705: 304 – ADULT HEALTH NURSING

 

CARE PLAN GUIDELINES

 

Use of appropriate sources and APA format (in-text citations and a reference page) are required for all care plans. No abbreviations will be accepted. 

 

Completing a care plan on a patient with a cardiac, respiratory, gastrointestinal, or neurological primary diagnosis is strongly recommended.

 

Student Name:							Date:
Patient Initials:			Room #:		Age:		Admin. Date:
Sex:	Height:					Weight:
Ethnicity:				Race:		PrimaryDiagnosis:
Occupation (current or previous):						SecondaryDiagnosis:
Allergies:		Diet:				Current SurgeryDate / Type (if applicable):

Fill out the above chart with the patient’s demographic and admission data.

 

History of Presenting Illness (Chief Compliant):

 

A narrative summary of the patent’s admission (i.e., admission date, presenting

signs and symptoms, reason for admission in the patient’s own words [i.e., “my stomach hurts”], and admitting medical and/or surgical diagnoses

 

Past Medical and Surgical History:

 

List your patients past medical and surgical history.

 

Diagnostic Testing (recently completed or to be complete):

 

Briefly describe any diagnostic test and discuss basic findings /

interpretations, if the test was already completed (i.e., Chest X-

ray, ultrasound, etc.)

 

Nursing Activities and Medical Equipment:

 

List nursing activities and medical equipment ordered for you patient and then

briefly discuss nursing care considerations for each [be sure to cite a source in APA format for nursing care considerations i.e., (Jones & Smith, 2012)].

 

• Nursing Activities (i.e., ambulate as tolerated, blood glucose checks, wound care, aspiration precautions, and contact isolation)

 

• Medical Equipment: (i.e., pneumatic compression boots, supplemental oxygen, chest tube, tracheostomy tube, mechanical ventilator, IV infusion pump etc)

 

 

Psychosocial Assessment:

 

Briefly describe Erikson’s Stage of Psychosocial Development (be sure to cite a source in APA format for Erikson’s Stage) that is relevant to your patient.  Discuss your patient’s psychosocial assessment findings and then discuss whether or not the patient is successfully navigating the above identified stage.

 

 

Cultural Assessment:

 

Briefly describe key cultural concepts related to your patient’s ethnicity in terms of preferences, values, and beliefs.  Discuss your patient’s cultural assessment findings and then discuss how these preferences, values, and beliefs may be incorporated in nursing care.

 

 

Spiritual Assessment:

 

Discuss your patient’s spiritual assessment findings (i.e., beliefs related to life, health, illness, and family; and if applicable, religious faith and beliefs). Discuss briefly how your patient’s spiritual beliefs may be incorporated in nursing care.

 

Pathophysiology:

 

Utilizing appropriate sources (be sure to cite in APA format), briefly discuss the pathophysiology of the patient’s admission diagnosis and significant past medical and /or surgical history. Information to be included for each disorder includes: a) definition of the disorder; b) overview of key pathophysiological processes; c) major clinical manifestations, and d) common nursing and collaborative interventions.  No more than one paragraph in length for each condition / disorder. Bullet points are encourage as noted below.

Example:   Hypertension

1. A) Definition
2. B) Overview of key pathophysiological processes
3. C) Major clinical manifestations
4. D) Common nursing and collaborative interventions

 

 

Nursing Diagnoses and Potential Complications:

 

List 5 nursing diagnoses in priority order for your patient (i.e., 1 = highest

priority and 5=lowest priority) and identify potential complications for each

diagnosis.

 

Example:

 

1. Acute pain related to recent colon surgery as evidence by grimacing upon

movement and a numeric pain rating of 8 on a 0-10 scale.

 

Potential Complications: Increased heart rate, increased blood pressure,

increased postoperative complications, decreased patient satisfaction with

care, and increased length of hospital stay

 

Vital Signs, Review of Systems (symptoms) Physical Assessment:

 

Discuss your patient’s physical assessment findings by system (within normal limits

[WNL] will NOT be accepted).

 

• Vital Signs

 

• Neurological:

 

• Cardiovascular:

 

• Respiratory:

 

• Musculoskeletal:

 

• Gastrointestinal:

 

• Genitourinary:

 

• Integumentary:

 

Analysis of Abnormal Laboratory Values:

 

Test	Patient’s Value	NormalRange	Descriptionof Test	Abnormal Value Analysis(General & Patient Specific)
Serum Sodium	130 mEq/L	135-145 mEq/L	Sodium is the major extra-cellular cation. Normal levels of sodium are necessary for regulation of body fluids, transmission of nerve impulses, proper cardiac functioning, and regulation of some metabolic functions.	Low sodium levels can be caused by a variety of factors including: a) inadequate dietary intake; b) excessive water intake; c) excessive GI / GU losses; and c) certain disorders such as Syndrome of Inappropriate Anti-diuretic Hormone (Pagana & Pagana, 2005).In my patient the low serum sodium level is likely caused by a combination of excessive water flushes and excessive GI losses from his nasogatric (NG tube).

 

Complete the chart above for all abnormal laboratory values.  If a laboratory test has been completed several times, utilize the most recent value and discuss trends in the individualized analysis section.  No need to include normal laboratory values.

 

Medications: Complete the chart below for all medications.

 

Medication Name (Generic and Brand Names)	Metoprolol (Lopresor)
Patient’s Dose, Route,                       and Frequency	50 mg PO q 12 hrs
Common Therapeutic Dose Range for the Adult Patient:	Usual Range 25–100 mg/daily (single or divided doses)
Class (Functional and Chemical)	Functional:  Antihypertensive; AntianginalChemical:  Beta 1 Blocker
Indications for Use	Hypertension, angina, prevention of myocardial infarction; and heart failure
Why given to your patient?	My patient has a past medical history of hypertension.
How To Evaluate Effectiveness:	Reduction of blood pressure and heart rate to within therapeutic ranges. Reduction in angina attacks or prevention of myocardial infaraction.
Major Side Effects	Insomnia, dizziness, depression, bradycardia, congestive heart failure, cardiac arrest, AV block, pulmonary edema, chest pain, palpitations, nausea, vomiting, diarrhea, hiccups, agranulocytosis, eosinophilia, thrombocytopenia, purpura, and bronchospasm
Major Nursing Considerations	Intake and output, daily weight to monitor for fluid overload and possible third spacing (fluid retention), monitor blood pressure and pulse rate rhythm and quality, measure apical pulse before administration notify physician is less than 60, monitor hepatic and renal studies, assess for edema, assess skin turgor and hydration status; teach client not to cease taking medication abruptly, to take pulse at home, to report bradycardia, dizziness, or confusion, fever or sore throat to healthcare provider. Do not crush extended release preparations.
Source: (Deglin & Vallerand, 2007)

 

 

 

Expanded Nursing Diagnosis #1

 

SUPPORTIVE DATA/ASSESSMENT:

SUBJECTIVE:   What the /patient or caregiver reports. (i.e., “my stomach hurts”)

OBJECTIVE:     What you observe, physical assessment findings and medical information as lab results and/or diagnostic testing.  (i.e., facial grimacing, abdominal guarding etc.)

                                                                                                                                                                                                                                   

NURSING DIAGNOSIS #1

From the previous list of 5 nursing diagnoses that you created; you must now identify the highest priority diagnosis for your

patient and discuss it individually in this section.

 

Example:  Acute pain related to recent colon surgery as evidence by grimacing upon movement and a numeric pain rating of 8

on a 0-10 scale.

                                                                                                                                                                                                                                   

SHORT-TERM GOALS:

            You must list at least 3 patient specific, realistic, measurable and time-sensitive short-term nursing goals.

 

Example Goal:  1. The patient will verbalize decrease in abdominal pain to a 3 or less on 0-10 numeric pain scale 60 minutes

after pharmacological interventions (Percocet 2 tabs) by 12 noon on 1-14-2015.

 

                                                                                                                                                                                                                                   

PLANNING CARE & SPECIFIC NURSING INTERVENTIONS: (INCLUDE RATIONALE FROM THE LITERATURE)

Establish at least 3 individualized nursing interventions (teaching should be included) for each above goals. Discuss interventions for each goal separately.  Rationale from appropriate sources must be used to support each nursing intervention include (i.e., clinical practice guidelines, evidence-based practice literature).

 

Example interventions and rationale:

 

1a.    Teach the patient the purpose of and how to rate his / her abdominal pain on a 0-10 numeric pain scale.

        Rationale: Ensuring the patient understands and can appropriately rate his / her pain on an objective pain scale such as 0-10 numeric

        pain scale increases the accuracy of pain assessments and promotes optimal acute pain management (American Pain Society Quality

       of Care Committee, 2014; JCAHO, 2013).

 

1b.   The nurse will assess the patient’s pain severity using the 0-10 numeric pain scale upon first interaction and at least every two

       hours.  Rationale: The severity of pain and discomfort should be assessed and documented after any known pain-producing

       procedure, with each new report of pain, and at regular intervals (American Pain Society Quality of Care Committee, 2014; JCAHO,

       2013).

 

1c.   The nurse reassess the patient’s abdominal pain severity within 60 minutes of oral opioid adminstration.

Rationale: Reassessment after pain interventions should be completed within 60 minutes of oral pharmacologic interventions and 30 minutes of intravenous pharmacologic interventions (Joint Commission, 2013).  Reassessment of pain after pharmacological interventions ensure optimal pain relief and assists in establishing the most effective pain relief regimen (Ignatavicius &Workman, 2014)

 

1d.  Nurse will administer Percocet 2 tabs prn as ordered by physician.

       Rationale: Percocet is an opiate analgesic that helps alter perception of pain in the CNS (Ignatavicius &Workman, 2014) and

pharmacological interventions are the cornerstone of pain management (Acute Pain Management Guideline Panel, 2014)

 

 

                                                                                                                                                                                                                                   

EVALUATION OF EXPECTED OUTCOMES/GOALS:

 

For each of the 3 goals established; you must now evaluate your patient to identify if your goals were met or not met. If the

goal was met describe how (be specific) and if it was not met describe how you could adjust your planning to achieve this goal.

 

 

Example Evaluation of Goal:

1. Goal Met:  The patient reported an abdominal pain level of 3 on a 0-10 within 60 minutes of Percocet administration on

                                  1-14-2014

                                                                                                                                                                                                                                   

DISCHARGE PLAN FOR NURSING DIAGNOSIS #1 

                                                                                                                                                                                                                                   

LONGER-TERM GOALS:

 

            You must list at least 2 patient specific, realistic, measurable and time-sensitive longer-term nursing goals.

 

            Example:  The patient will verbalize understanding of 3 sign and symptoms of a respiratory infection prior to time of discharge.

 

 

                                                                                                                                                                                                                                   

PLANNING CARE & SPECIFIC NURSING INTERVENTIONS: (INCLUDE RATIONALE FROM THE LITERATURE)

Establish at least 2 individualized nursing interventions (teaching should be included) for each above goals. Discuss interventions for each goal separately.  Rationale from appropriate sources must be used to support each nursing intervention include (i.e., clinical practice guidelines, evidence-based practice literature)

 

 

 

 

 

                                                                                                                                                                                                                                   

EVALUATION OF EXPECTED OUTCOMES/GOALS:

 

For each of the 2 goals established; you must now evaluate your patient to identify if your goals were met or not met. If the goal was met describe how (be specific) and if it was not met describe how you could adjust your planning to achieve this goal

 

Expanded Nursing Diagnosis #2

SUPPORTIVE DATA/ASSESSMENT:

SUBJECTIVE:   What the /patient or caregiver reports.

OBJECTIVE:     What you observe, physical assessment findings and medical information as lab results and/or diagnostic testing.

                                                                                                                                                                                                                                   

NURSING DIAGNOSIS #2

From the previous list of 5 nursing diagnoses that you created; you must now identify the second highest priority diagnosis (i.e.,

#2) for your patient and discuss it individually in this section.

 

 

                                                                                                                                                                                                                                   

SHORT-TERM GOALS:

            You must list at least 3 patient specific, realistic, measurable and time-sensitive short-term nursing goals.

 

 

 

 

 

                                                                                                                                                                                                                                   

PLANNING CARE & SPECIFIC NURSING INTERVENTIONS: (INCLUDE RATIONALE FROM THE LITERATURE)

Establish at least 3 individualized nursing interventions (teaching should be included) for each above goals. Discuss interventions for each goal separately.  Rationale from appropriate sources must be used to support each nursing intervention include (i.e., clinical practice guidelines, evidence-based practice literature)

 

 

 

 

 

                                                                                                                                                                                                                                   

EVALUATION OF EXPECTED OUTCOMES/GOALS:

 

For each of the 3 goals established; you must now evaluate your patient to identify if your goals were met or not met. If the

goal was met describe how (be specific) and if it was not met describe how you could adjust your planning to achieve this goal.

 

 

 

                                                                                                                                                                                                                                   

DISCHARGE PLAN FOR NURSING DIAGNOSIS #2

                                                                                                                                                                                                                                   

LONGER-TERM GOALS:

 

            You must list at least 2 patient specific, realistic, measurable and time-sensitive longer-term nursing goals.

 

           

 

 

                                                                                                                                                                                                                                   

PLANNING CARE & SPECIFIC NURSING INTERVENTIONS: (INCLUDE RATIONALE FROM THE LITERATURE)

Establish at least 2 individualized nursing interventions (teaching should be included) for each above goals. Discuss interventions for each goal separately.  Rationale from appropriate sources must be used to support each nursing intervention include (i.e., clinical practice guidelines, evidence-based practice literature)

 

 

 

 

 

                                                                                                                                                                                                                                   

EVALUATION OF EXPECTED OUTCOMES/GOALS:

 

For each of the 2 goals established; you must now evaluate your patient to identify if your goals were met or not met. If the goal was met describe how (be specific) and if it was not met describe how you could adjust your planning to achieve this goal.

References

 

Example:

Ignatavicius, D., & Workman, M.L. (2014).  Medical-Surgical Nursing: Patient-Centered

            Collaborative Care (7^th Edition).  St. Louis, MO:  Elsevier – Saunders.