncope Urinary retention, oliguria Ventricular tachycardia Visual disturbances Vomiting Weakness Constipation Drowsiness NURSING CARE PLAN TEMPLATE Norvasc Calcium channel PO blocker Daily 10 mg Inhibits transmembrane inﬂux of extracellular calcium ions across membranes of myocardial cells and vascular smooth muscle cells without changing serum calcium concentrations; this inhibits cardiac and vascular smooth muscle contraction, thereby dilating main coronary and systemic arteries Increases myocardial oxygen delivery in patients with vasospastic angina Headache (7.3%) Fatigue (4.5%) Palpitations (0.7-4.5%) Dizziness (1.1-3.4%) Nausea (2.9%) Flushing (0.7-2.6%) Abdominal pain (1.6%) Somnolence (1.4%) Asthenia (1-2%) Pruritus (1-2%) Skin rash (1-2%) Muscle cramps (1-2%) Male sexual dysfunction (1-2%) headache Hypotension NURSING CARE PLAN TEMPLATE Aspirin NSAID PO Daily 81 mg Inhibits synthesis of prostaglandin by cyclooxygenase; inhibits platelet aggregation; has antipyretic and analgesic activity Angioedema Bronchospasm CNS alteration Dermatologic problems GI pain, ulceration, bleeding Hepatotoxicity Hearing loss Nausea Platelet aggregation inhibition Premature hemolysis Pulmonary edema (salicylateinduced, noncardiogenic ) Rash Renal damage Tinnitus Urticaria Vomiting Bleeding Tinnitus Monitor Kidney function NURSING CARE PLAN TEMPLATE Metoprolol Beta blocker PO twice daily 25mg Metoprolol/ hydrochlorothiazide is a ﬁxed-combination tablet that combines a beta adrenergic receptor blocker, metoprolol tartrate (Lopressor HCT) or metoprolol succinate (Dutoprol) and a thiazide diuretic, hydrochlorothiazide Metoprolol is a beta-1selective (cardioselective) adrenergic blocking agent at low doses; at higher doses, it also inhibits beta-2 adrenoreceptors in the bronchial and vascular smooth muscles While the mechanism of the antihypertensive effects of beta-blocking agents has not been elucidated, it may involve competitive antagonism of catecholamines at peripheral (especially cardiac) adrenergic neuron sites, leading to decreased cardiac output; a central effect leading to reduced sympathetic outﬂow to the periphery; and suppression of renin activity Hydrochlorothiazide is a thiazide diuretic that inhibits Na reabsorption in distal renal tubules resulting in increased excretion of Na+ and water, also K+ and H+ ions Bradycardia Hypotension (3%), cold Bradycardia extremities(1%) Bronchospasm , constipation (1%), depression (5%), diarrhea (5%), dizziness (10%), dyspepsia (1%), dyspnea (3%), fatigue (10%), headache (10%), heart failure (1%), hypokalemiahy potension (1%), inﬂuenza-like symptomsnaus ea (1%), pruritus (5%), wheezing (1%)