Nursing Care Plan

Student Name/Date: _Jessica Reetz__________________

Nursing Diagnosis
(Dx, related to, & as evidenced by)

Expected Outcomes
(Short term (8-48 hr.) reasonable expectations stated in measurable, behavioral terms, i.e., action verbs)

Nursing Interventions/Rationale
List all interventions for each nsg. dx (include patient/family teaching)

Outcome Evaluation
(Patient outcome noted as met or unmet/responses described)

Nausea R/T GI irritation and pain AEB pallor, cool and clammy skin, and reports of feeling sick to my stomach.

Patient will demonstrate understanding by explaining techniques to decrease or alleviate nause symptoms within 24 hours.

Provide distraction from nausea using television or music, cold washcloth application or conversing with the patient. Watching television, listening to music or holding conversations can distract the patient from symptoms of nausea, in effect temporarily forgetting about it. Instruct patient to avoid sudden movements and remain lying still. Sudden or continuous movements can trigger nausea symptoms. Offer giner ale or clear soda and crackers. Ginger root has been shown to be an effective placebo for N/V. Bland foods can settle the stomach without irritation.

Outcome met. Patient was offered crackers to alleviate symptoms and instructed on distraction techniques (television and talking). Patient remained still most of the day and moved slowly when she needed to be mobile.

Nursing Care Plan

Student Name/Date: _Jessica Reetz__________________

Nursing Diagnosis
(Dx, related to, & as evidenced by)

Expected Outcomes
(Short term (8-48 hr.) reasonable expectations stated in measurable, behavioral terms, i.e., action verbs)

Nursing Interventions/Rationale
List all interventions for each nsg. dx (include patient/family teaching)

Outcome Evaluation
(Patient outcome noted as met or unmet/responses described)

Risk for falls R/T orthostatic hypotension, anemia, advanced age, confusion and use of antihypertensive medications AEB low RBC lab value (anemia), slow, unbalanced gait and c/o fatigue.

Patient will remain free of falls throughout hospital stay.

Ensure that the bed is kept in the lowest position with wheels locked and call light placed within reach. If pt does attempt to get up alone, if the bed is in the lowest position the pt can firmly anchor feet on the floor to aid in standing. If pt should fall out of bed, impact is minimized since the bed is close to the ground. Call light should be accessible so pt can call for a nurse to aid her instead of stading up alone. Routinely assist patient with toileting, especially on awakening and before bedtime. Majority of falls are related to toileting. Ensuring the pt uses the bathroom first thing in the morning and before bedtime can potentially eliminate the need for getting up to use the bathroom alone during the night. Encourage patient to use walking aid. Use of a walker aids pt in ambulation and can allow a greater sense of independence if she doesnt need a nurse to hold onto her arm while walking. Patient can work on strenght building while using a walker.

Outcome patially met. Bed was always placed in lowest position with call light within reach. Patient was assisted with toileting on awakening. Patient did not use a walker, preferred a wheel chair. Physical therapy is involved in working with her.

PACIFIC LUTHERAN UNIVERSITY SCHOOL OF NURSING NURSING PROCESS PAPER FOR NURS 340 SITUATIONS - ADULT HEALTH I Date(s) of care: Week 4 Occupation(s)/Significant Social History Pt lived with husband in a motel. Both are admitted in the hospital with plans to be discharged to a SNF. No other family is reported.
Number of days in hospital:

Age of pt (decade): 60s Allergies: NKDA

4 days

Weight: 160 lbs

Vital Signs Day of Care: ** note vaules and state a reason why it might be abnormal Day 1: BP 118/60 HR 64 Resp Rate 20 Temp 98.1 O2 Sat 97 RA Pain 4 out of 10 (abdominal pain probably due to UGIB, hiatal hernia, GERD) Intake & Output
I- 440 cc O- 200 cc

Intake & Output

I- 3900 cc O- 2000 cc

previous 24 hrs HR

this shift Temp

Day 2:

BP O2 Sat Intake & Output

Resp Rate Pain

previous 24 hrs

Intake & Output

this shift

Primary (Admitting) Medical Diagnosis: Upper GI Bleed Secondary Medical Diagnosis: Anemia, large hiatal hernia, asthma, hypokalemia, and schizophrenia. Surgery: Open heart surgery (heart valve replacement) 8 years ago.

History of Present Illness: Patient was visiting husband in the hospital. Nurse noticed that pt exhibited broken speech, weakness, and dizziness. Patient was pale and had bruising, and when asked about it she couldnt remember how she got them. Patient was then admitted to the hospital.

Definition and Pathophysiology of admitting diagnosis? If the patient had a surgery to treat the diagnosis, explain the surgery and why it was appropriate for this diagnosis. Upper GI bleeding (UGIB) can be caused by several factors. Most commonly, bleeding is caused by ulcers in the stomach or duodenum, which is commonly associated with H. pylori or NSAID use. NSAIDs and aspirins cause irritation to the gastric mucosal membrane. UGIB can also be caused by chronic esophagitis associated with GERD, bleeding varices, and Mallory-Weiss tears. UGIB is usually characterized by black, tarry stool (melena) or coffee ground-like emesis, since the blood is digested as it travels through the GI tract. Blood accumulation in the GI tract is irritating and and increases peristalsis. No evidence of surgery was found, but an upper GI endoscopy was performed which revealed a large hiatal hernia. Do not know if future surgery planned as patient was released this day.

Risk Factors (list risk factors noted in the book; circle or underline those that apply to your patient; if you add one that is not listed in the book, please indicate this): Advanced age, gender (F), H. pylori infection, NSAID, aspirin, corticosteroid, or anticoagulant use, alcohol use, smoking Signs and Symptoms (list the signs and symptoms that are usually associated with this diagnosis as noted in the book; circle or underline those that apply to your patient; if you add one(s) that is/are not listed in the book, please indicate this): Hematemesis, hematechezia, melena, dizziness, syncope, clammy skin, tachycardia, dyspnea, hypotension, pallor, abdominal pain. Secondary diagnosis: Give a definition and brief patho explaining how each secondary diagnosis can affect or be affected by the primary diagnosis/hospitalization. Anemia is the reduction in RBC count, a decrease in quality or quantitiy of hemoglobin, or a decrease in hematocrit. The many types of anemias are classified by their causes or the changes that affect the size or shape of the red blood cell. Anemias are always secondary to or a manifestation of a another disease process. In this case, I believe the patients anemia is probably iron-deficiency anemia caused by the chronic blood loss due to UGIB and GERD.

Hypokalemia is a potassium deficiency, less than 3.5 mEq/L. Potassium is lost from the ECF, and the concentration gradient favors the change by moving potassium from the ICF to the ECF to maintain the ratio, but causing body potassium depletion. GI disorders can cause potassium loss. Hiatal hernia is the protrusion (herniation) of the upper part of the stomach through the diaphragm and into the thorax (Huether 2004). A sliding hernia is when the stomach slides into the thoracic cavity through the esophageal hiatus. A paraesophageal hiatal hernia is when the curve of the stomach protrudes through a secondary opening in the diaphragm and stays alongside the esophagus. Hernias are usually associated with other GI disorders such as ulcers, which this patient suffers from.
Diagnostic Tests and/or Procedures:
ECG, Upper GI endoscopy, Chest X-ray

*Laboratory Data from admission to most recent (plus significant lab work, i.e.: PT/PTT
Tests Ordered
Hematology WBC RBC Hbg Hct MCV MCH MCHC RDW Plt WBC Differential Neuts
-Segs/PMNs -Bands

Admission Results
Studies 6.8 3.15 9.6 30.9 92.1 30.5 33.1 14.8 238 VSR 59.5

Recent Results
11.9 3.19 9.8 29.6 92.8 30.7 33.1 15.4 286 VSR 74.1

TG/MHS Norms

Interpretation of results: Specific for this pt? If unknown ? Abnormal: Elevated Low Hematology Studies WNL level d/t anemia and GI bleed level may be d/t anemia and GI bleed level may be d/t anemia and GI bleed WNL WNL WNL level may be d/t anemia WNL WBC Differential WNL

4.0-12.0 TH/mm3 4.0-5.5 mil/m3 12.0-16.0 g/dL 37-47%

150-450 th/mm3 45-77%

Lymphs Monos Eosin Basos Abs neuts Abs lymphs Abs monos

26.2 10.1 3.8 0.4 4.1 1.8 0.7

17.5 6.8 1.3 0.3 8.8 2.1 0.8

12-44% 4.0-13.0% 0 -5.0% 0-1.5% 1.8-7.8 th/mm3 0.8-3.3 th/mm3 0.2-1.0 th/mm3

WNL WNL WNL WNL level may be d/t stress or inflammation (possibly r/t GERD) WNL WNL

Abs eosin Abs basos Platlet/RBC Plt estimate Aniso Poly Poik Ovalocytes RBC frags Reactive lymphs

0.3 0.0 studies

0.2 0.0

0.0-0.4 th/mm3 0.0-0.2 th/mm3 ADEQ

WNL WNL Platelet & RBC Specific Studies

Serum Chem Na+ K+ ClCO2 HC03 BUN Creatinine Glucose Additional SGOT/AST Alk Phos SGPT/ALT Serum Protein Serum Albumin Globulin (calc) A:G Calcium Phosphorous Magnesium Triglyeride Cholesterol?? Amylase Lipase Prealbumin C-reactive protein Coagulation PT INR Normal mean PTT Normal mean

142 3.4 107 29 19 0.7 95 Chemistries 41 48 34 5.1 2.8 2.3 1.2 8.6

142 4.2 113 27 9 0.6 108

135-148 mEq/L 3.6-5.3 mEq/L 97-107 mEq/L 24-33 mEq/L 24-33 mEq/L 8-24 mg/dL 0.8-1.5 mg/dL 65-120 mg/dL

Serum Chemistries WNL level may be d/t deficient dietary intake, GI disorder (UGIB) level may be d/t anemia WNL WNL WNL WNL Additional Chemistries: Enzymes level may be r/t antihypertensive meds and coumadin use WNL WNL level may be d/t malnutrition, inflammatory disease (GERD) level may be d/t malnutrition, inflammatory disease (GERD) WNL WNL WNL

8.5 1.7-2.2 mg/dL

18-45 mg/dL 0-0.1 mg/dL

Studies 1.46 20.9 2.10 9.2-13.0 sec 0.0-3.5 21-31 sec level d/t coumadin use WNL

Urinalysis Color Appearance Sp Gr PH Urine Protein Urine Glucose Ketones Bilirubin Occult blood Urobilinogen Leukocyte esterase Nitrite

Yellow Clear 1.024 6.5 Trace Neg Trace Neg Trace 4 2+ Neg 1.003-1.030 N N N N N <1.1 EU N N

Normal finding Normal finding WNL WNL Transient proteinuria can be caused by emotional stress Normal finding May be d/t anorexia or fasting Normal finding

Possible UTI Normal finding

Other

References: Ackley, Betty J., Ladwig, Gail B. (2006). Nursing Diagnosis Handbook: A Guide to Planning Care. St. Louis, MO: Mosby Elsevier Huether, Sue E., McCane, Kathryn L. (2004). Understanding Pathophysiology. St. Louis, MO: Mosby Elsevier Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., OBrien, P. G., Bucher, L. (2007). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis, MO: Mosby Elsevier

Student Name:__Jessica Reetz____________

*MEDICATIONS

Allergies: __NKA____________

MEDICATION Name, Dose, Route Atenol (Tenormin) 50 mg; oral

Classification

INDICATION Why is your pt. taking? BP, HR, MI prevention GERD, gastric acid, prevention/treatment of ulcers Asthma

Pantoprazole (Protonix) 40 mg; oral Prednisone 40 mg; oral

Antihyperten sives, beta blockers, antianginals Antiuler agents, proton pump inhibitor Corticosteroid, antiasthmatics Bronchodilator Opioid analgesics
Anticoagulant

COMMON SIDE EFFECTS (look for what applies most to your patient)> Fatigue, weakness, bradycardia, mental status changes, hypotension Hypergylycemia, abdominal pain, headache HTN, depression, eccymoses, nausea HR, dry mouth

NURSING IMPLICATIONS (specific to your patient; include specific pt teaching points if applicable) Montitor BP, ECG, pulse, I & Os and daily weights.

Monitor for occult blood in stools & emesis, assess for gastric pain. Monitor I & Os, daily weights. Admister with meals to minimize GI irritation. Do not take with grapefruit juice. Do not stop medication suddenly, gradually taper off. Assess respiratory status (rate, breath sounds)

Tiotropium (Spiriva) 18 mcg; Inhaln Hydromorphone (Dilaudid) 2 mg; oral Enoxaparin (Lovenox) 70 mg; subcutaneous Risperidone (Risperdal) 3 mg; oral Warfarin (Coumadin) 6 mg; oral

incidence/severity of bronchospasm d/t COPD Pain relief

Prevention of DVT

Constipation, sedation, nausea, respiratory depression Anemia, nausea, edema, bruising Insomnia, sedation, constipation, nausea, dry mouth, dizziness Bleeding, dermal necrosis, nausea

Assess pain prior to and 1 hour after administration. Monitor respiratory rate, BP, pulse, LOC. Assess for signs of bleeding, hemorrhage. Monitor CBC and platelet count. Do not rub injection site. Monitor mental status, mood changes, orthostatic BP, pulse. Watch pt to ensure medication is swallowed. Advise pt to change positions slowly. Assess pt for s/s of bleeding and hemorrhage. Monitor PT/INR.

Antipsychotics
Anticoagulant

symptomps of psychoses or bipolar mania Prevention of thromboembolic events

DISCHARGE PLANNING GUIDE Anticipated discharge: _Today_________________ Pt. Diagnosis: _Upper GI bleed_______ Discharge to: __SNF___________ Functional Assessment Independent eating bathing dressing toileting transferring ambulating taking medications correctly X X Stand by assist (SBA) X X SBA X SBA X SBA X Needs supervision and reminding due to schizophrenia X Pt fatigues easily and has schizophrenia X Pt fatigues easily and has schizophrenia Assist (specify) Total Care

house keeping

preparing meals

The care of the patient and the plan for discharge require a multidisciplinary approach. It is often the nurse who contacts the members of the multidisciplinary team to assist in the care of the patient. Multidisciplinary Team Referral in hospital State specific involvement in plan of care or the patient needs that requirement involvement Social work is involved to handle placement of client and husband to a SNF PT involved in increasing mobility and activity Needs after discharge Listed are examples. Please delete the examples and state the specifics that relate to your patient.

Social Work/Case Manager Respiratory therapist Physical therapist Occupational therapist Visiting Nurse Home Health care worker

Pt will be supplied with a walker

State how the discharge needs identified above will be addressed. Please consider the following and write a short statement to assure the patients needs are being met for a safe discharge: Prior to hospitalization, patient lived with husband in a motel. Husband was the primary caretaker, but his advanced age and current ailment and disability will no longer allow him to care for them properly. Arrangements have been made to place them both in a skilled nursing facility as the patient is no longer able to completely care for herself. With proper supervision to ensure she continues to take her meds and increases her activity, she seems like she will be able to adjust well.

What specific teaching does the patient need for a safe discharge? Patient should be taught to take it easy and not overexert herself. She should know when she needs to notify the staff at the SNF if she is experiencing any s/s relating to her GI disorder. Patient was malnourished when admitted to the hospital and should learn the value of good nutrition to maintain and promote healthy living. If she is well nourished, perhaps her energy level will increase and she will fatigue less easily and wont need assistance ambulating, bathing or toileting. Patient should be aware of the medications she will continue to take after discharge. She is already aware of the effects of coumadin. Patient should also continue to take her Risperdal and should follow up periodically with psychotherapy.