comprehensive nursing care plan

Running head: COMPREHENSIVE NURSING CARE PLAN

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Comprehensive Nursing Care Plan

Inessa Borovskiy


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Introduction

On July 09, 2018, I provided care for an 88-year-old male patient, K.C. K.C. resides in

Long Island, New York, with his wife. The patient has four children, three sons and a daughter,

and six grandchildren. The patient is retired. K.C. was admitted to the Kimmel Pavilion

neurosurgery unit on July 06, 2018 for a surgical procedure, bilateral laminectomy. When asked

the patient’s reason for seeking healthcare, the patient stated, “On May 2017, I started having

pain in my lower back going all the way down to my legs.” When asked the patient what made

the pain worse and what alleviated the pain, the patient stated that standing, especially standing

for a long time aggravated the pain and laying in bed for a long time sometimes caused

numbness and tingling in his feet, specifically his left heel. While sitting would alleviate the

pain.

The patient was not on any specific isolation precautions. K.C. has no known drug

allergies. The patient is full-code. K.C. has a medical history of hypertension (HTN) diagnosed

at 15 years of age, benign prostatic hyperplasia (BPH), hypothyroidism, enlarged prostate, and

hyperlipidemia. The patient has a past surgery history of an appendectomy performed on

February 20, 1963, thyroidectomy on March 2010, bilateral cataract eye surgery on February

2013, and dental implant surgery in 2017. The patient denies any psychiatric history. The patient

denies smoking and denies any history of substance abuse. K.C. received an influenza vaccine on

July 01, 2018 and a pneumococcal vaccine on July 09, 1995.

Since being admitted to the hospital, the patient has not had any other surgeries other than

the scheduled bilateral laminectomy surgery. The patient is on fall precaution. During my shift,

the patient was third day postoperative, and he was discharged on July 09, 2018.


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Assessment

Upon assessment of the patient’s neurological status, the patient was alert and oriented to

person, place, time. At the time of the assessment, the patient reported no pain. The patient was

attentive and responded appropriately to questions. While conversing with the patient, K.C.

maintained eye contact and did not appear agitated or uncomfortable. His speech was clear and

understandable. The patient was wearing a clean hospital gown and appeared clean and well-

groomed with good hygiene. The patient was mobile and able to stand independently from the

seated position. The patient did not require assistance out of bed, to the bathroom, or with

toileting. The Hendrich II Fall Risk score was 3, indicating she is low risk for falls. The Hendrich

II Fall Risk score was graded based on one point for gender, male, one point for taking a

benzodiazepine, diazepam, and one point for pushes up successfully in one attempt. (Hendrich,

2016). During my shift, K.C. spent most of the day sitting in the chair next to his bed.

The patient weighs 73.3 kg, height of 175.3 cm and a BMI of 23.8 kg/m2 indicating he is

within the standard category for adults of his height and weight. According to the Centers for

Disease Control and Prevention, a BMI between 18.5 and 24.9 is within the healthy weight status

for adults based on the patient’s height and weight. (Centers for Disease Control and Prevention,

2015). The patient’s overall skin was appropriate for ethnicity and intact with no evidence of

redness, rashes, scars or lesions. The patient's face and facial expressions were symmetrical with

no weakness or involuntary movements. The patient had a skin tare on the left cheek. Patient's

head was normocephalic, and the skin on the head and neck was intact with no redness, lumps,

rashes, scars or lesions. The trachea was midline with the thyroid rising smoothly, no masses, or

unilateral enlargements and no presence of a jugular vein distention. The pupillary response was

direct and consensual, and pupils were equal, round, reactive to light and accommodation

(PERRLA). The patient wears prescriptive glasses, however, does not have a hearing aid. Upon


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inspection of the mouth, the buccal mucosa was pink and point with good dentition. There were

no lesions, redness of the gums, or bleeding. The patient presented with no pharyngeal exudates.

Upon assessment of the upper extremities, the skin was warm and dry to touch, with no presence

of edema bilaterally. However, ecchymosis was noted on the left upper extremity. The radial

pulse was regular rate and rhythm 3+ bilaterally. The capillary refill was brisk and less than 3

seconds bilaterally. The patient's hand grasp was 5/5 bilaterally. Upon assessment of the patient's

lower extremities, the skin was warm, dry, intact with no evidence of redness, edema, broken

skin, scars, rashes, or lesions. The dorsalis pedis pulses were 3+ bilaterally. The capillary refill of

the lower extremities was brisk and less than 3 seconds bilaterally. The hip flexion, plantar

flexion, and dorsiflexion strength test were 5/5 bilaterally. K.C. displayed a full range of motion

of the upper and lower extremities.

During the respiratory assessment, K.C. was sitting on the chair next to his bed. Upon

inspection of the skin on the anterior and posterior chest, the color was consistent with the

patient’s genetic background. The skin was intact with no evidence of cyanosis, pallor, redness,

broken skin, rashes, scars, or lesions. Patient's breathing was regular, rhythmic, relaxed, with

effortless respirations and no use of accessory muscles. The patient presented with no clinical

manifestations of acute respiratory distress. Patient's respiratory rate was within the normal range

of 18 breaths/min with the normal range of 12 – 20 breaths per minute, SpO2 was 95% on room

air with an average SpO2 range of 95 – 100%, and an oral temperature of 36.7 degrees Celsius or

98 degrees Fahrenheit with a regular oral temperature of 35.8 – 37.3 degrees Celsius or 96.4 –

99.1 degrees Fahrenheit. On auscultation of the lung sounds, breath sounds were clear bilaterally.

Following auscultation of the heart, S1, and S2 was noted, and no murmurs, rubs, or gallops

were heard with no visible pulsations on the aortic and pulmonic areas. Patient's heart rate was

66 beats per min with an average range between 60 - 100 beats per minute. The patient was not


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connected to telemetry. The patient’s blood pressure was taken on right arm, and the blood

pressure was high at 147/55 mmHg, which is consistent with his diagnosis of hypertension, with

an average range of systolic pressure of less than 120 mmHg systolic and a diastolic pressure less

than 80 mmHg.

Upon assessment of the abdomen, the skin was smooth with no lesions, scars, or striae.

Bowel sounds were present and normoactive. The abdomen was soft, non-distended, and non-

tender, with no rebound tenderness or guarding. K.C. was continent, and his last bowel

movement was on July 08, 2018. He reported no abdominal pain, nausea, vomiting, or diarrhea.

The patient was on a regular diet. He had a good appetite and ate more than 90% of his breakfast.

K.C. was continent and voided in the bathroom. The urine color was yellow and clear. The

patient reported voiding without difficulty and no pain upon urination. During my shift, the

patient's fluid intake was 1320 mL, and his total output was 835 mL.

The patient had a bilateral laminectomy. Therefore, he had a wound dressing that needed

to be changed. The location of the surgical site was on his lower back. The dressing was dry and

intact. The incision site was clean, dry, no dehiscence, erythema, swelling, foul odor, tenderness

was noted. Additionally, the patient had one Jackson-Pratt drain (JP drain). The JP drain was not

on suction instead it drained by gravity. The JP drain was intact and had sanguineous drainage.

The patient had a peripheral IV a heparin lock on the left extremity.

Pathophysiology

As people age, the anatomy of the spine changes which is a natural effect of aging.

However, normal wear and tear effects of aging can lead to the narrowing of the spinal canal a

condition known as spinal stenosis. Spinal stenosis often occurs in adults over the age of 60.

(OrthoInfo, 2013). Several months ago, the 88-year-old- male patient, K.C. started experiencing

pain in his lower back. The pain originated in the lower back and radiated down to his buttocks


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and alternated down the back of his thighs, calves, and into his ankles. The areas the patient

experienced symptoms of pain are evident in lumbar spinal stenosis (LSS). (OrthoInfo, 2013).

Spinal stenosis is the narrowing of the spinal canal, a hollow vertical hole that contains

the spinal cord, putting pressure on the spinal cord and the spinal nerve roots causes pain,

numbness, or weakness in the legs. Stenosis in the lumbar area of the spine is a common cause of

chronic low back pain. (Lewis, Dirksen, Heitkemper, & Bucher, 2014, p. 1547; OrthoInfo, 2013).

Spinal stenosis can be caused by either an acquired or an inherited condition. One of the most

common acquired causes is arthritis particularly osteoarthritis in the spine. The arthritic changes

such as bone spurs, calcification of spinal ligaments, or degeneration of discs narrow the space

around the spinal canal and nerve roots leading to compression which causes inflammation and

results in pain, weakness, and numbness. (Lewis, Dirksen, Heitkemper, & Bucher, 2014, p.

1547).

Arthritis in the spine can result as the disk degenerates and loses water content.

Compared to the elderly, the disks in children and young adults have a high-water content. As

people age, the disks start to dry out and weaken causing settling or collapse of the disk spaces

and loss of disk space height. Over time as the spine settles, the weight is transferred to the facet

joints and the tunnels through which the nerves exit through become smaller. The weight that is

transferred to the facet joints causes increased pressure and degeneration leading to the

development of arthritis. (OrthoInfo, 2013). Additionally, the cartilage that covers and protects

the joints wears away. If the cartilage wears away completely, it can result in bone rubbing on

bone. The body responds to lost cartilage by growing new bone in the facet joints to help support

the vertebrae. However, this bone overgrowth called spurs may narrow the space for the nerves

to pass through. (OrthoInfo, 2013). Arthritis in the lower back also causes the ligaments around


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the joints to increase in size decreasing the space for nerves. Eventually, the space becomes so

small that it irritates the spinal nerves resulting in painful symptoms. (OrthoInfo, 2013).

Some other acquired conditions that lead to spinal stenosis include rheumatoid arthritis,

spinal tumors, Paget’s disease, and traumatic damage to the vertebral column. (Lewis, Dirksen,

Heitkemper, & Bucher, 2014, p. 1547). Whereas, inherited conditions leading to spinal stenosis

include congenital spinal stenosis and scoliosis. (Lewis, Dirksen, Heitkemper, & Bucher, 2014,

p. 1547).

The most common clinical manifestation associated with lumbar spinal stenosis is pain

that starts in the lower back and radiates to the buttocks and legs. The pain exacerbates with

walking and standing. Some patients experience numbness, tingling, weakness, and heaviness in

the legs and buttocks. Pain that is alleviated when the patient bends forward or sits down is

usually a sign of spinal stenosis. Stenosis often slowly progresses and does not cause paralysis.

(Lewis, Dirksen, Heitkemper, & Bucher, 2014, p. 1547). The patient, K.C., first began

experiencing back pain that eventually radiated to his buttocks and legs. The pressure on the

spinal nerves resulted in pain in the areas that the nerves supply. The pain generally starts in the

buttocks and radiates down the leg. Patients describe the pain as an ache or burning feeling.

Furthermore, as it advances, it can result in foot pain. (OrthoInfo, 2013).

K.C. stated that after some time, standing for an extended period or laying in bed caused

numbness in his feet and calves and occasional tingling in his left heel. Due to the increased

pressure on the nerve patients experience numbness and tingling. As the pressure reaches a

critical level, patients develop weakness in one or both legs or a foot drop, the feeling that their

foot slaps on the ground while walking. (OrthoInfo, 2013). Patients often find that leaning

forward or sitting alleviates the pain. Additionally, leaning forward while sitting can further

lessen the pain. Leaning forward increases the space available for the nerves. As per K.C., he


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stated that in the beginning, the pain lessened while sitting. While standing up straight and

walking exacerbates the pain. (OrthoInfo, 2013).

To diagnosis lumbar spinal stenosis, a physician will obtain a medical history, complete a

physical examination, and order imaging tests such as an x-ray, a magnetic resonance imaging

(MRI), a computed tomography (CT) scan, or a myelogram. (OrthoInfo, 2013). A physical

examination includes examining the patients back and pushing on different areas to determine

the painful areas. An x-ray visualizes bones and illustrates aging changes such as the loss of disk

height or bone spurs. X-rays obtained while the patient is leaning forward and backward will

show instability in the joints. Additionally, x-rays can show too much mobility called

spondylolisthesis. (OrthoInfo, 2013). A magnetic resonance imaging (MRI) demonstrates images

of soft tissues such as muscles, disks, nerves, and the spinal cord. A computed tomography (CT)

scan displays cross-section images of the spine. (OrthoInfo, 2013). A myelogram is a diagnostic

imaging test, and it involves injecting a dye into the spine resulting in images that show the

nerves more clearly and can help determine whether the nerves are compressed. (OrthoInfo,

2013).

There are two methods of treatment for lumbar spinal stenosis, including a nonsurgical

treatment and a surgical treatment. (OrthoInfo, 2013). Nonsurgical treatments include physical

therapy, lumbar traction, anti-inflammatory medications, steroid injections, acupuncture, and

chiropractic manipulation. However, nonsurgical treatment options do not improve the narrowing

of the spinal canal. Instead, the treatment options restore function and relieve pain. (OrthoInfo,

2013). Surgical treatment options include laminectomy and spinal infusion. Physicians will often

recommend surgical treatment options for patients with reduced quality of life due to pain,

weakness, and difficulty walking for a long time. (OrthoInfo, 2013). Spinal infusion surgery is

recommended for patients whose arthritis has progressed to spinal instability. Whereas


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laminectomy involves removing the bone, bone spurs, and ligaments compressing the nerves.

(OrthoInfo, 2013).

In the case of K.C., before resorting to the surgical treatment option, he tried nonsurgical

treatments such as physical therapy, chiropractic manipulation, and anti-inflammatory

medications. However, none of the alternative options alleviated his pain. Within a short time,

his symptoms worsened dramatically, K.C. went from alleviating the pain by laying down to

experiencing numbness in his feet and calves when laying down. Therefore, the patient’s’

physician recommended a surgical procedure known as a laminectomy also known as

decompression surgery.

A laminectomy surgery is performed because the bony overgrowths, also known as bone

spurs a natural side effect of the aging process, within the spinal canal narrow the space available

for the spinal cord and nerves causing pressure. The pressure causes pain, weakness or numbness

that radiates down an individual’s arms or legs. (Mayo Clinic Staff, 2018). A laminectomy

surgery creates space by removing the back part of a vertebra that covers the spinal canal known

as the lamina. This results in the enlargement of the spinal canal and relieves pressure on the

spinal cord or nerves. (Mayo Clinic Staff, 2018). The laminectomy restores the spinal canal

space however it does not cure arthritis. Instead, it relieves radiating symptoms from compressed

nerves. (Mayo Clinic Staff, 2018).

Diagnostic Procedures & Laboratory Results

Diagnostic

Procedure/Laboratory

Test Results

Rationale Indicate specific reason(s) for doing or

obtaining this test for your patient

Analysis of Results Indicate if normal or abnormal (e.g., high or low values] and correlate results with patient’s health

problems by providing explanation of

abnormalities noted

Hemoglobin Hemoglobin is used to check for

anemia, a condition in which the body

has fewer red blood cells than normal.

Hemoglobin may also be ordered if the

patient’s diet is low in iron and

Hemoglobin = 10 g/dL, lab value low.

Low hemoglobin with low red blood cell

(RBC) count 3.27, and low hematocrit

29.3% can indicate anemia.


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minerals, excessive blood loss from an

injury or a surgical procedure, or long-

term infection. (MedlinePlus, 2018).

Hematocrit A hematocrit test is part of a complete

blood count (CBC). Hematocrit may be

ordered to diagnose a blood disorder.

(MedlinePlus, 2017).

Hematocrit = 29.3%, a low value

indicative of anemia.

WBC A WBC count is obtained as part of

the complete blood count (CBC), and

it was completed third-day post-op to

identify whether the patient acquired

an infection post-op and

inflammation. Additionally, this

patient is taking dexamethasone

which can decrease WBC resulting

in hypokalemia. (AACC, 2017;

Hodgson, Kizior, 2016, p. 349).

WBC = 16.9, a high value can be

indicative of inflammation and treatment

of inflammation includes dexamethasone

which can increase white blood cell count.

Platelets The patient is taking an

anticoagulant, Enoxaparin

(Lovenox), a medication that

requires the monitoring of platelet

count. (IBM Micromedex, 2018).

Platelets = 156, lab value is normal

Na Sodium lab levels were obtained to

monitor and evaluate the level of

electrolytes due to hypertension.

(AACC, 2018). Dexamethasone

use to treat inflammation may

increase sodium. (Hodgson, Kizior,

2016, p. 349).

Na = 142 mEq/L, lab value is normal

K Potassium lab levels were ordered

because this patient has high blood

pressure, hypertension, and is being

treated for hypertension. This patient

is taking dexamethasone, and this

medication can decrease serum

potassium levels resulting in

hypokalemia. (AACC, 2018;

Hodgson, Kizior, 2016, p. 349).

K = 4.3 mEq/L, lab value is normal

CO2 As part of the electrolyte panel and

to evaluate and monitor balance of

electrolytes in patients with

hypertension. (AACC, 2018).

CO2 = 21, low can be indicative of

metabolic acidosis.

Cl Chloride test was ordered as part of an

electrolyte or basic metabolic panel to

monitor the patient’s high blood

pressure. However, it can also be

ordered if acidosis or alkalosis is

Cl = 112 mEq/L, a high value indicates

dehydration and can occur when too much

base is lost from the body producing

metabolic acidosis or during

hyperventilation causing respiratory


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suspected or if the patient has

symptoms of prolonged vomiting,

diarrhea, weakness, fatigue, or

difficulty breathing. (AACC, 2017).

alkalosis which is consistent with the

patient’s low carbon dioxide level.

Mg The patient is taking pantoprazole

(Protonix) which may cause a decrease

in magnesium, hypomagnesemia.

(Vallerand, Sanoski, & Deglin, 2015, p.

963).

Mg = 1.7 mg/dL, lab value is normal

BUN The patient is taking Carvedilol

(Coreg) for hypertension and

Cholecalciferol (Vitamin D3) for

prophylaxis of vitamin D

deficiency both of which require

monitoring of blood urea nitrogen

levels. (Hodgson, Kizior, 2016, p.

207; Vallerand, Sanoski, & Deglin,

2015, p. 1265). The patient has

benign prostatic hyperplasia

(BPH), and BUN is completed to

evaluate kidney function. (AACC,

2017).

BUN = 14 mg/dL, lab value is normal

Creatinine Hypertension to monitor the effect of

medications on the kidneys. (AACC,

2018). Benign prostatic hyperplasia

(BPH) to evaluate kidney function.

(AACC, 2017). The patient is taking

Cholecalciferol (Vitamin D3) and

Pantoprazole (Protonix) both of which

require monitoring creatinine levels.

(IBM Micromedex, 2018; Vallerand,

Sanoski, & Deglin, 2015, p. 963).

Creatinine = 0.78 mg/dL, lab value is

normal

Glucose The patient is at risk for diabetes due to

risk factors of hypertension, taking

medication for high blood pressure such

as Carvedilol (Coreg), and

hyperlipidemia. The patient is taking

Dexamethasone for the treatment of

inflammation which may increase

serum glucose levels. (Hodgson, Kizior,

2016, p. 349). Glucose is monitored in

patients taking Glucagon (Glucagon)

and Insulin Lispro (Humalog).

(Vallerand, Sanoski, & Deglin, 2015, p.

42; 612).

Glucose = 135 mg/dL, lab value is high

indicating high blood sugar level and a

high blood glucose level can also be due

to the treatment of inflammation using

Dexamethasone (Decadron) which

increases glucose. (Hodgson, Kizior, 2016,

p. 349).

aPTT The patient is taking an anticoagulant

Enoxaparin (Lovenox) as prophylaxis of

31.7 seconds, lab value is normal.


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venous thromboembolism, deep vein

thrombosis, and/or pulmonary

embolism. (AACC, 2018; Vallerand,

Sanoski, & Deglin, 2015, p. 634).

Medications

Medication (as ordered by

M.D./NP)

– Classification – How does

the medication work (chemical action)?

Specific Reason

for Taking Them? (Example: To treat

Hypertension and CHF)

Side Effects,

Contraindications and

lab values to be

monitored (Only

important ones)

Patient and Family

Teaching (Only specific and relevant

instruction for that drug) Never

write: Take as directed?

Acetaminophen (Tylenol)

650 mg Tablet Oral Q4h

Classification: Analgesic,

Antipyretic

Chemical Action:

Inhibits prostaglandin

synthesis in the central

nervous system and

blocks pain impulses

through peripheral action.

Inhibits hypothalamic

heat-regulator center

(Hodgson, Kizior, 2016, p.

9).

To treat mild pain

post-operation and

relieve fever

greater than

100.4℉ (Hodgson,

Kizior, 2016, p. 9).

Side Effects: Rash,

anorexia nausea,

vomiting, and insomnia

(Vallerand, Sanoski, &

Deglin, 2015, p. 99).

Contraindications:

Hypersensitivity to

acetaminophen or any of

its components, severe

hepatic impairment or

severe active liver

disease (Hodgson,

Kizior, 2016, p.9).

Lab Values: Monitor

ALT, AST, bilirubin, and

prothrombin levels as an

increase in these may

indicate hepatotoxicity.

(Hodgson, Kizior, 2016,

p.10).

• Advise patient not to

exceed more than 4 g of

acetaminophen within 24

hours.

• Advise patient to

discontinue use of

acetaminophen and notify

HCP if rash occurs.

• Educate the patient to

notify HCP if discomfort

or fever is not relieved by

usual doses or if the fever

lasts longer than 3 days.


avoid alcohol intake

while taking

acetaminophen.


p.11; Vallerand, Sanoski,

& Deglin, 2015, p. 99).

AmLODIpine (Norvasc) 5

mg Tablet Oral Daily

Classification: Calcium

Channel Blocker

Chemical Action:

Prevents the transport of

calcium into the myocardial

and vascular smooth muscle

cells, resulting in the

inhibition of excitation-

contraction coupling and

subsequent contraction.


63).

To treat

hypertension

(Hodgson, Kizior,

2016, p. 63).

Side Effects: Peripheral

edema, headache,

flushing, dizziness,

palpitations, nausea,

unusual fatigue or

weakness (Hodgson,

Kizior, 2016, p. 63).

Contraindications:

Hypersensitivity to

AmLODIpine or any of

its components, systolic

blood pressure less than

90 mmHg (Vallerand,

Sanoski, & Deglin,

2015, p. 145).

• Educate the patient

against abruptly

discontinuing use of the

medication


avoid tasks that require

alertness and motors

skills until the patient is

aware of the response to

the drug.

• Teach patient to avoid

grapefruit products


p. 64).


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Lab Values: Monitor

renal and hepatic

function tests (Hodgson,

Kizior, 2016, p. 63).

Bacitracin Zinc Ointment

Topical 2 Times Daily

Classification:

Antibacterial, Antibiotic

Chemical Action:

Inhibits bacterial cell-wall

synthesis and damages the

cell-wall membrane

(Kee, Hayes, McCuistion,

2015, p. 445).

Prophylaxis to

prevent skin

infection on the

patient’s left

cheek tear. (Kee,

Hayes,

McCuistion, 2015,

p. 445).

Side Effects: Redness,

rash, nausea, and

vomiting (Kee, Hayes,

McCuistion, 2015, p.

445).

Contraindications:

Hypersensitivity or toxic

reaction to bacitracin

(IBM Micromedex,

2018).

Lab Values: No special

monitoring. (IBM

Micromedex, 2018).

• Advise patient that the

topical ointment is only

for use on minor cuts or

burns.

• Instruct patient to use the

ointment only as long as

prescribed because

prolonged use may cause

overgrowth of non-

susceptible bacteria.

• Educate patient on

potential side effects of

topical use such as

contact dermatitis or

pruritis. (IBM

Micromedex, 2018).

Bisacodyl (Dulcolax)

Suppository 10 mg Rectal

Daily

Classification: GI

Stimulant

Chemical Action:

Increases peristalsis by

direct effect on the smooth

muscle of the intestine.


2015, p. 687).

Prophylaxis to

constipation

(Hodgson, Kizior,

2016, p. 147).

Side Effects: Anorexia,

nausea, vomiting,

cramps, diarrhea (Kee,

Hayes, McCuistion,

2015, p. 687).

Contraindications:

Hypersensitivity, fecal

impaction, intestinal or

biliary obstruction, GI

bleeding, appendicitis,

abdominal pain, nausea,

vomiting, and rectal

fissures (Kee, Hayes,


687).

Lab Values: Monitor

serum electrolytes

specifically serum

potassium and calcium

(Kee, Hayes,


687).

• Teach the patient ways to

promote defecation by

increasing fluid intake,

exercising, and eating a

high-fiber diet.


avoid taking antacids,

milk or other medication

within 1 hour of taking

the medication because

this may decrease the

effectiveness of

Bisacodyl (Dulcolax)

• Teach the patient to

report unrelieved

constipation, rectal

bleeding, muscle pain or

cramps, dizziness, and

weakness to a health care

provider (HCP).


p. 148).

Carvedilol (Coreg) Tablet

6.25 mg Oral 2 times

Daily

Classification:

Beta adrenergic blocker

Treatment of

hypertension

(Hodgson,

Kizior, 2016, p.

207).

Side Effects: Fatigue,

dizziness, diarrhea,

bradycardia, rhinitis, and

back pain (Hodgson,

Kizior, 2016, p. 208).

• Educate the patient that

this medication takes one

to two weeks for the full

antihypertensive effect


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Chemical Action:

Blocks stimulation of

beta1 and beta2-adrenerfic

receptor sites. Also has

alpha2 blocking activity

which can result in

orthostatic hypotension.


Deglin, 2015, p. 275).

Contraindications:

Bronchial asthma or

related bronchospastic

conditions, cardiogenic

shock, decompensated

heart failure requiring

intravenous inotropic

therapy, severe hepatic

impairment, second or

third-degree AV block,

severe bradycardia, or

sick sinus syndrome

except in patients with

pacemaker (Hodgson,

Kizior, 2016, p. 207).

Lab Values: Monitor

EKG for cardiac

arrhythmias, BUN,

serum lipoprotein,

potassium, triglyceride,

uric acid levels, ANA

titers, and blood glucose

levels (Vallerand,

Sanoski, & Deglin,

2015, p. 276).

• Teach patient to take this

medication with food and

to restrict salt, alcohol

intake.

• Teach patient to measure

and monitor blood

pressure and pulse before

taking medication

• Instruct patient to avoid

abrupt discontinuation of

the medication and the

importance of taking this

medication to control

hypertension


tasks that require

alertness and motor skills

until the patient’s

response to the

medication has been

established


report excessive fatigue,

prolonged dizziness to

HCP


the use of nasal

decongestants, OTC cold

preparations (stimulants)

unless approved by HCP.


p. 209).

Cholecalciferol (Vitamin

D3) Tablet 400 units Oral

Daily

Classification:

Vitamin

Chemical Action:

Requires activation in the

liver and kidneys to create

the active form of vitamin

D3 (Vallerand, Sanoski, &

Deglin, 2015, p. 1266).

Prophylaxis of

vitamin D

deficiency

(Vallerand,

Sanoski, &

Deglin, 2015, p.

1265).

Side Effects: Nausea,

vomiting, loss of

appetite, constipation,

dehydration, fatigue,

irritability, confusion,

weakness, or weight

loss (Lexicomp, 2018).

Contraindications:

Hypercalcemia, primary

hyperparathyroidism,

sarcoidosis,

hypervitaminosis D,

Williams syndrome, and

patients who are pregnant.

(Lexicomp, 2018).

• Advise patient to avoid

simultaneous use of

antacids containing

magnesium


immediately report signs

of weakness, confusion,

fatigue, headache, nausea

and vomiting,

constipation, or bone pain

to a health care provider

as this may be signs of

high calcium levels.

• Educate the patient about

signs of a significant


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Lab Values: Monitor

serum, calcium levels,

serum phosphorus,

alkaline phosphatase,

urinary calcium

excretion, CBC, urine

protein, renal function

tests (creatinine, BUN),

serum amylase, and

lipid/lipoprotein levels.

(IBM Micromedex,

2018).

reaction such as

wheezing, chest

tightness, fever, itching,

severe cough, blue skin

color, seizures, or

swelling of the face, lips,

tongue, or throat.

(Lexicomp, 2018).

Dexamethasone

(Decadron) Tablet 2 mg

Oral Daily

Classification:

Corticosteroid

Chemical Action:

Suppresses neutrophil

migration, decreases the

production of

inflammatory mediators

and reverses increased

capillary permeability.


p.349).

Treatment of

inflammation.

(Hodgson, Kizior,

2016, p. 349).

Side Effects:

Hypersensitivity to

corticosteroids,

insomnia, facial edema

such as cushingoid

appearance, moderate

abdominal distention,

indigestion, increased

appetite, nervousness,

facial flushing, and

diaphoresis (Hodgson,

Kizior, 2016, p.350).

Contraindications:

Systemic fungal

infections and cerebral

malaria (Hodgson,

Kizior, 2016, p. 349).

Lab Values: Monitor

serum glucose, lipids,

sodium levels, serum

calcium, potassium,

thyroxine, and WBC.

(Hodgson, Kizior,

2016, p. 349).


report symptoms of fever,

sore throat, muscle aches,

sudden weight gain,

edema, and exposure to

measles or chickenpox.

• Advise patient to inform

the dentist and other

physicians of

dexamethasone therapy

within the past 12

months.

• Advise the patient against

changing dose, schedule,

or abruptly stopping the

use of medication

because the patient must

be gradually tapered off

the medication.


alcohol and limit caffeine

intake. (Hodgson, Kizior,

2016, p. 351).

Diazepam (Valium) 5 mg

Oral q6h

Classification: Skeletal

muscle relaxants

(Centrally acting)

Chemical Action:

Inhibits spinal

polysynaptic afferent

pathways. (Vallerand,

Sanoski, & Deglin, 2015,

p. 414).

To treat skeletal

muscle spasm

(Wilson,

Shannon, &

Shields, 2015, p.

464).

Side Effects: Dizziness,

drowsiness, lethargy,

depression, hangover,

ataxia, slurred speech,

headache, paradoxical

excitation, blurred

vision, respiratory

depression, constipation,

diarrhea, nausea,

vomiting, weight gain,

rashes, physical

• Instruct the patient

against taking more than

the prescribed dose and

educate against abrupt

discontinuation of the

medication as this can

cause insomnia, unusual

irritability or nervousness


driving and other

activities that require


16

dependence,

psychological

dependence, and

tolerance. (Vallerand,

Sanoski, & Deglin,

2015, p. 414 – 415).

Contraindications:

Hypersensitivity, cross-

sensitivity with other

benzodiazepines may

occur, comatose

patients, myasthenia

gravis, severe

pulmonary impairment,

sleep apnea, severe

hepatic dysfunction,

preexisting CNS

depression, uncontrolled

severe pain, angle-

closure glaucoma, some

products contain

alcohol, propylene

glycol, or tartrazine and

should be avoided in

patients with known

hypersensitivity or

intolerance (Vallerand,

Sanoski, & Deglin,

2015, p. 414).

Lab Values: Monitor

hepatic, renal function,

and complete blood

count (CBC).


Deglin, 2015, p. 416).

alertness until the

patient’s response to the

medication is known

• Educate geriatric patients

of increased risk for

central nervous system

effects and potential for

falls


alcohol intake and other

central nervous

depressants concurrently

with this medication.


Deglin, 2015, p. 417).

Docusate (Colace) 100 mg

Capsule Oral 3 times

Daily

Classification:

Gastrointestinal agent,

stool softener

Chemical Action:

Decreases surface film

tension by mixing liquid

with bowel contents.


p. 386).

Prophylaxis to

prevent constipation.

(Hodgson, Kizior,

2016, p. 385).

Side Effects: Mild

gastrointestinal cramping,

throat irritation with liquid

preparation. (Hodgson,

Kizior, 2016, p. 386).

Contraindications:

Acute abdominal pain,

concomitant use of mineral

oil, intestinal obstruction,

nausea, vomiting


386).

• Teach patient to take

measures to promote

defecation such as

increasing fluid intake,

exercising, increasing fiber

in their diet, and increasing

mobility.

• Inform the patient that this

medication only be used for

short-term therapy and

long-term therapy may


17

Lab Values: No special

monitoring (Hodgson,

Kizior, 2016, p. 386).

cause electrolyte imbalance

and dependence.

• Advise the patient against

the use of laxatives if

abdominal pain, nausea,

vomiting, or fever occurs.

• Instruct the patient not to

take docusate within 2

hours of other laxatives.


386; Vallerand, Sanoski, &

Deglin, 2015, p. 444).

Enoxaparin (Lovenox)

Injection 40 mg SubQ

Q24h

Classification:

Anticoagulants

Chemical Action:

Increases the inhibitory

effect of antithrombin on

factor Xa and thrombin.


Deglin, 2015, p. 635).

Prophylaxis of

venous

thromboembolis

m (VTE), deep

vein thrombosis

(DVT), and/or

pulmonary

embolism (PE) in

surgical patients.

(Vallerand,

Sanoski, &

Deglin, 2015, p.

634).

Side Effects: Injection

site hematoma, nausea,

peripheral edema.


p. 432).

Contraindications:

Active major bleeding,

concurrent heparin

therapy, hypersensitivity

to heparin, pork

products,

thrombocytopenia

associated with positive

in vitro test for

antiplatelet antibodies.


p. 431).

Lab Values: Anti-Factor

Xa levels, complete

blood count (CBC)

including platelet count,

and stool occult blood

test (IBM Micromedex,

2018).

• Instruct the patient to

report symptoms of

bleeding, pulmonary

edema, skin necrosis,

or atrial fibrillation.

• Advise the patient to

rotate injection sites,

and the patient should

lie down during

injection.


avoid concurrent

anticoagulants,

including NSAIDs

and aspirin, without

approval from HCP.

(IBM Micromedex,

2018).

Finasteride (Proscar)

Tablet 5 mg Daily Oral

Classification:

Androgen inhibitor

Chemical Action:

Inhibits the enzyme 5-

alpha-reductase, an

enzyme that is responsible

for converting testosterone

to its potent metabolite 5-

alpha-dihydrotestosterone

To treat benign

prostatic

hyperplasia

(BPH).

(Vallerand,

Sanoski, &

Deglin, 2015, p.

561).

Side Effects:

Contraindications:

Hypersensitivity, and

women (Vallerand,

Sanoski, & Deglin,

2015, p. 561).

Lab Values: Monitor

serum prostate specific

antigen (PSA)

concentrations

• Educate the patient

that at least 6 to 12

months of therapy

may be necessary to

determine whether the

patient responded to

finasteride.

• Inform the patient

that the volume of

ejaculate may be

decreased and erectile


18

in the prostate, liver, and

skin. 5-alpha-

dihydrotestosterone is

partially responsible for

prostatic hyperplasia and

hair loss. (Vallerand,


p. 561).


Deglin, 2015, p. 561).

dysfunction and

decreased libido may

occur during and after

therapy is completed.


report changes in

breasts such as lumps,

pain, and nipple

discharge to HCP.

• Inform patient of the

increased risk of high-

grade prostate cancer

in men while taking

this medication.

• Stress the importance

of periodic follow-up

exams to determine

whether a therapeutic

response has occurred.


Deglin, 2015, p. 561).

Glucagon (Glucagon)

Injection 1 mg

Intramuscular Daily

Classification:

Antihypoglycemic

Chemical Action:

Stimulates adenylate

cyclase to produce

increased cyclic

adenosine monophosphate

(AMP) promoting hepatic

glycogenolysis and

gluconeogenesis, resulting

in increased blood

glucose levels. (Hodgson,

Kizior, 2016, p. 563).

Prophylaxis to

prevent hypoglycemia

if blood glucose is

less than 70 mg/dL

(Hodgson, Kizior,

2016, p. 563).


vomiting, allergic

reaction such urticaria,

respiratory distress, and

hypotension (Hodgson,

Kizior, 2016, p. 564).

Contraindications:

Hypersensitivity,

pheochromocytoma,

some products contain

glycerin and phenol

patients with

hypersensitivities to

these should avoid use

avoid use of this

medication. (Vallerand,

Sanoski, & Deglin,

2015, p. 612).

Lab Values: Monitor

serum glucose levels

and fingerstick blood

glucose (Vallerand,

Sanoski, & Deglin,

2015, p. 612).

• Educate the patient on

signs and symptoms of

hypoglycemia such as

pale, cool skin, anxiety,

difficulty concentrating,

headache, hunger, nausea,

shakiness, diaphoresis,

unusual fatigue, unusual

weakness, and

unconsciousness.

• If symptoms of

hypoglycemia develop,

instruct the patient to

consume sugar first such

as orange juice, honey,

hard candy, sugar cubes,

or table sugar dissolved

in water or juice followed

by cheese and crackers,

half a sandwich, or a

glass of milk.

• Instruct patient on correct

technique to prepare,

draw up, and administer

injection including

instructing the patient to


19

check expiration date

monthly and to replace

outdated medication

immediately. (Hodgson,

Kizior, 2016, p. 564;

Vallerand, Sanoski, &

Deglin, 2015, p. 613).

HydrALAZINE

(Apresoline) 10 mg

Injection IV q10 min

Classification:

Vasodilator

Chemical Action: Direct-

acting peripheral arteriolar

vasodilator. (Vallerand,


p. 647).

To treat moderate

to severe

hypertension,

systolic blood

pressure greater

than 160 mmHg.

(Vallerand,

Sanoski, &

Deglin, 2015, p.

647).


drowsiness, headache,

tachycardia, angina,

arrhythmias, edema,

orthostatic hypotension,

diarrhea, nausea,

vomiting, rash, sodium

retention, arthralgias,

arthritis, peripheral

neuropathy, drug

induced lupus syndrome


Deglin, 2015, p. 647 –

648).

Contraindications:

Coronary artery disease,

mitral valvular rheumatic

heart disease, dissecting

aortic aneurysm


p. 581).

Lab Values: Monitor

complete blood count,

electrolytes, lupus

erythematosus (LE) cell

prep, and antinuclear

antibodies (ANA) titer


Deglin, 2015, p. 648).

• Instruct the patient to rise

slowly from lying to

standing to reduce

orthostatic hypotension


report manifestations of

muscle or joint aches,

fever such as a lupus-like

reaction, and flu-like

symptoms.


limit alcohol intake.


p. 583).

Insulin Lispro

(HumaLOG) Injection 0-

10 SubQ 3 times Daily

Classification:

Antidiabetic

Chemical Action:

Stimulates glucose uptake

in the skeletal muscle and

fat inhibiting hepatic

glucose production.

Inhibits lipolysis and

To lower blood

sugar and control

diabetes mellitus

(Kee, Hayes,

McCuistion,

2015, p. 762).

Side Effects: Confusion,

agitation, tremors,

headache, flushing,

hunger, weakness,

lethargy, fatigue,

urticaria, redness,

irritation or swelling at

the injection site. (Kee,

Hayes, McCuistion,

2015, p. 762).

• Teach proper use

including injection

technique, syringe

disposal, and monitoring

requirements.

• Instruct the patient never

to share insulin pens or

cartridges.

• Educate patient to report

signs of hypoglycemia

such as dizziness,


20

proteolysis, enhances

protein synthesis.


Deglin, 2015, p. 683).

Contraindications:

Hypersensitivity to

insulin lispro or any of

its components, during

episodes of

hypoglycemia. (Kee,

Hayes, McCuistion,

2015, p. 762).

Lab Values: Monitor

HbA1c, serum glucose

and glycosylated

hemoglobin, serum

electrolytes, renal

function tests, and liver

function tests

(Lexicomp, 2018;

Vallerand, Sanoski, &

Deglin, 2015, p. 42).

headache, fatigue,

weakness, shaking, fast

heartbeat, confusion,

hunger, or sweating or

hypokalemia including

muscle pain or weakness,

muscle cramps, or an

abnormal heartbeat

(Lexicomp, 2018).

Levothyroxine

(Synthroid) Tablet 150

mcg Oral every morning

Classification:

Thyroid hormone

Chemical Action:

Increases metabolic rate,

oxygen consumption, and

body growth. (Kee,

Hayes, McCuistion, 2015,

p. 747).

To treat

hypothyroidism.

(Kee, Hayes,

McCuistion,

2015, p. 747).


vomiting, anorexia,

diarrhea, cramps,

tremors, nervousness,

irritability, insomnia,

headache, weight loss,

diaphoresis, amenorrhea

(Kee, Hayes,


747).

Contraindications:

Thyrotoxicosis,

myocardial infarction,

severe renal disease, and

adrenal insufficiency

(Kee, Hayes,


747).

Lab Values: Monitor

thyroid function studies,

thyroid-stimulating

hormone serum levels,

blood, urine glucose,

and PT/INR.


Deglin, 2015, p. 758).


take levothyroxine at the

same time each day. If

the patient misses a dose,

the dose should be taken

as soon as he or she

remembers unless it is

almost time for the next

dose. If the patient misses

2 to 3 doses notify HCP.

• Educate the patient that

the medication does not

cure hypothyroidism

instead it provides a

thyroid hormone

supplement, and this is a

lifelong therapy

treatment.


report a headache,

nervousness, diarrhea,

excessive sweating, heat

intolerance, chest pain,

increased pulse rate,

palpitations, or weight

loss greater than 2

pounds per week.

• Emphasize the

importance of follow-up


21

exams to monitor the

effectiveness of the

medication. (Vallerand,


p. 759).

Pantoprazole (Protonix)

EC Tablet 40 mg Oral

Daily

Classification:

Proton pump inhibitor

Chemical Action:

Irreversibly binds to and

inhibits hydrogen-

potassium adenosine

triphosphate an enzyme

on the surface of gastric

parietal cells and

hydrogen ion transport

into the gastric lumen.


p. 946).

Treatment of

erosive

esophagitis

associated with

gastroesophageal

reflux disease

(GERD).

(Hodgson, Kizior,

2016, p. 947).

Side Effects: Diarrhea,

headache, dizziness,

pruritis, and rash


p. 947).

Contraindications:

Hypersensitivity to

proton pump inhibitors


p. 947).

Lab Values: Monitor

liver function including

AST, ALT, alkaline

phosphatase, bilirubin,

serum magnesium,

creatinine, cholesterol,

uric acid, and glucose.


Deglin, 2015, p. 963).

• Advise the patient to report

symptoms of a headache,

an onset of black, tarry

stools, diarrhea, or

abdominal pain.


swallow whole tablets and

not to chew, crush,

dissolve, or divide the

tablets.

• Advise patient it is best to

take the medication before

breakfast and to avoid

alcohol. (Hodgson, Kizior,

2016, p. 948).

Rosuvastatin (Crestor) 10

mg Oral Daily

Classification:

Antihyperlipimic; HMG-

CoA reductase inhibitor

Chemical Action:

Inhibits HMG-CoA

reductase, the enzyme

essential for hepatic

production of cholesterol.


2015, p. 669).

To treat

hyperlipidemia.

(Kee, Hayes,

McCuistion,

2015, p. 669).

Side Effects: Headache,

rash, pruritus,

constipation, diarrhea

(Kee, Hayes,


669).

Contraindications:

Active liver disease,

pregnancy (Kee, Hayes,


669).

Lab Values: Monitor

serum cholesterol,

triglycerides, liver

function tests including

AST and ALT, bilirubin

levels, cardiovascular

status in patients with

hypertension, creatine

phosphokinase (CPK)

levels, INR values with

concurrent warfarin

therapy. (Vallerand,

• Teach the patient that

rosuvastatin can be taken

any time of day and may

be taken without regard

to food.

• Educate the patient that it

is essential to maintain an

appropriate diet.

• Instruct patient to report

unexplained muscle pain,

tenderness, weakness,

fever, and malaise.

• If the patient is taken

magnesium or aluminum-

containing antacids while

taking rosuvastatin,

instruct the patient to take

antacid at least 2 hours

after rosuvastatin.


p. 1107; Vallerand,


p. 645; Wilson, Shannon,


22

Sanoski, & Deglin,

2015, p. 645; Wilson,

Shannon, & Shields,

2015, p. 1409).

& Shields, 2015, p.

1409).

Tamsulosin (Flomax) 0.4

mg Capsule Oral Daily

Classification:

Alpha1-adrenergic blocker

Chemical Action:

Decreases the contractions

in the smooth muscle of

the prostatic capsule by

binding to alpha1-

adrenergic receptors.


1170).

Treatment of

symptoms of

benign prostatic

hyperplasia

(BPH). (Hodgson,

Kizior, 2016, p.

1170).


drowsiness, headache,

anxiety, insomnia,

orthostatic hypotension


p. 1171).

Contraindications:

Hypersensitivity


p. 1171).

Lab Values: No specific

lab values, however,

monitor intake and

output and daily weight.


p. 1171).


take tamsulosin at the

same time each day, 30

minutes after the same

meal.

• Advise the patient to go

slowly go from lying to

standing position.

• Advise the patient to

avoid tasks that require

alertness, motor skills

until the patient’s

response to the drug has

been established.

• Educate the patient no to

break, crush, or open

capsule. (Hodgson,

Kizior, 2016, p. 1171).

Senna (Senokot) 17.2 mg

Tablet Oral Bedtime

Classification:

Stimulant laxative

Chemical Action: Direct

action on the intestinal

mucosa, resulting in an

increased rate of colonic

motility, enhanced

colonic transit, and

inhibition of water and

electrolyte secretion.

(IBM Micromedex,

2018).

Treatment for

constipation.

(Hodgson, Kizior,

2016, p. 1119).

Side Effects: Red, brown

discoloration of urine


1120).

Contraindications:

Undiagnosed abdominal

pain, appendicitis,

intestinal obstruction or

perforation, nausea,

vomiting (Hodgson, Kizior,

2016, p. 1119).

Lab Values: Monitor

serum electrolytes


1120).

• Inform the patient that the

medication may produce a

yellowish brown or

reddish-brown urine and

feces.


increase fluid intake,

exercise, and incorporate a

high-fiber diet to increase

defecation.

• Instruct the patient not to

take other medications

within one hour of taking

Senna as this may

decrease the effectiveness

of the medication.


p. 1120).

Intravenous Fluid

Peripheral IV at the left extremity and heparin lock (IV/hep-lock)



23

Nursing

Diagnoses (List 3 priority

Nursing Diagnoses in

order of priority. Must

include one

psychosocial nursing

diagnosis.)

Expected Outcomes (Must complete short &

long-term goals for EACH

priority nursing diagnosis

listed. Goals should be SMART: specific,

measurable, attainable,

realistic, & time-framed.)

Nursing Interventions &

Rationales (Evidenced based rationale for each

intervention for each priority

nursing diagnosis. Describe in your

own words with references cited

here & in reference list in APA

format.)

Evaluation (How did/will you evaluate

the effectiveness of planned

interventions listed in

previous column? HINT: Assess attainment of

SMART goals.)

Impaired physical

mobility related to

prescribed movement

restrictions as

evidenced by

hesitation to attempt

movement. (Ackley,

Ladwig, & Makic,

2017, p. 588).

By the end of the shift,

the patient will

demonstrate techniques

that promote ambulating

and transferring including

demonstrating the use of

a belt to increase

mobility.

Within two weeks, the

patient will increase

strength and function and

will verbalize decreased

fear of falling and pain

with physical activity.

Monitor the patient’s mobility

skills by using the Assessment

Criteria and Care Plan for Safe

Patient Handling and Movement

tool to screen for bed mobility,

supported and unsupported

sitting, transition movements such

as sit to stand, sitting down, and

transfers, and standing and

walking activities. Assessment of

low mobility, functional

difficulties, cognitive impairment,

and multiple comorbidities is

useful for evaluating patient

safety and rehabilitation

interventions. (Ackley, Ladwig, &

Makic, 2017, p. 589).

Assess the patient for the cause of

impaired mobility and establish

whether the cause is physical,

psychological, or motivational.

Some patients prefer not to move

because of psychological factors

such as the fear of falling, pain,

inability to cope, or depression.

The fear of falling is associated

with immobility and functional

dependence. Therefore, an

adequate assessment and

measurement are required.

(Ackley, Ladwig, & Makic, 2017,

p. 590).

Assist the patient to achieve

mobility and start walking as soon

as possible. To prevent hospital-

acquired disability nurses should

implement safety such as fall

prevention and injury protection

The patient’s need for

assistance has decreased, the

patient requires minimal

assistance with mobility,

transition movements, and

walking activities. The

patient shows no cognitive

impairment and is being

more mobile.

The patient has been

demonstrating and

verbalizing that his fear of

falling, pain, and depression

associated with immobility

and functional dependence

has diminished.

The patient exhibits a

progression of joint stability

and maintains proper joint

position and body

alignment. Additionally, the

patient demonstrates proper

use of the belt.


24

along with a conception that

enables older adults to be self-

directed and independent. Early

mobilization prevents medical

complications such as deep vein

thrombosis, allows patients time

to practice using assistive devises

or changes in weight-bearing

status, and promotes improved

function, reduces pain, and

facilitates earlier return to

independence. (Ackley, Ladwig,

& Makic, 2017, p. 591).

Deficient knowledge

related to insufficient

information and

knowledge of

resources about the

laminectomy as

evidenced by request

for information and

insufficient

knowledge. (Ackley,

Ladwig, & Makic,

2017, p. 556).


the patient will verbalize

an understanding of the

treatment regimen

including the need for

medications, prognosis,

and potential

complications.

By the end of the week,

the patient will verbalize

and list signs and

symptoms requiring

medical attention and

implement necessary

lifestyle changes.

Discuss postsurgical prognosis,

potential complications, and

future expectations. Open

discussion regarding prognosis,


future expectations provide the

patient knowledge necessary for

making informed choices and

commitment to the therapeutic

regimen. (Ackley, Ladwig, &

Makic, 2017, p. 556).

Provide information and

demonstrate positioning and

weight shifting including

restrictions. Positioning promotes

circulation and reduces tissue

pressure and risk of

complications. (Ackley, Ladwig,

& Makic, 2017, p. 556).

Identify signs and symptoms that

the patient should report

immediately to a healthcare

provider such as an infection,

urinary and respiratory problems,

or skin breakdown. Providing the

patient with early identification

allows intervention to prevent or

minimize complications.

Stress the importance of

following the recommended

therapy treatment to achieve

specific functional goals and

The patient verbalizes

postsurgical prognosis,


future expectations such as

the reoccurrence of chronic

back pain.

The patient demonstrates

and verbalizes proper

application of the belt and

verbalizes an understanding

of the importance of gaining

the most benefit from the

belt.

The patient identifies signs

and symptoms that require

contacting the healthcare

provider such as fever,

increased incisional pain,

inflammation, wound

drainage, decreased

sensation and motor activity

in extremities. The patient

verbalizes the importance of

follow-up care and long-

term medical supervision to

manage problems and

potential complications.


25

continue long-term monitoring of

therapy needs. (Ackley, Ladwig,

& Makic, 2017, p. 557).

Risk for impaired

tissue integrity related

to temporary weakness

of vertebral column,

balancing difficulties,

changes in muscle

coordination due to

laminectomy. (Ackley,

Ladwig, & Makic,

2017, p. 882).


the patient will

demonstrate adequate

tissue perfusion as

evidenced by the warm

and dry skin with no

appearance of edema,

rash, erythematous, or

dehiscence on his surgical

incision.

Within a week, the

patient will verbalize and

demonstrate knowledge

of treatment regimen of

the surgical incision

including appropriate

wound treatment

techniques.

Inspect and monitor the color and

temperature of the skin at the

surgical incision site for

erythema, color changes,

swelling, warmth, pain, or other

signs of infection such as

increased temperature. Elevation

or a spike in temperature after the

second postoperative day may be

suggestive of infection. Erythema

and other signs of irritation can be

indicative of impaired circulated

caused by the belt. (Ackley,

Ladwig, & Makic, 2017, p. 884).

Assess the patient for pain,

discomfort at the incision site, or

uncomfortable fit of the belt. A

finger should be able to fit

between the belt and the patient’s

skin. Additionally, inspect both

sides of the belt for redness,

swelling, bruising, or chafing,

close the open side and repeat on

the opposite side. A rash may

signify an allergic reaction to the

belt's lining. (Ackley, Ladwig, &

Makic, 2017, p. 884).

Instruct and assist the patient and

caregivers in understanding how

to change dressings and the

importance of maintaining a clean

environment. Additionally,

provide written instruction and

observe them completing the

dressing change. (Ackley,

Ladwig, & Makic, 2017, p. 885).

The surgical incision site is

clean, dry, with no

dehiscence, and no presence

of erythema, swelling, or

other signs of infection. The

patient’s oral temperature is

36.7 °C (98 °F) indicating

that the patient does not

have a fever.

The patient reported no pain,

discomfort at the incision

site, and no discomfort of

the belt. The skin under the

belt manifested no evidence

of redness, swelling,

bruising, or chafing.

The patient and the

caregivers performed and

verbalized an adequate

understanding of dressing

changes at the incision site.

The patient and the

caregivers were given

written instructions on

completing proper dressing

changes.


26

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