Expert answer:Create an Care Plan and follow the NURSING CARE PL
Expert answer:Create an Care Plan and follow the NURSING CARE PLAN RUBRIC instructions.Patient information:Patient female 48 years oldAdmission Diagnosis: Stroke non-hemorrhagic, deficit right sided, speech History: High cholesterol 350Diabetes – blood glucose 320HypertensionDepressionPatient admitted after stroke, patient was at home complains with right sided weakness called 911 brought to hospital where she was diagnostic with stroke.Patient is married has two child, husband is god (catholic)Physical Assessment 5-61- lung sounds2- bowel sounds 3- skin4- upper extremities (right sided 0/5)5- lower extremities (right sided 2/5)Diagnose: CT of the brain _Lab glucose_Hemoglobin_CBCMedications: Crestor, Coreg, Insuline Novolog and Cymbalta Here are the care plan rubric instruction, care plan example and care plan template please follow the instructions
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CARE PLAN TEMPLATE
Student
David Perez
Date
Instructor Professor Montero
Course
Patient Initials
J.S.
Code Status
Full Resuscitation
Allergies
Unit/Room
NURS100
WCU/301
DOB 07/04/27
Height/Weight
186.5 lbs/ 6’ (72”)
Heparin
Temp (C/F Site)
99 F
10/11/16
Pulse (Site)
82 Radial
Respiration
20
History of Present Illness including Admission Diagnosis and
Relevant Physical Assessment Findings (normal & abnormal)
Pulse Ox (O2
Sat)
95%
Blood Pressure
162/76
Pain Scale 1-10
2
Relevant Diagnostic Procedures & Surgeries /Results
(include dates, if not found state so)
J.S. came to WCU Hospital due to a fall he had at home after a left
In 1993 J.S. underwent a Coronary Artery Bypass Graft (CABG).
foot amputation. He was able to contact life alert after his fall and
In 2016 J.S. had a left forefoot amputation.
they brought him to the Emergency Room. The patient has a past
medical history of Coronary Artery Disease, Peripheral Vascular
Disease, Diabetes Mellitus Type 2, Hypertension, Atrial Fibrillation,
and Myocardial Infarction. NECK: There is no jugular vein
distension. CARDIO: Heart regular rate and rhythm. There are no
audible murmurs, thrills, rubs, or gallops. Positive pedal pulse in the
right foot. RESP: Upon auscultation lungs clear bilaterally.
ABDOMEN: Abdomen soft, tender, and nondistended with normal
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 1
Term: Fall I, 2016
bowel sounds. EXTREMETIES: Healing left forefoot amputation
with necrosis noted at the tip of the residual limb. NEURO: Patient
is alert, awake, and oriented x3. Cranial Nerves 1-12 grossly intact.
Deep tendon reflexes 1+ at the right bicep but otherwise 2+ and
symmetric at the bilateral upper limbs. Deep tendon reflexes are 0
throughout the bilateral lower limbs. SKIN: Necrotic appearing
healing site at the left forefoot amputation.
Past Medical & Surgical History, Pathophysiology of medical
diagnoses (with APA citations)
Medical Diagnosis:
Pertinent Lab tests/ Results (with normal ranges)
with dates and rationales
Test
Norms
Date
Coronary Artery Disease: Atherosclerosis is the underlying
pathophysiologic basis of CAD. It produces an increase in the
number of smooth muscle cells and a collection of lipids within the
intima of medium- and large-size arteries (Copstead, & Banasik,
2013). In time this process narrows the lumina and reduces their
ability to dilate.
Peripheral Vascular Disease: Atherosclerosis is the underlying
pathophysiologic basis of PVD. When atherosclerosis involves the
peripheral vascular system, it is most often the lower extremities,
and it’s often know as atherosclerosis obliterans (Copstead, &
Banasik, 2013). The atherosclerotic process can gradually progress
Current
Value
WBC
5,000 – 10,000
09/25/16
9.1
RBC
3.6 – 5.0
09/25/16
3.4 L
HGB
12 -16
09/25/16
9.8 L
HCT
36% – 48%
09/25/16
30.6 L
PLATELET
150,000 – 450,000
09/25/16
226
NA+
135 – 145
09/25/16
140
K+
3.5 – 5.0
09/25/16
3.8
GLUCOSE
70 – 110
09/25/16
147 H
BUN
8 – 23
09/25/16
23
CREATNINE
0.6 – 1.35
09/25/16
1.1
to complete occlusion of medium and large arteries.
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 2
Term: Fall I, 2016
Diabetes Mellitus Type 2: The pathophysiology of type 2 diabetes
Rationales:
mellitus is characterized by peripheral insulin resistance, impaired
RBC: Lowered due to Normocytic Anemia.
regulation of liver glucose production, and declining β cell function,
HGB: Lowered due to Normocytic Anemia.
eventually leading to β cell failure (Copstead, & Banasik, 2013).
HCT: Lowered due to Normocytic Anemia.
Glucose: Increased due to Diabetes Mellitus.
Hypertension: There is no clear identifiable pathophysiology of
(Fisbach, 2015)
hypertension. Although, it is believed genetics may be responsible
for low renin levels and salt sensitivity, heightened responses to
angiotensin II, altered amounts or responses to local tissue factors
such as endothelin and nitric oxide, and any number of mechanisms
accounting for primary hypertension (Copstead, & Banasik, 2013).
Atrial Fibrillation: The pathophysiology of AF is characterized by
hypertensive, valvar, ischaemic, and other types of structural heart
disease which underlie most cases of persistent and permanent AF
(Markides, & Schilling, 2003).
Myocardial Infarction: The pathophysiology of most MI are
caused by a disruption in the vascular endothelium associated with
an unstable atherosclerotic plaque that stimulates the formation of an
intracoronary thrombus, which results in coronary artery blood flow
occlusions (Bolooki, & Askari, 2010).
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 3
Term: Fall I, 2016
Normocytic anemia: The pathophysiology of normocytic anemia is
multifactorial and is related to hypo-activity of the bone marrow,
with relatively inadequate production of erythropoietin or a poor
response to erythropoietin, as well as slightly shortened red blood
cell survival (Brill, & Baumgardner, 2000).
Surgical History:
CABG (Coronary Artery Bypass Grafting)
Left forefoot amputation
J.S. is in the 8th stage of Erikson’s. This stage is called Ego Integrity
Socioeconomic/Cultural/Spiritual Orientation
& Psychosocial Considerations
J.S. is a widow and currently lives alone. He is also a recent widow.
vs. Despair. The age group for this stage is 65 years and older. The
He has been retired for 24 years. He has no religious preference. He
patients that enter this stage are looking back at all their
also has a hard time managing his diabetes as he does not have
accomplishments in life. He has 1 child who he is very proud of. He
enough knowledge about diabetes or how to manage it. His family
believes that his son is his proudest achievement.
is very supportive of him. Although his son does not live with him
(McLeod, 2013)
he has agreed to hire private duty help if needed post discharge.
Erikson’s Developmental Stage with Rationale (APA citations)
Psychosocial considerations
1. Patient will have an altered self-image due to recently
amputated foot.
2. Patient will have possible depression due to recently losing
his life.
3. Patient experience difficulty gathering a support group due
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 4
Term: Fall I, 2016
to lack of transportation.
Potential Health Deviations, Predisposing & Related Factors;
Interventions to Assess or Prevent Potential Health Deviations
“At Risk for…” nursing dx (AT LEAST TWO)
1. At risk for unstable blood glucose levels related to
Interprofessional Consults, Discharge Referrals, & Current
Orders (include diet, test, and treatments) with Rationale With
APA citations
1. Physical Therapist are health care professionals who
insufficient knowledge on diabetes as evidenced by
specialize in increasing the musculoskeletal function so that
inadequate blood glucose monitoring and patient verbalizing
patients can maintain mobility and continue activities for
that he does not know a lot about the disease.
daily living. (Sommer, et al., 2016) In the case of J.S. this
a. Monitor dietary intake
would be very helpful due to the fact that he has undergone
b. Monitor daily weight and body mass index
a recent amputation surgery of the left forefoot.
c. Monitor blood glucose
2. A Registered Dietician can assess, plan for, and educate J.S.
2. At risk for chronic low self-esteem related to amputation of
forefoot as evidenced by ineffective adaption to loss.
on his nutritional needs. The dietician can design a special
diet and supervise meal preparations. (Sommer, et al.,
a. Promote use of coping resources
2016). This will help J.S. in his diabetes management.
b. Enhance the patients sense of self
3. A psychologist helps patients overcome negative thoughts
c. Assist the person to reduce present anxiety level
and improve self-esteem. (Feature, 2005). This would be a
great referral for J.S. sue to the fact that he is becoming
depressed due to is low self-esteem related to his forefoot
amputation.
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 5
Term: Fall I, 2016
Diagnostic
Label
Nursing Diagnosis
(at least 2)
Related to
Planning
(outcome/goal)
Measurable goal
during your shift (at
least 1 per Nursing
diagnosis)
Contributing
Factors
As Evidenced
by
Signs and
Symptoms
At risk for injury related
J.S. will relate intent to
Prioritized
Independent and
collaborative nursing
interventions; include
further assessment,
intervention and
teaching (at least 4 per
goal)
1. Implement a home
Rationale
(use APA citations)
Evaluation
Goal Met, Partially met,
or not Met and
Explanation
to loss of limb as
use safety measures to
hazard assessment and
assessments can assist
evidenced by
prevent injury such as
discuss the proposed
the patient in identifying that should be
amputation of left
the removal of rugs,
changes that will assist
the factors of the home
eliminated from his
forefoot.
having adequate
J.S. in safety.
that could be dangerous
home.
lighting, and installing
2. Encourage J.S. to hire and should be changed.
bathroom safety devices
personnel to install
(Potter & Perry, 2013)
by the end of my shift.
handgrips in the
2. Modifying the home
bathroom. Teach client
will help J.S. reduce
to eliminate rugs, litter,
hazardous conditions
and highly polished
and diminish the risk for
1. Home hazard
Goal met J.S. was able
to verbalize the hazards
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 6
Term: Fall I, 2016
floors
falls. (Potter & Perry,
3. Teach client the
2013)
various ways that he can 3. Educating the patient
reduce risks and what
regarding hazards can
can cause a fall.
reduce the risk for falls.
4. Refer the patient to a
(Potter & Perry, 2013)
physical therapist to
4. Exercise and a
increase strength in the
physical therapist can be
lower limbs.
effective in reducing
falls by strengthening
the musculoskeletal
system of the lower
limbs. (Potter & Perry,
2013)
Acute pain related to
J.S. will reach a
1. Educate patient on
1. Nonpharmacological
Goal met J.S. pain level
tissue trauma and reflex
tolerable pain level by
nonpharmacological
approaches supplement
reached a tolerable level
muscle spasms as
discharge.
interventions such as
pharmacological
by discharge.
evidenced by patient
music, guided imagery,
therapy and help
stating pain 8 out 10.
and simple relaxation to
patients improve quality
reduce pain.
of life and decrease
2. Teach son how to
anxiety and depression.
(Potter & Perry, 2013)
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 7
Term: Fall I, 2016
perform slow-stroke
back massage.
2. Slow-stroke back
massage is easy to do,
3. Provide optimal pain
takes a brief amount of
relief with analgesics as
time, and induces
prescribed by the
relaxation. (Potter &
physician.
Perry, 2013)
4. Give accurate
information to correct
misconceptions about
pain or addiction to
medication.
3. Pain medication is the
most effective
medication to reduce
pain. (Carpenito, 2013)
4. Helping the patient
understand the pain
experience can enhance
positive coping.
(Carpenito, 2013)
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 8
Term: Fall I, 2016
MEDICATION LIST
Medications
(with APA
citations)
Class/Purpose
Route
Frequency
Mechanism of action
/
Onset of action
Cyanocobala
Therapeutic: antianemics,
min
vitamins Pharmacologic:
Common side
effects
PO
QD
Necessary coenzyme
CNS: headache.
Nursing
considerations
specific to this
patient
● Encourage patient
for metabolic
CV: heart failure.
to comply with diet
(For low RBC water soluble vitamins
processes, including
GI: diarrhea.
recommendations of
& low H&H)
fat and carbohydrate
Derm: itching,
health care
metabolism and
swelling of the
professional. Explain
protein synthesis.
body. F and E:
that the best source
Required for cell
hypokalemia.
of vitamins is a well-
reproduction and
Hemat:
balanced diet with
hematopoiesis.
thrombocytosis.
foods from the four
Therapeutic Effects:
Resp: pulmonary
basic food groups.
Corrects
edema. Local:
● Foods high in
manifestations of
pain at IM site.
vitamin B12 include
pernicious anemia
Misc:
meats, seafood, egg
Corrects vitamin B12
hypersensitivity
yolk, and fermented
deficiency.
reactions
cheeses; few
including
vitamins are lost
anaphylaxis
with ordinary
cooking.
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 9
Term: Fall I, 2016
● Emphasize the
importance of
follow-up exams to
evaluate progress.
Folic Acid
Therapeutic: antianemics,
Required for protein
Derm: rash.
● Encourage patient
(For low RBC vitamins. Pharmacologic:
synthesis and red
CNS: irritability,
to comply with diet
& low H&H)
blood cell function.
difficulty
recommendations of
Stimulates the
sleeping, malaise,
health care
production of red
confusion.
professional. Explain
blood cells, white
Misc: fever.
that the best source
water soluble vitamins
PO
QD
blood cells, and
of vitamins is a well-
platelets. Necessary
balanced diet with
for normal fetal
foods from the four
development.
basic food groups
Therapeutic Effects:
● Foods high in folic
Restoration and
acid include
maintenance of normal
vegetables, fruits,
hematopoiesis.
and organ meats;
heat destroys folic
acid in foods.
● Explain that folic
acid may make urine
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 10
Term: Fall I, 2016
more intensely
yellow. ● Instruct
patient to notify
health care
professional if rash
occurs, which may
indicate
hypersensitivity. ●
Emphasize the
importance of
follow-up exams to
evaluate progress
Atenolol
Therapeutic: antianginals,
(Due to
PO
QD
Blocks stimulation of
CNS: fatigue,
● Instruct patient to
antihypertensives
beta1(myocardial)-
weakness,
take atenolol as
previous MI,
Pharmacologic: beta
adrenergic receptors.
anxiety,
directed at the same
AFIB, CAD,
blockers
Does not usually
depression,
time each day, even
PVD,
affect
dizziness,
if feeling well; do
hypertension)
beta2(pulmonary,
drowsiness,
not skip or double up
vascular, uterine)-
insomnia,
on missed doses.
receptor sites.
memory loss,
Take missed doses
Therapeutic Effects:
mental status
as soon as possible
Decreased BP and
changes,
up to 8 hr before
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 11
Term: Fall I, 2016
heart rate. Decreased
nervousness,
next dose. Abrupt
frequency of attacks of nightmares.
withdrawal may
angina pectoris.
EENT: blurred
cause life-
Prevention of MI.
vision, stuffy
threatening
nose. Resp:
arrhythmias,
bronchospasm,
hypertension, or
wheezing. CV:
myocardial
bradycardia, hf,
ischemia.
pulmonary
● Advise patient to
edema,
make sure enough
hypotension,
medication is
peripheral
available for
vasoconstriction.
weekends, holidays,
GI: constipation,
and vacations. A
diarrhea,
written prescription
increased liver
may be kept in
enzymes, nausea,
wallet in case of
vomiting.
emergency.
erectile
● Teach patient and
dysfunction,
family how to check
decreased libido,
pulse and BP.
urinary
Instruct them to
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 12
Term: Fall I, 2016
frequency. Derm: check pulse daily
rashes. Endo:
and BP biweekly and
hyperglycemia,
to report significant
hypoglycemia.
changes.
MS: arthralgia,
● May cause
back pain, joint
drowsiness or
pain. Misc: drug-
dizziness. Caution
induced lupus
patients to avoid
syndrome.
driving or other
activities that require
alertness until
response to the drug
is known.
● Advise patients to
change positions
slowly to minimize
orthostatic
hypotension.
● Caution patient
that atenolol may
increase sensitivity
to cold.
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 13
Term: Fall I, 2016
● Instruct patient to
notify health care
professional of all
Rx or OTC
medications,
vitamins, or herbal
products being
taken, to avoid
alcohol, and to
consult health care
professional before
taking any new
medications,
especially cold
preparations.
● Patients with
diabetes should
closely monitor
blood glucose,
especially if
weakness, malaise,
irritability, or fatigue
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 14
Term: Fall I, 2016
occurs. Medication
does not block
sweating as a sign of
hypoglycemia.
● Advise patient to
notify health care
professional if slow
pulse, difficulty
breathing, wheezing,
cold hands and feet,
dizziness, lightheadedness,
confusion,
depression, rash,
fever, sore throat,
unusual bleeding, or
bruising occurs.
● Instruct patient to
inform health care
professional of
medication regimen
before treatment or
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 15
Term: Fall I, 2016
surgery.
● Advise patient to
carry identification
describing disease
process and
medication regimen
at all times.
● Hypertension:
Reinforce the need
to continue
additional therapies
for hypertension
(weight loss, sodium
restriction, stress
reduction, regular
exercise, moderation
of alcohol
consumption, and
smoking cessation).
Medication controls
but does not cure
hypertension.
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 16
Term: Fall I, 2016
Clopidogrel
Therapeutic: antiplatelet
(To reduce
Inhibits platelet
CNS: depression,
● Instruct patient to
agents Pharmacologic:
aggregation by
dizziness, fatigue,
take medication
risk of
platelet aggregation
irreversibly inhibiting
headache. EENT: exactly as directed.
recurring MI
inhibitors
the binding of ATP to
epistaxis. Resp:
Take missed doses
platelet receptors.
cough, dyspnea,
as soon as possible
Therapeutic Effects:
eosinophilic
unless almost time
Decreased occurrence
pneumonia. CV:
for next dose; do not
of atherosclerotic
chest pain,
double doses. Do not
events in patients at
edema,
discontinue
risk.
hypertension. GI:
clopidogrel without
GI bleeding,
consulting health
abdominal pain,
care professional;
diarrhea,
may increase risk of
dyspepsia,
cardiovascular
gastritis. Derm:
events. Advise
drug rash with
patient to read the
eosinophilia and
Medication Guide
systemic
before starting
symptoms,
clopidogrel and with
pruritus, purpura,
each Rx refill in case
rash. Hemat:
of changes.
Bleeding,
● Advise patient to
or stroke)
PO
QD
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 17
Term: Fall I, 2016
neutropenia,
notify health care
thrombotic
professional
thrombocytopenic promptly if fever,
purpura. Metab:
chills, sore throat,
hypercholesterole
rash, or unusual
mia. MS:
bleeding or bruising
arthralgia, back
occurs.
pain. Misc: fever,
● Advise patient to
hypersensitivity
notify health care
reactions.
professional of
medication regimen
prior to treatment or
surgery.
● Instruct patient to
notify health care
professional of all
Rx or OTC
medications,
vitamins, or herbal
products being taken
and to consult health
care professional
West Coast University Course Syllabus
Revision Date:July 8, 2016
Page 18
Term: Fall I, 2016
before taking any
other Rx, OTC, or
herbal products,
especially those
containing aspirin or
NSAIDs or proton
pump inhibitors.
Metformin
Therapeutic: antidiabetics
(For diabetes
management)
PO
BID
Decreases hepatic
GI: abdominal
● Instruct patient to
Pharmacologic:
glucose production.
bloating, diarrhea, take metformin at
biguanides
Decreases intestinal
nausea, vomiting,
the same time each
glucose absorption.
unpleasant
day, as directed.
Increases sensitivity to
metallic taste.
Take missed doses
insulin. …
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