Nursing Holistic + care plan + meds + labs
description
Transcript of Nursing Holistic + care plan + meds + labs
HOLISTIC ASSESSMENT PAGE 1
Client Initials MW Admit Date 1/21/09 Date of Care 1/29/09-1/30/09 F Age 84 Marital Status S
Diagnosis weakness, dyspnea, plural effusion, sinus bradycardia, CHF
Operation/Procedure (include date) thorocentisis (1/23/09),
Advance Directives (what type): no
Reason for admission(chief complaint) SOB
Significant History/Other pertinent information pneumonia (right lower lobe, 3 weeks PTA) , HTN, myocardial infarction, CHF, stent placement, dysrhythmias, lipidemia, diabetes mellitus, right lower lung lobe mass (nonmalignant),
Report Data: (information obtained from RN, morning report, clarification of information obtained from clinical instructor) Activity/Risk for Fall: up with assist, at risk for falls
Allergies: NKA
Vital signs(frequency): TID
Code Status: full code
Diet: Cardiac/ ADA 1800/ soft
IV/Saline lock: SL right hand
Telemetry: yes (sinus bradycardia)
I/O (last void; last bowel movement): BRP , slight urine incontinence, urine yellow, clear; last BM 1/29. monitor I/O.
Oxygen: RA
Drains/Wounds: puncture wound, right middle upper back, skin intact, open to air; stage II DU, coccyx, Allevyn wound dressing and skin barrier cream applied 1/30/09 930; rt upper arm, ecchymotic.
Procedures/specimens/medications: meds: 800, 900, 1200.
Isolation: Contact precautions, hx MRSA (bronchial wash) 1/2/09.
Scheduled Therapies/Other: PT
Plan of Care:1. Obtain report from RN.2. Review chart and MAR.3. Introduce self to Pt. and complete assessment4. Up-to-date pt on plan of care for the day5. Assist with AM care6. administer meds7. Ambulate8. gather holistic information9. report off to RN at end of clinical
What are the client’s top priorities regarding his or her own care for today?-assessment/ meds-diuresis-ambulation, OOB for meals-AM care
MEDICATIONS
:NAME
TIME DUE
INDICATION FOR RECEIVING MEDICATION
NURSING CONSIDERATIONS
ASSESSMENT RESULTS PRIOR TO
LAB RESULTS TO MONITOR PRIOR TO ADMINISTRATION
ADVERSE REACTIONS/SIDE EFFECTS TO ASSESS PRIOR TO
HOLISTIC ASSESSMENT PAGE 2
DOSAGE
ROUTE
ADMINISTRATION ADMINSTRATION
Pantoprazole
(Protonix)
40mg (1 tablet)
PO
900 To suppress gastric
secretions
No nausea, no vomiting, no
diarrhea, no constipation. No
epigastric or abd pain. No
bloody stools or emesis. No
headache.
-may inc glucose, uric acid, and
lipid levels
-may inc/dec liver function
BG:134
BUN:41 (elevated)
Creatinine: 1.9 (elevated)
CNS: anxiety, dizziness, headache,
insomnia. CV: chest pain, peripheral
edema. EENT: rhinitis, sinusitis. GI: abd
pain, constipation, diarrhea, dyspepsia,
flatulence, gastroenteritis, GI disorder,
nausea, vomiting. GU: rectal disorder,
urinary frequency, UTI. METAB:
hyperglycemia, hyperlipidemia.
MUSCSKEL: arthralgia, back pain,
hypertonia, neck pain. RESP: bronchitis,
dyspnea, inc cough, upper resp tract
infection. INTEG: rash. Flulike
symptoms, infections.
Insulin Regular
(Novalin R vial)
5 units
SubQ injection
800
1200
Antidiabetic Injection site: no bleeding, no
pain, no severe ecchymosis.
Blood glucose 830: 134
Urine ketones: wnl
-may dec magnesium, and
potassium levels
METAB: hyperglycemia, hypoglycemia.
RESP: dyspnea, inc cough, reduced
pulmonary function, resp tract infection.
INTEG: itching, rash, redness, stinging,
swelling, urticaria, warmth at injection
site. OTHER: anaphylaxis,
hypersensitivity reactions, rash.
Insulin Regular
(Novalin R vial)
Sliding Scale
SubQ injection
BG<150 0 units
151-199 2 units
200-249 4 units
250-299 6 units
300-349 8 units
>350 notify MD
Aspirin
(Ecotrin 81 mg)
81mg (1 tablet)
PO
900 Antiplatelet,
antipyretic
No GI bleed/distress, nausea,
occult bleeding, vomiting.
-may inc liver enzymes, BUN,
serum creatinine, s. K, and may
prolong bleeding times.
-may dec WBC and platelet count.
BUN and creatinine elevated.
EENT: hearing loss, tinnitus GI:
dyspepsia, GI bleeding, GI distress,
nausea, occult bleeding, vomiting. GU:
transient renal insufficiency HEMO:
prolonged bleeding time,
HOLISTIC ASSESSMENT PAGE 3
Plt count low (consistently
decreasing).
thrombocytopenia. METAB: HEPAT:
hepatitis. INTEG: bruising, rash,
urticaria. OTHER: angioedema,
hypersensitivity reactions (anaphylaxis,
asthma) Reye syndrome.
Magnesium
Oxide (Mag-Ox
400mg)
400mg (1 tablet)
PO
900 Mg replacement No abd pain, no diarrhea, no
nausea.
-may inc mag levels GI: abd pain, diarrhea, nausea METAB:
hypermagnesemia (hypotension, n/v,
depressed reflexes, resp depression,
coma)
Spironolactone
(Aldactone)
25mg PO
900 Anti-HTN (diuretic) BP: 142/58 P: 69
No v/d/n/c.
No edema.
Monitor I/O
Wt
-may inc BUN, creatinine, K
-may dec Na
-may dec granulocyte count
-may falsely inc digoxin level
Na:137
K:4.6
Cl:100
Ca:8.1 (Low)
PT: 11.3
INR:1.08
BUN:41 (elevated)
Creatinine: 1.9 (elevated)
CNS: ataxia, confusion, drowsiness,
headache, lethargy. GI: cramping,
diarrhea, gastric bleeding, gastric
ulceration, vomiting. GU: impotence,
menstrual disturbances. HEMO:
agranuloctosis. METAB: dehydration,
hyperkalemia, hyponatremia, mild
acidosis. INTEG: erythematous rash,
urticaria OTHER: anaphylaxis,
angioedema, breast soreness, drug fever,
gynecomastia.
Ramipril
(Altace)
2.5mg PO
900 Anti-HTN (ACE
inhibitor)
No cough.
No n/v/d/c.
No headaches, lightheadedness.
No chest pain, no edema.
No abd pain.
-may inc BUN, creatinine, bilirubin,
liver enzyme, glucose, K.
-may dec hgb and hct
K: 4.6
Na:137
Ast:
Alt:
BG: 134
Hgb:10.6 (low)
Hct: 33.2
CNS: amnesia, anxiety, asthenia,
depression, dizziness, fatigue, headache,
insomnia, syncope, lightheadedness,
malaise, nervousness, neuropathy,
seizures, tremors, vertigo . CV: angina,
arrhythmias, chest pain, edema, MI,
orthostatic hypotension, palpitations .
EENT: epistaxis, tinnitus. GI: abd pain,
anorexia, constipation, diarrhea, dry
mouth, dyspepsia, gastroenteritis, nausea,
vomiting. METAB: hyperkalemia,
HOLISTIC ASSESSMENT PAGE 4
weight gain. MUSCSKEL: arthritis,
myalgia. RESP: dry persistent, tickling,
nonproductive cough. dyspnea. INTEG:
dermatitis, inc diaphoresis, pruritis, rash.
OTHER: andioedema.
Bumetanide
(Bumex)
1mg PO
900 Anti-HTN (diuretic) No dizziness, no headache.
I/O balanced.
BP:142/58
P: 69
Lung sounds (rt. post. Lower
lobe diminished)
No peripheral edema
Creatinine: 1.9 (elevated)
BUN: 41 (elevated)
BG: 134
K: 4.6
Mg:
Na:137
Ca: 8.3 (low)
Plt count: 86 (low)
CNS: dizziness, headache . CV: ECG
changes, orthostatic hypotension, volume
depleteion and dehydration . EENT:
transient deafness GI: nausea GU: freq
urination, nocturia, oliguria, polyuria,
renal failure HEMO: thrombocytopenia
METAB: asymptomatic hyperuricemia,
fluid and electrolyte imbalance, dilutional,
hyponatremia/hypocalcemia/
hypomagnesemia, hyperglycemia,
hypokalemia, impaired glucose tolerance.
MUSCSKEL: muscle pain and
tenderness. INTEG: rash
Metoprolol
tartrate
(Lopressor
50mg)
50mg PO
900 Anti-HTN (beta
blocker)
BP: 142/ 58
P: 69
CNS: dizziness, fatigue, fever, lethargy .
CV: AV block, bradycardia, heart failure,
hypotension, peripheral vascular disease.
GI: diarrhea, nausea, vomiting.
MUSCSKEL: arthralgia. RESP:
bronchospasms, dyspnea. INTEG: rash
Diagnostic and/or Laboratory Test
NormalValues
Client’s Results Clinical Significance:
HOLISTIC ASSESSMENT PAGE 5
On-Admission
Current Reason this being monitored for this client.
What nursing interventions and clinical decisions are essential for this client’s care as a result of their diagnostic and/or laboratory tests?
HEMATOLOGY
WBC 4.5-11.0
K/mm3
10.2 12.9 Evaluation of pt with infection,
neoplasm, allergy or
immunosuppression. Pt was
recently hospitalized for
pneumonia.
Keep skin clean to avoid infections, cover open wounds, avoid
aspiration pneumonia,
RBC 3.90-5.20
L M/uL
3.78 3.85 Pt admitted SOB Monitor O2 sats.
HBG 11.2-15.0
g/dL
10.2 10.6 Used as a rapid indirect
measurement of the red blood cell
count.
HCT 32.8-44.7
L %
32.7 33.2 Used as a rapid indirect
measurement of the red blood cell
count.
PLATELETS 125-400
K/mm3
115 86
aPTT/PTT 33.8
PT 11.3
INR 1.08
SED RATE
BLOOD CHEMISTYRY
POTASSIUM 3.5-5.1
mmol/L
4.2 Electrolyte is very important in the
function of the heart and is part of
routine evaluations for pt on
diuretics or heart medications
Proper dietary intake
SODIUM 136-145
mmol/L
137 Routinely performed. Used to
evaluate and monitor fluid and
electrolyte balance and therapy.
Monitor I/O for fluid balance
MAGNESIUM
CALCIUM 8.5-10.1
mg/dL
8.3 To monitor Ca in relation to serum
albumin levels. Also electrolyte
Increase weight bearing activity. Supplements.
HOLISTIC ASSESSMENT PAGE 6
imbalances are dangerous to the
functioning of the heart
PHOSPHORUS 2.5-4.9
Mg/dL
4.0
CHLORIDE 98-107
mmol/L
101 100 In correlation with other
electrolytes, Cl gives indication of
acid-base balance and hydration
status.
Monitor I/O
BUN 7-23 mg/dL 41 Indirect and rough measurement of
renal function and glomerular
filtration rate.
Adequate protein intake, monitor I/O to avoid overhydration
CREATININE 0.6-1.0
mg/dL
2.0 Used to diagnose impaired renal
function
BUN/CREATININ RATIO 7-23 24
TOTAL BILIRUBIN <1.0 mg/dL To evaluate liver function
TOTAL PROTEIN 6.4-8.2 g/dL 6.4 Increase intake of protein to aid in tissue reconstruction and wound
healing
ALBUMIN 3.4-5.0 g/dL 2.3 To evaluate for hepatic
malfunction and nutrition
GLOBULIN 1.4-4.8 g/dL To evaluate for liver malfunction
ALBUMIN/
GLOBULIN RATIO
1.0-1.9 g/dL To distinguish between certain
diseases of kidneys and liver
TOTAL ALK PHOSPHATE 50-136 U/L
CO2 21-32
mmol/L
To assist in evaluating the pH
status of the pt and to assist in
evaluation of electrolytes.
Decreased levels can be
contributed to medications
administered.
GLUCOSE 70-99
mg/dL
134 In evaluation of diabetic pt. Blood
glucose levels rise as a response to
stress and several types of
Monitor intake, ambulate.
HOLISTIC ASSESSMENT PAGE 7
medications.
SERUM LIPIDS
CHOLESTEROL
TRIGLYCERIDES
LDL’S
HDL’S
LIVER ENZYMES
ALT 30-65 U/L Used to identify hepatocellular
disease of liver.
AST 15-37 U/L Used to identify pt with suspected
coronary artery occlusive disease
or suspected hepatocellular
disease.
CARDIAC MARKERS
TROPONIN <0.4 Cardiac enzyme which is measured
for evidence of cardiac muscle
injury.
MYOGLOBIN
CK-MB
Diagnostic and/or Laboratory Test
NormalValues
Client’s Results Clinical Significance:
On-Admission
Current Reason this is being monitored for this client.
What nursing interventions and clinical decisions are essential for this client’s care as a result of their diagnostic and/or laboratory tests?
BLOOD GASES
Ph
PCO2
PO2
HCO3
URINALYSIS
COLOR Yellow Yellow
GLUCOSE Absent
KETONE Absent
BLOOD Absent
HOLISTIC ASSESSMENT PAGE 8
PH 4.6-8.0 5.0
PROTEIN 0-8
Mg/dL
15
UROBILINOGEN
RBC <2 9
WBC 0-4 66 Infection. Increase fluids.
URINE OSMOLARITY
SPECIFIC GRAVITY
OTHERS
CXR No
pneumothorax
Lung US Large left
pleural
effusion that
is 3cm below
skin surface.
Small rt
pleural
effusion.
Lung biopsy Nonmalignant
cells
Abd US No evidence
of renal
stenosis.
Mildly inc
contical
echogeniaty.
Suggestive of
renal
parenchymal
disease.
Gallstones.
HOLISTIC ASSESSMENT PAGE 9
HOLISTIC ASSESSMENT PAGE 10
NEUMAN’S VARIABLES OF ASSESSMENT (Plan of Care based on the Nursing Process)
I. PSYCHOLOGICAL VARIABLES A. Interpersonal Communication Style
Pt is quiet and very friendly, open about medical and personal history.
B. Emotional status/Anxiety level
Coping, current outlook is good, pt is looking forward being discharged. Pt is worried about the
health status of her younger sister who is also hospitalized after a stroke. She has been keeping in tough
with her and are planning to being discharge together soon. Pt has slight anxiety and irritation because
she is not able to move about the same way she did before the previous admission in January.
C. Stress/concerns related to hospitalization
Pt’s concern is that she is unable to do self-care because she is weak, she is also concerned that
after her discharge home she will have to stay alone overnight and she might fall with no help around.
She does not want to go to an assisted living home but doesn’t not feel safe going home without the help
of her sister, who will most likely not being discharged as soon as she is to be.
D. Defense/coping mechanisms
Pt expresses her feeling by talking to her family. She has realistic views of her health and her
future and responds eagerly when discussing the importance of sitting in the chair for meals and
throughout the day.
II. SOCIOCULTURAL VARIABLES A. Living Arrangements/Dwelling
Pt lives alone but recently, before her hospitalization, her sister has been staying with her. They
live together in an apartment with easy access to the living quarters. She does not have to walk up stairs, she
uses the elevator. Upon discharge, pt will be going back to live back at her apartment with her sister as they
have previously been living together. She has a son visits her at home frequently throughout the week. Patient
feels comfortable with this living arrangement as long as someone spends the night with her.
B. Occupation/Retired/Student
Pt is retired.
C. Support Systems
Pt is very independent. Just recently she has been relying on her sister more often. Her family is
her support system. He is available to the patient throughout the day even during working hours. I did not
observe any domestic violence behavior cues. I did not inquire about other support systems available to the
patient.
D. Educational Status
n/a – specifics did not come up in conversation. I felt that the patient was very willing to learn
how to maintain her health.
HOLISTIC ASSESSMENT PAGE 11
E. Ethnic Heritage, Cultural Beliefs (other than spiritual), Customs and Health Practices
n/a – did not come up in conversation
F. Use of Complementary/Alternative Modalities of Treatment
n/a – did not come up in conversation
III.DEVELOPMENTAL VARIABLES (Erikson’s Stage)
A. Age 84
B. Life Stage Older Adult
C. Task Sense of Integrity vs. Despair
Has your assigned client achieved previous life stage tasks and is currently showing evidence of
mastering current life stage task? Explain.
Yes, pt is open about her life and her life experiences. She believes her life was lived to its
potential. She has a health self-esteem, she discusses her son as her great accomplishment for being a caring
child that has taken her in to care for her.
Age related risks
Depression, deprived nutrition and fluid intake, decreased activity and exercise, alcohol abuse, Self-concept and self-image changes, change in roles and relationships, personal loss, coping strategies.
IV. SPIRITUAL VARIABLES (Religious Affiliation/Activities/Use of Belief System as a Source of Hope
and Support)
Pt is a catholic who attends church weekly. She prays often. She states her prayers give her hope.
Chart states that pt received spiritual support on 11/2/08.
V. PHYSIOLOGIC VARIABLES
A. Neurological
1. Mental Status
a. LOC: alert
b. Orientation: alert to time, place, person and situation
HOLISTIC ASSESSMENT PAGE 12
c. Memory(short/long): no recent and remote memory deficits. Pt has no trouble recalling what she
was doing yesterday. Pt recalls clearly that she has met me yesterday also. Pt can recall
memories of when she was younger and where is lived.
d. Judgment: Pt is acting in a logical and rational manner. She is calm and cooperative. She calls
for assistance before getting up to go to the bathroom.
2. Appearance/Behavior
Pt is wearing a hospital gown with visibly good personal hygiene. Pt is weak related to her
condition. Pt is properly expressing her emotion in relation to her developmental stage. She is
cooperative and interested in our conversation. She maintains a calm manner and does not express
any feeling of anger.
3. Ability to communicate
Pt communicates clearly, does not have any noticeable speech deficits and is can be clearly
understood by the receiving party during a conversation. She maintains good eye contact and does
not speak off on tangents. Pt uses glasses. She speaks English.
4. Neurosensorya. Vision: History of cataract removal. Eye movements are symmetrical and no amblyopia
present. Eyebrows, eyelids, and lashes intact. Pt requires glasses.
b. Hearing: Patient responds to normal speaking volume and tone. Patient does not wear hearing
aids. No discharge or excessive cerumen in ears, skin of ears intact, pink, and warm.
5. Interventions: Fall precautions, up with assistance; assistance with ADLs. Make sure patient is
wearing glasses while communicating with others or as needed.
B. Musculoskeletal1. Gait/Ambulation: Patient ambulates with a rolling walker . Patient is ambulating safely when
walking with someone at her side to prevent falls, needs assistance of one. Gait is slightly leaning
forward, steady, slow, small steps. No shuffling gait present. No significant weakness on either side
of body. Patient has all four limbs, no prosthetic limbs.
HOLISTIC ASSESSMENT PAGE 13
2. Alignment/Posture: Patient is slightly stooped over while walking (mainly curvature of upper spine
and neck), able to maintain proper alignment while sitting in bed, chair or walking. Patient does not
lean toward right or left side while sitting up in bed or during ambulation.
3. Immobilizing/Assistive Devices: Patient uses a rolling walker. Two side rails are up while patient is
in bed and table is positioned in front of patient wile she is sitting in chair.
4. Motor Strength (moves all extremities)a. Symmetry: patient is moving all extremities symmetrically when prompted. Patient can move all
ten fingers and toes.
b. Strength: Lower and upper extremities are equally strong
c. Range of Motion: all active.
5. Neurovascular integrity of extremities (CMS): Upper extremities and lower extremities skin equally slightly pale, warm and dry. Capillary refill of both upper and lower extremities 2-3 sec. Upper peripheral pulses palpable and equally strong, in lower extremities peripheral pulses not palpable. Patient senses light touch to extremities. No numbness, tingling or pain in any extremities.
6. Interventions: ; physical therapy to ambulate; activity every two hours ( up from bed and ambulate),
up to chair for meals; assistance with ADLs. Bed mobility: moderate assist; Transfers: minimum
assistance to stand; Gait: contact-guard assistance; Device: rolling walker; Activity with nursing: out
of bed for meals and as tolerated; Ambulate in hallway.
C. Respiratory Integrity
1. Respiration (rate, rhythm, and depth): unlabored breathing, regular rhythm, regular rate 18
breaths/minute. Eupnea. Nasal flaring absent. Pursed lips absent while breathing. Patient breathing
comfortable while sleeping, sitting up in bed, sitting in chair. While walking patient increases
breaths per minute to about 20, once activity decreased, breathing rate returns to normal at 18 in less
than 5 minutes. No audible breathing sounds.
2. Lung sounds : clear except in right lower posterior lobe diminished. Pleural effusion.
3. Cough- patient is not coughing
HOLISTIC ASSESSMENT PAGE 14
4. Sputum (color and amount)-patient is not expectorating any sputum
5. Assistive Respiratory Treatments/Interventions: Oxygen protocol initiated as needed: per nasal
canula 2-4L LPM – currently patient 94% on room air, no supplemental O2 need.
D. Cardiovascular Integrity 1. Vital signs
a. Peripheral pulses (rate, rhythm, quality): right arm 69 bpm; regular, strong peripheral pulse
rhythm. In lower extremities, pulse non-palpable. Patient admitted with sinus bradycardia with
symptoms and placed on remote telemetry.
b. Apical pulse: 70 bpm. Regular and strong. No murmurs. PMI located in the left 4th or 5th
intercostal space just medial to the midclavicular line.
c. BP: 142/58 right arm (0800 1/29/09). Pt currently medicated for hypertension.
d. Temperature: 97.9 degrees F, oral.
e. Pulse oximetry: 94% on RA.
2. Color and warmth: Patients body is equally slightly pale and warm.
3. Capillary refill: 2-3 sec in both upper and both lower extremities.
4. Edema (peripheral): no peripheral edema present.
5. Interventions: Remote telemetry.
E. Gastrointestinal
1. Weight, Height, BMI, Nutritional State : Ht: 5ft 6in; Wt: 132 lbs. BMI: 21.3 (healthy range) frail
stature.
2. Note condition of mouth/teeth/gums and overall oral hygiene: Remaining teeth intact, inner mouth
moist and pink. No scabbing, skin abrasion or lesion in mouth.
3. Mucous membranes (moist/dry): mouth moist.
4. Capillary Blood Glucose: 134 (800 1/30/09)
HOLISTIC ASSESSMENT PAGE 15
5. Diet: Cardiac, ADA 1800, soft. Patient needs additional nutrients, currently in process of
assessments and changes.
6. Ability to Feed Self, Chew/Swallow: Pt does not needs set up of meal trays, able to feed self.
7. Appetite: good appetite, breakfast 11/5/08: 80% 180cc.
8. Abdomen (LOOK, LISTEN, FEEL): bowel sounds present in all four quadrants: normoactive, no
distention or abdomen, abdomen soft without pain; not tender.
9. Stool and Usual Bowel Characteristics, last BM (any changes in patterns): stools soft brown,
decreased in frequency while institutionalized. Patient has full control over bowels. No unusual
characteristics.
10. Perianal area/Rectal conditions: rectal area clean, no fissures, redness or external hemorrhoids, Stage
II DU on coccyx. Allyven wound dressing applied. Perineal area slight redness and irritation, inner
groin, Nystatin powder applied.
11. Intake/Output: intake by mouth. Output: BM with no unusual characteristics.
12. Interventions: monitor intake and output, encourage to eat during meals. Maximum assist with
bathing.
F. Genitourinary
1. Mode of elimination: Bathroom, walking and clean up with assist
2. Any changes in voiding pattern (pain/burning/frequency): no pain or burning while voiding, no
feelings of urgency, increased frequency or incomplete bladder emptying; slight incontinence
reported by pt, pt wears Depends at home.
3. Characteristics of urine: yellow, clear.
4. Intake/Output: breakfast 200cc. Output: 0800 1/30/09 – 300cc, slightly cloudy, yellow.
5. Interventions: monitor I/Os. Frequent perineal care to maintain genitalia clean and dry. Keep
dressing clean and intact, change dressing.
G. Integumentary (Skin)
HOLISTIC ASSESSMENT PAGE 16
1. General condition (color, turgor, rashes, moisture, bruises): skin pinkish white (pt is Caucasian) and
warm, no erythema, no jaundice, . Skin turgor is slightly elastic. No rashes on body. Skin is dry to
touch, no diaphoresis, slight dryness or flakiness. Ecchymosis on rt upper lateral arm.
2. Check bony prominences/protective aids: DU stage II on coccyx, wound dressing applied.
3. Wound/Incisions/Dressing: coccyx pressure ulcer as noted above.
4. Interventions: moisturize skin with lotion to preserve elasticity and to aid in the prevent tears, dry
skin well after bathing in skin to skin contact areas (genitalia, underarms, neck, under breasts and
abdomen). Protective dressings to coccyx, elevate heels on pillow to avoid heel contact with bed to
prevent possible skin breakdown. Measure and document all wounds and abrasion daily. Activity
every 2 hrs while awake to promote circulation and skin integrity. Nutritional consult requested
regarding skin integrity issues.
VI. Discharge Planning Assessment
A. Anticipated date of discharge: patient is to be d/c home within couple of days. Date of potential
discharge was not acquired from pt.
B. Self care needs: mod assist with dressing and bathing.
C. Educational needs/Health Promotion: discuss all of discharge planning and patient education with son
who will be helping care for pt.
D. Barriers to learning: diminished and slowed motor skills due to weakness.
E. Equipment/environmental needs: rolling walker . Potentially a type of monitoring/emergency calling
device to call for help when home alone.
F. Resources for discharge: nurse to follow up with doctor
Plan upon discharge: move back to own apartment with sister.
VI. Neuman Wheel
HOLISTIC ASSESSMENT PAGE 17
Based on the holistic variables of the individual (physiological, psychological, sociocultural, developmental and spiritual) chart on the Neuman Wheel to depict the priority of needs based on your assessment of the client. Give reasons for depicted priorities.
Pt is a 84 yo female. Admitted with SOB. Dx plural effusion, weakness, sinus bradycardia, dyspnea. Pt is a catholic who prays and attends church regularly. She has a son who she relies on mostly for emergencies. She lives alone in an apartment building which her sister also lives in. She is worried about her sister’s current medical condition and her ability to be potentially d/c soon. She states she is independent and able to complete her ADL independently with min assistance although she is quite weak and does need additional help. She relies on her family and friends for support and does not belong to any community groups.
Complete the following regarding your assigned client:
1. Explain the pathophysiology as it relates to your client’s medical diagnosis.
Transudative plural effusion is caused by some combination of increased hydrostatic pressure and decreased plasma oncotic pressure. Heart failure is the most common cause, followed by cirrhosis with ascites and hypoalbuminemia, usually from the nephrotic syndrome.
Sociocultural
Developmental
Physiological
Spiritual
Psychological
HOLISTIC ASSESSMENT PAGE 18
2. What are the most important assessments (including lab values) for your client today?
Auscultate and percuss lungs for abnormalities, BP, pulse, asses for dyspnea and tachypnea,
3. What complications may occur? What could go wrong?
Large effusions could lead to respiratory failure.
4. What health promotion interventions and/or activities are essential to optimize your assigned client’s wellness potential or condition?
Coughing and deep breathing exercises, ambulation, proper nutrition, frequent assessment to observe pt breathing pattern, oxygen sat, for evidence of improvement or deterioration.
5. Identify three pertinent actual or potential NANDA nursing diagnoses and list in order of priority.
Ineffective breathing pattern related to collection of fluid in pleural space. Impaired gas exchange related to right lower lung lobe mass.
HOLISTIC ASSESSMENT PAGE 19
Medication Administration: Nursing Process Focus**
Classification/Prototype: proton pump inhibitor
Generic Name: Pantoprazole sodium Trade Name: Protonix, Protonix IV
Assessment* Indication(s) for client receiving
this medicationHeartburn symptoms, increased stomach acid formation r/t stress of being
institutionalized Route and dosage for this client 40mg PO Therapeutic dosage ranges: 40mg
PO Required assessments prior to
administration with results of assessments
Required: asses underlying condition; asses pt for complaints of epigastric or abd pain and for bleeding
Results of: no abd pain, no n/v. no bloody stools or emesis.
Baseline data to consider prior to administration
Serum lipid enzyme levels, liver function test.
Allergies nka
Reason(s) to hold medication Abd pain, bloody stools or emesis, headache, pain, chest pain, peripheral edema, c/d,n/v, uti, dyspnea, increased cough, rash.
Reason(s) to notify M.D. Bloody stools or emesis, abd pain,n/v
Any contraindications to the administration of this medication?
In pt hypersensitive to the drug
Drug-Drug or Drug-Herbal/Food that may interact with this medication
Ampicillin esters, iron salts, ketoconazole, St.John’s wort, food delays absorption
Diagnosis* Identify actual/potential Nursing
Diagnosis for the client receiving this medication
Risk for imbalanced fluid volume related to drug-induced adverse reactions.
Planning: Client Goals and Expected Outcomes* Identify expected outcomes
related to the administration of this medication
Pt maintains adequate hydration throughout therapy.
Implementation*Nursing Interventions and Administration Alerts-can be given without regards to food. -monitor fluid intake
Client/Family Education-instruct pt take exactly as prescribed and at approx the same time every day. –drug can be taken with or without food. –table is to be swallowed whole. –instruct to report abd pain, or signs of bleeding, such as tarry stools. – not to drink etoh, eat food or take drugs that can cause gastric irritation.
Evaluation (effectiveness of interventions, therapeutic effects, and adverse/side effects)* Expected therapeutic effects
achievedDecrease gastric secretions
Any occurrence of adverse/side effects
Abd pain, constipation, diarrhea, nausea, vomiting, urinary frequency, inc cough, rash.
Need for further client/family education
As above
HOLISTIC ASSESSMENT PAGE 20
Any additional documentation required in the client’s chart besides the MAR? If so, where in the client’s chart would this data be documented? Allergies and diet.
**Adams, M. P., Holland, L. N. and Bostwick, P. M. (2008). Pharmacology for nurses: A pathophysiologic approach (2nd ed.). New Jersey: Pearson Prentice Hall.