Running head: COMPREHENSIVE NURSING CARE PLAN
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Comprehensive Nursing Care Plan
Inessa Borovskiy
Running head: COMPREHENSIVE NURSING CARE PLAN
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Comprehensive Nursing Care Plan
Introduction
On July 09, 2018, I provided care for an 88-year-old male patient, K.C. K.C. resides in
Long Island, New York, with his wife. The patient has four children, three sons and a daughter,
and six grandchildren. The patient is retired. K.C. was admitted to the Kimmel Pavilion
neurosurgery unit on July 06, 2018 for a surgical procedure, bilateral laminectomy. When asked
the patient’s reason for seeking healthcare, the patient stated, “On May 2017, I started having
pain in my lower back going all the way down to my legs.” When asked the patient what made
the pain worse and what alleviated the pain, the patient stated that standing, especially standing
for a long time aggravated the pain and laying in bed for a long time sometimes caused
numbness and tingling in his feet, specifically his left heel. While sitting would alleviate the
pain.
The patient was not on any specific isolation precautions. K.C. has no known drug
allergies. The patient is full-code. K.C. has a medical history of hypertension (HTN) diagnosed
at 15 years of age, benign prostatic hyperplasia (BPH), hypothyroidism, enlarged prostate, and
hyperlipidemia. The patient has a past surgery history of an appendectomy performed on
February 20, 1963, thyroidectomy on March 2010, bilateral cataract eye surgery on February
2013, and dental implant surgery in 2017. The patient denies any psychiatric history. The patient
denies smoking and denies any history of substance abuse. K.C. received an influenza vaccine on
July 01, 2018 and a pneumococcal vaccine on July 09, 1995.
Since being admitted to the hospital, the patient has not had any other surgeries other than
the scheduled bilateral laminectomy surgery. The patient is on fall precaution. During my shift,
the patient was third day postoperative, and he was discharged on July 09, 2018.
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Assessment
Upon assessment of the patient’s neurological status, the patient was alert and oriented to
person, place, time. At the time of the assessment, the patient reported no pain. The patient was
attentive and responded appropriately to questions. While conversing with the patient, K.C.
maintained eye contact and did not appear agitated or uncomfortable. His speech was clear and
understandable. The patient was wearing a clean hospital gown and appeared clean and well-
groomed with good hygiene. The patient was mobile and able to stand independently from the
seated position. The patient did not require assistance out of bed, to the bathroom, or with
toileting. The Hendrich II Fall Risk score was 3, indicating she is low risk for falls. The Hendrich
II Fall Risk score was graded based on one point for gender, male, one point for taking a
benzodiazepine, diazepam, and one point for pushes up successfully in one attempt. (Hendrich,
2016). During my shift, K.C. spent most of the day sitting in the chair next to his bed.
The patient weighs 73.3 kg, height of 175.3 cm and a BMI of 23.8 kg/m2 indicating he is
within the standard category for adults of his height and weight. According to the Centers for
Disease Control and Prevention, a BMI between 18.5 and 24.9 is within the healthy weight status
for adults based on the patient’s height and weight. (Centers for Disease Control and Prevention,
2015). The patient’s overall skin was appropriate for ethnicity and intact with no evidence of
redness, rashes, scars or lesions. The patient's face and facial expressions were symmetrical with
no weakness or involuntary movements. The patient had a skin tare on the left cheek. Patient's
head was normocephalic, and the skin on the head and neck was intact with no redness, lumps,
rashes, scars or lesions. The trachea was midline with the thyroid rising smoothly, no masses, or
unilateral enlargements and no presence of a jugular vein distention. The pupillary response was
direct and consensual, and pupils were equal, round, reactive to light and accommodation
(PERRLA). The patient wears prescriptive glasses, however, does not have a hearing aid. Upon
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inspection of the mouth, the buccal mucosa was pink and point with good dentition. There were
no lesions, redness of the gums, or bleeding. The patient presented with no pharyngeal exudates.
Upon assessment of the upper extremities, the skin was warm and dry to touch, with no presence
of edema bilaterally. However, ecchymosis was noted on the left upper extremity. The radial
pulse was regular rate and rhythm 3+ bilaterally. The capillary refill was brisk and less than 3
seconds bilaterally. The patient's hand grasp was 5/5 bilaterally. Upon assessment of the patient's
lower extremities, the skin was warm, dry, intact with no evidence of redness, edema, broken
skin, scars, rashes, or lesions. The dorsalis pedis pulses were 3+ bilaterally. The capillary refill of
the lower extremities was brisk and less than 3 seconds bilaterally. The hip flexion, plantar
flexion, and dorsiflexion strength test were 5/5 bilaterally. K.C. displayed a full range of motion
of the upper and lower extremities.
During the respiratory assessment, K.C. was sitting on the chair next to his bed. Upon
inspection of the skin on the anterior and posterior chest, the color was consistent with the
patient’s genetic background. The skin was intact with no evidence of cyanosis, pallor, redness,
broken skin, rashes, scars, or lesions. Patient's breathing was regular, rhythmic, relaxed, with
effortless respirations and no use of accessory muscles. The patient presented with no clinical
manifestations of acute respiratory distress. Patient's respiratory rate was within the normal range
of 18 breaths/min with the normal range of 12 – 20 breaths per minute, SpO2 was 95% on room
air with an average SpO2 range of 95 – 100%, and an oral temperature of 36.7 degrees Celsius or
98 degrees Fahrenheit with a regular oral temperature of 35.8 – 37.3 degrees Celsius or 96.4 –
99.1 degrees Fahrenheit. On auscultation of the lung sounds, breath sounds were clear bilaterally.
Following auscultation of the heart, S1, and S2 was noted, and no murmurs, rubs, or gallops
were heard with no visible pulsations on the aortic and pulmonic areas. Patient's heart rate was
66 beats per min with an average range between 60 - 100 beats per minute. The patient was not
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connected to telemetry. The patient’s blood pressure was taken on right arm, and the blood
pressure was high at 147/55 mmHg, which is consistent with his diagnosis of hypertension, with
an average range of systolic pressure of less than 120 mmHg systolic and a diastolic pressure less
than 80 mmHg.
Upon assessment of the abdomen, the skin was smooth with no lesions, scars, or striae.
Bowel sounds were present and normoactive. The abdomen was soft, non-distended, and non-
tender, with no rebound tenderness or guarding. K.C. was continent, and his last bowel
movement was on July 08, 2018. He reported no abdominal pain, nausea, vomiting, or diarrhea.
The patient was on a regular diet. He had a good appetite and ate more than 90% of his breakfast.
K.C. was continent and voided in the bathroom. The urine color was yellow and clear. The
patient reported voiding without difficulty and no pain upon urination. During my shift, the
patient's fluid intake was 1320 mL, and his total output was 835 mL.
The patient had a bilateral laminectomy. Therefore, he had a wound dressing that needed
to be changed. The location of the surgical site was on his lower back. The dressing was dry and
intact. The incision site was clean, dry, no dehiscence, erythema, swelling, foul odor, tenderness
was noted. Additionally, the patient had one Jackson-Pratt drain (JP drain). The JP drain was not
on suction instead it drained by gravity. The JP drain was intact and had sanguineous drainage.
The patient had a peripheral IV a heparin lock on the left extremity.
Pathophysiology
As people age, the anatomy of the spine changes which is a natural effect of aging.
However, normal wear and tear effects of aging can lead to the narrowing of the spinal canal a
condition known as spinal stenosis. Spinal stenosis often occurs in adults over the age of 60.
(OrthoInfo, 2013). Several months ago, the 88-year-old- male patient, K.C. started experiencing
pain in his lower back. The pain originated in the lower back and radiated down to his buttocks
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and alternated down the back of his thighs, calves, and into his ankles. The areas the patient
experienced symptoms of pain are evident in lumbar spinal stenosis (LSS). (OrthoInfo, 2013).
Spinal stenosis is the narrowing of the spinal canal, a hollow vertical hole that contains
the spinal cord, putting pressure on the spinal cord and the spinal nerve roots causes pain,
numbness, or weakness in the legs. Stenosis in the lumbar area of the spine is a common cause of
chronic low back pain. (Lewis, Dirksen, Heitkemper, & Bucher, 2014, p. 1547; OrthoInfo, 2013).
Spinal stenosis can be caused by either an acquired or an inherited condition. One of the most
common acquired causes is arthritis particularly osteoarthritis in the spine. The arthritic changes
such as bone spurs, calcification of spinal ligaments, or degeneration of discs narrow the space
around the spinal canal and nerve roots leading to compression which causes inflammation and
results in pain, weakness, and numbness. (Lewis, Dirksen, Heitkemper, & Bucher, 2014, p.
1547).
Arthritis in the spine can result as the disk degenerates and loses water content.
Compared to the elderly, the disks in children and young adults have a high-water content. As
people age, the disks start to dry out and weaken causing settling or collapse of the disk spaces
and loss of disk space height. Over time as the spine settles, the weight is transferred to the facet
joints and the tunnels through which the nerves exit through become smaller. The weight that is
transferred to the facet joints causes increased pressure and degeneration leading to the
development of arthritis. (OrthoInfo, 2013). Additionally, the cartilage that covers and protects
the joints wears away. If the cartilage wears away completely, it can result in bone rubbing on
bone. The body responds to lost cartilage by growing new bone in the facet joints to help support
the vertebrae. However, this bone overgrowth called spurs may narrow the space for the nerves
to pass through. (OrthoInfo, 2013). Arthritis in the lower back also causes the ligaments around
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the joints to increase in size decreasing the space for nerves. Eventually, the space becomes so
small that it irritates the spinal nerves resulting in painful symptoms. (OrthoInfo, 2013).
Some other acquired conditions that lead to spinal stenosis include rheumatoid arthritis,
spinal tumors, Paget’s disease, and traumatic damage to the vertebral column. (Lewis, Dirksen,
Heitkemper, & Bucher, 2014, p. 1547). Whereas, inherited conditions leading to spinal stenosis
include congenital spinal stenosis and scoliosis. (Lewis, Dirksen, Heitkemper, & Bucher, 2014,
p. 1547).
The most common clinical manifestation associated with lumbar spinal stenosis is pain
that starts in the lower back and radiates to the buttocks and legs. The pain exacerbates with
walking and standing. Some patients experience numbness, tingling, weakness, and heaviness in
the legs and buttocks. Pain that is alleviated when the patient bends forward or sits down is
usually a sign of spinal stenosis. Stenosis often slowly progresses and does not cause paralysis.
(Lewis, Dirksen, Heitkemper, & Bucher, 2014, p. 1547). The patient, K.C., first began
experiencing back pain that eventually radiated to his buttocks and legs. The pressure on the
spinal nerves resulted in pain in the areas that the nerves supply. The pain generally starts in the
buttocks and radiates down the leg. Patients describe the pain as an ache or burning feeling.
Furthermore, as it advances, it can result in foot pain. (OrthoInfo, 2013).
K.C. stated that after some time, standing for an extended period or laying in bed caused
numbness in his feet and calves and occasional tingling in his left heel. Due to the increased
pressure on the nerve patients experience numbness and tingling. As the pressure reaches a
critical level, patients develop weakness in one or both legs or a foot drop, the feeling that their
foot slaps on the ground while walking. (OrthoInfo, 2013). Patients often find that leaning
forward or sitting alleviates the pain. Additionally, leaning forward while sitting can further
lessen the pain. Leaning forward increases the space available for the nerves. As per K.C., he
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stated that in the beginning, the pain lessened while sitting. While standing up straight and
walking exacerbates the pain. (OrthoInfo, 2013).
To diagnosis lumbar spinal stenosis, a physician will obtain a medical history, complete a
physical examination, and order imaging tests such as an x-ray, a magnetic resonance imaging
(MRI), a computed tomography (CT) scan, or a myelogram. (OrthoInfo, 2013). A physical
examination includes examining the patients back and pushing on different areas to determine
the painful areas. An x-ray visualizes bones and illustrates aging changes such as the loss of disk
height or bone spurs. X-rays obtained while the patient is leaning forward and backward will
show instability in the joints. Additionally, x-rays can show too much mobility called
spondylolisthesis. (OrthoInfo, 2013). A magnetic resonance imaging (MRI) demonstrates images
of soft tissues such as muscles, disks, nerves, and the spinal cord. A computed tomography (CT)
scan displays cross-section images of the spine. (OrthoInfo, 2013). A myelogram is a diagnostic
imaging test, and it involves injecting a dye into the spine resulting in images that show the
nerves more clearly and can help determine whether the nerves are compressed. (OrthoInfo,
2013).
There are two methods of treatment for lumbar spinal stenosis, including a nonsurgical
treatment and a surgical treatment. (OrthoInfo, 2013). Nonsurgical treatments include physical
therapy, lumbar traction, anti-inflammatory medications, steroid injections, acupuncture, and
chiropractic manipulation. However, nonsurgical treatment options do not improve the narrowing
of the spinal canal. Instead, the treatment options restore function and relieve pain. (OrthoInfo,
2013). Surgical treatment options include laminectomy and spinal infusion. Physicians will often
recommend surgical treatment options for patients with reduced quality of life due to pain,
weakness, and difficulty walking for a long time. (OrthoInfo, 2013). Spinal infusion surgery is
recommended for patients whose arthritis has progressed to spinal instability. Whereas
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laminectomy involves removing the bone, bone spurs, and ligaments compressing the nerves.
(OrthoInfo, 2013).
In the case of K.C., before resorting to the surgical treatment option, he tried nonsurgical
treatments such as physical therapy, chiropractic manipulation, and anti-inflammatory
medications. However, none of the alternative options alleviated his pain. Within a short time,
his symptoms worsened dramatically, K.C. went from alleviating the pain by laying down to
experiencing numbness in his feet and calves when laying down. Therefore, the patient’s’
physician recommended a surgical procedure known as a laminectomy also known as
decompression surgery.
A laminectomy surgery is performed because the bony overgrowths, also known as bone
spurs a natural side effect of the aging process, within the spinal canal narrow the space available
for the spinal cord and nerves causing pressure. The pressure causes pain, weakness or numbness
that radiates down an individual’s arms or legs. (Mayo Clinic Staff, 2018). A laminectomy
surgery creates space by removing the back part of a vertebra that covers the spinal canal known
as the lamina. This results in the enlargement of the spinal canal and relieves pressure on the
spinal cord or nerves. (Mayo Clinic Staff, 2018). The laminectomy restores the spinal canal
space however it does not cure arthritis. Instead, it relieves radiating symptoms from compressed
nerves. (Mayo Clinic Staff, 2018).
Diagnostic Procedures & Laboratory Results
Diagnostic
Procedure/Laboratory
Test Results
Rationale Indicate specific reason(s) for doing or
obtaining this test for your patient
Analysis of Results Indicate if normal or abnormal (e.g., high or low values] and correlate results with patient’s health
problems by providing explanation of
abnormalities noted
Hemoglobin Hemoglobin is used to check for
anemia, a condition in which the body
has fewer red blood cells than normal.
Hemoglobin may also be ordered if the
patient’s diet is low in iron and
Hemoglobin = 10 g/dL, lab value low.
Low hemoglobin with low red blood cell
(RBC) count 3.27, and low hematocrit
29.3% can indicate anemia.
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minerals, excessive blood loss from an
injury or a surgical procedure, or long-
term infection. (MedlinePlus, 2018).
Hematocrit A hematocrit test is part of a complete
blood count (CBC). Hematocrit may be
ordered to diagnose a blood disorder.
(MedlinePlus, 2017).
Hematocrit = 29.3%, a low value
indicative of anemia.
WBC A WBC count is obtained as part of
the complete blood count (CBC), and
it was completed third-day post-op to
identify whether the patient acquired
an infection post-op and
inflammation. Additionally, this
patient is taking dexamethasone
which can decrease WBC resulting
in hypokalemia. (AACC, 2017;
Hodgson, Kizior, 2016, p. 349).
WBC = 16.9, a high value can be
indicative of inflammation and treatment
of inflammation includes dexamethasone
which can increase white blood cell count.
Platelets The patient is taking an
anticoagulant, Enoxaparin
(Lovenox), a medication that
requires the monitoring of platelet
count. (IBM Micromedex, 2018).
Platelets = 156, lab value is normal
Na Sodium lab levels were obtained to
monitor and evaluate the level of
electrolytes due to hypertension.
(AACC, 2018). Dexamethasone
use to treat inflammation may
increase sodium. (Hodgson, Kizior,
2016, p. 349).
Na = 142 mEq/L, lab value is normal
K Potassium lab levels were ordered
because this patient has high blood
pressure, hypertension, and is being
treated for hypertension. This patient
is taking dexamethasone, and this
medication can decrease serum
potassium levels resulting in
hypokalemia. (AACC, 2018;
Hodgson, Kizior, 2016, p. 349).
K = 4.3 mEq/L, lab value is normal
CO2 As part of the electrolyte panel and
to evaluate and monitor balance of
electrolytes in patients with
hypertension. (AACC, 2018).
CO2 = 21, low can be indicative of
metabolic acidosis.
Cl Chloride test was ordered as part of an
electrolyte or basic metabolic panel to
monitor the patient’s high blood
pressure. However, it can also be
ordered if acidosis or alkalosis is
Cl = 112 mEq/L, a high value indicates
dehydration and can occur when too much
base is lost from the body producing
metabolic acidosis or during
hyperventilation causing respiratory
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suspected or if the patient has
symptoms of prolonged vomiting,
diarrhea, weakness, fatigue, or
difficulty breathing. (AACC, 2017).
alkalosis which is consistent with the
patient’s low carbon dioxide level.
Mg The patient is taking pantoprazole
(Protonix) which may cause a decrease
in magnesium, hypomagnesemia.
(Vallerand, Sanoski, & Deglin, 2015, p.
963).
Mg = 1.7 mg/dL, lab value is normal
BUN The patient is taking Carvedilol
(Coreg) for hypertension and
Cholecalciferol (Vitamin D3) for
prophylaxis of vitamin D
deficiency both of which require
monitoring of blood urea nitrogen
levels. (Hodgson, Kizior, 2016, p.
207; Vallerand, Sanoski, & Deglin,
2015, p. 1265). The patient has
benign prostatic hyperplasia
(BPH), and BUN is completed to
evaluate kidney function. (AACC,
2017).
BUN = 14 mg/dL, lab value is normal
Creatinine Hypertension to monitor the effect of
medications on the kidneys. (AACC,
2018). Benign prostatic hyperplasia
(BPH) to evaluate kidney function.
(AACC, 2017). The patient is taking
Cholecalciferol (Vitamin D3) and
Pantoprazole (Protonix) both of which
require monitoring creatinine levels.
(IBM Micromedex, 2018; Vallerand,
Sanoski, & Deglin, 2015, p. 963).
Creatinine = 0.78 mg/dL, lab value is
normal
Glucose The patient is at risk for diabetes due to
risk factors of hypertension, taking
medication for high blood pressure such
as Carvedilol (Coreg), and
hyperlipidemia. The patient is taking
Dexamethasone for the treatment of
inflammation which may increase
serum glucose levels. (Hodgson, Kizior,
2016, p. 349). Glucose is monitored in
patients taking Glucagon (Glucagon)
and Insulin Lispro (Humalog).
(Vallerand, Sanoski, & Deglin, 2015, p.
42; 612).
Glucose = 135 mg/dL, lab value is high
indicating high blood sugar level and a
high blood glucose level can also be due
to the treatment of inflammation using
Dexamethasone (Decadron) which
increases glucose. (Hodgson, Kizior, 2016,
p. 349).
aPTT The patient is taking an anticoagulant
Enoxaparin (Lovenox) as prophylaxis of
31.7 seconds, lab value is normal.
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venous thromboembolism, deep vein
thrombosis, and/or pulmonary
embolism. (AACC, 2018; Vallerand,
Sanoski, & Deglin, 2015, p. 634).
Medications
Medication (as ordered by
M.D./NP)
– Classification – How does
the medication work (chemical action)?
Specific Reason
for Taking Them? (Example: To treat
Hypertension and CHF)
Side Effects,
Contraindications and
lab values to be
monitored (Only
important ones)
Patient and Family
Teaching (Only specific and relevant
instruction for that drug) Never
write: Take as directed?
Acetaminophen (Tylenol)
650 mg Tablet Oral Q4h
Classification: Analgesic,
Antipyretic
Chemical Action:
Inhibits prostaglandin
synthesis in the central
nervous system and
blocks pain impulses
through peripheral action.
Inhibits hypothalamic
heat-regulator center
(Hodgson, Kizior, 2016, p.
9).
To treat mild pain
post-operation and
relieve fever
greater than
100.4℉ (Hodgson,
Kizior, 2016, p. 9).
Side Effects: Rash,
anorexia nausea,
vomiting, and insomnia
(Vallerand, Sanoski, &
Deglin, 2015, p. 99).
Contraindications:
Hypersensitivity to
acetaminophen or any of
its components, severe
hepatic impairment or
severe active liver
disease (Hodgson,
Kizior, 2016, p.9).
Lab Values: Monitor
ALT, AST, bilirubin, and
prothrombin levels as an
increase in these may
indicate hepatotoxicity.
(Hodgson, Kizior, 2016,
p.10).
• Advise patient not to
exceed more than 4 g of
acetaminophen within 24
hours.
• Advise patient to
discontinue use of
acetaminophen and notify
HCP if rash occurs.
• Educate the patient to
notify HCP if discomfort
or fever is not relieved by
usual doses or if the fever
lasts longer than 3 days.
• Educate the patient to
avoid alcohol intake
while taking
acetaminophen.
(Hodgson, Kizior, 2016,
p.11; Vallerand, Sanoski,
& Deglin, 2015, p. 99).
AmLODIpine (Norvasc) 5
mg Tablet Oral Daily
Classification: Calcium
Channel Blocker
Chemical Action:
Prevents the transport of
calcium into the myocardial
and vascular smooth muscle
cells, resulting in the
inhibition of excitation-
contraction coupling and
subsequent contraction.
(Hodgson, Kizior, 2016, p.
63).
To treat
hypertension
(Hodgson, Kizior,
2016, p. 63).
Side Effects: Peripheral
edema, headache,
flushing, dizziness,
palpitations, nausea,
unusual fatigue or
weakness (Hodgson,
Kizior, 2016, p. 63).
Contraindications:
Hypersensitivity to
AmLODIpine or any of
its components, systolic
blood pressure less than
90 mmHg (Vallerand,
Sanoski, & Deglin,
2015, p. 145).
• Educate the patient
against abruptly
discontinuing use of the
medication
• Educate the patient to
avoid tasks that require
alertness and motors
skills until the patient is
aware of the response to
the drug.
• Teach patient to avoid
grapefruit products
(Hodgson, Kizior, 2016,
p. 64).
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Lab Values: Monitor
renal and hepatic
function tests (Hodgson,
Kizior, 2016, p. 63).
Bacitracin Zinc Ointment
Topical 2 Times Daily
Classification:
Antibacterial, Antibiotic
Chemical Action:
Inhibits bacterial cell-wall
synthesis and damages the
cell-wall membrane
(Kee, Hayes, McCuistion,
2015, p. 445).
Prophylaxis to
prevent skin
infection on the
patient’s left
cheek tear. (Kee,
Hayes,
McCuistion, 2015,
p. 445).
Side Effects: Redness,
rash, nausea, and
vomiting (Kee, Hayes,
McCuistion, 2015, p.
445).
Contraindications:
Hypersensitivity or toxic
reaction to bacitracin
(IBM Micromedex,
2018).
Lab Values: No special
monitoring. (IBM
Micromedex, 2018).
• Advise patient that the
topical ointment is only
for use on minor cuts or
burns.
• Instruct patient to use the
ointment only as long as
prescribed because
prolonged use may cause
overgrowth of non-
susceptible bacteria.
• Educate patient on
potential side effects of
topical use such as
contact dermatitis or
pruritis. (IBM
Micromedex, 2018).
Bisacodyl (Dulcolax)
Suppository 10 mg Rectal
Daily
Classification: GI
Stimulant
Chemical Action:
Increases peristalsis by
direct effect on the smooth
muscle of the intestine.
(Kee, Hayes, McCuistion,
2015, p. 687).
Prophylaxis to
constipation
(Hodgson, Kizior,
2016, p. 147).
Side Effects: Anorexia,
nausea, vomiting,
cramps, diarrhea (Kee,
Hayes, McCuistion,
2015, p. 687).
Contraindications:
Hypersensitivity, fecal
impaction, intestinal or
biliary obstruction, GI
bleeding, appendicitis,
abdominal pain, nausea,
vomiting, and rectal
fissures (Kee, Hayes,
McCuistion, 2015, p.
687).
Lab Values: Monitor
serum electrolytes
specifically serum
potassium and calcium
(Kee, Hayes,
McCuistion, 2015, p.
687).
• Teach the patient ways to
promote defecation by
increasing fluid intake,
exercising, and eating a
high-fiber diet.
• Educate the patient to
avoid taking antacids,
milk or other medication
within 1 hour of taking
the medication because
this may decrease the
effectiveness of
Bisacodyl (Dulcolax)
• Teach the patient to
report unrelieved
constipation, rectal
bleeding, muscle pain or
cramps, dizziness, and
weakness to a health care
provider (HCP).
(Hodgson, Kizior, 2016,
p. 148).
Carvedilol (Coreg) Tablet
6.25 mg Oral 2 times
Daily
Classification:
Beta adrenergic blocker
Treatment of
hypertension
(Hodgson,
Kizior, 2016, p.
207).
Side Effects: Fatigue,
dizziness, diarrhea,
bradycardia, rhinitis, and
back pain (Hodgson,
Kizior, 2016, p. 208).
• Educate the patient that
this medication takes one
to two weeks for the full
antihypertensive effect
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Chemical Action:
Blocks stimulation of
beta1 and beta2-adrenerfic
receptor sites. Also has
alpha2 blocking activity
which can result in
orthostatic hypotension.
(Vallerand, Sanoski, &
Deglin, 2015, p. 275).
Contraindications:
Bronchial asthma or
related bronchospastic
conditions, cardiogenic
shock, decompensated
heart failure requiring
intravenous inotropic
therapy, severe hepatic
impairment, second or
third-degree AV block,
severe bradycardia, or
sick sinus syndrome
except in patients with
pacemaker (Hodgson,
Kizior, 2016, p. 207).
Lab Values: Monitor
EKG for cardiac
arrhythmias, BUN,
serum lipoprotein,
potassium, triglyceride,
uric acid levels, ANA
titers, and blood glucose
levels (Vallerand,
Sanoski, & Deglin,
2015, p. 276).
• Teach patient to take this
medication with food and
to restrict salt, alcohol
intake.
• Teach patient to measure
and monitor blood
pressure and pulse before
taking medication
• Instruct patient to avoid
abrupt discontinuation of
the medication and the
importance of taking this
medication to control
hypertension
• Instruct patient to avoid
tasks that require
alertness and motor skills
until the patient’s
response to the
medication has been
established
• Educate the patient to
report excessive fatigue,
prolonged dizziness to
HCP
• Instruct patient to avoid
the use of nasal
decongestants, OTC cold
preparations (stimulants)
unless approved by HCP.
(Hodgson, Kizior, 2016,
p. 209).
Cholecalciferol (Vitamin
D3) Tablet 400 units Oral
Daily
Classification:
Vitamin
Chemical Action:
Requires activation in the
liver and kidneys to create
the active form of vitamin
D3 (Vallerand, Sanoski, &
Deglin, 2015, p. 1266).
Prophylaxis of
vitamin D
deficiency
(Vallerand,
Sanoski, &
Deglin, 2015, p.
1265).
Side Effects: Nausea,
vomiting, loss of
appetite, constipation,
dehydration, fatigue,
irritability, confusion,
weakness, or weight
loss (Lexicomp, 2018).
Contraindications:
Hypercalcemia, primary
hyperparathyroidism,
sarcoidosis,
hypervitaminosis D,
Williams syndrome, and
patients who are pregnant.
(Lexicomp, 2018).
• Advise patient to avoid
simultaneous use of
antacids containing
magnesium
• Advise patient to
immediately report signs
of weakness, confusion,
fatigue, headache, nausea
and vomiting,
constipation, or bone pain
to a health care provider
as this may be signs of
high calcium levels.
• Educate the patient about
signs of a significant
Running head: COMPREHENSIVE NURSING CARE PLAN
15
Lab Values: Monitor
serum, calcium levels,
serum phosphorus,
alkaline phosphatase,
urinary calcium
excretion, CBC, urine
protein, renal function
tests (creatinine, BUN),
serum amylase, and
lipid/lipoprotein levels.
(IBM Micromedex,
2018).
reaction such as
wheezing, chest
tightness, fever, itching,
severe cough, blue skin
color, seizures, or
swelling of the face, lips,
tongue, or throat.
(Lexicomp, 2018).
Dexamethasone
(Decadron) Tablet 2 mg
Oral Daily
Classification:
Corticosteroid
Chemical Action:
Suppresses neutrophil
migration, decreases the
production of
inflammatory mediators
and reverses increased
capillary permeability.
(Hodgson, Kizior, 2016,
p.349).
Treatment of
inflammation.
(Hodgson, Kizior,
2016, p. 349).
Side Effects:
Hypersensitivity to
corticosteroids,
insomnia, facial edema
such as cushingoid
appearance, moderate
abdominal distention,
indigestion, increased
appetite, nervousness,
facial flushing, and
diaphoresis (Hodgson,
Kizior, 2016, p.350).
Contraindications:
Systemic fungal
infections and cerebral
malaria (Hodgson,
Kizior, 2016, p. 349).
Lab Values: Monitor
serum glucose, lipids,
sodium levels, serum
calcium, potassium,
thyroxine, and WBC.
(Hodgson, Kizior,
2016, p. 349).
• Educate the patient to
report symptoms of fever,
sore throat, muscle aches,
sudden weight gain,
edema, and exposure to
measles or chickenpox.
• Advise patient to inform
the dentist and other
physicians of
dexamethasone therapy
within the past 12
months.
• Advise the patient against
changing dose, schedule,
or abruptly stopping the
use of medication
because the patient must
be gradually tapered off
the medication.
• Advise patient to avoid
alcohol and limit caffeine
intake. (Hodgson, Kizior,
2016, p. 351).
Diazepam (Valium) 5 mg
Oral q6h
Classification: Skeletal
muscle relaxants
(Centrally acting)
Chemical Action:
Inhibits spinal
polysynaptic afferent
pathways. (Vallerand,
Sanoski, & Deglin, 2015,
p. 414).
To treat skeletal
muscle spasm
(Wilson,
Shannon, &
Shields, 2015, p.
464).
Side Effects: Dizziness,
drowsiness, lethargy,
depression, hangover,
ataxia, slurred speech,
headache, paradoxical
excitation, blurred
vision, respiratory
depression, constipation,
diarrhea, nausea,
vomiting, weight gain,
rashes, physical
• Instruct the patient
against taking more than
the prescribed dose and
educate against abrupt
discontinuation of the
medication as this can
cause insomnia, unusual
irritability or nervousness
• Instruct patient to avoid
driving and other
activities that require
Running head: COMPREHENSIVE NURSING CARE PLAN
16
dependence,
psychological
dependence, and
tolerance. (Vallerand,
Sanoski, & Deglin,
2015, p. 414 – 415).
Contraindications:
Hypersensitivity, cross-
sensitivity with other
benzodiazepines may
occur, comatose
patients, myasthenia
gravis, severe
pulmonary impairment,
sleep apnea, severe
hepatic dysfunction,
preexisting CNS
depression, uncontrolled
severe pain, angle-
closure glaucoma, some
products contain
alcohol, propylene
glycol, or tartrazine and
should be avoided in
patients with known
hypersensitivity or
intolerance (Vallerand,
Sanoski, & Deglin,
2015, p. 414).
Lab Values: Monitor
hepatic, renal function,
and complete blood
count (CBC).
(Vallerand, Sanoski, &
Deglin, 2015, p. 416).
alertness until the
patient’s response to the
medication is known
• Educate geriatric patients
of increased risk for
central nervous system
effects and potential for
falls
• Advise patient to avoid
alcohol intake and other
central nervous
depressants concurrently
with this medication.
(Vallerand, Sanoski, &
Deglin, 2015, p. 417).
Docusate (Colace) 100 mg
Capsule Oral 3 times
Daily
Classification:
Gastrointestinal agent,
stool softener
Chemical Action:
Decreases surface film
tension by mixing liquid
with bowel contents.
(Hodgson, Kizior, 2016,
p. 386).
Prophylaxis to
prevent constipation.
(Hodgson, Kizior,
2016, p. 385).
Side Effects: Mild
gastrointestinal cramping,
throat irritation with liquid
preparation. (Hodgson,
Kizior, 2016, p. 386).
Contraindications:
Acute abdominal pain,
concomitant use of mineral
oil, intestinal obstruction,
nausea, vomiting
(Hodgson, Kizior, 2016, p.
386).
• Teach patient to take
measures to promote
defecation such as
increasing fluid intake,
exercising, increasing fiber
in their diet, and increasing
mobility.
• Inform the patient that this
medication only be used for
short-term therapy and
long-term therapy may
Running head: COMPREHENSIVE NURSING CARE PLAN
17
Lab Values: No special
monitoring (Hodgson,
Kizior, 2016, p. 386).
cause electrolyte imbalance
and dependence.
• Advise the patient against
the use of laxatives if
abdominal pain, nausea,
vomiting, or fever occurs.
• Instruct the patient not to
take docusate within 2
hours of other laxatives.
(Hodgson, Kizior, 2016, p.
386; Vallerand, Sanoski, &
Deglin, 2015, p. 444).
Enoxaparin (Lovenox)
Injection 40 mg SubQ
Q24h
Classification:
Anticoagulants
Chemical Action:
Increases the inhibitory
effect of antithrombin on
factor Xa and thrombin.
(Vallerand, Sanoski, &
Deglin, 2015, p. 635).
Prophylaxis of
venous
thromboembolis
m (VTE), deep
vein thrombosis
(DVT), and/or
pulmonary
embolism (PE) in
surgical patients.
(Vallerand,
Sanoski, &
Deglin, 2015, p.
634).
Side Effects: Injection
site hematoma, nausea,
peripheral edema.
(Hodgson, Kizior, 2016,
p. 432).
Contraindications:
Active major bleeding,
concurrent heparin
therapy, hypersensitivity
to heparin, pork
products,
thrombocytopenia
associated with positive
in vitro test for
antiplatelet antibodies.
(Hodgson, Kizior, 2016,
p. 431).
Lab Values: Anti-Factor
Xa levels, complete
blood count (CBC)
including platelet count,
and stool occult blood
test (IBM Micromedex,
2018).
• Instruct the patient to
report symptoms of
bleeding, pulmonary
edema, skin necrosis,
or atrial fibrillation.
• Advise the patient to
rotate injection sites,
and the patient should
lie down during
injection.
• Instruct the patient to
avoid concurrent
anticoagulants,
including NSAIDs
and aspirin, without
approval from HCP.
(IBM Micromedex,
2018).
Finasteride (Proscar)
Tablet 5 mg Daily Oral
Classification:
Androgen inhibitor
Chemical Action:
Inhibits the enzyme 5-
alpha-reductase, an
enzyme that is responsible
for converting testosterone
to its potent metabolite 5-
alpha-dihydrotestosterone
To treat benign
prostatic
hyperplasia
(BPH).
(Vallerand,
Sanoski, &
Deglin, 2015, p.
561).
Side Effects:
Contraindications:
Hypersensitivity, and
women (Vallerand,
Sanoski, & Deglin,
2015, p. 561).
Lab Values: Monitor
serum prostate specific
antigen (PSA)
concentrations
• Educate the patient
that at least 6 to 12
months of therapy
may be necessary to
determine whether the
patient responded to
finasteride.
• Inform the patient
that the volume of
ejaculate may be
decreased and erectile
Running head: COMPREHENSIVE NURSING CARE PLAN
18
in the prostate, liver, and
skin. 5-alpha-
dihydrotestosterone is
partially responsible for
prostatic hyperplasia and
hair loss. (Vallerand,
Sanoski, & Deglin, 2015,
p. 561).
(Vallerand, Sanoski, &
Deglin, 2015, p. 561).
dysfunction and
decreased libido may
occur during and after
therapy is completed.
• Advise patient to
report changes in
breasts such as lumps,
pain, and nipple
discharge to HCP.
• Inform patient of the
increased risk of high-
grade prostate cancer
in men while taking
this medication.
• Stress the importance
of periodic follow-up
exams to determine
whether a therapeutic
response has occurred.
(Vallerand, Sanoski, &
Deglin, 2015, p. 561).
Glucagon (Glucagon)
Injection 1 mg
Intramuscular Daily
Classification:
Antihypoglycemic
Chemical Action:
Stimulates adenylate
cyclase to produce
increased cyclic
adenosine monophosphate
(AMP) promoting hepatic
glycogenolysis and
gluconeogenesis, resulting
in increased blood
glucose levels. (Hodgson,
Kizior, 2016, p. 563).
Prophylaxis to
prevent hypoglycemia
if blood glucose is
less than 70 mg/dL
(Hodgson, Kizior,
2016, p. 563).
Side Effects: Nausea,
vomiting, allergic
reaction such urticaria,
respiratory distress, and
hypotension (Hodgson,
Kizior, 2016, p. 564).
Contraindications:
Hypersensitivity,
pheochromocytoma,
some products contain
glycerin and phenol
patients with
hypersensitivities to
these should avoid use
avoid use of this
medication. (Vallerand,
Sanoski, & Deglin,
2015, p. 612).
Lab Values: Monitor
serum glucose levels
and fingerstick blood
glucose (Vallerand,
Sanoski, & Deglin,
2015, p. 612).
• Educate the patient on
signs and symptoms of
hypoglycemia such as
pale, cool skin, anxiety,
difficulty concentrating,
headache, hunger, nausea,
shakiness, diaphoresis,
unusual fatigue, unusual
weakness, and
unconsciousness.
• If symptoms of
hypoglycemia develop,
instruct the patient to
consume sugar first such
as orange juice, honey,
hard candy, sugar cubes,
or table sugar dissolved
in water or juice followed
by cheese and crackers,
half a sandwich, or a
glass of milk.
• Instruct patient on correct
technique to prepare,
draw up, and administer
injection including
instructing the patient to
Running head: COMPREHENSIVE NURSING CARE PLAN
19
check expiration date
monthly and to replace
outdated medication
immediately. (Hodgson,
Kizior, 2016, p. 564;
Vallerand, Sanoski, &
Deglin, 2015, p. 613).
HydrALAZINE
(Apresoline) 10 mg
Injection IV q10 min
Classification:
Vasodilator
Chemical Action: Direct-
acting peripheral arteriolar
vasodilator. (Vallerand,
Sanoski, & Deglin, 2015,
p. 647).
To treat moderate
to severe
hypertension,
systolic blood
pressure greater
than 160 mmHg.
(Vallerand,
Sanoski, &
Deglin, 2015, p.
647).
Side Effects: Dizziness,
drowsiness, headache,
tachycardia, angina,
arrhythmias, edema,
orthostatic hypotension,
diarrhea, nausea,
vomiting, rash, sodium
retention, arthralgias,
arthritis, peripheral
neuropathy, drug
induced lupus syndrome
(Vallerand, Sanoski, &
Deglin, 2015, p. 647 –
648).
Contraindications:
Coronary artery disease,
mitral valvular rheumatic
heart disease, dissecting
aortic aneurysm
(Hodgson, Kizior, 2016,
p. 581).
Lab Values: Monitor
complete blood count,
electrolytes, lupus
erythematosus (LE) cell
prep, and antinuclear
antibodies (ANA) titer
(Vallerand, Sanoski, &
Deglin, 2015, p. 648).
• Instruct the patient to rise
slowly from lying to
standing to reduce
orthostatic hypotension
• Educate the patient to
report manifestations of
muscle or joint aches,
fever such as a lupus-like
reaction, and flu-like
symptoms.
• Instruct the patient to
limit alcohol intake.
(Hodgson, Kizior, 2016,
p. 583).
Insulin Lispro
(HumaLOG) Injection 0-
10 SubQ 3 times Daily
Classification:
Antidiabetic
Chemical Action:
Stimulates glucose uptake
in the skeletal muscle and
fat inhibiting hepatic
glucose production.
Inhibits lipolysis and
To lower blood
sugar and control
diabetes mellitus
(Kee, Hayes,
McCuistion,
2015, p. 762).
Side Effects: Confusion,
agitation, tremors,
headache, flushing,
hunger, weakness,
lethargy, fatigue,
urticaria, redness,
irritation or swelling at
the injection site. (Kee,
Hayes, McCuistion,
2015, p. 762).
• Teach proper use
including injection
technique, syringe
disposal, and monitoring
requirements.
• Instruct the patient never
to share insulin pens or
cartridges.
• Educate patient to report
signs of hypoglycemia
such as dizziness,
Running head: COMPREHENSIVE NURSING CARE PLAN
20
proteolysis, enhances
protein synthesis.
(Vallerand, Sanoski, &
Deglin, 2015, p. 683).
Contraindications:
Hypersensitivity to
insulin lispro or any of
its components, during
episodes of
hypoglycemia. (Kee,
Hayes, McCuistion,
2015, p. 762).
Lab Values: Monitor
HbA1c, serum glucose
and glycosylated
hemoglobin, serum
electrolytes, renal
function tests, and liver
function tests
(Lexicomp, 2018;
Vallerand, Sanoski, &
Deglin, 2015, p. 42).
headache, fatigue,
weakness, shaking, fast
heartbeat, confusion,
hunger, or sweating or
hypokalemia including
muscle pain or weakness,
muscle cramps, or an
abnormal heartbeat
(Lexicomp, 2018).
Levothyroxine
(Synthroid) Tablet 150
mcg Oral every morning
Classification:
Thyroid hormone
Chemical Action:
Increases metabolic rate,
oxygen consumption, and
body growth. (Kee,
Hayes, McCuistion, 2015,
p. 747).
To treat
hypothyroidism.
(Kee, Hayes,
McCuistion,
2015, p. 747).
Side Effects: Nausea,
vomiting, anorexia,
diarrhea, cramps,
tremors, nervousness,
irritability, insomnia,
headache, weight loss,
diaphoresis, amenorrhea
(Kee, Hayes,
McCuistion, 2015, p.
747).
Contraindications:
Thyrotoxicosis,
myocardial infarction,
severe renal disease, and
adrenal insufficiency
(Kee, Hayes,
McCuistion, 2015, p.
747).
Lab Values: Monitor
thyroid function studies,
thyroid-stimulating
hormone serum levels,
blood, urine glucose,
and PT/INR.
(Vallerand, Sanoski, &
Deglin, 2015, p. 758).
• Instruct the patient to
take levothyroxine at the
same time each day. If
the patient misses a dose,
the dose should be taken
as soon as he or she
remembers unless it is
almost time for the next
dose. If the patient misses
2 to 3 doses notify HCP.
• Educate the patient that
the medication does not
cure hypothyroidism
instead it provides a
thyroid hormone
supplement, and this is a
lifelong therapy
treatment.
• Educate the patient to
report a headache,
nervousness, diarrhea,
excessive sweating, heat
intolerance, chest pain,
increased pulse rate,
palpitations, or weight
loss greater than 2
pounds per week.
• Emphasize the
importance of follow-up
Running head: COMPREHENSIVE NURSING CARE PLAN
21
exams to monitor the
effectiveness of the
medication. (Vallerand,
Sanoski, & Deglin, 2015,
p. 759).
Pantoprazole (Protonix)
EC Tablet 40 mg Oral
Daily
Classification:
Proton pump inhibitor
Chemical Action:
Irreversibly binds to and
inhibits hydrogen-
potassium adenosine
triphosphate an enzyme
on the surface of gastric
parietal cells and
hydrogen ion transport
into the gastric lumen.
(Hodgson, Kizior, 2016,
p. 946).
Treatment of
erosive
esophagitis
associated with
gastroesophageal
reflux disease
(GERD).
(Hodgson, Kizior,
2016, p. 947).
Side Effects: Diarrhea,
headache, dizziness,
pruritis, and rash
(Hodgson, Kizior, 2016,
p. 947).
Contraindications:
Hypersensitivity to
proton pump inhibitors
(Hodgson, Kizior, 2016,
p. 947).
Lab Values: Monitor
liver function including
AST, ALT, alkaline
phosphatase, bilirubin,
serum magnesium,
creatinine, cholesterol,
uric acid, and glucose.
(Vallerand, Sanoski, &
Deglin, 2015, p. 963).
• Advise the patient to report
symptoms of a headache,
an onset of black, tarry
stools, diarrhea, or
abdominal pain.
• Instruct the patient to
swallow whole tablets and
not to chew, crush,
dissolve, or divide the
tablets.
• Advise patient it is best to
take the medication before
breakfast and to avoid
alcohol. (Hodgson, Kizior,
2016, p. 948).
Rosuvastatin (Crestor) 10
mg Oral Daily
Classification:
Antihyperlipimic; HMG-
CoA reductase inhibitor
Chemical Action:
Inhibits HMG-CoA
reductase, the enzyme
essential for hepatic
production of cholesterol.
(Kee, Hayes, McCuistion,
2015, p. 669).
To treat
hyperlipidemia.
(Kee, Hayes,
McCuistion,
2015, p. 669).
Side Effects: Headache,
rash, pruritus,
constipation, diarrhea
(Kee, Hayes,
McCuistion, 2015, p.
669).
Contraindications:
Active liver disease,
pregnancy (Kee, Hayes,
McCuistion, 2015, p.
669).
Lab Values: Monitor
serum cholesterol,
triglycerides, liver
function tests including
AST and ALT, bilirubin
levels, cardiovascular
status in patients with
hypertension, creatine
phosphokinase (CPK)
levels, INR values with
concurrent warfarin
therapy. (Vallerand,
• Teach the patient that
rosuvastatin can be taken
any time of day and may
be taken without regard
to food.
• Educate the patient that it
is essential to maintain an
appropriate diet.
• Instruct patient to report
unexplained muscle pain,
tenderness, weakness,
fever, and malaise.
• If the patient is taken
magnesium or aluminum-
containing antacids while
taking rosuvastatin,
instruct the patient to take
antacid at least 2 hours
after rosuvastatin.
(Hodgson, Kizior, 2016,
p. 1107; Vallerand,
Sanoski, & Deglin, 2015,
p. 645; Wilson, Shannon,
Running head: COMPREHENSIVE NURSING CARE PLAN
22
Sanoski, & Deglin,
2015, p. 645; Wilson,
Shannon, & Shields,
2015, p. 1409).
& Shields, 2015, p.
1409).
Tamsulosin (Flomax) 0.4
mg Capsule Oral Daily
Classification:
Alpha1-adrenergic blocker
Chemical Action:
Decreases the contractions
in the smooth muscle of
the prostatic capsule by
binding to alpha1-
adrenergic receptors.
(Hodgson, Kizior, 2016, p.
1170).
Treatment of
symptoms of
benign prostatic
hyperplasia
(BPH). (Hodgson,
Kizior, 2016, p.
1170).
Side Effects: Dizziness,
drowsiness, headache,
anxiety, insomnia,
orthostatic hypotension
(Hodgson, Kizior, 2016,
p. 1171).
Contraindications:
Hypersensitivity
(Hodgson, Kizior, 2016,
p. 1171).
Lab Values: No specific
lab values, however,
monitor intake and
output and daily weight.
(Hodgson, Kizior, 2016,
p. 1171).
• Instruct the patient to
take tamsulosin at the
same time each day, 30
minutes after the same
meal.
• Advise the patient to go
slowly go from lying to
standing position.
• Advise the patient to
avoid tasks that require
alertness, motor skills
until the patient’s
response to the drug has
been established.
• Educate the patient no to
break, crush, or open
capsule. (Hodgson,
Kizior, 2016, p. 1171).
Senna (Senokot) 17.2 mg
Tablet Oral Bedtime
Classification:
Stimulant laxative
Chemical Action: Direct
action on the intestinal
mucosa, resulting in an
increased rate of colonic
motility, enhanced
colonic transit, and
inhibition of water and
electrolyte secretion.
(IBM Micromedex,
2018).
Treatment for
constipation.
(Hodgson, Kizior,
2016, p. 1119).
Side Effects: Red, brown
discoloration of urine
(Hodgson, Kizior, 2016, p.
1120).
Contraindications:
Undiagnosed abdominal
pain, appendicitis,
intestinal obstruction or
perforation, nausea,
vomiting (Hodgson, Kizior,
2016, p. 1119).
Lab Values: Monitor
serum electrolytes
(Hodgson, Kizior, 2016, p.
1120).
• Inform the patient that the
medication may produce a
yellowish brown or
reddish-brown urine and
feces.
• Educate the patient to
increase fluid intake,
exercise, and incorporate a
high-fiber diet to increase
defecation.
• Instruct the patient not to
take other medications
within one hour of taking
Senna as this may
decrease the effectiveness
of the medication.
(Hodgson, Kizior, 2016,
p. 1120).
Intravenous Fluid
Peripheral IV at the left extremity and heparin lock (IV/hep-lock)
Comprehensive Nursing Care Plan
Running head: COMPREHENSIVE NURSING CARE PLAN
23
Nursing
Diagnoses (List 3 priority
Nursing Diagnoses in
order of priority. Must
include one
psychosocial nursing
diagnosis.)
Expected Outcomes (Must complete short &
long-term goals for EACH
priority nursing diagnosis
listed. Goals should be SMART: specific,
measurable, attainable,
realistic, & time-framed.)
Nursing Interventions &
Rationales (Evidenced based rationale for each
intervention for each priority
nursing diagnosis. Describe in your
own words with references cited
here & in reference list in APA
format.)
Evaluation (How did/will you evaluate
the effectiveness of planned
interventions listed in
previous column? HINT: Assess attainment of
SMART goals.)
Impaired physical
mobility related to
prescribed movement
restrictions as
evidenced by
hesitation to attempt
movement. (Ackley,
Ladwig, & Makic,
2017, p. 588).
By the end of the shift,
the patient will
demonstrate techniques
that promote ambulating
and transferring including
demonstrating the use of
a belt to increase
mobility.
Within two weeks, the
patient will increase
strength and function and
will verbalize decreased
fear of falling and pain
with physical activity.
Monitor the patient’s mobility
skills by using the Assessment
Criteria and Care Plan for Safe
Patient Handling and Movement
tool to screen for bed mobility,
supported and unsupported
sitting, transition movements such
as sit to stand, sitting down, and
transfers, and standing and
walking activities. Assessment of
low mobility, functional
difficulties, cognitive impairment,
and multiple comorbidities is
useful for evaluating patient
safety and rehabilitation
interventions. (Ackley, Ladwig, &
Makic, 2017, p. 589).
Assess the patient for the cause of
impaired mobility and establish
whether the cause is physical,
psychological, or motivational.
Some patients prefer not to move
because of psychological factors
such as the fear of falling, pain,
inability to cope, or depression.
The fear of falling is associated
with immobility and functional
dependence. Therefore, an
adequate assessment and
measurement are required.
(Ackley, Ladwig, & Makic, 2017,
p. 590).
Assist the patient to achieve
mobility and start walking as soon
as possible. To prevent hospital-
acquired disability nurses should
implement safety such as fall
prevention and injury protection
The patient’s need for
assistance has decreased, the
patient requires minimal
assistance with mobility,
transition movements, and
walking activities. The
patient shows no cognitive
impairment and is being
more mobile.
The patient has been
demonstrating and
verbalizing that his fear of
falling, pain, and depression
associated with immobility
and functional dependence
has diminished.
The patient exhibits a
progression of joint stability
and maintains proper joint
position and body
alignment. Additionally, the
patient demonstrates proper
use of the belt.
Running head: COMPREHENSIVE NURSING CARE PLAN
24
along with a conception that
enables older adults to be self-
directed and independent. Early
mobilization prevents medical
complications such as deep vein
thrombosis, allows patients time
to practice using assistive devises
or changes in weight-bearing
status, and promotes improved
function, reduces pain, and
facilitates earlier return to
independence. (Ackley, Ladwig,
& Makic, 2017, p. 591).
Deficient knowledge
related to insufficient
information and
knowledge of
resources about the
laminectomy as
evidenced by request
for information and
insufficient
knowledge. (Ackley,
Ladwig, & Makic,
2017, p. 556).
By the end of the shift,
the patient will verbalize
an understanding of the
treatment regimen
including the need for
medications, prognosis,
and potential
complications.
By the end of the week,
the patient will verbalize
and list signs and
symptoms requiring
medical attention and
implement necessary
lifestyle changes.
Discuss postsurgical prognosis,
potential complications, and
future expectations. Open
discussion regarding prognosis,
potential complications, and
future expectations provide the
patient knowledge necessary for
making informed choices and
commitment to the therapeutic
regimen. (Ackley, Ladwig, &
Makic, 2017, p. 556).
Provide information and
demonstrate positioning and
weight shifting including
restrictions. Positioning promotes
circulation and reduces tissue
pressure and risk of
complications. (Ackley, Ladwig,
& Makic, 2017, p. 556).
Identify signs and symptoms that
the patient should report
immediately to a healthcare
provider such as an infection,
urinary and respiratory problems,
or skin breakdown. Providing the
patient with early identification
allows intervention to prevent or
minimize complications.
Stress the importance of
following the recommended
therapy treatment to achieve
specific functional goals and
The patient verbalizes
postsurgical prognosis,
potential complications, and
future expectations such as
the reoccurrence of chronic
back pain.
The patient demonstrates
and verbalizes proper
application of the belt and
verbalizes an understanding
of the importance of gaining
the most benefit from the
belt.
The patient identifies signs
and symptoms that require
contacting the healthcare
provider such as fever,
increased incisional pain,
inflammation, wound
drainage, decreased
sensation and motor activity
in extremities. The patient
verbalizes the importance of
follow-up care and long-
term medical supervision to
manage problems and
potential complications.
Running head: COMPREHENSIVE NURSING CARE PLAN
25
continue long-term monitoring of
therapy needs. (Ackley, Ladwig,
& Makic, 2017, p. 557).
Risk for impaired
tissue integrity related
to temporary weakness
of vertebral column,
balancing difficulties,
changes in muscle
coordination due to
laminectomy. (Ackley,
Ladwig, & Makic,
2017, p. 882).
By the end of the shift,
the patient will
demonstrate adequate
tissue perfusion as
evidenced by the warm
and dry skin with no
appearance of edema,
rash, erythematous, or
dehiscence on his surgical
incision.
Within a week, the
patient will verbalize and
demonstrate knowledge
of treatment regimen of
the surgical incision
including appropriate
wound treatment
techniques.
Inspect and monitor the color and
temperature of the skin at the
surgical incision site for
erythema, color changes,
swelling, warmth, pain, or other
signs of infection such as
increased temperature. Elevation
or a spike in temperature after the
second postoperative day may be
suggestive of infection. Erythema
and other signs of irritation can be
indicative of impaired circulated
caused by the belt. (Ackley,
Ladwig, & Makic, 2017, p. 884).
Assess the patient for pain,
discomfort at the incision site, or
uncomfortable fit of the belt. A
finger should be able to fit
between the belt and the patient’s
skin. Additionally, inspect both
sides of the belt for redness,
swelling, bruising, or chafing,
close the open side and repeat on
the opposite side. A rash may
signify an allergic reaction to the
belt's lining. (Ackley, Ladwig, &
Makic, 2017, p. 884).
Instruct and assist the patient and
caregivers in understanding how
to change dressings and the
importance of maintaining a clean
environment. Additionally,
provide written instruction and
observe them completing the
dressing change. (Ackley,
Ladwig, & Makic, 2017, p. 885).
The surgical incision site is
clean, dry, with no
dehiscence, and no presence
of erythema, swelling, or
other signs of infection. The
patient’s oral temperature is
36.7 °C (98 °F) indicating
that the patient does not
have a fever.
The patient reported no pain,
discomfort at the incision
site, and no discomfort of
the belt. The skin under the
belt manifested no evidence
of redness, swelling,
bruising, or chafing.
The patient and the
caregivers performed and
verbalized an adequate
understanding of dressing
changes at the incision site.
The patient and the
caregivers were given
written instructions on
completing proper dressing
changes.
Running head: COMPREHENSIVE NURSING CARE PLAN
26
References
Ackley, J.B., Ladwig, B.G., & Makic, F.B.M. (2017). Nursing Diagnosis Handbook (11th Ed.).
St. Louis, MO: Elsevier, Inc.
American Association for Clinical Chemistry. (2017, November, 16). Benign Prostatic
Hyperplasia. Retrieved from https://labtestsonline.org/conditions/benign-prostatic-
hyperplasia
American Association for Clinical Chemistry. (2017, December, 04). Chloride. Retrieved from
https://labtestsonline.org/tests/chloride
American Association for Clinical Chemistry. (2018, June, 07). Hypertension. Retrieved from
https://labtestsonline.org/conditions/hypertension
American Association for Clinical Chemistry. (2018, March, 27). Partial Thromboplastin Time
(PTT, aPTT). Retrieved from https://labtestsonline.org/tests/partial-thromboplastin-time-
ptt-aptt
American Association for Clinical Chemistry. (2017, December, 30). Potassium. Retrieved from
https://labtestsonline.org/tests/potassium
American Association for Clinical Chemistry. (2017, December, 30). White Blood Cell Count
(WBC). Retrieved from https://labtestsonline.org/tests/white-blood-cell-count-wbc
Centers for Disease Control and Prevention. (2015, May 15). Adult BMI Calculator. Retrieved
from
https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi
_calculator.html
Hendrich, A. (2016). Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model.
Retrieved from https://consultgeri.org/try-this/general-assessment/issue-8.pdf
Running head: COMPREHENSIVE NURSING CARE PLAN
27
Hodgson, B.B., & Kizior, R.J. (2016). Nursing Drug Handbook 2016. St. Louis, MO: Saunders
Elsevier.
Kee, J.L., Hayes, E.R., McCuistion, L.E. (2015). Pharmacology: A Patient-Centered Nursing
Process Approach. (8th Edition). St. Louis, MO: Elsevier Saunders.
Lewis, L.S., Dirksen, R.S., Heitkemper, M.M., Bucher, L. (2014). Medical Surgical Nursing
Assessment and Management of Clinical Problems. (9th ed.). St. Louis, MO: Mosby
Elsevier.
Lexicomp. (2018, June 26). Cholecalciferol. Retrieved from
http://online.lexi.com.proxy.library.nyu.edu/lco/action/doc/retrieve/docid/patch_f/6606#p
ai
Lexicomp. (2018, July 13). Insulin Lispro. Retrieved from
http://online.lexi.com.proxy.library.nyu.edu/lco/action/doc/retrieve/docid/patch_f/320046
#fbnlist
Mayo Clinic Staff. (2018, June 13). Laminectomy. Retrieved from
https://www.mayoclinic.org/tests-procedures/laminectomy/about/pac-20394533
MedlinePlus. (2017, December, 19). Hematocrit Test. Retrieved from
https://medlineplus.gov/labtests/hematocrittest.html
MedlinePlus. (2018, July, 12). Hemoglobin Test. Retrieved from
https://medlineplus.gov/labtests/hemoglobintest.html
Micromedex. (2018, March 02). Bacitracin. Retrieved from
http://www.micromedexsolutions.com.proxy.library.nyu.edu/micromedex2/librarian/CS/
D09E60/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/F8
3969/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T
Running head: COMPREHENSIVE NURSING CARE PLAN
28
/evidencexpert/PFActionId/evidencexpert.IntermediateToDocumentLink?docId=1049&c
ontentSetId=31&title=BACITRACIN&servicesTitle=BACITRACIN#
IBM Micromedex. (2018, June 04). Enoxaparin Sodium. Retrieved from
http://www.micromedexsolutions.com.proxy.library.nyu.edu/micromedex2/librarian/CS/
DBD3F9/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/9
F2E4A/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND
_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Enoxapar
in%20&UserSearchTerm=Enoxaparin%20&SearchFilter=filterNone&navitem=searchAL
L#
IBM Micromedex. (2018, June 27). Vitamin D. Retrieved from
http://www.micromedexsolutions.com.proxy.library.nyu.edu/micromedex2/librarian/CS/
C5873B/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/37
C987/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_
T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Cholecalci
ferol&UserSearchTerm=Cholecalciferol&SearchFilter=filterNone&navitem=searchALL
#indepthpanelprint
OrthoInfo. (2013, December). Disease & Conditions: Lumbar Spinal Stenosis. Retrieved from
https://orthoinfo.aaos.org/en/diseases--conditions/lumbar-spinal-stenosis/
Wilson, B.A., Shannon, M.T., & Shields, K.M. (2015). Pearson Nurse’s Drug Guide. Hoboken,
NJ: Pearson Education, Inc.
Vallerand, A.H., Sanoski, C.A., & Deglin, J.H. (2015). Davis’s Drug Guide for Nurses. (14th
Ed.). Philadelphia, PA: F.A. Davis Company
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