Nur 412: Case Study Plan Of Care
NUR 412
PLAN OF CARE
Nursing Problem
Interventions (Minimum of 3)
(with rationales)
Evaluation
Problem statement: Aspiration precaution.
Related to: Feeding/trach
As manifested by: PEG tube and tracheostomy
Expected Outcome: Pt. will not experience any aspiration episodes while in the hospital.
Problem statement: Risk for infection
Related to: Foley cath
As manifested by: erosion to urethral site
Expected Outcome: Pt. will not have infection while in the hospital
..HOB elevated 35 degrees.(gravity will help keep food down)
..Check residual. (Tells if the medication/food is being passed.
..Hold feed for care and turning. (laying the pt. flat changes gravity and the stomach content ability to aspirate) …show more content…
did not experience any infection while in the hospital.
NUR 412
WEEKLY PATIENT ASSESSMENT GUIDE (include your head to toe physical assessment in addition to information obtained from patient and medical record)
Neurological status/ sensory status/ pain/ orientation/ teaching learning readiness/ communication style
Pt. is alert but not oriented. Pt. is does not respond to verbal response but respond to tactile stimuli. Pt. is nonverbal and cannot express pain level, communication is difficult.
Oxygenation level/ respiratory assessment/ aspiration risk
Pt. o2 level is 100%, pt. has tracheostomy. Pt. appears to have difficulty breathing as evidenced by thick mucus production and rhoni noted bilaterally Pt. has high aspiration risk due to feeding/trach.
Cardiac Rhythm /Circulation & pulses/ IV’s/ fluid volume …show more content…
is on cardiac monitor, B/P=138/48 and pulse 86. Pulses noted to be 2+. RRR, no gallops, no present edema
Abdominal assessment Nutrition/ oral health, dentures/ weight & BMI/ diet amt consumed/emesis
BS present in all 4 quadrants, pt. is on diabetic diet, wt. 68.6kg. PEG tube, clean and intact. There is no evidence of emesis and pt. is tolerating tube feeding well, on 18hrs isosource.
Elimination/ continence/ urine & stool color, amt, odor/ drains output color, odor
Urine output: 300 light yellow and clear, no odor unusual via Foley cath, bowel movement x2. No drains noted.
Mobility/ Activity
Exercise
Pt. is immobile and cannot participate in active nor passive ROM without assistance
Skin/Wound care/ Dressings/Protection/ Safety
Pt. has a stage two sacral ulcer and a healing stage two ulcer on left ankle. Duaderm is intact and no sign of drainage noted.
Psychosocial/spiritual/ growth & development level/ sleep- wake pattern
Pt. is non-verbal- cannot assist psychosocial or spiritual, sleep wake pattern details.
Client Data Sheet (Weekly)
NUR 412
PHARMACOLOGICAL RECORD (Weekly)
Medications:
Generic/Brand Name
Dose
Route
Frequency
Reason this client receiving med
Assessment of response to med
Toprol XL
25mg
PEG
Q10am
Treat
PLAN OF CARE
Nursing Problem
Interventions (Minimum of 3)
(with rationales)
Evaluation
Problem statement: Aspiration precaution.
Related to: Feeding/trach
As manifested by: PEG tube and tracheostomy
Expected Outcome: Pt. will not experience any aspiration episodes while in the hospital.
Problem statement: Risk for infection
Related to: Foley cath
As manifested by: erosion to urethral site
Expected Outcome: Pt. will not have infection while in the hospital
..HOB elevated 35 degrees.(gravity will help keep food down)
..Check residual. (Tells if the medication/food is being passed.
..Hold feed for care and turning. (laying the pt. flat changes gravity and the stomach content ability to aspirate) …show more content…
did not experience any infection while in the hospital.
NUR 412
WEEKLY PATIENT ASSESSMENT GUIDE (include your head to toe physical assessment in addition to information obtained from patient and medical record)
Neurological status/ sensory status/ pain/ orientation/ teaching learning readiness/ communication style
Pt. is alert but not oriented. Pt. is does not respond to verbal response but respond to tactile stimuli. Pt. is nonverbal and cannot express pain level, communication is difficult.
Oxygenation level/ respiratory assessment/ aspiration risk
Pt. o2 level is 100%, pt. has tracheostomy. Pt. appears to have difficulty breathing as evidenced by thick mucus production and rhoni noted bilaterally Pt. has high aspiration risk due to feeding/trach.
Cardiac Rhythm /Circulation & pulses/ IV’s/ fluid volume …show more content…
is on cardiac monitor, B/P=138/48 and pulse 86. Pulses noted to be 2+. RRR, no gallops, no present edema
Abdominal assessment Nutrition/ oral health, dentures/ weight & BMI/ diet amt consumed/emesis
BS present in all 4 quadrants, pt. is on diabetic diet, wt. 68.6kg. PEG tube, clean and intact. There is no evidence of emesis and pt. is tolerating tube feeding well, on 18hrs isosource.
Elimination/ continence/ urine & stool color, amt, odor/ drains output color, odor
Urine output: 300 light yellow and clear, no odor unusual via Foley cath, bowel movement x2. No drains noted.
Mobility/ Activity
Exercise
Pt. is immobile and cannot participate in active nor passive ROM without assistance
Skin/Wound care/ Dressings/Protection/ Safety
Pt. has a stage two sacral ulcer and a healing stage two ulcer on left ankle. Duaderm is intact and no sign of drainage noted.
Psychosocial/spiritual/ growth & development level/ sleep- wake pattern
Pt. is non-verbal- cannot assist psychosocial or spiritual, sleep wake pattern details.
Client Data Sheet (Weekly)
NUR 412
PHARMACOLOGICAL RECORD (Weekly)
Medications:
Generic/Brand Name
Dose
Route
Frequency
Reason this client receiving med
Assessment of response to med
Toprol XL
25mg
PEG
Q10am
Treat