PN2 Care Plan 2022/2023 - Rasmussen College | NUR 2571 Care Plan 2022/2023 - A Grade

PN2 2571 Care Plan 2022/2023 - Rasmussen College Nursing Clinical Packet Patient Assessment and Care Plan Instructions to student: 1) You must submit a minimum of two acceptable packets to pass your clinical. Each packet is worth 35pts towards your Fundamentals course grade. 2) Please submit the packet electronically in your clinical course shell, then please record your answers in bold or in a colored or lower case font. This helps us identify your answers more quickly. PATIENT ASSESSMENT FORM STUDENT NAME: Marina Marmolejo DATE: 2/8/2019 CLIENT INITIALS: JC ROOM # 124 DOB:8/18/34 AGE : 84 GENDER: F ADMISSION DATE: 1/25/15 CODE STATUS: N/A ALLERGIES: N/A MARITAL STATUS: Widow OCCUPATION (FORMER): teacher MEDICAL DIAGNOSIS (ES) Dementia ADMITTING CHIEF COMPLAINT : forgetfulness PAST HISTORY (SURGERY/PROCEDURES) WITH DATES N/A ORDERS (current orders) RATIONALE (Why is this ordered for this client???) EXAMPLE: DIET 2 g Sodium diet with nectar thick liquids only Sodium is restricted due to edema in the bilateral lower extremities and nectar thick liquids due to dysphagia from a past stroke. DIET regluar No difficulty swallowing ACTIVITY Mobile No need for assistive devices I/O Q8 Check output once per shift VS Q8 Check vitals once per shift BLOOD GLUCOSE daily General monitoring FOLEY N/A NG N/A PEG/PEJ TUBE N/A WOUND CARE N/A RESPIRATORY TREATMENT Breathing treatments BID Shortness of breath TRACHEOSTOMY N/A SUCTIONING N/A CHEST TUBE N/A SPECIAL EQUIPMENT N/A LAB ORDERS UA, CBC To monitor increasing confusion OTHER REHAB SERVICES ACTIVITY OR TREATMENT PLAN & SCHEDULE RATIONALE PHYSICAL THERAPY daily Increase activity SPEECH THERAPY N/A OCCUPATIONAL THERAPY daily Increase ADL`s / 1 pts IVs (if applicable) IV FLUID AND RATE: N/A SITE LOCATION AND CONDITION: N/A LAST DRESSING CHANGE: N/A LAST TUBING CHANGE: N/A GAUGE: N/A REASON FOR IV ACCESS: N/A DIAGNOSTIC TESTS: (at least 2) DATE RESULTS REASON FOR TESTING AND IMPLICATIONS FOR NURSING CARE Mini Cognitive test 1/13/17 Positive Patient expressed confusion and orientation CT of brain 12/30/18 Positive confusion, frequent falls, eloping LAB TEST (fill in each line- 13 lines) DATE RESULTS NORMS REFERENCE RANGES IMPLICATIONS FOR NURSING CARE (WHAT CAN YOU DO TO HELP IMPROVE AN ABNORMAL RESULT?) UA 1/13/17 Positive Negative leukocytes Good peri care, frequent toileting Amnonia 12/3/18 Negative 15-45 U-DL Administer lactolose Lactic acid 2/5/12 Negative <2 Administer antibiotics, IV fluid Procalcitonin 12/3/17 Negative < .15 NG per ML Administer antibiotics, IV fluid Blood cultures 1/3/17 Negative Negative Administer anitbiotcs, repeat blood cultures within 24 hours. Sodium 12/3/18 137 135-145 IV fluid, incread/decrease salt intake Potassium 1/12/17 4.0 3.5-5 Kayexalate to lower potassium- supplements to rise. Glucose 1/15/18 109 60-110 Insulin or dextrose, administer juice or cracker BUN 12/15/18 15 6-20 IV fluids, rehydrate Creatinine 12/12/18 1.0 .5-1.5 IV fluids, rehydrate kidneys TSH 1/16/18 3.5 .4-4 IV fluids A1C 5/8/18 4 <6 Diabetes education, diabetic diet, calorie counting Vit B12 6/12/18 350MG per ML 200 to 900 MG per ML Vitamin B12 injections, iron replacements, folic acid supplements GROWTH and DEVELOPMENT: (see pages 378-379 Taylor, Lillis and White) CLIENT’S DEVELOPMENTAL STAGE ACCORDING TO HAVIGHUSRT CLIENT’S SUPPORT SYTEMS (FAMILY or FRIENDS) Three adult children live out of state, Husband passed away TASKS OF THIS STAGE: Late maturity ASSESSMENT OF CLIENT’S SUCESSFUL ACHIEVEMENT OF TASKS Patient completes all ADL`s up to her ability. Some assistance needed at night. / 1 pts MEDICATIONS - - - - - - - - - - - - - - - - - - - - - - - - - SUBJECTIVE DATA: Patient refuses shower/grooming as she states already been done SHORT TERM: Daily shower and oral hygiene 1. Frequent toileting 2. Shower schedule 3. Reward system 1. Frequent toileting will prevent incontinent occurrences. 2. Repetitive behavior will create routine for patient 3. Positive reinforcements will create positive behavior. Short term: shower daily Long term goal: patient needs prompting but no longer refuses hygiene regimens. (Nursing Diagnoses: Definitions and Classification, N.D). OBJECTIVE DATA: Poorly groomed hair, foul odors, dirty clothes LONG TERM: Patient will perform ADL’s without assistance Short term outcome: An outcome that can be accomplished by the end of the student clinical day. Long term outcome: An outcome that can be accomplished by a week, a month or by discharge. Interventions: Each nursing intervention must come from a reliable nursing reference or source and be individualized to the client. Please note: do not use nursing care planning book exclusively. Not more than one intervention and validating scientific rationale can come from a source outside your textbooks. Scientific Rationales: Give enough of the text to validate your intervention. Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org) /12 References: Nursing Diagnoses: Definitions and Classification. (n.d.). Retrieved from Student Name: Clinical Date: Site: Section Grading Criteria Satisfactory Or Unsatisfactory Comments, Kudos, Things to Improve for Next Time 2 points Patient Demographics, Diagnoses, Surgeries, Orders, Rehab, IV, Imaging and Lab Page 1 fully and correctly completed Page 2 fully and correctly completed ___/2pts___ 5 points Medications Medication Trade Name/ Medication Generic Name Pharmacological Classification Normal Dosage Range Dose ordered Route and Frequency Contraindications Adverse Effects/Reactions Why is client on the medication? Effects of medication on Client Nursing Considerations & Teaching __ /5pts__ 2 points Narrative Notes Head-to-Toe Assessment Narrative note is in Head to Toe order Head-to-toe assessment documented. Abnormal results noted __/2 pts__ 26 points Patient Care Plan 2 nursing diagnoses Related to” “As evidenced by” 2 nursing diagnoses “at risk” 2 NANDA nursing diagnoses 2 Assessment data 4 Outcomes specific, measurable, timed 6 Interventions are logical, appropriate 6 Scientific Rationales Evaluations ____/26 pts Total Points ___/35_pts__