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					NURSING CARE PLAN SAMPLE DATABASE Mr. Jose Rodriguez, an 84-year-old client, was admitted to the hospital on 6/20/02 with shortness of breath. This retired Hispanic grower, a widower, states that for the past 3- weeks he has had increasing -4 fatigue and shortness of breath. He visited his doctor two days ago, and his medication was increased. His preferred foods are fresh fruits and vegetables, rice, red beans and tortillas. Mr. Rodriguez lives with one of his daughters and her family since experiencing a myocardial infarction in 1988. He has six other children. He is a Catholic and attends church regularly; however, since his declining health, he has been confined to his home. He is visited at home weekly by his church pastor and/or representative. He speaks with pride about his grocery store that he started for his family. He smoked two packs per day x 40 years and quit in 1990. Mr. Rodriguez was admitted with a diagnosis of chronic congestive heart failure (CHF) with acute exacerbation. His medical history includes coronary artery disease x 10 years. He had a balloon angioplasty in 2000 and an M.I. in 1988. He is hearing impaired and wears bilateral hearing aids. He wears glasses and reads without difficulty. This is his third admission for CHF since his diagnosis five years ago. Physician progress notes from 6/22/02 state: Condition improving; c/o decreasing SOB; chest x-ray improving; serum K+ is 3.3, and weight decreased 8# in past two months. Admitting history and Physical exam 6- -02 -20Moderate respiratory distress; crackles auscultated in left lung base Currently sleeping on 3 pillows at night to ease breathing. Nocturia X4 this past week. Mild heart murmur; no JVD, peripheral pulses +2; VS: 98.6- -28, 176/94, Ht. 5’7”, Wt. 154#, Baseline BP 145/90 -88c/o increasing fatigue and severe shortness of breath (SOB) O2 SAT level - 90% on room air. Denies chest pain. 6- -02 -206- -02 -206- -02 -206- -02 -206- -02 -206/22/02 6/20/02 Digoxin 0.25 mg po QD Lasix 40 mg po bid Nitro-Bid 2.5 mg po qid Metamucil 15 ml po q hs in glass of water/juice KCl 20 mEq po bid Chest x-ray-mild left ventricular hypertrophy; pulmonary congestion resolving. Serum electrolytes: Na+ 138 mEq/L K+ 3.3 mEq/L Ca+ 9.1 mg/dl CL- 102 mEq/L Serum albumin 2.8 g/dl Serum digoxin level 2.6 ng/dl Bun 30 mg/dl Cr 0.6 mg/dl

Medications ordered

Diagnostic tests results

6/20/02 6/20/02 6/20/02 Other admitting orders

No added salt diet; I & O, daily wts, activity as tolerated BRP with assist, VS Q 4 hours O2 at 3L/min per nasal cannula Heparin lock States “my old heart is just wearing out. I get this extra fluid every now and then. I come here to the hospital to get rid of it.” Seems well oriented and is a fluent historian; accurately reported meds he had been on at home. c/o constipation. Skin reddened over bony prominences. Currently requires HOB elevated to ease breathing. Requires W/C for transport. Needs ADL assist. Gait unsteady. Family at bedside. - -1NSGCAREPLAN(Sample):1:1/06

Nursing Interview & Observations

SAMPLE NURSING CARE PLAN RIVERSIDE COMMUNITY COLLEGE DATE NURSING EDUCATION STUDENT________________________________ SEMESTER INSTRUCTOR____________________________ ROTATION
Client’s Initials J.R. Gender M Age 84 Code Status Full Admission Date 6- -02 -20-

Presenting Signs/Symptoms (What brought the client to the hospital?) Increasing fatigue and SOB x 3- weeks -4 Admitting/Primary Diagnosis Chronic CHF with acute exacerbation Surgeries Related to this Admission None

Secondary Diagnoses (Diagnoses other than admitting diagnosis that impact this admission.) CAD (coronary artery disease). S/P MI (1988) History of Present Illness (What led up to this hospitalization?) Client became more SOB and tired 3- weeks ago. Lasix was increased to 40 mgs qd on 6/18/02. Presented to -4 E.R. with ↑ SOB and dyspnea. Previous Surgical Procedure(s) / Date(s) Balloon Angioplasty (1 vessel) 2000 Health History (Include length of time client has had disease processes; significant family history; social issues.) CAD x 10 years. CHF x 5 years. MI 1988. Substance Use (Include use of tobacco, alcohol, street drugs, over- -counter drugs, length of use and time of last use.) -the2 PPD x 40 years. Quit 1990. Denies ETOH, drug use. Allergies/Reactions Religious Preference NKA Catholic Ethnicity Hispanic Marital Status W Occupation Retired

Pathophysiology/Current Health Problems and Related Functional Changes: Define each primary and secondary diagnosis and explain the disease process of each. Also include signs and symptoms, risk factors, treatment options, possible complications, and functional changes that affect activities of daily living (ADLs). Source: Smeltzer and Bare, 2000 CHF: Congestive heart failure (CHF) often referred to as cardiac failure, is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. As with coronary artery disease, incidence increases with age. Common underlying conditions that lead to decreased myocardial contractility include myocardial dysfunction (especially from coronary atherosclerosis), arterial hypertension and valvular dysfunction (p. 622). Functional changes relate to inadequate tissue perfusion, dizziness, confusion, fatigue, exercise or heat intolerance, cool extremities, oliguria, sodium and fluid retention. Increased pulmonary venous pressure leads to cough, SOB and pulmonary edema. Increased systemic venous pressure may result in generalized edema and weight gain (p. 665). CAD: The most common heart disease in the U.S. is atherosclerosis, which is an abnormal accumulation of lipid, or fatty substances and fibrous tissue in the vessel wall. These substances create blockages or narrow the vessel in a way that reduces blood flow to the myocardium (p. 594). Functional changes depend on the degree of narrowing. Angina pectoris is recurrent chest pain that is brought on by physical exertion or emotional stress and relieved by rest or medication (p. 595).

- -2-

NSGCARE PLAN(Sample):2:1/06

Therapeutic/Multidisciplinary Treatment Plan: (Textbook)

Source

Smeltzer and Bare, 2000

CHF: Medical: Reduce workload of heart; increase the force and efficiency of myocardial contraction and eliminate the excessive accumulation of body water by avoiding excess fluid intake; controlling the diet and monitoring diuretic and angiotensin-converting enzyme (ACE) inhibitor therapy (p. 665). Nursing: Administer medications and assess the medication effects. Assess patient’s: intake and output; weight; lung sounds; vital signs; skin turgor and mucous membranes. Assess patient for JVD, edema and signs/symptoms of fluid overload (p. 668). Nurses perform counseling and education concerning regular exercise, sodium restriction, and avoidance of excessive fluid intake, alcohol and smoking (p. 668). Pharmacist: Review of medications used for treatment of CHF including ACE inhibitors, diuretic therapy, digitalis. Monitoring blood levels such as digoxin (in collaboration with MD and nursing) (p. 666). Registered dietitian: Nutrition assessment and counseling regarding sodium restriction, avoidance of excessive fluid intake and alcohol (p. 668). Respiratory therapist: Administer oxygen therapy based on the degree of pulmonary congestion and resulting hypoxia. Some patients may need supplemental oxygen therapy during activity. Others may require hospitalization and endotracheal intubation (p. 666). CAD: Prevention of CAD by controlling these risk factors is important: high cholesterol, cigarette smoking, hypertension and diabetes mellitus (p. 595). If CAD is associated with angina, medical management with drugs and control of risk factors is implemented to decrease the oxygen demands of the myocardium and to increase the oxygen supply (p. 598). Revascularization procedures include coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA, also known as balloon angioplasty) (p. 598). Medications include: Ntg, Beta blockers, calcium channel blockers, antiplatelet and anticoagulants (pp. 598-599).

Prescribed Treatments (as per physician’s orders) Oxygen: 3 LPM via N/C N/A

Respiratory Treatment: IV Infusion: Diet: Feeding: NAS

Heparin lock

Requires assistance BRP with assistance

Bowel/Bladder: Hygiene: Activity: Other:

Assist As tolerated with assist I & O; daily wts. Requires W/C for transport Elevate HOB

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NSGCAREPLAN(Sample):3:1/06

PRESCRIBED MEDICATIONS Allergies
Source Action (A)
(include common/ life-threatening)

T - herapeutic effect A - ction C - ontraindications T - oxic effects/Side effects I - nterventions S - afe dose Mosby’s Nursing Drug Reference 2002 Interventions (I)
Ordered Date Stop Date 6- -02 -20-

NKA MSI - minimum safe infusion MSD - minimum safe dilution Safe Dose (S) include MSI/MSD (IV Meds)* Maintenance 0.063-0.5 mg/day Dose safe.
7- -02 -20-

Drug Classification/ Medication Generic/Brand dose/route/interval

Time Med Due

Therapeutic Effect (T)

Contraindications (C)

Toxic Effects (T) & Side Effects

Digoxin 0.25 P.O. q day (Lanoxin) Cardiac glycoside

0900 Increase cardiac (Hold output

Dig level 2.6)

Inhibits sodiumpotassium ATPase. Results in increased cardiac output. Hypersensitive to sulfonamides, anuria, hypovolemia, infants, lactation, electrolyte depletion.

Hypersensitive to digitalis; V. fib; V. tach; carotid sinus syndrome; 2nd or 3rd degree heart block.

Headache, dysrhythmias, hypotension, AV block, blurred vision, yellow-green halos, N/V

Apical pulse 1 minute. Hold P < 60. Assess lytes, BUN/Cr, ALT, AST, H&H. I & O, daily wts, √ dig level.

Lasix 40 mgs. P. O. BID (furosemide) Loop diuretic

0900 Decrease edema 1700 and blood pressure

6- -02 -20-

Inhibits reabsorption of Na+ and CL-- at proximal, distal tubules and loop of Henle.

Circulatory collapse, loss of hearing, hypokalemia, hypochloremic alkalosis, ↓ mg++, hyperuricemia, hypocalcemia, hyponatremia, hyperglycemia, nausea, polyuria, renal failure, thrombocytopenia, agranulocytosis, leukopenia, neutropenia, anemia, rash pruritis, Stevens-Johnson syndrome.

Assess client for s/s dehydration. adm in a.m. K+ replacement if < 3.0. adm. with food if nauseated.

7- -02 -20-

20- mg/day in -80 a.m. May give another dose in 6 hours up to 600 mg/day. Dose safe.

- -4-

NSGCAREPLAN(Sample):4-5:1/06

Action (A)
Date Stop Date 6- -02 -20-

Drug Classification/ Medication Generic/Brand dose/route/interval
(include common/ life-threatening)

Time Med Due

Therapeutic Effect (T) Safe Dose (S) include MSI/MSD (IV Meds)*

Contraindications (C)

Toxic Effects (T) & Side Effects

Interventions (I)

Ordered

Nitro-Bid 2.5 mgs. P.O. QID (Nitroglycerin) Vasodilator (Nitrate)
7- -02 -20-

0900 Prevent chest 1300 pain; increase 1700 cardiac output 2100

Dilates coronary arteries; decreases preload and afterload

Hypersensitive to nitrates; severe anemia; increased intracranial pressure; cerebral hemorrhage

Postural hypotension, collapse, HA, flushing, dizziness

Assess BP, pulse, pain. May develop tolerance. Adm. with 8 oz. H20 on empty stomach, 1 hr. before or 2 hrs. after
6- -02 -20-

Sustained release capsule 2.5 mg (lowest dose) q6- hrs. on -12 empty stomach. Safe Dose.

2100 Prevent (Hold, constipation

** Metamucil 15 ml P. O. qHs (Psyllium) Bulk-forming laxative

√ PDR)

Bulkforming laxative

Hypersensitivity, N/V, anorexia, intestinal obstruction, diarrhea, cramps abd. pain, N/V, impaction

1- teaspoons in -2 8 oz. H2O BID or TID. Ordered dose outside safe.**
7- -02 -206- -02 -20-

Assess then adm. alone for better absorption. Give with 8 ozs of H20 followed by 8 oz. fluid

KCl 20 mEq P. O. BID Potassium supplement

0900 Replace 1700 potassium

40-100 mEq/day in divided doses.

Needed for transmission of nerve impulses and cardiac contraction

Severe renal disease, hemolytic disease, Addison’s, hyperkalemia, acute dehydration, extensive tissue breakdown

Cardiac depression, dysrhythmias, arrest, peak T waves, low R & RST, prolonged PR interval, wide QRS

Assess EKG, K+ level, I & O, ↓ u. o., heart. Adm. with or after meal. Do not give IM or SQ powder, dissolve in 8 oz. cold water/juice

7- -02 -20-

*All meds being titrated (i.e. heparin) state appropriate lab results related to medication administration.

- -5-

NSGCAREPLAN(Sample):4-5:1/06

C B C

ADMISSION DATE 6/20/02 ADULT LABORATORY/ DIAGNOSTIC TOOL SOURCE: Nurse’s Manual of Lab Tests (Watson & Jaffe) Test Range Adm. Date/ Date/ Identify ↑ ↓ WNL Significance/ Trends Result Result Result WBC 5,000-10,000/ mm3 RBCs 4.2-6.1 x 106/µg Hgb 11.5-17.5 g/dl Hct 40-52% MCV MCH MCHC RDW Retic. Platelet 90-95 mm3 27-31 µg 32-36 g/dl 11%-14.5% 0.5%-3.1% 150,000400,000 mm3 55-70% 20-40% 2-8% 1-4% 0.5-1.0% 135-145 mEq/L 98-106 mEq/L 3.5-5.0 mEq/L 24-30 mEq/L 1.3-2.1 mEq/L 9.0-10.5 mg/dl See lab result 11-12.5 seconds 60-70 seconds 1.5-2.5 x control 10-20 mg/dl 0.5-1.2 mg/dl 138 102 3.3 WNL – most abundant cation in ECF. Normal fluid status. (p. 275) WNL – most abundant anion in ECF. Normal fluid status. (p. 278) ↓ Hypokalemia secondary to Lasix (diuretic therapy). (p. 276)

W B C D i f f

Neutrophils Lymphocytes Monocytes Eosinophils Basophils

L y t e s

Sodium Chloride Potassium CO2 Magnesium Calcium

9.1

C o a g

WNL – Reflects overall calcium metabolism and indicates normal regulation of calcium.

INR PT PTT
On anticoag. →

R e n a l

BUN Creatinine

30 0.6

↑ Evaluates kidney function. Reduced renal blood flow, no renal damage. Possible protein catabolism. WNL – evaluates kidney function. No renal damage. (p. 162)

Note: Normal value range will vary depending on laboratory used.

-6-

NSGCAREPLAN(Sample):6-7:1/06

Test Glucose
B l o o d C h e m.

Range 70-110 mg/dl 4.4-6.4% 0-35 U/L 4-36 IU/L 0.13-0.63 U/L 80-110 µg/dl 100-190 U/L 30-220 U/L 0-160 U/L 3-4.5 mg/dl 30-120 U/L .3-1.0 mg/dl <200 mg/dl 2.7-8.5 mg/dl 6.4-8.3 g/dl 3.5-5.0 g/dl 2.3-3.4 g/dl 0.8- 2.0 ng/ml 10-20 µg/ml 10-20 µg/ml

Adm. Result

Date/ Result

Date/ Result

Identify ↑ ↓ WNL Significance/ Trends

Hgb A1c AST ALT Acid Phosphatase Ammonia LDH Amylase Lipase Phosphorus Alk. Phos. Total Bilirubin Cholesterol Uric acid Total protein Albumin Globulin Digoxin level Theophylline level Dilantin level

2.8

↓ Evaluates protein deficiency, hemodilution, ↓ protein in diet, malnutrition (p. 157) ↑ Possible early digoxin toxicity. (p. 992)

2.6

Urinalysis

Diagnostic Tests

ABGS

Date/Result Date/Results Date/Results Date/Results Color X-rays CXR 6-22 mild pH pH Appearance Left Ventricular pCO2 pCO2 Spec. gravity Hypertrophy pO2 PO2 Protein Nuclear scans Pulmonary B.E B.E. Glucose Congestion O2 sat O2 sat Ketones CT/MRI Resolving Comments ___________________________ Bacteria_________________________ _____________________________ Blood________________________ Other _____________________________ Other_________________________________________________________________________________________

Note: Normal value range will vary depending on laboratory used. -7NSGCAREPLAN(Sample):6-7:1/06

ADMISSION DATE _________ Test Range

LABORATORY/ DIAGNOSTIC TOOL SOURCE:______________________ Adm. Date/ Date/ Identify ↑ ↓ WNL Significance/ Trends Result Result Result

-8-

NSGCAREPLAN(Sample):8-9:1/06

ADMISSION DATE _________ Test Range

LABORATORY/ DIAGNOSTIC TOOL SOURCE:______________________ Adm. Date/ Date/ Identify ↑ ↓ WNL Significance/ Trends Result Result Result

-9-

NSGCAREPLAN(Sample):8-9:1/06

CONCEPT MAP Developmental Stage Very Old Age Psycho- Social Crisis Health Illness Immortality vs. Extinction Death Nutrition/Hydration Prefers fruits/vegs, rice, red beans, tortillas K+ 3.3. KCL Wt. ↓ 8 pounds Na+ 138 K+ 3.3 Ca+ 9.1 Cl- 102 Albumin 2.8 ↓ NAS diet Daily Wts H.L.

Health-Illness Continuum: Maximum Health Oxygen Needs/Circulation Admitted 6/20/02 SOB Increasing fatigue SOB x 3- 4 weeks O2 3 LPM n/c MI 1988 Smoked 2 PPD x 40 yrs. Quit 1990 CHF with acute exacerbation CAD x 10 yrs. Balloon angioplasty 2000 Mod. resp. distress Crackles L lung base Elevate HOB Sleeps 3 pillows Mild heart murmur BP 176/94 VS Q 4 hrs. O2 sat 90% 6/22 CXR - mild L ventricular hypertrophy; pulm congesting resolving Dig level ↑ 2.6 Digoxin Lasix; Nitro-Bid Neurological/Neurovascular Oriented x 4 Alert Fluent historian Elimination

→

Nocturia x 4 past week I&O c/o Constipation Metamucil Medical Diagnoses: 1. Chronic CHF with acute exacerbation. CAD

2.

Problem List/Nursing Diagnosis Prioritize according to Maslow’s Hierarchy 1. Impaired gas exchange. 2. 3. Decreased cardiac output. Nutrition, imbalanced, less than body requirements. Perceived constipation. Impaired physical mobility. Anxiety Concerns/Fear Knowledge Needs Confined to home 3- 4 weeks Third admission CHF Rest/Activity Activity as tolerated BRP with assistance W/C for transport Assist ADL

Safety/Skin/Wounds/ Drains/Infections/ Sensory Hearing impaired Bilat H.A.s. Glasses Reads with no diff. Skin reddened over bony prominences Gait unsteady

4. 5.

Love/Belonging/Culture Coping/Body Image Retired Hispanic grower Widower Lives with daughter Six children Catholic, attends church regularly Family at bedside

Comfort/Sexuality

Denies chest pain Widower

- 10-

NSGCAREPLAN(Sample):10:1/06

NURSING DIAGNOSES (NANDA, 2005-2006) GROUPED ACCORDING TO CONCEPTUAL FRAMEWORK
Oxygen Needs/Circulation Breathing Airway Clearance, Ineffective Aspiration, Risk for Breathing Pattern, Ineffective Gas Exchange, Impaired Infection, Risk for Sudden Infant Death Syndrome, Risk for Suffocation, Risk for Ventilation, Impaired, Spontaneous Ventilatory Weaning Response, Dysfunctional Circulation Cardiac Output, Decreased Fluid Balance, Readiness for Enhanced Fluid Volume Deficit Fluid Volume Excess Fluid Volume, Risk for Deficit Fluid Volume, Risk for Imbalanced Tissue Perfusion, Ineffective (specify: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral) Neurological/Neurovascular Neurological Confusion, Acute Confusion, Chronic Environmental Interpretation Syndrome, Impaired Infant Behavior, Disorganized Infant Behavior, Readiness for Enhanced Organized Infant Behavior, Risk for Disorganized Intracranial, Decreased Adaptive Capacity Memory, Impaired Thought Processes, Disturbed Neurovascular Dysreflexia, Autonomic Dysreflexia, Risk for Autonomic Peripheral Neurovascular Dysfunction, Risk for Nutrition/Hydration Breastfeeding, Effective Breastfeeding, Ineffective Breastfeeding, Interrupted Dentition, Impaired Failure to Thrive, Adult Fluid Volume, Deficit Fluid Volume, Deficit, Risk for Infant Feeding Pattern, Ineffective Nausea Nutrition: Imbalanced, Risk for More Than Body Requirements Nutrition: Imbalanced, Less Than Body Requirements Nutrition: Imbalanced, More Than Body Requirements Nutrition: Readiness for Enhanced Oral Mucous Membranes, Impaired Self-Care Deficit, Feeding Swallowing, Impaired Elimination Bowel Constipation Constipation, Perceived Constipation, Risk for Diarrhea Incontinence, Bowel Nausea Urinary Fluid Volume, Risk for Imbalanced Infection, Risk for Incontinence, Functional Incontinence, Reflex Incontinence, Risk for Urge Incontinence, Stress Incontinence, Total Incontinence, Urge Tissue Perfusion, Ineffective Urinary Elimination, Impaired Urinary Elimination, Readiness for Enhanced Urinary Retention Rest/Activity Activity Intolerance Activity Intolerance, Risk for Disuse Syndrome, Risk for Diversional Activity Deficient Fatigue Mobility, Impaired Bed Mobility, Impaired Physical Mobility, Impaired Wheelchair Perioperative Positioning Injury, Risk for Sedentary Lifestyle Sleep Deprivation Sleep Pattern, Disturbed Sleep, Readiness for Enhanced Transfer Ability, Impaired Walking, Impaired Comfort/Sexuality Comfort Pain, Acute Pain, Chronic Sexuality Sexuality Pattern, Ineffective Sexual Dysfunction Safety/Skins/Wounds/Infections/Sensory Temperature Hyperthermia Hypothermia Temperature, Risk for Imbalanced Body Thermoregulation, Ineffective Skin Infection, Risk for Injury, Risk for Latex Allergy Response Latex Allergy Response, Risk for Protection, Ineffective Skin Integrity, Impaired Skin Integrity, Impaired, Risk for Tissue Integrity, Impaired Physical Falls, Risk for Growth, Risk for Disproportional Mobility, Impaired Physical Perioperative Positioning Injury, Risk for Trauma, Risk for Self-Care Deficit, Bathing/Hygiene Self-Care Deficit, Dressing/Grooming Self-Care Deficit, Toileting Surgical Recovery, Delayed Wandering Perception Energy Field, Disturbed Environmental Interpretation Syndrome, Impaired Infant Behavior, Disorganized Infant Behavior, Disorganized, Risk for Infant Behavior, Readiness for Enhanced Organized Poisoning, Risk for Self-Mutilation Self-Mutilation, Risk for Sensory/Perception, Disturbed (specify): Visual, Kinesthetic, Auditory, Gustatory, Tactile, Olfactory Suicide, Risk for Unilateral Neglect Violence, Risk for Other-Directed Violence, Risk for Self-Directed Love/Belonging/Culture/Coping/Body Image Adjustment, Impaired Caregiver Role Strain Caregiver Role Strain, Risk for Communication, Impaired Verbal Communication, Readiness for Enhanced Community Coping, Ineffective Community Coping, Readiness for Enhanced Delayed Development, Risk for Family Coping: Compromised, Ineffective Family Coping: Disabled Family Coping: Readiness for Enhanced Family Processes, Dysfunctional: Alcoholism Family Processes, Interrupted Family Processes, Readiness for Enhanced Growth and Development, Delayed Loneliness, Risk for Parental Role Conflict Parent/Infant/Child Attachment, Impaired, Risk for Parenting, Impaired Parenting, Impaired, Risk for Parenting, Readiness for Enhanced Role Performance, Ineffective Social Interaction, Impaired Social Isolation Violence, Risk for Anxiety Concerns/Fear/Knowledge Needs Self-Esteem Adjustment, Impaired Anxiety Body Image Disturbed Coping, Defensive Coping, Ineffective Coping, Readiness for Enhanced Death Anxiety Decisional Conflict (Specify) Denial, Ineffective Fear Grieving, Anticipatory Grieving, Dysfunctional Grieving, Dysfunctional, Risk for Hopelessness Personal Identity, Disturbed Post-Trauma Syndrome Post-Trauma Syndrome, Risk for Powerlessness Powerlessness, Risk for Rape-Trauma Syndrome Rape-Trauma Syndrome, Compound Reaction Rape-Trauma Syndrome, Silent Reaction Religiosity, Impaired Religiosity, Readiness for Enhanced Religiosity, Risk for Impaired Relocation Stress Syndrome Relocation Stress Syndrome, Risk for Self-Esteem, Chronic Low Self-Esteem, Situational Low Self-Esteem, Situational Low, Risk for Self-Mutilation Self-Mutilation, Risk for Sorrow, Chronic Spiritual Distress Spiritual Distress, Risk for Spiritual Well-Being, Readiness for Enhanced Self-Actualization Health Maintenance, Ineffective Health Seeking Behaviors (Specify) Home Maintenance, Impaired Knowledge, Deficient (Specify) Knowledge, Readiness for Enhanced (Specify) Noncompliance Therapeutic Regimen: Community, Ineffective Management of Therapeutic Regimen: Families, Ineffective Management of Therapeutic Regimen: Management, Effective Therapeutic Regimen: Management, Ineffective Therapeutic Regimen: Management, Readiness for Enhanced

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NSGCAREPLAN(Sample):11:1/06

Section 1: Physical Assessment GENERAL APPEARANCE Admitted in moderate repiratory distress Allergies: NKA

*Include all dates/times of care provided. Date/Time* Related Nursing Diagnoses DATE/TIME INITIAL ASSESSMENT Explanation of (Circle appropriate 6- 23- 02 - 0800 Abnormal diagnoses) Condition has stabilized since initial Assessment Factors assessment in E.R.
Latex Allergy Response Latex Allergy Respoonse, Risk for

Thin, Obese, Emaciated, Well-developed, Well-nourished, No Acute Distress (NAD)

Height 5’7” Weight 154 lbs. BMI 24 Admitting Vital Signs 98.6 - 88- 28 176/94 I. PHYSIOLOGIC ASSESSMENT A. OXYGENATION 1. BREATHING 28 Rhythm: -Regular =Irregular Depth: -Deep =Shallow -Dyspneic -Apneic ___ sec. -Accessory muscle use -Tachypneic L R BREATH SOUNDS Cl - Clear Cl Cl Cr - Crackles Wh - Wheezing Cr Cl D - Decreased A - Absent Posterior =NC -Mask -Trach -Other Respiratory Rate Moderate resp. p distress, uses 3 di pillows at night, c/o ↑ fatigue & SOB, crackles L base

-No distress =Labored R L Cl Cl Anterior Cl
Cl

Airway Clearance, Ineffective y , Aspiration, Risk for Breathing Pattern, Ineffective Gas Exchange, Impaired Infection, Risk for Suffocation, Risk for Ventilation, Impaired, Spontaneous Ventilatory Weaning Response, Dysfunctional

Oxygen Therapy: -RA =FiO2 3 L / or %

O2 Saturation: -N/A =q 8 hr -Continuous pulse oximeter Pulse Oximetry Readings (Identify on R.A. or O2): 90RA ; ______; ______ Chest Config: Cough: =Symmetrical -Asymmetrical -Flail -No cough -Weak -Strong -Frequent =Infrequent =Nonproductive -Productive Description: Color _______ Odor ________ Viscosity ________ -Incentive Spirometer Shape of Chest: AP diameter 1:2, barrel, pectus excavatum, (circle) pectus carinatum, kyphotic Drainage: Chest Tube/Pleuravac: -R Suction ____ cm of water =N/A Medications R/T Breathing: -Yes 2. CIRCULATION -L -Water seal only

=No Type Weak radial & dorsalis pedal d li d l pulses bilat. cap refill prolonged. Bilat ankle edema pitting 2+ BP 176/94 Baseline 145/90
Cardiac Output, Decreased p , Fluid Balance, Readiness for Enhanced Fluid Volume Deficit Fluid Volume Deficit, Risk for Fluid Volume Excess Fluid Volume, Risk for Imbalanced Tissue Perfusion, Ineffective (specify: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral)

Heart Rate 88 Rhythm Regular Heart Sounds: Describe S1, S2, Mild heart murmur Neck Veins (45o angle): =Flat -Distended BP: 176/94 R L Apical Pulse: 88 Arterial Pulses Right/ Left C B R F PT DP
D - Doppler A - Absent 1+ - Barely Palpable 2+ - Weak 3+ - Normal 4+ - Full Bounding

3+ 3+ 3+ 3+

2+ 2+ 3+ 3+ 3+ 3+ 2+ 2+

Capillary Refill: -Brisk <3 sec. Nail bed Color: =Pink Chest Pain: =No -Yes

=Prolonged >3 sec. _________ sec. -Pale -Cyanotic

Describe

Edema: Location Bilat. Ankle -None -Generalized -Non- pitting =Pitting 1 + 2 + 3 + 4 + (circle) -Other Pacemaker: =N/A -Permanent -External Rate_____ Location: Type

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NSGCAREPLAN(Sample):12:1/06

2.

CIRCULATION (Continued)

Date/Time Related Nursing Diagnoses Explanation of (Circle appropriate Abnormal diagnoses) Assessment Factors

Homan’s sign: Left: -pos. =neg. Right: -pos. =neg. Calf redness/tenderness: Left: -yes =no Right: -yes =no Anti- embolism stockings: =N/A -Remove/Replaced q shift Sequential compression device: =N/A -Remove/Replaced q shift -Other IV’s / INVASIVE LINE MONITORING Type/Port Solution ID** Heparin Lock Rate Dosage Location R wrist Site Code C Digoxin .25 qd NitroNit - Bid 2 5 2.5 Lasix 40 BID KCl 20 mEq BID Digoxin level 2.6 hold digoxin and notify M.D.
Confusion, Acute , Confusion, Ch i C f i Chronic Environmental Interpretation Syndrome, Impaired Infant Behavior, Disorganized Infant Behavior, Readiness for Enhanced Organized Infant Behavior, Risk for Disorganized Intracranial, Decreased Adaptive Capacity Memory, Impaired Thought Processes, Disturbed

*SITE CODE: **ID C - Clear INFUSION S - Swelling DEVICE: R - Redness I - Inflamed DI - Dsg Dry & Intact Medications R/T Circulation: =Yes 3. NEUROLOGICAL

c p pca+ g

-

controller pump PCA gravity See above

-No Type

Level Of Consciousness: =Awake =Alert =Oriented x 4 (time, place, person, event) -Restless -Drowsy -Sedated -Confused Glasgow Coma Scale: (Circle number that applies.) a) Best eye opening: 4 Spontaneously 3 To Speech 2 To Pain 1 None b) Best verbal response: 5 Oriented 4 Confused 3 Inappropriate words 2 Incomprehensible sounds 1 None c) Best motor response: 6 Obeys commands 5 Localizes to pain 4 Withdraws 3 Flexion (decorticate) 2 Extension (decerebrate) 1 None

Total Glasgow Coma Scale 15 / 15 (Add a, b, c above) =PERRL -Pinpoint -Fixed -Dilated, but reactive to light -Dilated, nonreactive Unequal: -R>L -L>R -Dolls eyes -Other Brain Stem Signs: (+/- ) X N/A ____ cough ____ gag ____ corneal ____ Babinski Sensation: =Intact Location all extremities -Numbness -Absent -Tingling

Communication: =Verbal -Writes notes -Mouths words -Nods head appropriately to yes/no questions Medications R/T Neurological Condition: -Yes 4. NEUROVASCULAR -No Type
Dysreflexia, Autonomic y , Dysreflexia, Ri k f D fl i Risk for Autonomic Peripheral Neurovascular Dysfunction, Risk for

Extremities Examined: CSM q ___ hr Traction/Cast: =N/A Type Color: -Pink -Reddened -Blue -Blanched Temperature: -Cool -Warm -Hot Movement: -Active -Passive -Limited Sensation: -Numbness -Tingling -Pain Restraints: =N/A Type CSM q ___ hr -Restraint Protocol Instituted -Remove/Replaced q shift

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NSGCAREPLAN(Sample):13:1/06

B. NUTRITION

Abdomen: =Soft -Firm -Hard -Tender -Distended _____cm. Bowel Sounds: =Active -Hyper -Hypo -Absent Flatus: =Yes -No Diet: Type NAS -NPO -TPN -Tube feeding Meal: =Breakfast -Lunch -Dinner % taken 90%___ Type gastric tube =N/A -Placement Verified Purpose: -Feeding -Decompression -Other Formula: Type Rate cc’s q ___ hrs =N/A Suction: =N/A -Intermittent -Low continuous Drainage: Describe Mucous Membranes: =Moist -Dry -Cracked -Sores -Patches =Pink -Dusky - Other Dentures: -Full -Upper -Lower =N/A Diet toleration: =Anorexia =Nausea -Vomiting =Weight Loss: Amount 8 lbs. Time Period 2 mos. -N/A 24o Intake 1500 24o Output 1800 on 6/25 Balance: -Positive =Negative/300 cc Blood Glucose Monitoring q ___ hrs Time/Result _____________ =N/A =Self- feed -Assist- feed -Swallowing precautions Medications R/T Nutrition: -Yes -No Type C. ELIMINATION 1. BOWEL Stool: =Formed -Loose -Impacted Last BM 6- 22 Color: Brown -Regular -Irregular Outlet: =Rectum -Colostomy -Ileostomy -Rectal Tube -Fistula Output: Tube Drainage ______ cc’s Describe: Stoma: =N/A -Pink -Edema -Dusky Surrounding Skin: -D/I -Excoriated -Other Toileting: =Self -Assist History Laxative Use: -No =Yes Medications R/T Bowel: =Yes -No Type Metamucil 2. URINARY GU Drainage: =Voiding -Straight Catheter q ___ hrs -Indwelling Foley -3- way cath (irrigation) -External cath -Other Other: -Bladder Training -Catheter Care -Hourly Urine Output Bladder Irrigation: -Continuous -Manual Solution: Urine: =Clear -Cloudy -Sediment Odor: -Faint -Offensive Color: =Light Yellow -Dark Yellow -Orange -Clots -Hematuria Patterns:-Incontinent -Polyuria =Nocturia -Oliguria -Urgency -Dysuria -Retention -Anuria -Other Genitalia: =No Anomalies -Discharge -Excoriation -Other Medications R/T Bladder: =Yes -No Type Lasix D. ACTIVITY/REST Range of Motion: =Active -Passive -Limitations Bed Mobility: =Self Assist: -Partial -Total Assistive Devices: Type CPM: -Right -Left =N/A =N/A

Date/Time Related Nursing Diagnoses Explanation of (Circle appropriate Abnormal diagnoses) Assessment Factors Breastfeeding, Effective Serum albumin Breastfeeding, Breastfeeding Ineffective ↓ 2.8 28 Breastfeeding, Interrupted Wt loss 8 lbs. in Dentition, Impaired 2 months Failure to Thrive, Adult Fluid Volume, Deficit Lack of appetitie Fluid Volume, Deficit, Risk for and nausea Infant Feeding Pattern, Retired grocer, Ineffective Hispanic, lives with Nausea Nutrition: Imbalanced, Risk for daughter More Than Body Prefers fruit/veg, Requirements rice, red beans, Nutrition: Imbalanced, Less tortillas Than Body Requirements Nutrition: Imbalanced, More Consider dietary Than Body Requirements consult Nutrition: Readiness for
Enhanced Oral Mucous Membranes, Membranes Impaired Self- Care Deficit, Feeding Swallowing, Impaired

Constipation Constipation, Constipation Perceived Constipation, Risk for p , Diarrhea Di h Incontinence, Bowel Nausea

Nocturia x 4 p past week k BUN 30 mg/dl Cr 0.6 mg/dl Daily wts.

Fluid Volume, Risk for Imbalanced Infection, Risk for Incontinence, Functional Incontinence, Reflex Incontinence, Risk for Urge Incontinence, Stress Incontinence, Total Incontinence, Incontinence Urge Tissue Perfusion, Ineffective Urinary Elimination, Impaired Urinary Elimination, Readiness for Enhanced Urinary Retention

Requires 3 pillows at night to sleep c/o difficulty sleeping in hospital p g p

Joints: -Tenderness -Pain -Swelling =No abnormalities Ordered Activity level: Activity as Tolerated Sleep Patterns: Usual # Hours 8 # Last 24 hours 4 Special Needs: 3 pillows Medications R/T Activity/Rest: -Yes =No Type

Activity Intolerance Activity Intolerance, Risk for Disuse Syndrome, Risk for Diversional Activity Deficient at gue Fatigue Mobility, Impaired B d M bili I i d Bed Mobility, Impaired Physical Mobility, Impaired Wheelchair Perioperative Positioning Injury, Risk for Sedentary Lifestyle Sleep Deprivation Sleep Pattern, Disturbed Sleep Readiness for Enhanced Transfer Ability Impaired Ability, Walking, Impaired

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NSGCAREPLAN(Sample):14:1/06

E. COMFORT

Date/Time Related Nursing Diagnoses (Circle appropriate Explanation of diagnoses) Abnormal Assessment Factors denies chest or other pain Last Medicated: N/A -PCA -Epidural Nitro- Bid Comfort Pain, Acute Pain, Chronic Sexual Sexuality Pattern, Ineffective Sexual Dysfunction Safety and Security Temperature Hyperthermia Hypothermia Temperature, Risk for Imbalanced Body Thermoregulation, Ineffective Skin Infection, Risk for Injury, Risk for Latex Allergy Response Latex Allergy Response, Risk for Protection, I ff ti P t ti Ineffective Skin Integrity, Impaired Skin Integrity, Impaired, Risk f Ri k for Tissue Integrity, Impaired Physical Falls, Risk for Growth, Risk for Disproportional Mobility, Impaired Physical Perioperative Positioning Injury, Risk for Trauma, Risk for au a, s o Self-Care Deficit, Bathing/ Hygiene Self-Care Deficit, Dressing/ Grooming Self-Care Deficit, Toileting Surgical Recovery, Delayed Wandering Perception Energy Field Disturbed Environmental Interpretation Syndrome, Impaired Infant Behavior, Disorganized Infant Behavior, Disorganized, Risk for Infant Behavior, Readiness for Enhanced Organized Poisoning, Poisonin Risk for Self-Mutilation Self- Mutilation, Risk for Self -Mutilation, Sensory/Perception, Disturbed (specify): Visual, Kinesthetic, Auditory, Gustatory, Tactile, Olfactory Suicide, Risk for Unilateral Neglect Violence, Risk for OtherDirected Violence, Ri k f S lf -Directed Vi l Risk for Self- Di d

Pain/Discomfort: Describe: Pain Scale: (0- 10) ∅ Location: Quality: -PRN Analgesic/Narcotic Other Modalities: F. SEXUAL

Medications R/T Comfort: =Yes

-No Type

Reproductive: LMP _____ -Premenopausal -Postmenopausal =Male Hysterectomy: =N/A -Ovaries Removed - Ovary/Ovaries Remain Breasts: =Symmetrical -Asymmetrical Describe: Self Breast/Testicle Exams: -Yes =No Freq: __________ Cancer Screen: Date 2001 Test PSA Result WNL Date _______ Test ________ Result ________ (Breast, Pap, Prostate, Colon) Sexual/Fertility Concerns: None expressed; Widower -Hormone Replacement Medications Related to Sexuality: -Yes =No Type II. SAFETY AND SECURITY Temperature: Skin: 98.6 Route Taken: =Oral -Tympanic -Ax. -Rectal Turgor: Location: Sternum =Elastic -Tented -Taut -Shiny Temp: -Hot =Warm -Cool -Dry -Clammy -Diaphoretic Color: Location: __________ =Pink -Pale -Cyanotic -Flushed -Jaundiced -Mottled -Other Bony Prominences: -Skin Intact =Reddened -Gray -Pressure Sore Stage: _____ Location: _______________ Reddened coccyx and both heels

Wound Location: Wound: =N/A -Sutures -Staples -Drain -Dehiscence -Evisceration -Healing by secondary intention -Other Dressing: =N/A -Dry/Intact -Open to Air -Stained -Saturated Changed: q ___ hrs -Wet to Dry -Other Describe: Isolation/Precautions: -Transmission Based Precautions -Additional Protocols: =Braden Scale -Restraints -Special Bed -Other Physical: General -Unassisted -Supervised =Assisted Movement: -Hemiparesis/plegia -Paraparesis/plegia -Quadriparesis/plegia -Unable

Bathing/Hygiene: -Self =Assist -Total =Partial -PM Care Oral Care: -Self =Assist Assistive Devices: Type Weight Bearing Status: =FWB -L PWB =N/A -R PWB -NWB

Precautions: -Swallowing -Seizure -Spinal -Fall -Subarachnoid Perception: Vision Deficits: -Blind (legally) =Glasses -Contacts Hearing Deficits: -Deaf -HOH =Hearing Aid(s): -L -R =Bilat. Other: Precautions: -Danger to Self -Suicide -Danger to Others -Self Mutilation -Alcohol and Drug Withdrawal

Medications R/T Safety and Security: - Yes = No Type

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NSGCAREPLAN(Sample):15:1/06

Section 2: Psychosocial Assessment
Note: It is not appropriate to ask the client direct questions as you would during a history. Information is obtained by observing verbal and nonverbal behaviors and making inferences as you and the patient work toward accomplishing goals and objectives.

III. LOVE AND BELONGING 1. Emotional State a. What seems to be the client’s mood? =Normal for Age/Culture -Withdrawn -Depressed -Anxious -Fearful -Uncooperative -Flat Affect -Elevated -Euphoric -Expressive -Other 2. Client’s Life Experience a. How have previous life experiences affected the client’s perception of the current health problems? “My old heart is wearing out. I get this fluid every now and then. I come here to the hospital to get rid of it.” Third admission for CHF. b. How has life changed as a result of the current health problem? Mr. R has been confined to his home 3- 4 weeks. He needs assistance in ADLs. c. Describe any signs or symptoms that may indicate actual/potential physical/emotional abuse. No indication of physical/emotional abuse.

3.

Family a. What is the client and family’s perception of the illness/admission? “I’ve had a good life. I just want to be comfortable.” Close Hispanic family - 6 children. b. What evidence indicates that family life has changed? Mr. R. lives with one of his daughters and her family. c. How do family members seem to be coping? Ongoing presence of family members at bedside. No indications of ineffective coping currently. d. What supportive behaviors from family/significant others are evident? Visits, concern, supportive family

Related Nursing Diagnoses Adjustment, Impaired Caregiver Role Strain Caregiver Role Strain, Risk for Communication, Impaired Verbal Communication, Readiness for Enhanced Community Coping, Ineffective Community Coping, Readiness for Enhanced Delayed Development, Risk for Family Coping: Compromised, Ineffective Family Coping: Disabled Family Coping: Readiness for Enhanced Family Processes, Dysfunctional: Alcoholism Family Processes, Interrupted Family Processes, Readiness for Enhanced Growth and Development, Delayed Loneliness, Risk for Parental Role Conflict Parent/Infant/Child Attachment, Impaired, Risk for Parenting, Impaired Parenting, Impaired, Risk for Parenting, Readiness for Enhanced Role Performance, Ineffective Social Interaction, Impaired Social Isolation Violence, Risk for

4.

Erikson/Newman/Newman Developmental Stage: a.

Very Old Age

What tasks are appropriate for this stage of development? Immortality vs. Extinction

b.

How has this health problem interfered with accomplishing the development tasks for this client? Communicates confidence. Although his illness has interfered with his ADLs, he is coping with the physical changes of aging.

c.

What evidence indicates negative or positive developmental resolution? Talks with pride over his life’s accomplishments. Voices acceptance of his condition.

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NSGCAREPLAN(Sample):16-17:1/06

IV. SELF- ESTEEM: 1. Self- Esteem and Body Image a. How is the client’s self- esteem threatened by this illness/admission? Loss of independence can threaten self- esteem. b. What is the client’s perception of body image and how has it changed? “I’m glad I’m able to do what I can.” c. What fears/concerns were expressed by the client that relate to client’s present illness? Concern regarding his condition causing “stress” to his daughter and her family. 2. Culture a. What is the client’s ethnic background? b. Hispanic

Related Nursing Diagnoses
Self-Esteem Adjustment, Impaired Anxiety Body Image Disturbed Coping, Defensive Coping, Ineffective Coping, Readiness for Enhanced Death Anxiety Decisional Conflict (Specify) Denial, Ineffective Fear Grieving, Anticipatory Grieving, Dysfunctional Grieving, Dysfunctional, Risk for Hopelessness Personal Identity, Disturbed Post-Trauma Syndrome Post-Trauma Syndrome, Risk for Powerlessness Powerlessness, Risk for Rapep -Trauma Syndrome y Rape-Trauma Syndrome, Compound Reaction Rape-Trauma Syndrome, Silent Reaction Religiosity, Impaired Religiosity, Readiness for Enhanced Religiosity, Risk for Impaired Relocation Stress Syndrome Relocation Stress Syndrome, Risk for Self-Esteem, Chronic Low Self-Esteem, -Esteem Situational Low Self-Esteem, Situational Low, Risk for Self-Mutilation Self-Mutilation, Risk for Sorrow, Chronic Spiritual Distress Spiritual Distress, Risk for Spiritual Well-Being, Readiness for Enhanced Self-Actualization Health Maintenance, Ineffective Health Seeking Behaviors (Specify) Home Maintenance, Impaired Knowledge, Deficient (Specify) Knowledge, Readiness for Enhanced (Specify) Noncompliance Therapeutic Regimen: Community, Ineffective Management of Therapeutic Regimen: Families, Ineffective Management of Therapeutic Regimen: Management, Effective Therapeutic Regimen: Management, Ineffective Therapeutic Regimen: Management, Readiness for Enhanced

How does culture/language influence communication between client/family and healthcare workers? Hispanic culture has strong family support.

c.

Which communication factors are relevant and why do you think so?
(Touch, personal space, eye contact, facial expressions, body language)

Family is demonstrative in affection toward each other. d. Who seems to be making the healthcare decisions in the family? Mr. R’s eldest daughter is the surrogate decision maker. e. Based on your observations, what role does each family member play? Oldest daughter is “in charge” of others. f. Who is responsible for care of a sick family member at home? Eldest daughter. g. What cultural practices related to hospitalization need to be considered? Allow time/room for visitors. 3. Spirituality a. a What spiritual/religious beliefs does the client express? Mr. R. is Catholic and attends church. b. What signs and symptoms if present indicate spiritual distress? None. c. What spiritual practices related to hospitalization need to be considered? Allow/encourage visits from congregation members/priest. V. SELF- ACTUALIZATION 1. What is the client’s/family’s current level of understanding of their health/illness problem? Accepts condition and understands the diagnosis. What type of relationship exists with healthcare providers? Cooperative, respectful. Education/discharge planning: See M.E.T.H.O.D. attached.

2.

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NSGCAREPLAN(Sample):16-17:1/06

SAMPLE CARE PLAN FORM The following pages are an example of how to write a care plan using the accepted format for RCC. This is not a complete care plan related to JR’s problems, but rather a brief example to show proper use of the format.

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NSGCAREPLAN(Sample):18:1/06

RCC Nursing Education Programs Nursing Care Plan
Student Name: Jane Doe Client Initials: JR Medical Diagnosis: Admission date:
Congestive Heart Failure

ID: 11111 2/02/02 Age: 84

Course: N17 Gender: M

Date: 2/16/02

Nursing Diagnosis
NDX: (Problem) Cardiac output, decreased R/T: (etiology/factor) (not the medical diagnosis): Altered myocardial contractility AEB: (s/sx; defining characteristics) (Identify all that apply) 1. Dyspnea: c/o shortness of breath with mild exertion. 2. Blood pressure, increased: 176/94 3. Rales in left base of lung *If ‘risk for’ identify what the client would exhibit (note there are no signs and symptoms for ‘risk for’ problems):

Desired Outcomes
Goal: (Reversal of problem) Adequate cardiac output Client will (list measurable outcomes; reverse signs and symptoms) 1. Demonstrate no dyspnea within 24 hrs 2. BP returns to baseline of 145/80 within 24 hrs 3. Lungs clear to auscultation by time of discharge

Interventions (I)-Independent (C) – Collaborative (Circle)
ASSESS: (May have less or more than 4) N1-(I) Assess general appearance for weakness, fatigue, edema q shift and prn

Rationale & APA Reference (Use various sources)
R1- These s/s develop as the heart attempts to compensate for a decreased C.O. with resultant decrease in O2 supply to body’s tissues (Smeltzer & Bare, 1996, p. 581-2). R2- Fluid accumulation in lungs may occur with decreased C.O. (Carpenito, 2000, p. 14) R3- With decreased C.O. peripheral pulses may be weakened & pulse count may be inaccurate at peripheral sites (Smeltzer & Bare, 1996, p. 582). R4- Assessment of respiratory rate can reveal symptoms r/t fluid overload (Sparks & Taylor, 2004, p. 59). R5- To ascertain response to therapy-increased BP is a sign of stress on the system (Smeltzer & Bare, p. 582) R6- Peripheral circulation maybe be impaired with decreased C.O. (Smeltzer & Bare, p. 582)

Evaluation of Interventions

E1- Denies fatigue/weakness at present. No edema noted.

N2-(I) Assess lungs sounds q 4 hrs N3- (I) Count apical pulse rate q 4 hrs

E2- Rales decreased but present in L base. R lung clear.

E3- Apical pulse 78 bpm

N4- (I) Evaluation of Outcomes (address each outcome) 1.Dyspnea decreased but still present with exertion 2. BP still elevated (154/96) 3.Rales diminished but still present Count respiratory rate q 4 hrs

E4- RR 14-18

N5- (I) Measure BP q 4 hours

E5- BP 154/96; decreased from 176/94

N6- (I) Assess peripheral pulses q 4 hrs

E6- Radial and dorsalis pedal pulses 2+, others 3+

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NSGCAREPLAN(Sample):19-22:1/06

RCC Nursing Education Programs Nursing Care Plan
Student Name: Jane Doe Client Initials: JR Medical Diagnosis: Admission date:
Congestive Heart Failure

ID: 11111 2/02/02 Age: 84

Course: N17 Gender: M

Date: 2/16/02

Nursing Diagnosis

Desired Outcomes
Evaluation of Goal: (circle one) Goal met Goal not met Goal partially met Continuation of plan: (circle one) Continue plan of care Discontinue plan of care Revise plan of care

Interventions (I)-Independent (C) – Collaborative (Circle)
ACTIVITIES: (May have less or more than 4) N1- (I) Elevate head of bed 15-45 degrees. Use cardiac chair when OOB

Rationale & APA Reference (Use various sources)
R1- These anatomical positions facilitate ease of breathing & promote rest (Smeltzer & Bare, 2000, p. 583)

Evaluation of Interventions

E1- Positions self with HOB elevated 15 degress. Sat in chair X30 min twice during day.

N2- (I) Assist as needed with ambulation and with shower

R2- Client may tire easily or become dyspneic-need to conserve energy (Smeltzer & Bare, 2000, p. 621)

E2- Ambulated to BR without respiratory distress. Partial bed bath given instead of shower.

N3- (I) Measure and document intake & output q 4 hrs & prn.

R3- Accurate I & O is essential for monitoring for potential fluid overload (Sparks & Taylor, 2004, p. 42)

E3- Intake 400cc this shift, output 850cc.

N4- (I) (C)

R4-

E4-

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NSGCAREPLAN(Sample):19-22:1/06

RCC Nursing Education Programs Nursing Care Plan
Student Name: Jane Doe Client Initials: JR Medical Diagnosis: Admission date:
Congestive Heart Failure

ID: 11111 2/02/02 Age: 84

Course: N17 Gender: M

Date: 2/16/02

Nursing Diagnosis

Desired Outcomes

Interventions (I)-Independent (C) – Collaborative (Circle)
MEDICATIONS: (May have less or more than 4) N1- (I) Give Nitro Bid 2.5 mg po QD as ordered @0900 after checking Digoxin level N2- (I) Give Lasix 40 mg p.o. BID after checking K+ level.

Rationale & APA Reference (Use various sources)

Evaluation of Interventions
Evaluate TACTIS of each Medication.

R1- SEE TACTIS on medication sheet

E1- Med held. Digoxin level 2.6. M.D. called.

R2- SEE TACTIS on medication sheet

E2T – BP remains elevated 154/96; No edema noted. A – Na+ and Cl- reabsorption inhibited. C – No hypersensitivity or other contraindications noted. T – K+ 3.3 K-rider given I – Assess for dehydration – No S/S. S – 40 mg safe dose (20-80 mg/day safe).

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NSGCAREPLAN(Sample):19-22:1/06

RCC Nursing Education Programs Nursing Care Plan
Student Name: Jane Doe Client Initials: JR Medical Diagnosis: Admission date:
Congestive Heart Failure

ID: 11111 2/02/02 Age: 84

Course: N17 Gender: M

Date: 2/16/02

Nursing Diagnosis

Desired Outcomes

Interventions (I)-Independent (C) – Collaborative (Circle)
TEACHING: (May have less or more than 4)

Rationale & APA Reference (Use various sources)
May use “See Method” only if you include the teaching point on the Method.

Evaluation of Interventions
May use “See Method” only if you include the teaching point on the Method.

N1- (I) (C) Teach patient about medications and activity restrictions

R1- See METHOD

E1- See METHOD

N2- (I) (C)

R2-

E2-

N3- (I) (C)

R3-

E3-

N4- (I) (C)

R4-

E4-

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NSGCAREPLAN(Sample):19-22:1/06

M.E.T.H.O.D. Daily Teaching Plan and Evaluation PATIENT INITIALS: J.R. Client X Family Sig.Other Other Daughter

LEARNERS PRESENT (circle):

MEDICAL DIAGNOSES: CHF; CAD TECHNIQUES: Date Complete & Initials 06/23/02 JD Discussion Q/A Demos Handout(s) Other ______________

Content M (Medications):

Evaluation

M = Discussed each Lasix (Furosemide). Decreases swelling and blood medication. Knew the pressure by increasing the amount of urine. Expect purpose of each drug. Was increased frequency and volume of urine. Report checking his own blood irregular heartbeat, changes in muscle strength, tremor, pressure each week at and muscle cramps, change in mental status, fullness, home, using cuff he bought ringing/roaring in ears. Eat foods high in potassium such at the drugstore. Needs to as whole grains (cereals), legumes, meat, bananas, review side effects and apricots, orange juice, potatoes, and raisins. Avoid precautions of both lasix sun/sunlamps. Take with breakfast to avoid GI upset. and digoxin. Given written Digoxin (Lanoxin). Used to treat CHF. Taking too patient drug information. much can result in GI disturbances, changes in mental
status and vision. Report the following signs/ symptoms to your doctor: Nausea, vomiting, lack of appetite, fatigue, headache, depression, weakness, drowsiness, confusion, nightmares, facial pain, personality changes, sensitivity to light, light flashes, halos around bright objects, yellow or green color perception. Take pulse rate for one minute before dose and call doctor if pulse is below 60 before taking medication. Don’t increase or skip doses. Don’t take over the counter medications without talking to MD. Report for follow-up visits with your doctor to monitor lab values.

06/23/02 JD

E (Environment):
Your eldest daughter will provide help with activities of daily living in the home. She will transport you to followup appointments. It is important to take steps to prevent falls: use of a 3-point cane for stability with ambulation; removing objects like throw rugs, cords that may cause fall; pausing before standing and again before walking to prevent drop in blood pressure. The “life line” allows you to access 911 for emergency help. You may resume activities as tolerated and you have a follow-up appointment with the doctor in 1 week.

E = He lives with his eldest daughter who helps him with meals, medication administration, getting to appointments, etc. Verbalizes understanding of fall prevention and activity level. Understands appointment date and time for follow-up.

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NSGCAREPLAN(Sample):23-24:1/06

06/23/02 JD

T = Daughter was able to Apply A & D ointment to reddened coccyx and heels demonstrate proper three times a day. Keep pressure off of these areas by positioning. Client and keeping off of back and elevating heels off of bed. Keep daughter able to describe skin clean and dry. Report any changes in skin condition skin care. T (Treatments):
to doctor. (i.e. open areas, drainage, elevated temp.)

6/23/02 JD

H (Health knowledge of disease):
Lasix can cause a loss of potassium. It is important to eat foods high in potassium and to have regular blood levels drawn to make sure potassium level stays normal. Monitoring the pulse rate before taking digoxin is important because this medicine can cause the pulse to drop. Call the doctor if pulse rate is below 60 beats per minute. New signs and symptoms should be reported to the physician, because they may indicate electrolyte imbalance &/or digoxin toxicity. Sodium causes water retention so it is important to limit sodium intake by eating a no added salt diet. Be careful to check labels for hidden salt content.

H = Verbalizes signs and symptoms of electrolyte imbalance and digoxin toxicity. He stated what foods are high in potassium and what foods to avoid that are high in sodium. Demonstrated how to assess pulse rate and when to call the doctor.

6/23/02 JD

O (Outpatient/inpatient referrals): (include resources such as websites and organizations):
American Heart Association www.americanheart.org Visiting Nurses’ Association for F/U skin assessment. Referral made to outpatient dietician for diet planning. Meals on Wheels.

O = Given information for national and regional resources related to heart disease. Referrals to VNA, dietician and Meals on wheels completed.

6/23/02 JD

D: (Diet):
Do not add salt to your diet. Eat foods high in potassium such as bananas. We will arrange for you to meet with the dietician.

D = Diet teaching completed regarding low salt, high potassium diet. F/U with dietician as outpatient arranged. Client and daughter state they understand diet. . Meals on
wheels contacted.

Schuster, P. (2000). The key to the therapeutic relationship. Philadelphia: FA Davis. Schuster, P. (2002). Concept Mapping: A critical thinking approach to care planning. Philadelphia: FA Davis.

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NSGCAREPLAN(Sample):23-24:1/06

Directions for Using METHOD Daily Teaching Plan General Guidelines
1. 2. 3. 4. 5. 6. 7. Write the instructions for the client. These are not guidelines for the nurse who will be doing the teaching. Complete all sections, recognizing that each section may not be taught in one session. Complete one METHOD per client. In the Evaluation column, either describe the client response to the teaching or indicate the reason the teaching did not take place. The content must be stated in simple, specific terms, so the client can understand the instructions. Assessment forms the basis for teaching in each area, and is therefore always the first step. Use learning principles when preparing the teaching plan. This would include such things as selecting the right time for the teaching and building on the client’s prior knowledge of the subject.

Environment
1. 2. Definition: Factors that affect the client’s health care in the facility or home. Examples a. safety b. activity order, including restrictions c. availability of transportation d. psychosocial issues e. finances f. cleanliness Directions a. Identify pertinent environmental factors assessed by the nurse. b. Describe teaching needed to help the client modify the environment.

3.

Treatments
1. 2. If the client is in a facility: Teach the purpose of the treatment(s) and how the client can assist when the treatment(s) is/are performed. If the client is at home: Provide simple directions about how to perform the procedure, including technique, safety measures, and supplies/equipment needed.

Health Knowledge of Disease
1. 2. 3. Assess the client’s knowledge about the disease and provide information essential for managing the condition. Provide web sites for obtaining information about the disease. Teach S/S of complications. Examples a. wound: S/S infection b. heart: S/S of heart failure Teach when to contact the primary healthcare provider and how to do that.

4.

Outpatient/Inpatient Referrals: Instructions are included on the form. Diet 1. 2.

Include purpose and cultural adaptations. Consider finances and who will be shopping for and preparing the food.

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NSGCAREPLAN(Sample):25:1/06