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Rectal cancer, renal insufficiencies, hypertension
In and out hospital for cancer CARE PLAN CONCEPT MAP
Student_Lyndsey Duplessis_____ Date_5/9/13________
VitalsBPPRespTempO2 %Admit152/90971499.098Pre Clin.147/73981897.9980800152/79751899.2971200126/79701698.1981600
Nursing Diagnoses Expected OutcomesNursing Care/Interventions
Rationale
Evaluation
Skin Integrity Impairment related to cholestomy and urostomy placement as evidence by left upper quad cholestomy and right upper quad urostomy *
Risk for Falls related to syncopical episode
Great job, remember to cite references.
Have at least 3 prioritized Nursing Diagnoses
Patient will be free from infection and skin break down by the end of the shift.
Patient will be free from falls the entire shift
Include at least 1 outcome per Nursing Diagnoses
Incision care as ordered
-This will prevent incisions from becoming infected
Report redness, swelling, and drainage
-proper documentation to show it was acted upon
Teach proper wound care and cleaning to the patient
-This is to prevent infection when patient is discharged.
Place call light in reach
-The light is used to call the nurses station id needed assistance to move
Collaborate with the doctor for physical therapy
-The PT will evaluate the patients balance and transfer mobility to prevent falls
Fall preventions safety measures
-Placing the bedrails up to make sure the patient is safe
Have at least 3 nursing interventions for each Nursing Diagnoses
Patient was free from infection and showed no signs of skin break down by the end of my shift.
The patient was free from falls this shift.
Nursing Diagnoses Expected OutcomesNursing Care/Interventions
Rationale
Evaluation
Acute pain related to choletomy and urostomy placement as evidence by patient stated he has pain the comes and goes rating it 6 out of 10 *
Have at least 3 prioritized Nursing Diagnoses
Patient will have a decrease level of pain within two hours of administering pain medication.
Include at least 1 outcome per Nursing Diagnoses
Administer medication as ordered
-Pain medication will relieve the pain
Assist patient in changing positions
-This is a non-pharmacological pain relieving method
Reassess the patient after pain medication or repositioning
-This will show if the interventions have worked
Have at least 3 nursing interventions for each Nursing Diagnoses
Patient stated he had a decrease in pain rating it 3 out of 10 one hour after medication was administered.
Admit Diagnosis-relate the diagnosis to a conceptPathophysiologyClinical ManifestationsDiagnostic Studies include your patients resultsComplications
Syncopal episode * *
Pertinent History (relate to a concept):
Rectal Cancer
Hypokalemia *
Renal insufficiency *
Fainting, temporary loss of consciousness, caused by not having enough blood flow to the brain
Pale, increased sweating, nauseated, dizzy or light-headed, fatigue
CT scan- negative
Chest X-ray- negative
Blood Cultures- positive for C. diff
ECG- normal
Depends on the underlying cause of the fainting. Can lead to brain damage, heart complications, tissue damage, and death
Teaching Learning Plan
AssessmentObjectives/GoalsContent/Information Teaching Strategies Evaluation
Patient admitted to the hospital due to a syncopal episode. Patient has rectal cancer with led to the placement of a left upper quad cholestomy bag and a right upper urostomy bag. Blood culture test shows positive for C. diff. He states some pain and discomfort in his abdomen and is at risk for falls.
Patient will verbalize understanding of the cholestomy and urostomy bags and proper maintenance by the end of teaching
Patient will verbalized 3 signs and symptoms of medication to treat the infection by the end of teaching
Patient will verbalize fall prevention activities by the end of teaching
Information on cholestomy and urostomy bags and demonstration of proper maintenance
Information on the side effects of antibiotics and prevention measures
Home assessment guide for fall hazards pamphlet
Demonstrate how to proper maintain the bags
Teach/educate side effects of medication and what to do if it happens
Read over pamphlet and demonstrate fall prevention techniques
Patient verbalized understanding of the bags and proper maintenance at the end of teaching
Patient verbalized 3 side effects of medications by the end of teaching
Patient verbalized fall prevention activities by the end of teaching
Medications Sheet
Medication, Dose, Route, FrequencyClassification and ActionRational for Administration
(Explain why the patient is receiving the medication)Major Side EffectsNursing ImplicationsHome Medications:
Metoprolol 50 mg PO QD
Simvastatin 10 mg PO HS *
Hospital Medications:
Linezolid 600mg/30 ml IVPB Q12 hrs
Meropenem 1gm IVPB q 12h
Enoxaporin 30mg SC QD
Antihypertensive- Lowers B/P by - b l o c k i n g e f f e c t s ; r e d u c e s e l e v a t e d r e n i n p l a s m a l e v e l s
A n t i l i p e m i c - I n h i b i t s H M G - C o A r e d u c t a s e e n z y m e , w h i c h r e d u c e s c h o l e s t e r o l s y n t h e s i s
A n t i - i n f e c t i v e - p r e v e n t i n g b a c t e r i a l t r a n s l a t i o n i n g r a m p o s i t i v e o r g a n i s m s
A n t i - i n f e c t i v e - c a u s e s b a c t e r i cidal
Anticoagulant- Binds to antithrombin III inactivating factors Xa/IIa, thereby resulting in a higher ratio of anti-factor Xa to IIa
To maintain normal blood pressure levels
Maintain normal cholesterol levels
Used to treat bacterial infections
Used to treat bacterial infections
Used to prevent blood clots that can result in DVT and PE
Hypotension, bradycardia, insomnia, cardiac arrest, pulmonary edema, NVD
Liver dysfunction, NVD, constipation, muscle pain, respiratory tract infection
Headache, dizziness, NVD, lactic acidosis
Seizures, hepatitis, NVD, PE, hypotension
Assess ECG
I&O which can indicate CHR,
Hepatic and renal
Turgor
Assess renal studies
I&O, BUN, creatinine levels
Appropriate diet
Monitor CBC levels, assessing for leukopenia, thrombocytopenia, anemias, AST and ALT
Assess for renal disease, may require a lower dose
Make sure to reconstitute with sterile water
Assess bleeding, renal studies, BUN, blood studies Hct/Hbg, thrombocytopenia
Review of Systems include use of therapeutic devices
Respiratory
Respirations 18
Regular and unlabored
Bilateral breath sounds clear
No problems swallowing
Cough absent
Cardiovascular
Regular
Bilateral radial pulse palpable +2
Pedal pulse palpable +1
Capillary refill less than 3 secs
No edema, extremities warm to touch
Pain
Patient stated he had pain in his abdomen that comes and goes at a rate of 6 out of 10 and a liitle discomfort from the tubes inserted
Neurological
Alert and oriented to person, place, and time
MAE equally
Speech clear
Musculoskeletal
Gait unsteady
Need slight assistance with ADLs
Gastrointestinal
Abdomen soft with hypoactive bowel sounds
Tolerates cardiac diet
Cholestomy bag in place with stools brow and paste like
Genitourinary
Able to void with Urostomy in place
Urine yellow and clear
Skin/Mucosa-include IV site assessment *
Skin color appropriate to ethnicity
Extremities warm and dry
Turgor elastic
IV site clear, patent and dry
No redness, swelling or pain
Psychosocial
Thinking is congruent with situation. Patient stated he felt a little depressed due to the C. diff diagnosis but still had a positive attitude
No support system was present
Miscellaneous include any other pertinent vitals, etc.
Labs:
RBC L 3.31
Hgb L 9.5
Hct L 28.2
Segs H 91
CO2 L 21
Creatine level H 1.76
Calcium L 7.5
Holistic Factors
Patient in unemployed which could result in non-compliance of medication
No family came to visit
Knowledge deficit of what caused the fainting
Developmental
Integrity vs. despair
Admitting Medical Diagnosis:
Syncopical episode * *
Chief Complaint:
Abdominal pain
Other Medical Dx. /Health Problems:
C. Diff, Rectal Cancer, Renal insufficiency *, UTI
hypertention
Surgeries:
Placement of cholestomy and urostomy
Surgical History:
Treatment Orders
Contact isolation
Cardiac diet
IV site observation every 4 hours
Vitals every 4 hours *
Mode of transport every 12 hours
Great job! Way to go connecting things. Remember to cite references. You were the ONLY student to include the concept key as you should have.
Concepts Key
Cognition/ perception
Mobility
Nutrition/ elimination
Perfusion
Protection/ Adaptation
Great you were the ONLY one to do this correctly!
Patient Strengths
Positive attitude
Compliant with medication regimen
Teaching/Learning Needs
Diet- cardiac low sodium diet
Fall Risk Interventions
Side effects of new antibiotic
Care for cholestomy and urostomy bags
Discharge Planning Needs
Continue antibiotic medications
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