NUR2115 Module 10 Comprehensive Plan of Care Assignment

Want create site? With you can do it easy.

NUR2115 Module 10 Comprehensive Plan of Care Assignment

In this third and final submission of your Course Project, you will be completing a comprehensive care plan. This written assignment should include the following: Comprehensive Plan of Care Develop a comprehensive plan of care/treatment with short and long term goals and include safety needs, special considerations regarding personal needs, cultural/spiritual implications, and needed health restoration, maintenance, and promotion.

Don't use plagiarized sources. Get Your Custom Essay on
NUR2115 Module 10 Comprehensive Plan of Care Assignment
Just from $13/Page
Order Essay

Patient education: (Example: medication, safety, possible complications associated with the patient).Complete in a narrative format exactly how you would educate the patient.Include at least 7 narrated sentences.

Outcome: Caring:

Identify one example from your clinical day in which you observed, participated in or provided some aspect of caring for the provision of psychosocial and/or cultural diversity needs.

Evidence-based Practice (EBP): Summarize one article published within the last 3 years that you could use to improve the care you provide to this patient. Utilize learning resources available through Rasmussen Online library. Include APA citation in reference list.

References

Clinical Site/ Unit: TCU
Patient Initials: S.D
Gender: Female
Age: 71
Weight: 287lbs
Height: 64.0
Baseline vitals (from the patient chart)
Date: 02/07/19; B/P: 127/52; Pulse: 85 bpm; RR: 16 bpm; T/mode: 98 (Tympanic)
Pulse ox: 98.0%
Vital Signs Assessment (Taken by me)
B/P: 143/58; HR: 72 bpm; RR: 19 bpm; T: 97; SpO2: 94%
Allergies: Amlodipine, Meperidine, Nitroglycerin, Polyethylene Glycol, Simvastatin, NSAIDs, Penicillin, Sulfa Antibodies
Code Status: Full code
Social Health: Husband of 44 years; Daughter (EMT); Son (EMT Firefighter)
Marital Status: Married
Cultural Background: Caucasian
Primary Language: English
Past Medical/ Surgery History: Had depression in the past and is treated for it.
Family Health History: Mental health problem, had depression in the past
Diet: Consistent carbohydrate diet, Regular Texture texture, Thin Liquid consistency
Special Instructions: Preferences for taking medications – water with ice, ice tea
Activity/Assistive Devices: No assistive devices required
Treatment Orders: Not required
Tubes/ Drains/ Ostomies: No Tubes/ Drains/ Ostomies required
Interdisciplinary Cares (OT/ PT/ ST) and frequency: No interdisciplinary cares noted
Dressings/ Wounds: (type & location): No Dressing/ Wounds noted

ASSESSMENT SUMMARY
Body System Subjective: Patient’s Health History Objective: My assessment findings
Pain Level (pain scale 0-10/ location): Patient reports pain of 6.5 out of 10 (leaning forward) and 3 out of 10 (still sitting) Pain rating: 0-10:
Characteristic: Temporal

Onset: When leaning forward

Location: Right shoulder

Description (dull, aching,
sharp): Sharp pain

Exacerbating factors factor(s): Comes and go.

Relieving factor(s): Pain medications (oxyCODONE)
Orientation:

Head/Eyes/ Ears/ Nose/ Throat (HEENT): Patient reports no trauma to the head. Does not experience any headache.

Patient reports no problem with vision, no eye pain, no glasses or contact lenses, no history of an ocular problem, no blurring, no blind spot.

Patient reports no ear pain, no history of ear infections, no ear discharge, and no hearing loss.

Patient reports nose is always clogged. Patient reports no experience of headaches and trauma to the head.

Orientation (person, place, time and situation): Patient alert and oriented X 4. Had four (4) brain surgery to stop trimmers.

Speech (clear/appropriate): Speech is clear

PERL (pupils equal and reactive to light): Pupils are equal and reactive to light. Had a cataract surgery.

Ears (clean/dry): No lesions, no drainage, CN8 intact, no hearing aids

Nose (clean/dry/intact): Symmetrical no deformities, no lesions, mucosa and turbinate are pink, moist, no exudates, no septal deviation, no perforations.

Throat (pink, moist): Thrush on her tongue from a fungal infection, has sore on the mouth (lip), oral mucosa is pink and moist, and the patient has good dentition. Good symmetrical movement. The pharynx is normal in appearance without tonsillar or exudates. No adenopathy is noted. CNS I-XII (All intact).
Musculoskeletal: Patient reports arthritis in fingers but does not have rheumatoid arthritis

MAE (moves lower extremities very well, and left upper extremity

Weakness: Right shoulder

Assist (transfers/ambulation): Stand by assist with all transfers and ambulation.

Assistive device (walker, cane): no use of any assistive devices (walker or cane).
Respiratory: Patient reports no cough, no shortness of breath, no chest pain, no smoking history, no history of respiratory infections, and no environmental exposure. Respirations: 19 bpm

Rate: Regular

Lung sounds: quick deep on inspiration and quick shallow on expiration

Cough: No cough noted

SOB: no shortness of breath
Cardiac: Patient reports no chest tightness, no recent fatigue. AP (apical pulse): 72 bpm

Rate (regular): Is regular.

Chest pain: No chest pain

Peripheral pulses: Brachial, Carotid, Radial, Dorsal Pedis

Edema: Lower extremities – 4+ pitting edema

Capillary refill: Less than 3 seconds
Integument: Patient reports no leg pain, no leg cramps Skin ( moist, intact): Skin is moist and intact, not dehydrated, warm to touch

Color (pink, pale, cyanotic): Skin is pink

Wound(s): 2-3 inches red bruise on left foot from blister.

Dressing(s): No dressings on any part of body.
Gastrointestinal (GI): Patient reports no bowel problems. Patient reports having a bowel a day before. Bowel sounds (x4): Bowel sounds regular and present in all 4 quadrant.

Nausea/vomiting: no nausea or vomiting

Pain/tenderness with palpation: No pain on palpation

Last BM: 2 bowel movements a day ago (02/06/19)

Continent: Continent of bowels
Genitourinary (GU); Patient reports no problem with voiding. Patient reports voiding 8-10 times a day Frequency of urination (q2h, q4h, foley): 8-10 times a day. Approximately q2h.

Color: Pale yellow

Dysuria (frequency, burning):
No pain or burning sensation

Continent: Continent
Endocrine; Patient reports no abnormal growth, no endocrine disease or disorders, no abnormal temperature Diabetic/ Blood sugar: 193.0

Diet: Consistent carbohydrate diet, Regular Texture texture, Thin Liquid consistency

Appetite (%): 75%
Psychosocial/ Spiritual: Patient reports associating with Native American Spirituality and is Buddhist. Patient reports having a strong family support. Good spirits/ Pleasant: Very active and good spirit

Sad/ Tearful/ Anxious: She is not sad, tearful or anxious

What is resident main concern during their stay? To walk 3-4 times a day to get lower extremities working.

Main concern after they discharge? To be able to go back to work and go about normal business.

Medication Data Sheet
Drug Name Trade and generic name, dose, route& frequency Drug Classification Expected action and indication for use Medical Diagnosis
Side Effects and Adverse Reactions Nursing Administration special instructions and assessments Client Education Evaluation of medication effectiveness, e.g., Pin Scale
Acetaminophen (Tylenol) Tablet 500 mg. Give 2 tablets by mouth orally 3 times a day. No more than 4000 mg in 24 hours, also a PRN dose of 1000 mg. It is used to treat mild to moderate pain. For pain experiencing in Right shoulder. Side effects: Nausea, stomach pain, loss of appetite, itching, rash, headache, dark urine.
Adverse reaction: Difficulty breathing or swallowing, swelling of the face, lips, throat or tongue. Hives, severe itching

Assess the history of pain.

Demonstration of relieving of pain on the pain scale 0-10

Vitamin D3 (Cholecalciferol) tablet 5000 units. Give one pill by mouth two times a day.

Treatment or prevention of vitamin D deficiency. For Closed Fracture off the head of the right humerus Side Effects: Kidney stones, confusion, disorientation, muscle weakness, frequent urination, nausea, vomiting, constipation.
Adverse Effects: Extremely large doses can cause toxicity. I am assessing patient carefully for evidence of hypocalcemia, assessing for symptoms of vitamin deficiency before and periodically.

Normalization of serum calcium and parathyroid hormone levels.
Resolution of prevention of vitamin D deficiency.
Gabapentin (Neurontin) Capsule 300 mg. Give 300 mg by mouth two times daily. Neuropathic pain, diabetic peripheral neuropathy. For neuropathic pain Side effects: sleepiness, dizziness, fatigue, clumsiness while walking, weight gain, tremor
Adverse effects: Skin rash, unusual bruising, swollen glands, muscle aches. Assess the location, characteristics, and intensity of pain periodically during therapy.

Decreased intensity of neuropathic pain.
Wellbutrin (buPROPion HCL, ER) SR Tablet Extended Release. Every 12 hours 200 mg.
Give 1 tablet by mouth two times a day. Treatment of depression. The patient is taking for depression and has a history of depression. Side Effects: dry mouth, sore throat, nausea, vomiting, flushing, headache, abdominal pain.
Adverse Effects: mood or behavior changes, anxiety, depression, panic attack. Assess mental status and mood changes, inform health care provider if the patient demonstrates a significant increase in signs of depression.

Increased sense of well-being, renewed interest of surroundings.
Protonix (Pantoprazole Sodium) Tablets Delayed-Release 40 mg.
Give 1 mg tablet by mouth two times a day. Erosive esophagitis associated with GERD. Maintenance of healing of erosive esophagitis. The patient is taking this medication for GERD. Side Effects: headache, nausea, vomiting, diarrhea, stomach or abdominal pain, gas, dizziness.
Adverse Effects: Facial edema, hyperglycemia, photosensitivity
I am assessing patient routinely for epigastric or abdominal pain.

Decreased in abdominal pain, heartburn, gastric irritation and bleeding in patients with GERD.

Nursing Diagnosis Expected Outcomes (S.M.A.R.T) Specific, measurable, attainable, realistic, & time oriented (ID a future time or date for reassessment/ evaluation Nursing Interventions
#1
Acute pain

R.T.
Movement of bone fragments, edema, and injury to the soft tissue

A.M.B.
Reports of pain The patient will verbalize relief of pain.

Short-term goal: Patient verbalizes minimized or controlled feeling of pain.

Long-term goal: Patient is free of pain on surgical site.

Maintain immobilization of affected part by means of bed rest, cast, splint, traction.

#2
Impaired Physical Mobility

R.T.
Neuromuscular skeletal impairment; pain/discomfort; restrictive therapies (limb immobilization)

A.M.B.
Reluctance to attempt movement; limited ROM The patient maintain position of function.

Short-term goal: After 4 days of nursing intervention, the patient will be able to demonstrate techniques and behaviors that enables resumptions of activities.

Long-term goal: After 4 days of nursing intervention, the patient will be able to maintain or increase strength and functions of affected body part.

Instruct patient or assist with active and passive ROM exercises of affected and unaffected extremities.

#3
Skin/Tissue Integrity, impaired: actual/risk for

R.T.
Physical immobilization

A.M.B.
Reports of itching, pain, numbness, pressure in affected/surrounding area The patient verbalize relief of discomfort.

Short-term goal: After 6-8 hours of nursing intervention the patient will have reduced risk of further impairment of skin integrity.

Long-term goal: After 3-4 days of nursing intervention the patient will be able to reduce risk of infections.

Assess position of splint ring of traction device.

Which of your diagnoses are Priority using Maslow’s Hierarchy of Needs: Impaired Physical Mobility according to Maslow’s Hierarchy of Needs, physiologic needs should satisfy first, so that the patient should satisfy this to satisfy her physiologic needs.

Evaluation: Were any of your short term expected outcomes met during your shift? None of the short-term expectations were met during my shift.

How might you revise your care plan next time to achieve at least one outcome during your shift? I plan on improving my care plan next time by monitoring my patients’ recovery process keenly and offering effective ways to have my patient be able to decrease edema and promotes venous return.

Medical Diagnosis
1. The patient diagnosed with an Unspecified Displaced Fracture of Surgical Neck of Right Humerus the pieces of bone at the fracture site are separated and shifted out of position. This type of fracture typically requires surgery. Proximal humerus fractures are diagnosed by a thorough physical examination and diagnostic imaging (Stanley, n.d.).
2. Humerus fractures are caused by direct harm to the arm shoulder. About 20% of humerus fractures are displaced and mostly occur in baseball games. Such type of fracture requires a more intrusive treatment like surgery
3. A subsequent encounter is experienced when an active treatment of the patient’s injury has been offered, and the patient is now receiving routine care for the injury in the healing process (Deter, 2006). An example is medical ex-rays to monitor the healing process of the fracture
4. Asthma is an inflammatory disease of the airway demonstrated by various recurring symptoms and bronchospasm. Common symptoms of asthma include; coughing, wheezing, short breaths, and chest tightness.
5. A major depressive disorder is a mental disorder demonstrated by two weeks or more of low mood. It is accompanied by loss of interest in several things, low self-esteem, pain with no clear cause and low energy. Patients with depression often hear or see things that are unseen by other people. They affect patients negatively as some end up committing suicide (Deter, 2006).
LAB RESULTS
DATE LAB TEST NORMAL VALUE CLIENT VALUE SIGNIFICANCE OF ABNORMAL LAB VALUE
01/27/19 Sodium

135-145 mmol/L 134 (L) The significance of abnormal sodium lab value is hyponatremia.
01/27/19 BUN/Creatinine Ratio

10-20 mg/DI 27 (H) This mean the patient may not be getting enough blood flow to their kidneys, and could have conditions such as congestive heart failure, dehydration, or gastrointestinal bleeding.
01/27/19 Hemoglobin

12.0-16.0 g/DI 7.8 (L) This mean that there is a nutritional deficiencies such as iron, folate or B12 deficiency.

01/27/19 ALK Phosphate 50-136 IU/L 144 (H)

Elevated ALK Phosphate is most commonly caused by liver disease or bone disorders.
01/27/19 RBC 4.00-5.20 mil/cu mm 2.95 (L)

This could signify trauma in the patient.

Diagnostic Tests
Tests Results Significance

US Venous Upper Extremity Right Indication: Right Humerus Fracture The right arm veins are negative of DVT It enables the nurse to know where exactly the fracture happened and the intensity of the fracture to administer proper medication.
EKG 12- Lead Interpretation: Artifact, Sinus rhythm, right Atrial enlargement, Abnormal ECQ It directs the nurse on the exact medication to use.

References

Deter, L. L. (2006). Basic medication administration skills. Australia: Thomson Delmar Learning.
Stanley, L. (n.d.). Moving Forward: Physical Therapy Brings Motion to Life. https://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=937e6560-3300-4bdc-9285-16d9cb759554

Did you find apk for android? You can find new and apps.

What Will You Get?

We provide professional writing services to help you score straight A’s by submitting custom written assignments that mirror your guidelines.

Premium Quality

Get result-oriented writing and never worry about grades anymore. We follow the highest quality standards to make sure that you get perfect assignments.

Experienced Writers

Our writers have experience in dealing with papers of every educational level. You can surely rely on the expertise of our qualified professionals.

On-Time Delivery

Your deadline is our threshold for success and we take it very seriously. We make sure you receive your papers before your predefined time.

24/7 Customer Support

Someone from our customer support team is always here to respond to your questions. So, hit us up if you have got any ambiguity or concern.

Complete Confidentiality

Sit back and relax while we help you out with writing your papers. We have an ultimate policy for keeping your personal and order-related details a secret.

Authentic Sources

We assure you that your document will be thoroughly checked for plagiarism and grammatical errors as we use highly authentic and licit sources.

Moneyback Guarantee

Still reluctant about placing an order? Our 100% Moneyback Guarantee backs you up on rare occasions where you aren’t satisfied with the writing.

Order Tracking

You don’t have to wait for an update for hours; you can track the progress of your order any time you want. We share the status after each step.

image

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

image

Trusted Partner of 9650+ Students for Writing

From brainstorming your paper's outline to perfecting its grammar, we perform every step carefully to make your paper worthy of A grade.

Preferred Writer

Hire your preferred writer anytime. Simply specify if you want your preferred expert to write your paper and we’ll make that happen.

Grammar Check Report

Get an elaborate and authentic grammar check report with your work to have the grammar goodness sealed in your document.

One Page Summary

You can purchase this feature if you want our writers to sum up your paper in the form of a concise and well-articulated summary.

Plagiarism Report

You don’t have to worry about plagiarism anymore. Get a plagiarism report to certify the uniqueness of your work.

Free Features $66FREE

  • Most Qualified Writer $10FREE
  • Plagiarism Scan Report $10FREE
  • Unlimited Revisions $08FREE
  • Paper Formatting $05FREE
  • Cover Page $05FREE
  • Referencing & Bibliography $10FREE
  • Dedicated User Area $08FREE
  • 24/7 Order Tracking $05FREE
  • Periodic Email Alerts $05FREE
image

Our Services

Join us for the best experience while seeking writing assistance in your college life. A good grade is all you need to boost up your academic excellence and we are all about it.

  • On-time Delivery
  • 24/7 Order Tracking
  • Access to Authentic Sources
Academic Writing

We create perfect papers according to the guidelines.

Professional Editing

We seamlessly edit out errors from your papers.

Thorough Proofreading

We thoroughly read your final draft to identify errors.

image

Delegate Your Challenging Writing Tasks to Experienced Professionals

Work with ultimate peace of mind because we ensure that your academic work is our responsibility and your grades are a top concern for us!

Check Out Our Sample Work

Dedication. Quality. Commitment. Punctuality

It May Not Be Much, but It’s Honest Work!

Here is what we have achieved so far. These numbers are evidence that we go the extra mile to make your college journey successful.

0+

Happy Clients

0+

Words Written This Week

0+

Ongoing Orders

0%

Customer Satisfaction Rate
image

Process as Fine as Brewed Coffee

We have the most intuitive and minimalistic process so that you can easily place an order. Just follow a few steps to unlock success.

See How We Helped 9000+ Students Achieve Success

image

We Analyze Your Problem and Offer Customized Writing

We understand your guidelines first before delivering any writing service. You can discuss your writing needs and we will have them evaluated by our dedicated team.

  • Clear elicitation of your requirements.
  • Customized writing as per your needs.

We Mirror Your Guidelines to Deliver Quality Services

We write your papers in a standardized way. We complete your work in such a way that it turns out to be a perfect description of your guidelines.

  • Proactive analysis of your writing.
  • Active communication to understand requirements.
image
image

We Handle Your Writing Tasks to Ensure Excellent Grades

We promise you excellent grades and academic excellence that you always longed for. Our writers stay in touch with you via email.

  • Thorough research and analysis for every order.
  • Deliverance of reliable writing service to improve your grades.
Place an Order Start Chat Now
image