MirekuG_CarePlan.doc - Howard Assignments

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Student Name: Gladys Mireku

Week: 2

Dates of Care:5/20/2023

Patient Initials

Sex

Age

Room

837

Admitting Date

5/19/2023

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Intractable headache

Attending physician/Treatment team:

Ayman M. Jabr, MD

Consults:

No consult

Present Diagnosis: (Why patient is currently in the hospital)

Headache and dizziness

ER Management: (if applicable)

Nile Township high school

Allergies:

Shrimp, Ibuprofen, Aspirin

Code Status:

Full code

Isolation: (type and reason)

none

Admission Height:

165.1 centimeters (5,5)

Admission Weight:

107.9 kilograms (237 lbs)

Arm Band Location (colors & reasons)

on the right arm and it's white

Communication needs: (verbal, nonverbal, barriers, languages)

the patient has no communication barriers

Past Medical History: (pertinent & how managed)

Diabetes Mellitus

Gerd

Hypertension

Obstructive Sleep Apnea

Sciatica

Spinal Stenosis

Degenerative Joint Disease

Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)

Tests/Treatments/Interventions impacting clinical day’s care (include current orders)

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Time

8: 00

98.6

B/P

138/80

Time

13: 00

97.9

B/P

111/73

GI:

Diet: Regular

Swallow precautions:

Tube feedings:

NG / G tube:

Blood Glucose: (time & date)

Last bowel movement: (time & date)

Pertinent Labs/Test:

Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

Respiratory:

02 modalities:

02 Saturation: 96

Suction:

Resp Rx’s:

Trach: none

Chest Tubes: none

Pertinent Labs/Test:

Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

Neurosensory:

Neuro checks:

Alert & Orientated: x4

Follows commands: yes

Speech Comprehensible: yes

Pertinent Labs/Test:

Assessments/Interventions:

(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)

patient had dizziness and headache

Cardiovascular:

Telemetry:

Pacemaker/IAD:

DVT Prevention: heparin (5000 units)

Daily Weights:

Pertinent Labs/Test:

Assessments/Interventions:

(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)

Musculoskeletal:

Activity: independent

Traction: none

Casts/Slings:

Pertinent Labs/Test:

Assessments/Interventions:

(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps

Renal:

Catheter (indwelling/external):

CBI:

Dialysis:

A/V access:

Pertinent Labs/Test:

Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)

Pain:

Pain score: 10 in the head

Assessments/Interventions: acetaminophen was given

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

morphine

Vascular Access: (IV site)

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)

Gyn:

Gravida/Para: none

LMP: none

Last Pap: none

Breast exam: none

Pertinent Labs/Test

Assessment/Interventions: (bleeding, discharge) none

Post-operative /procedural:

Assessments/Interventions: none

(immediate post procedure care)

Safety:

Call light:

Bed Rails:

Bed alarms: no need

Fall risk: not at 4 risk

Assistive Devices: none

Sitter use: none

Restraints (type, duration & reason):

Assessment/Interventions (modifications to room, environment, Patient)

Advance Directives/Ethical considerations:

DPOA: has no advanced directives

Hospice:

Pertinent Data (Labs, X-rays, Etc.)

Results

Normal Lab Values

Significance to your patient

WBC

7.2

5.2-12.4

RBC

5.37

4.7-6.2

HGB

17.3

12.0-15.0

HCT

48.9

37-50%

MCV

91.0

95.3

MCH

32.3

27-31

MCHC

35.5

32-36

Platelets

207

151-401

RDW

14.5

12-15%

MPV

8.3

7-9

CBC

INR

APTT

Glucose

225

70-99

BUN

7-25

Creatinine

0.86

0.6-1.3

Sodium

134

135-145

Potassium

5.3

3.5-5.2

Cloride

98-107

Calcium

9.0

8.6-10.3

T Protein

6.4

Albumin

3.8

SGOT

SGPT

Alk Phos

Magnesium

Amylase

Lipase

CPK

LDH

Cholestrol

CK-MB

Troponin I

Myoglobin

LDI

Urinalysis

Color

Character

Spec. Grav.

Protein

Glucose

Acetone

Bilirubin

Blood

Nitr

Urobili

RBC

WBC

Epithelium

Urine Culture

Chest X-ray

MRI

CT Scan

Others test:

Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics)

Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions)

Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:

Current overall plan of care: (A short statement that summarizes the anticipated plan of care)

Discharge plans and needs:

Teaching needs:(Disease process, medications, safety, style, barriers)

Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. Include appropriate references and use APA format.

Attach a research article pertaining to diagnosis of patient. Write a summary about the article.

The study was about proportion of people suffering from headache and dizziness during the prodromal stage of migraine and the related effects. Approximately one third experience headache phase-associated dizziness or vertigo, with similar rates for both symptoms. The findings from the meta-analysis indicate the current research criteria for vestibular migraine may be inadequate, as migraine patients where dizziness is the primary manifestation of the vestibular symptom might be overlooked. However, methodological variations confound comparisons of epidemiological patterns. Future studies should use rigorous methodology and adhere to standardized definitions to enable accurate measurements of vestibular symptoms during both the prodromal phase and headache phase of migraine.

Iljazi, A., Ashina, H., Lipton, R. B., Chaudhry, B., Al-Khazali, H. M., Naples, J. G., … & Ashina, S. (2020). Dizziness and vertigo during the prodromal phase and headache phase of migraine: A systematic review and meta-analysis. Cephalalgia, 40(10), 1095-1103.

List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis.

Priority	Nursing Diagnosis	Related to	As Evidence By	Rationale (reason for priority)
1	Acute pain	Acute pain related to or coming from a medical problem	Evidenced by patient verbalizing pain and rating the pain at 10 in a numeric pain scale	Pain results in an unpleasant sensory and emotional experience which is a risk to potential tissue damage due to unpredictable events following pain effects.
2	Imbalanced nutrition more than the body requirements	Imbalanced nutrition related to imbalanced nutrient intake due to a metabolic disorder.	Evidenced by basal metabolic index of 39.6.	Obesity is a major risk factor to some conditions in the body. It exacerbates the severity of diseases such as diabetes mellitus and hypertension. Managing obesity improves the prognosis to patients suffering from these conditions and many others
3	Risk of infection	Risk of infection related to a possible site of organism invasion-indwelling catheter		Indwelling catheterization is a procedure which, if aseptic technique and hygiene is not properly observed may be a possible site for organism invasion and therefore risk a patient to an infection.
4
5

Medications

Classification

Dose

Route

Freq

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Ascorbic acid (Vitamin C)

100 mg tablet

Oral

Daily

Atorvastatin (Lipitor)

10 mg tablet

Oral

Daily

Dexamethasone (Decdron)

8mg IM

Injection

Intravenous

Acetaminophen

650 mg

Orally

PRN

Diphenhydramin (Benadryl)

25 mg injection

Injection

Intravenous

Enalapril (Vasotech)

10 mg

Oral

Daily

Furosemide (Lasix)

40 mg

Oral

Daily

Glucagon

1 mg

PRN

Heparin

5000 units

Continuous

Insulin Aspart (Novolog)

18 units

IM, Subcontanous

3 times daily with meals

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Statement of purpose for the patient to achieve

Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

(Must have at least two short term outcomes and two long term outcomes)

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

Acute Pain

Patient describes satisfactory pain control of less than 3 in the same numeric pain scale

1. Patient will exhibit signs of pain relief within 30 minutes

2. Patient displays improved wellbeing, mood and coping.

3. Patient remains comfortable with no pain disturbance.

1. Administer analgesics i.e. acetaminophen. They work by blocking the synthesis of prostaglandins which stimulate nociceptors thereby relieving pain.

2. Provide rest periods to promote rest relief and sleep. Ones experiences of pain may become exaggerated as a result of exhaustion. A peaceful and quiet environment may stimulate pain relief

3. Get rid of stressors or any form of discomfort by all means possible. A patient may experience an exaggerated painful situation if exposed to stressors leading to further pain.

Patient could now rate pain at 2 in a numeric pain scale of one to ten. Patient exhibited signs of comfort.

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Statement of purpose for the patient to achieve

Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

(Must have at least two short term outcomes and two long term outcomes)

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

Imbalanced nutrition more than body requirements

Patient designs a dietary modification to achieve weight control.

1. Patient knows the necessary dietary modifications so as to reduce weight.

2. Patient will verbalize accurate information on benefits of weight loss.

3. Patient will maintain an overall balanced nutrition

1. Negotiate as well as educate the patient the aspects of his diet that require to be modified. Such negotiations and agreements with the patients allow harmonious care to the patient and hence a good prognosis.

2. Educate the patient on risks associated with obesity. Informed decisions are important in the patient’s own decision making on issues that will affect him.

3. Suggest to the patient to keep a diary of food intake and the circumstances surrounding its consumption. Self-monitoring helps the patient assess self-adherence to self-determined performance criteria and progress towards desired goals

Patient reduced weight; patient nutritional status was maintained at balanced state.

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