Southeastern
Louisiana University

School
of Nursing

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NLAB
382

Care
Plan Cover Page

 

Student:
_Everlyne Tuimur___

Date:
01/26/2018    Patient’s Age: 51    Gender: M

 

Medical
Diagnosis:

Symptomatic
Anemia

CHF

COPD

Type
2 DM

Hyperlipidemia

 

Nursing
Diagnoses Prioritized:

 

1.  Decreased cardiac output R/T decreased amount of circulating blood S/T blood loss causing
symptomatic Anemia

 

2.  Ineffective airway clearance R/T Bronchospasms and excess
mucus production as a result of constriction of bronchioles S/T COPD

 

3. Activity
intolerance R/T decreased
amount of circulating oxygen S/T
Anemia

 

 4.Infection, risk for R/T high glucose levels and decreased amount of circulating
leukocytes S/T Type 2 DM

 

5. Falls,
risk for R/T altered mobility
S/T AKA of the LLE

Southeastern Louisiana
University

School of
Nursing-Nursing Lab 382

Nursing Plan of Care

Student:                                                                                                                                                                                                                                                                        
Date: _____

Age:     _Sex:

Defining
Characteristics

Nursing Diagnosis (NANDA or Faculty
Approved)

Nursing Interventions and Rationale
(MUST cite source
for ALL)
 

Intervention Evaluation

Outcome Explanation
Was the goal met?
Problem resolved or prevented?
Should plan be: Continued? Revised?  Terminated?

 
Subjective
characteristics.
ED notes 01/20/2018 1800
“Pt. had a syncope episode during discharge while trying to get up from the
wheelchair to the car”
 
01/26/2018 1600 Pt. states
that they feel tired easily
 
 
 
 
 
 
 
 
Objective
characteristics.
 
-01/24/2018 Hgb 8.4
-01/24/2018 Hct 24.8
-01/24/2018 Pt. lost 400cc
of blood from bleeding at the chest port site.
-Medical hx.
 CHF
 Hypertension
 
 
 
 
 
 
 
 
 
 
 
 

Dx: Decreased
Cardiac output.
 
 
R/T(etiology
the nurse can manipulate): decreased amount of circulating blood
 
 
Secondary to:
blood loss causing symptomatic anemia.
 
 
Expected Pt. Goals & Outcomes:
-Have Improved cardiac
output.
 
Pt. will:
-Maintain cap refill 3 sec indicates decreased cardiac
output. It also indicates adequate perfusion to the extremities which is also
a goal for the pt.
 
 
 
2. Observe for Cyanosis on
the mucus membranes q2hrs.
    -Cyanosis on mucus membranes would
indicate inadequate perfusion which is caused by a decreased cardiac output.
Pink and moist would indicate adequate perfusion.
 
 
 
3. Monitor HR q4hrs
      -HR affects the amount of blood that is
pumped out, increased HR indicates decreased cardiac output because there is
not enough time to fill up the ventricles before the heart pumps the blood
out.
 
 
 
4. Monitor Hgb, Hct, and
RBC levels daily.
     – Although it may take a while for these
levels to go back to normal, an increase would indicate the level of
effectiveness of the therapy used.
 
5. Administer Ferrous
Sulfate 325mg PO TID.
     – This
med provides Iron which is an essential mineral needed to make hemoglobin
which is a component of RBCs.

 1. 01/26/2018
1600-Cap
refill55)

 

Stage
of Development: Middle adulthood: Generativity vs Stagnation.

 

1.   
 General health history:

-Symptomatic anemia

-CHF

-COPD

-ESRF

-Hyperlipidemia

-GERD

 

2.    Conditions that prevent normal
functioning: (physical, mental, etc.):


Left AKA

 

 

 

3.    Alcohol/drug use: yes, x no,
amount :  ___________________________

 

4. 
Tobacco use: x yes, no, amount (packs/day):­­­_2__, years: Smoked for 30 years before
he quit two years ago.

 

5.    Major medical diagnosis:Symptomatic
anemia

 

6.  Surgical Procedure:  Removal of central line,

 

7.   
Psycho-social
concerns: Pt. states that he is concerned about how his health is making him
dependent on others.

 

8.    Perception of current illness:

Pt.
states that his health has been deteriorating fast, he is concerned not only of
this hospitalization but his overall health. He is aware that his acute blood
loss also affects other illnesses that he is already diagnosed with. 

 

9.    Cultural beliefs related to health:

None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.  Pathophysiology:(include specific source using
APA format) :

 

Anemia

This is a condition in which
the blood has low levels of Hgb, Hct, and RBC’s.

This reduces the amount of
circulation oxygen available for the body.

The patient therefore
presents with symptoms of fatigue, SOB, dizziness, headache, or irregular
heartbeat. This diagnosis is confirmed by a blood CBC test which provides the
levels of Hgb, Hct, and RBC’s. Treatment of anemia depends on the type of
anemia the patient has been diagnosed with. The different types of anemia
include: iron deficiency anemia, vitamin B12 deficiency, folic acid deficiency
anemias. In this pt’s situation, the he has anemia due to acute blood loss.
Treatment will therefore involve a blood transfusion, iron infusion, or iron
supplements. Treatment is long term and will require continuous monitoring of
RBC’s, Hgb, and Hct levels until they are within the normal range.

References.

Hagler, D., Lewis, S. M.,
& Dirksen, S. R. (2017). Clinical
companion to Medical-surgical nursing: assessment and management of clinical
problems. St. Louis, MO: Elsevier.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEUROLOGICAL

GASTROINTESTINAL

Assessment

Day 1

Day
2

Comments

Assessment

Day
1

Day
2

Comments

LOC

Awake, Alert

 

 

BOWEL SOUNDS

Orientation

Pt orientated to place, time and
person

 

 

   Normal (X4)

Normoactive X4

 

 

Speech

clear

 

 

   Hyperactive

 

 

 

Pupils

Round, equal, reactive to light.

 

 

   Hypoactive

 

 

 

 

   Absent

 

 

 

  
Hearing

Able to hear verbal instructions
during the assessment

 

 

Abdomen
(soft, firm, distended, tender)

Soft,
non-distended,
non-tender

 

 

  
Sight

 

 

 

  
Touch

Able to feel sensation when touched

 

 

GASTRIC
SUCTION (Type)

 

 

 

  
Taste

 

 

 

  
Smell

 

 

 

   Continuous

 

 

 

 

   Intermittent

 

 

 

Color
of emesis (clear, green, yellow, red, coffee ground) 

 

 

 

CARDIOVASCULAR

Amount
(cc’s)

 

 

 

Assessment

Day 1

 

Comments

Stools
(describe)
 

Loose brown stools

 

 

B/P

01/26/2018
1600  BP 126/92
2000 BP 120/90

 

 

Last
BM (Date)

1/26/2018

 

 

Pulse rate

1600 HR 77
2000 HR 70

 

 

RELEVANT
HX:
GERD

  
Quality

 

 

 

Temperature

1600 Temp 98.6
2000 Temp 98.3

 

 

Peripheral
Pulses-quality

+2/4 in BUE
+2/4 in RLE

 

Unable to assess LLE d/t AKA

Edema:amt/location

No edema in RLE
No edema in BUE

 

Unable to assess LLE d/t AKA

GENITOURINARY

Cap refill