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Nursing Care Plan Patient Introduction.

Nursing Care Plan Patient Introduction.

Nursing Care Plan Patient Introduction.

 

CAREPLAN TEMPLATE IS ATTACHED

PATIENT INTRODUCTION

Location: Rehabilitation unit 0800

Report from charge nurse:

Situation: Kim Johnson is a 26-year-old female police officer with paraplegia from a thoracic 8 (T8) spinal cord injury. She was transferred to us yesterday.

Background: The complete spinal cord injury was caused by a low-velocity gunshot wound to her back at the T8 level while she was responding to a robbery 8 days ago. The bullet penetrated the spinal column with no injury to visceral organs.

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Assessment: Last bowel movement was yesterday at 1900, and the gunshot wound appears healed. Her neurological status is stable. She is awake and oriented. Bilateral upper extremity motor response is +4, and there is no movement or sensation to the lower extremities. She has been out of bed to a wheelchair. She is on a regular, high-fiber diet, and had breakfast at 0700. At 0400 she was catheterized for 300 mL of clear, yellow urine. The measured urine volume from the bladder scan 5 minutes ago was 321 mL.

Recommendation: She is due for assessment of vital signs and the 0800 intermittent urinary catheterization, which can be done after you have reviewed the chart. You should also begin the patient education on her bladder management program and the steps for a straight catheterization. The physical therapist is scheduled to see the patient at 1030.

FUNDAMENTALS OF NURSING CARE

  1. Rehabilitation Centers,
  2. Problems Affecting the Central Nervous System
  3. Urinary Elimination
  4. Characteristics of Urine
  5. Common Diagnostic Procedures Used to Study the Urinary Tract
  6. Promoting Normal Urination

DISEASES AND CONDITIONS

  1. Expert Clinical Content from Lippincott Advisor

  2. Spinal Injury Spinal Injury
  3. Neurogenic Bladder Neurogenic Bladder

PHARMACOLOGY

  1. Expert Clinical Content from Lippincott Advisor

  2. Omeprazole Omeprazole
  3. enoxoparin sodium enoxoparin sodium
  4. oxybutynin chloride oxybutynin chloride
  5. docusate calcium docusate calcium

DIAGNOSTIC TESTS

  1. Expert Clinical Content from Lippincott Advisor

  2. Creatinine level (serum) Creatinine level (serum)

PROCEDURES

  1. Expert Clinical Content from Lippincott Procedures

  2. Intermittent (straight) urinary catheter insertion, female Intermittent (straight) urinary catheter insertion, female
  3. Bladder ultrasonography Bladder ultrasonography
  4. Intake and output assessment Intake and output assessmet

 

UNFORMATTED ATTACHMENT PREVIEW

Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L Student Instructor Patient Initial Code Status Allergies Temp (C/F Site) Unit/ Room# DNR= Do not resuscitate/Full code/Partial DNR Pulse (Site) Respiration History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with Evidence Based Citations HPI= it’s like a short story about why the patient came to the facility, with description of patient’s age, ethnic background/race, significant medical, social and surgical history…(will find information in vSIM case in the section of SBAR reporting-Situation and Background) Admission diagnosis: Diagnosis made by the physician at the time of admission (Ex. CHF exacerbation, asthma exacerbation, stroke, head trauma, GIB…)—-THIS IS THE MEDICAL DIAGNOSIS Chief complaint: what the patient is telling you, reason for coming to the facility (Ex. “SOB for 3 days”, “pain..”, “weakness..”, “diarrhea…”, bleeding…..)-use quotations Pulse Ox (O2 Sat) Date Course DOB Height/Weight Blood Pressure Pain Scale 1-10 Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations Only your head to toe assessment—-No vital signs Organize from head to toes (Ex. Neuro, Resp, Cardiac…..) Cite-APA and using evidence based citations Cite (use APA format)- using evidence based citations- Ex: Hypertension: hypertension is the force (pathophysiology of hypertension/description from an evidence based sites/sources (ex. Mayo Clinic, John Hopkins, your Taylor or ATI book or Davis Drug book…)- and cite the source from where you got the information (using APA format) Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges), include dates and rationales supported with Evidence Based Citations Ex. Xrays, CAT scans, any diagnostic procedures including labs
Page 1 of 4 Past Medical & Surgical History, Pathophysiology of medical diagnoses (include dates, if not found state so) Supported with Evidence Based Citations Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L Cite- using evidence based citations past medical or surgical history AND pathophysiology of medical diagnoses Cite- using evidence based citations Erikson’s Developmental Stage with Rationale And supported by Evidence Based Citations Check the different Erikson’t stages (by age) and use the stage that belongs to your patient Cite- using evidence based citations Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations Religion, socioeconomic status, family support?…. Cite- using evidence based citations Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each (“At Risk for…” nursing dx) Nursing diagnosis: 2 types (choose any of the formats below to write your nursing diagnosis)——- Nursing Care Plan Patient Introduction.
Only need to write 2 nursing diagnosis Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale supported with Evidence Based Citations Cite- using evidence based citations 1- Problem-focused example: (Problem)Activity intolerance related to (main etiology) as evidenced by (signs and symptoms) 2- Risk example: Risk for Impaired Skin Integrity related to (main etiology) At risk for falls related to CVA (patient with stroke/cerebrovascular accident) At risk for aspiration related to CVA Then, Write 3 interventions for each nursing diagnosis Diagnostic Label Page 2 of 4 Related to Contributing Factors As evidenced by Signs and Symptoms Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L Priority Nursing Diagnosis (at least 2) Written in three part statement Ex: (Problem)Activity intolerance related to (main etiology) as evidenced by (signs and symptoms)—-
Look explanations above in potential health deviations- They need to be Prioritized (write first your nursing diagnosis priority #1) Page 3 of 4 Planning (outcome/goal) Measureable goal during your shift (at least 1 per Nursing diagnosis) Ex: patient will improve activity tolerance during my shift 1 Goal per nursing diagnosis—Goal needs to be measurable, short timed, reasonable Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) 4 nursing interventions per goal- how you will be improving the activity tolerance, and how Rationale Each must be supported with Evidence Based Citations Rationale to each intervention (4 interventions=4 rationale (to each intervetion) Cite- using evidence based citations Evaluation Goal Met, Partially Met, or Not Met & Explanation See above question Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L MEDICATION LIST Medications (with APA citations Cite- using evidence based citations References: Page 4 of 4 Class/Purpose Ex. Antihypertensive.. Route Frequency Dose (& range) If out of range, why? Mechanism of action Onset of action How the medication exerts its therapeutic effects.. Common side effects Nursing considerations specific to this patient Your nursing interventions. What will you do to monitor this med, etc Nursing Care Plan Patient Introduction.