579b care plan

8/3/2019 579B Care Plan

1/21

NURSING CARE PLAN FOR

1

1

Azusa Pacific University

School of Nursing

GNRS 579BCare Write-Up with Nursing Process

Name: Crystal Mann Young Chang Date: 02/10/12 Care Write-Up 1

IDENTIFYING DATA

Patient initials: D.L.

Age: 18

Ethnicity: White European

Gender: Female

Occupation: Student

Allergies (include allergen and reaction to allergen): Amoxil causes skin rash and/or hives; lactose class (not screened) causes skin rash

and/or hives, shock and/or unconsciousness, asthma and/or shortness of breath, nausea and vomiting, anemia and/or blood disorders;amoxicillin trihydrate causes skin rash and/or hives

Admit date: November 29, 2011

Hospital day #: 1 Post-operative day #: Same day of operation

Physician(s) (include physician specialty): D.M. (operating room surgeon); J.J. (anesthesiologist); S.G. (physician); G.P. (physician)

ADMITTING DATA

Medical diagnosis (admitting): Appendicitis

8/3/2019 579B Care Plan

2/21


2

2

History of Present Illness (HPI):

On November 28th, 2011, D.L. began having abdominal pain with nausea and vomiting in the morning. The pain gradually worsened and was

continuous. The pain radiated from the periumbilical region to the right lower quadrant or McBurneys point. Moving and coughing

aggravated her pain. D.L. was admitted to the hospital 11-28-11 and was diagnosed with appendicitis without the rupture of the appendix. Sheunderwent a laparoscopic appendectomy. Postoperatively, she has been experiencing continuous cramping in her ribs due to the air trapped in

the abdominal and thoracic regions. She feels a sharp pain when she inhales, especially when using the incentive spirometer. Relaxedbreathing minimizes the cramping and eliminates the sharp pain.

Past Medical and Surgical History: D.L. had varicella on 12-21-95. D.L. has no history of surgeries.

Findings that support admittingmedical diagnosis

Physical Exam Diagnostic Tests

Nausea and vomiting, acute pain radiating to right

lower quadrant from the umbilical region.

CT scan was performed and revealed acute

appendicitis.

Admit Plan (per physicians notes): D.L. will undergo diagnostic laparoscopy and laparoscopic appendectomy.

PATHOPHYSIOLOGY

Pathophysiology of admitting diagnosis:

Appendicitis is the inflammation of the appendix, which is the finger like organ located at the beginning of the colon. Appendicitis occurs in7%-12% of the worlds population. It occurs most often in young adults although it can occur at any age and more often in males. The

mortality and morbidity rates are higher in patients over 70 years old. Causes of appendicitis include fecal accumulation obstructing thelumen of the appendix, excessive growth of lymphoid tissue, presence of foreign bodies, or tumors in the cecum or appendix. Obstruction can

cause distention, venous engorgement, and the accumulation of mucus and bacteria, which can lead to gangrene and perforation of theappendix. Without treatment, the appendix may burst, releasing the pathogens into the abdominal cavity and resulting in peritonitis.

Fortunately, in the case of D.L., her appendix did not burst.

(Lewis, Bucher, Camera, Dirksen, & Heitkemper, 2011, p. 1020).

8/3/2019 579B Care Plan

3/21


3

3

Correlation of admitting diagnosis to comorbidities or past surgical history (if any):

D.L. is an adolescent at the age of 18. Adolescence is not a comorbidity but it is a major risk factor for appendicitis. She does not have a pastsurgical history. Appendicitis often occurs on its own without regard to genetic or lifestyle.

(Monahan, Green, & Neighbors, 2011, p. 466)

PHYSICAL EXAM

Ht: 51 Wt: 67.858 kg (149 lb) BMI: 28.28

VITAL SIGNS: 2 sets required

Time Temperature (include

route)

Pulse (apical/radial) Resp BP Pulse Ox

0800 98.6F 69/67 16/min 116/69 96%

1230 99.3F 68/66 20/min 107/70 98%

PAIN ASSESSMENT: 2 sets required

Time Pain Tool Used Pain Rating Pain Description

(OLDCART)

Functional Pain Goal Pain Medication Response To Tx

0800 Numeric Scale 5/10 3/10 Norco 10-325 mg

1 tab at 0820

Pain was reduced to

3/10

1230 Numeric Scale 7/10 (see below) 3/10 Morphine 4 mg

IV at 1245

Pain was reduced to

4/10

8/3/2019 579B Care Plan

4/21


4

4

O (Onset) Began around 1215 after the patient ate a cup of ice chips

L (Location) Left and right lower ribs and the incisions at the infraumbilical region and suprapubic region.

D(Duration) Continuous

C (Characteristics, i.e. sharp, burning, ache, etc.) Pain in the ribs feels like cramping. Soreness around the incisions.

A (Aggravating factors) Ambulating, deep breathing

R(Relieving factors) Lying quietly, sleeping

T (Treatment) Morphine 4 mg IV at 1245

General

Level of consciousness (awake, alert, drowsy, lethargic, etc.): Awake, alert, and oriented x 4

Orientation to: Person: Yes Place: Yes Time: Yes Purpose: Yes

Able to hold conversation: Yes Speech: Clear and articulate Follows directions: Easily follows direction

Stature, posture and position: The patient stands erect. Posture is straight.

Nutrition (Well nourished, well developed, obese or cachectic, etc.): Patient is well nourished, overweight.

Medical appliances patient is currently using: The patient is using an IV infusion pump attached to a single-lumen peripherally insertedcentral catheter. D.L. is also using an incentive spirometer.

I.V. Site #1 Location: Right forearm Solution: 1000 ml of 2O mEq/L in 5% Dextrose and half normal saline Rate: 125 ml/hr

Assessment of site: Dry, clean, and intact. No pain or tenderness.

I.V. Site #2 Location: Right forearm Solution: Cleocin Phosphate piggyback in 5% dextrose Rate: 900g/50 ml Assessment ofsite: Dry, clean, and intact. No pain or tenderness.

Skin

Skin:

8/3/2019 579B Care Plan

5/21


5

5

Color: Even and appropriate for ethnicity Turgor: Within normal range Temp: Warm to touch Moisture: DryEdema: No edema

Lesions (describe findings): Moderate acne on face

Incisions (location): Infraumbilical region and suprapubic region Description of incision (dressing, S/S of infection, etc.): Incisionsare about 1 inch in length. Dressing is dry, clean and intact. There are no signs of infection.

Drains (type such as JP, Penrose, negative pressure, chest tubes and location): None

Varicose Veins: None Scars: None Nails: No clubbing or fungal infections in the hands or feet. Capillary refilling isless than 2 seconds.

Unusual Pigmentations/Tattoos/Piercings: 1 piercing in each lobe.

Head, Face and Neck

Head: General size (i.e. normocephalic): Normocephalic Deformities (i.e. atraumatic): No deformities

Face: Symmetry: Symmetrical Involuntary movements: No involuntary movements

Neck: ROM (Supple): Supple with Full ROM without pain or crepitus Cervical lymph nodes: Not palpable Thyroid gland: Not enlargedor palpable Trachea (midline): midline with

Ears, Eyes, Nose, Mouth, Throat

Ears: Size, shape: Equal size bilaterally. No swelling or lesions Tenderness: No tenderness Drainage: No drainage or dischargeHearing: CN VIII intact, response is appropriate.

Otoscope exam (external canal, tympanic membrane): N/A

Eyes: Inspect external/interior eye structures: Symmetrical, equal bilateral shape and position. Sclera is white, conjunctiva clear, iris intact, no

discharge, no excessive tearing. Bilateral eyebrow movement. Eyes approximate completely Cardinal eye gazes: CN III, IV, VI intact

PERRLA: PERRLA intact with no lid lag

8/3/2019 579B Care Plan

6/21


6

6

Nose: Symmetry: Symmetrical and midline Patency: Patent without obstruction Drainage: None Sinus Tenderness: No frontal ormaxillary sinus tenderness

Mouth: Mucosa (color, lesions): Red/pink with no inflammation. No tenderness. No lesions. Number of teeth: 32 teeth

Dentures: No Ability to eat/drink: CN V, IX, X, XII intact.

Throat: Tonsils (grade): 1+

Pulmonary

Respirations: Rate: 16/min at 0800. 20/min at 1230 Rhythm: Regular Depth: Relaxed

Labored (ICS retractions or use of accessory muscles)/ Unlabored: Unlabored breathing with no use of accessory muscles Chestexpansion: Symmetrical chest expansion

Percussion (which sound and where): Posterior and anterior equal bilateral resonance

Breath Sounds (posterior, anterior and lateral): Posterior: Equal bilateral clear sounds with mostly vesicular sounds in peripheral fields andbronchovesicular between scapulae. Anterior: Equal bilateral clear sounds with bronchovesicular sounds near the sternum at the 2nd, 3rd, 4th

ICS. Adventitious sounds: No adventitious sounds.

Oxygen Therapy: None How Delivered (nasal cannula, face mask, etc.): N/A Rate in Liters: N/A

Trach: N/A Ventilator and settings: N/A Chest tube (water seal or suction, cm of water): N/A

Cardiovascular

Precordium: Visible heaves or lifts: No lifts of heaves Palpate for presence of thrills: No thrills

Neck Vessels: JVD: No JVD Carotid Artery Bruit (with bell): No bruit

Heart Sounds: Rate: 69/min at 0800. 68/min at 1230 Rhythm: Regular Extra Sounds or Murmurs: No murmurs, rubs, clicks or

gallops PMI (location and size): N/A

Pulses (R/L): Temporal: +2 equal bilateral Carotid: +2 equal bilateral Brachial: +2 equal bilateral Radial: +2 equal bilateral

Femoral: N/A Popliteal: N/A Posterier Tibialis: +2 equal bilateral Dorsalis Pedis: +2 equal bilateral

8/3/2019 579B Care Plan

7/21


7

7

Capillary Refill (

8/3/2019 579B Care Plan

8/21


8

8

Activity Level (Ad lib/BRP/BR): Ambulatory ROM (active/passive): All joints have active full ROM

Mobility (self/assisted): Self. Independent mobility Gait (even/uneven): Even, smooth, coordinated

Muscle Tone/Strength (handgrips, footpushes): Strength to resistance in all joints. Less strength at hip joint due do strain on the incisions.

Assistive Devices: None Prosthesis: No

Other Devices (i.e. CMP, location of use and degree): No

Mental

Mood/ affect: Calm, relaxed Coping: N/A Suicidal ideation: None

Thought process/content: Logical and coherent Perceptions: Consistently aware of reality

LABORATORY TESTS

Test: Results: Normal range: High orLow Relevant Rationale for ABNORMAL Test Results:

CBC & DIFF:

WBC 17.4 4.0-11.0 High Inflammation of the appendix

RBC 3.64 4.3-5.7 Low Blood loss from surgery

HGB 12.0 11.7-15.5 Normal

HCT 35.1 35-47 Normal

Platelets 260 150-400 Normal

Neutrophils 64 42-75 Normal

Lymphocytes 13 20-40 Low Immune system uses WBC against inflammation first

Monocytes 11 4-8 High Inflammation of appendix

Eosinophils N/A

8/3/2019 579B Care Plan

9/21


9

9

Basophils N/A

BMP:

Na N/A

K N/A

Cl N/A

CO2 N/A

BUN N/A

Creatinine N/A

Glucose N/A

CMP (BMP plus

the following):

Calcium N/A

Albumin N/A

Total Protein N/A

AST N/A

ALT N/A

Alk Phos N/A

Bilirubin N/A

UA:

Color

Appear N/A

8/3/2019 579B Care Plan

10/21


10

10

PH N/A

Specific Gravity N/A

Protein N/A

Glucose N/A

Ketone N/A

Bilirubin N/A

Hgb N/A

Uro-bilinogen N/A

WBC N/A

Nitrate N/A

OTHERS:

Coagulation Panel:PT/INR, PTT,

D-dimer

N/A

Cultures:

Blood, urine,

wound

N/A

Diabetic:

HgbA1C

N/A

Inflammation

Panel:

ESR, CRP, ANA,

RF

N/A

8/3/2019 579B Care Plan

11/21


11

11

(Lewis et al., 2011, p. 1799)

DIAGNOSTIC TESTS (X-Ray, Ultrasound, CT, MRI, EKG, etc.)

Test Rationale for Ordering

Test

Results Normal Value Explanation

CT scan of abdomen andpelvis with contrast

To confirm appendicitisand rule out other

illnesses

Liver, lung bases,gallbladder, spleen,

pancreas, kidneys, adrenalglands, aorta, urinary

bladder are unremarkable.Appendix is dilated. Few

appendicoliths seen withinthe appendix.

Periappendiceal fatstranding is noted. No

abscess formation seen.

Appendix is not dilated. Noappendicoliths.

The patients symptomsare due to the

inflammation of theappendix. The appendix

has not ruptured.

Iron Panel:

Serum iron, ferritin,

TIBC, UIBC

N/A

Lipid Panel:Cholesterol, HDL,LDL, Triglycerides

N/A

Thyroid Panel:

TSH, T4, T3

N/A

Tumor Markers:

AFB, CEA, CA-

125, PSA, etc.

N/A

8/3/2019 579B Care Plan

12/21


12

12

MEDICATIONS

Name (generic

and trade), doseand route

Class Indication

(specific to yourpatient)

Mechanism of Action Side Effects Nursing

Implications (labsto monitor, etc)

Patient Education

Acetaminophen

tab 650 mg(Tylenol), every 4

hours PRN, oral

(Epocrates

online, 2011)

Nonopioid

analgesic,antipyretic

For temperatures

greater than38.5C/101.3F

Does not have anti-

inflammatoryproperties.

Antipyretic actionresults from

inhibitingprostaglandins in the

CNS or thehypothalamic heat-

regulating center

Hemolytic

anemia,drowsiness,

nausea, vomiting,renal failure,

rash, urticarial,cyanosis

Monitor quantity

of red bloods,urinalysis for renal

failure. Inspectskin for rashes.

Monitor liverfunction, assess

temperature.Contraindications

are alcohol andtable sugar.

Do not exceed

recommended doselest liver damage

occur. Toxicityincludes nausea and

vomiting andabdominal pain.

Signs of overdose:bleeding, bruising,

malaise, fever, sorethroat.

Clindamycin in

D5W IV premix900 mg

(Epocrates

online, 2011)

Antibacterial,anti-infective

Treatment ofsusceptible

bacterialinfections,

mainly thosecaused by

anaerobes,streptococci,

pneumococci,

andstaphylococci;also for pelvic

inflammatorydisease

Binds to 50S subunitof bacterial ribosomes

and suppressesprotein synthesis

Nausea andvomiting.

Abdominal paindiarrhea, weight

loss, jaundice,rash, urticaria,

pruritus

Assess forabdominal

tenderness.Monitor bowel

movements,nutrition, and liver

function. Inspectskin for rash and

urticaria.

Contraindicationsincludehypersensitivity to

this drug orlincomycin,

tartrazine dye, andulcerative

colitis/enteritis.

Take oral with fullglass of water. Take

with food to reduceGI symptoms.

Complete the entirecourse to prevent

resistance. Reportsore throat, fever,

fatigue. Do not

break, crush, orchew caps.

8/3/2019 579B Care Plan

13/21


13

13

D5 NaCl 0.45%

KCl 20 mEq/L IVpremix,

continuous, 1000ml, rate of 125

ml/hr

(Epocrates

online, 2011)

Hypertonic

electrolytesolution

initially.Dextrose

metabolizesand solution

becomeshypotonic

Maintain

hydration andelectrolyte

balance

Balances osmolality

between bloodvessels and tissues.

This particularhypertonic solution

pulls fluids out of thetissues.

Hypervolemia Monitor blood

pressure, inspectbody for edema

Educate patient of

symtoms ofhypervolemia

Diphenhydramine

Inj 25 mg(Benadryl), every6 hours PRN, IV

(Epocratesonline, 2011)

1st

generation

nonselectiveantihistamine

For itching Affects blood vessels.

Competes withhistamine for H1-receptor site;

decreases allergicresponse by blocking

histamine.

Dizziness,

drowsiness, poorcoordination,fatigue, anxiety,

euphoria,confusion,

seizures,wheezing, chest

tightness,

hemolyticanemia, nausea,vomiting,

diarrhea, blurredvision

Contraindications:

hypersensitivity toH1-receptorantagonist, acute

asthma attack,lower respiratory

tract disease.

Watch for urinary

retention,

frequency, dysuria.Monitor CBCduring long-term

therapy. Monitorrespiratory status.

Notify prescriber of

confusion, sedation,hypotension.Avoid driving and

other hazardousactivities. Avoid

alcohol and otherCNS depressants.

Famotidine (PF)inj 20 mg

(Pepcid), every12 hours, IV


H2-histaminereceptor

antagonist

For maintenancetherapy and

treatment ofduodenal ulcer,

treatment ofgastroesophageal

reflux disease(GERD), active

benign gastriculcer,

Competitivelyinhibits histamine at

histamine H2 receptorsite, decreasing

gastric secretionwhile keeping pepsin

at a stable level.

Headache,dizziness

paresthesia,depression,

anxiety,somnolence,

insomnia, fever,taste change,

constipation,nausea, vomiting,

Assess epigastricand/or abdominal

pain. Inspectemesis or stools for

blood. Monitorblood counts for

decreased platelets.Assess patient for

fatigue. Inspectskin for bruising,

Must be taken forthe entire

prescribed time.Report bleeding,

bruising, fatigue,malaise. Possibility

of decreased libido.Avoid alcohol,

aspirin, smoking.Avoid tasks

8/3/2019 579B Care Plan

14/21


14

14

pathological

hypersecretoryconditions.

anorexia, cramps,

abnormal liverenzymes,

diarrhea, rash,myalgia,

dysrhythmias

bleeding, poor

healing.

requiring alertness

due to dizzinessand drowsiness.

Gentamicin IV

piggy back 70mg, every 8

hours, duration30 minutes


Anti-infective Treatment of

infections causedby susceptible

strains of Proteusaeruginosa,

ProteusKlebsiella,

Serratia,Escherichia coli

Enterobacter,Citrobacter,

Staphylococcus,

Shigella,Salmonella,Acinetobacter,

acute PID.

Inhibits protein

synthesis of bacterialcells by binding to

ribosomal subunit,with misinterpretation

of genetic code.Peptide sequences of

protein chains arecompromised causing

bacterial death

Renal

damage/failure,confusion,

depression,numbness,

tremors,convulsions,

dizziness,vertigo, deafness,

visualdisturbances,

nausea, vomiting,

anorexia,hypotension,hypertension,

rash.

Weight before

treatment. Monitorintake/output.

Daily urinalysis.Monitor vital signs

during infusion.Check IV site for

pain, redness,swelling, phlebitis.

Monitor renalfunction. Hearing

tests.

Contraindications:severe renaldisease,

hypersensitivity.

Report headache,

dizziness, renalimpairment,

symptoms ofovergrowth of

infection. Reportloss of hearing,

ringing or roaringin ears, or feeling

of fullness in thehead.

Metoclopramid

Inj 10 mg(Reglan), every 6

hours PRN, IV(Epocrates

online, 2011)

Cholinergic,

antiemetic

For nausea and

vomiting

Enhances response to

acetylcholine oftissue in upper GI

tract and causescontraction of gastric

muscle, relaxespyloric, duodenal

segments, increasesperistalsis without

stimulatingsecretions, blocks

dopamine in

Sedation, fatigue,

restlessness,headache,

dizziness,drowsiness,

suicide ideation,seizures, dry

mouth,constipation,

nausea, vomiting,diarrhea,

decreased libido,

Assess mental

status fordepression, anxiety

and irritability.Assess GI

complains fornausea, vomiting,

anorexia,constipation.

Contraindications:Hypersensitivity,

seizure disorder,

Avoid driving or

other hazardousactivities. Avoid

alcohol, other CNSdepressants that

may enhancesedation.

8/3/2019 579B Care Plan

15/21


15

15

chemoreceptors in

CNS.

hypotension,

supraventriculartachycardia, rash,

breast cancer, GI

obstruction.

Morphine Inj Syg2 mg or Syg 4

mg, every 2 hoursPRN, IV


Opiateanalgesic

2 mg for severebreakthrough

pain (7-10) andfor moderate pain

(4-6).

4 mg for severe

pain (7-10).

Inhibits transmissionof pain impulse at the

spinal cord level byinteracting with

opioid receptors

Drowsiness,dizziness,

confusion,headache,

sedation,euphoria,

palpitations,bradycardia,

change in B/P,shock, cardiac

arrest, nausea,vomiting,

anorexia,constipation,

cramps, urinary

retention, rash,bruising, pruritus,respiratory

depression, apnea

Assess pain. Givebefore pain

becomes severe.Assess bowel

status. Monitorintake and output.

Assess respirationsand B/P, pulse.

Monitor CNSchanges such as

hallucinations,euphoria, LOC,

pupil reaction,drowsiness. Assess

respirations. Notify

prescriber ifrespirations areless than 12 per

minute.

Change positionsslowly. Orthostatic

hypotension mayoccur. Report any

symptoms of CNSchanges and allergic

reactions. Physicaldependency can

occur. Avoidalcohol, CNS

depressants.Withdrawal

symptoms mayoccur such as

nausea vomiting,

and faintness.

Norco 10-325 or

5-325 mg 1 tab(Hydrocodone-

acetaminophen),every 4 hours

PRN, oral

(Epocrates

online, 2011)

Antitussive

opioidanalgesic

For moderate

pain (1-3)

Directly acts on

cough center inmedulla to suppress

cough. Binds toopiate receptors in

CNS to reduce pain.

Drowsiness,

dizziness,confusion,

headache,sedation,

hallucinations,dependence,

convulsions,nausea, vomiting,

dry mouth,constipation,

increased urinary

Assess pain, CNS

changes such asdizziness,

hallucinations,LOC, pupil

reaction. Assessfor allergic

reactions. Monitorcoughing and

respiratorydysfunction.

Notify prescriber if

Report any

symptoms of CNSchanges and allergic

reactions. Physicaldependency may

result with extendeduse. Withdrawal

symptoms mayoccur such as

nausea andvomiting. Avoid

driving or

8/3/2019 579B Care Plan

16/21


16

16

output, urinary

retention, rash,pruritus,

tachycardia,bradycardia,

respiratorydepression

respirations are

less than 10 perminute.

hazardous activities.

Avoid other CNSdepressants. Do not

break, crush orchew tabs.

Ondansetron (PF)inj 4 mg (Zofran),

every 6 hoursPRN, IV


Antiemetic For nausea andvomiting

Prevents nausea andvomiting by blocking

serotoninperipherally, centrally

and in the smallintestine

Diarrhea,constipation,

abdominal pain,headache

dizziness,drowsiness,

fatigue, rash,shivering, fever,

urinary retention

Assess absence ofnausea and

vomiting duringchemotherapy.

Monitor and assessbowel movements.

Assess forhypersensitivity.

Report diarrhea,constipation, rash,

or changes inrespirations or

discomfort atinsertion site.

Zolpidem tab 5

mg (Ambien),

every bedtimePRN, oral

(Epocrates

online, 2011)

Sedative-

hypnotic

For insomniaProduces CNS

depression at limbic,thalamic,hypothalamic levels

of CNS; possiblemediation by

neurotransmitters y-aminobutyric acid.

Causes sedation,

hypnosis, skeletalmuscle relaxation,anticonvulsant

activity, anxiolyticaction

Leukopenia,

headache,

lethargy,drowsiness,dizziness,

confusion,irritability,

amnesia, poorcoordination,

nausea, vomiting,diarrhea,

heartburn,abdominal pain,

constipation,chest pain,

palpitation

Blood studies for

Hct, Hgb, RBC.

Hepatic studies forAST, ALT,bilirubin if liver

damage hasoccurred. Mental

status for mood,sensorium, affect

memory (long,short). Inspect skin

for bruising, rash, jaundice. Assess

for fever, sorethroat, and

epistaxis.

Dependence is

possible after long-

term use. Avoiddriving and otherhazardous activities.

Avoid alcohol,other CNS

depressants.Alternative

nonpharmocologicalmethods should be

used assupplementary.

Hangover iscommon. Effects

may take 2 nights.

8/3/2019 579B Care Plan

17/21


17

17

OTHER TREATMENTS

(Examples include RT, PT, OT, ST, TCDB, IS, ROM, CPM, TEDs, Trapeze, Traction, Sitz Bath, Drains, Dressing Changes, etc.)

Treatment Schedule Rationale for Treatment

N/A

CULTURAL & SPIRITUAL ASSESSMENT

General: The patient was suffering from extreme nausea and vomiting. Moving and coughing and simply talking were exasperating her

symptoms. She was scared and uncertain as to why she was suffering from her symptoms. She could not eat or drink anything and justwanted to lie still. The patient was treated immediately after the onset of her symptoms. It disrupted her life for approximately two days. She

had to miss school for two days. She is uncertain as to the cause of her diagnosis.

Cultural:D.L. describes herself as Caucasian. Her primary language is English. She does not eat red meat but that is more of a dietarypreference rather than a religious or cultural practice. Her mother is an Emergency Department nurse and is the authoritative voice over health

care related decisions.

Spiritual: D.L. identifies herself as culturally Christian but does consider herself as a practicing Christian.

DISCHARGE PLAN

The discharge plan will begin from admission. Follow up care will be scheduled. The patient is an adolescent female, living at home, and

commutes to her university. Her mother is an RN and will be home to care for her during her recovery. She is ambulatory and will not needassistance walking due to the minimal nature of her surgery. However, she will need written and verbal information about her medications

such as the drug name, dosage purpose, schedule, precautions, and potential side effects. Contraindications and interactions will be included.Emphasis will be put on about taking the entire prescription of her antibiotic. Instruction on how to care for her incisions will be given such as

dressing changes and bathing instructions. Patient will be informed about indicators of infections such as fevers, chills, incisional pain,redness, swelling, and purulent drainage. She will be instructed not to lift heavy objects of more than 10 pounds for the first 6 weeks or as

directed, be on the watch for symptoms and rest if fatigue occurs, get as much rest as possible and gradually increase the intensity of activitiesto tolerance. Avoid using enemas for the first few weeks after surgery.

(Monahan, Green, & Neighbors, 2011, p. 469)

8/3/2019 579B Care Plan

18/21


18

18

NURSING DIAGNOSIS AND PLAN OF CARE

1. Patient care needs of the day: I encouraged the patient to rest and ambulate at regular intervals without placing too much strain onher abdomen. The patient was not compliant with using the incentive spirometer so I was there to watch her use it about 3 times. Hermother, an RN, was also there to help her throughout the day. Her most prominent complaints were about the pain in her ribs from the

air entrapped there and about using the incentive spirometer. Norco and morphine were administered to reduce her pain. I took hervitals at 0800 and 1230. She request ice water and preferred drinking to eating. Her mood was stable throughout the morning and was

amiable.

2. Prioritized nursing diagnosis:1. Ineffective health maintenance2. Risk for infection3. Delayed surgical recovery4. Impaired skin integrity5. Acute pain

3. Explainwhy you choose these particular diagnoses and prioritized them as you did. Please describe the assessment evidencethat supports the choice of your nursing diagnoses for your specific patient? Ineffective health maintenance is top priority

because if the patient is unable or unwilling to properly self-manage her recovery then all other interventions will not be as effective asthey can be. Risk for infection is second because the probability of infection increases after a surgical operation due to the break intissue. Delayed surgical recovery is third because if the client is unable or unwilling to self-manage her recovery or an infection occurs

then recovery time will lengthen. Impaired skin integrity is fourth because in addition to her surgical wound the patient also has IVsites on her right forearm. Acute pain is fifth because the client is not suffering from life-altering pain but it is nevertheless a

complaint that must be remedied.

4. Develop a nursing care plan: Take the top 2 nursing diagnosis and process them each with the following criteria: complete nursingdiagnosis, goal/outcome criteria and interventions. Each diagnosis must have at least one goal and three interventions (with scientificrationale included for each intervention) and evaluation. Goals must be SMART (specific, measurable, attainable, realistic and timed).

8/3/2019 579B Care Plan

19/21


19

19

Nursing Diagnosis #1: Ineffective health maintenance related to deficient knowledge regarding self-care after appendectomy as evidenced byher noncompliance with the incentive spirometer and young age of 18 (Ackley & Ludwig, 2011, p. 430).

Nursing Goal/ Expected Outcome By the end of shift, patient will take initiative to collaborate with health providers to plan the therapeutic

regimen that is harmonious with her health goals and lifestyle. She will verbalize her ability to manage therapeutic regimens by the end ofshift (Ackley & Ludwig, 2011, p. 431).

Intervention #1: Establish rapport and a collaborative partnership with the client to plan and meet health-related goals by the end of shift.

y Rationale: Avoiding the paternalistic approach to care and implementing a partnership approach to care results in an effectivecollaboration between health-care provider and client (Doss, DePascal, & Hadley, 2011).

Intervention #2: Explore the clients interpretation of her illness and experience and identify uncertainties and needs through open-endedquestions.

y Rationale: Studies show that there are discrepancies between the clients view of self-management and the providers view.Noncompliance does not always mean ineffective self-management (Ackley & Ludwig, 2011, p. 431).

Intervention #3: Involve family members in knowledge development, planning for self-management, and shared decision making.

y Rationale: Family support is a strong factor in the full recovery of the patient, especially because D.L. is still young of age at 18 andmay have an immature or undeveloped attitude to her self-care regimen. The involvement of her mother, an RN, is especiallydesirable (Ackley & Ludwig, 2011, p. 431).

Evaluation Patient has verbalized instructions on how to care for her incisions and the use of her medications, especially the antibiotics, bythe end of shift. Family has also verbalized instructions and has encouraged the patient to use the incentive spirometer 10 times per hour by

end of shift. Patient understands the importance of recovery with self-management by verbalizing such sentiment at the end of shift. She hastaken initiative to plan a self-care regimen with the provider by the end of shift.

8/3/2019 579B Care Plan

20/21


20

20

Nursing Diagnosis #2: Risk for infection related to incisions in the infraumbilical and suprapubic locations and the patients young age of 18(Ackley & Ludwig, 2011, p. 491).

Nursing Goal/ Expected Outcome Patient will verbalize and demonstrate instructions on how to care for her incisions, remain free from

symptoms of infection, verbalize symptoms of infection to be on the alert for, and demonstrate proper hygiene such as handwashing, perinealcare, and oral care by the end of shift (Ackley & Ladwig, 2011, p. 491).

Intervention #1: Observe and report signs of infection such as redness, warmth, discharge from the incisions and an increased body

temperature by the end of shift.

y Rationale: Fever is a common sign of infection and must be reported immediately. Fever can occur without discharge or otherobservable symptoms (Ackley & Ladwig, 2011, p. 492).

Intervention #2: Assess skin for color, moisture, texture, and turgor every hour throughout shift.

y Rationale: The skin is the bodys first line of defense against infection (Ackley & Ladwig, 2011, p. 492).Intervention #3: Use appropriate hand hygiene such as hand washing with soap and alcohol-based hand rubs followed by wearing gloves

during contact with the incisions throughout shift.

y Rationale: A lower MRSA rate was linked to good hand hygiene and many infectious pathogens are carried via hands. Duringassessment or wound change, gloves must be worn to prevent contact with blood and mucous membranes (Morton & Schultz, 2004).

Evaluation At the end of shift, there are no signs of infection in the incisions at the suprapubic and infraumblical locations. Patient has

demonstrated proper hand hygiene and on how to care for her incisions. She verbalized the symptoms of an infection and has understood thatimportance of reporting them immediately.

8/3/2019 579B Care Plan

21/21


21

21

References

Ackley, B.J., & Ladwig, G.B. (2011).Nursing diagnosis handbook: An evidence-based guide to planning care (9th

ed.): Mosby, Inc.

Doss, S., DePascal, P., & Hadley, K. (2011). Patient-nurse partnerships. Nephrology Nursing Journal, 38(2), 115-124. Retrieved from

http://search.proquest.com/docview/857241101?accountid=8459

Epocrates online (2011). Retrieved 12/09/2011, from Https://online.epocrates.com

Lewis, S. L., Bucher, L., Dirksen, S. R., Camera, I. M., Heitkemper, M. M. . (2011).Medical-surgical nursing: assessment and management

of clinical problems (eighth ed. Vol. 2). St. Louis, Missouri: Mosby.

Monahan, F. D., Green, C.J., Neighbors, M. (2011).Manual of medical-surgical nursing: a care planning resource (7th ed.). Maryland

Heights, MO: Mosby.

Morton, J. L., & Schultz, A. A. (2004). Healthy Hands: Use of Alcohol Gel as an Adjunct to Handwashing in Elementary School Children.

Journal Of School Nursing, 20(3), 161-167.

579b care plan

Documents