Nursing Care Plan

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Medical Diagnoses:Acute cellulitis of bilateral lower extremities with necrosis; hyponatremia; community acquired pneumonia

Demographic Information

Health History

Care Prescriptions

Age: XX

Chronic Health Conditions & Previous Health Problems:

Diet:  Regular

Gender: male

Race:  XX

                 

Right>Left pleural effusion; Chronic A Fib; Chronic Renal Insufficiency; Hypokalemia; Constipation; Traumatic Pneumothorax x2 thoracentesis; cellulites bilateral with necrosis

›  G tube

› NG tube 

NOT APPLICABLE

Code Status:   DNR

  

Weight:  192 lbs.

Height:

68 in.

                 

Activity:    ambulate with walker and assist with clinical assistant

Reason for Admission [residents own words]:

                 

                 

                 

n/v for 5 days and went to the hospital and got pneumonia, and got cellulites in both lower extremities

                 

                 

Medical Complications:

I & O:  Client is encouraged to consume fluids. Voids while using the urinal    

        

Medical Diagnosis [medical terms]:

                 

Pain in lower extremities; pain in right upper extremities.

Wound Care:  dressing change on bilateral lower extremities once a day

Acute cellulitis of bilateral lower extremities with necrosis; hyponatremia; community acquired pneumonia


  

                 

                 

Turning/Repositioning program

NOT APPLICABLE

                 

                 

                 

                 

                 

Pulmonary care: 

Date of admission:  [date]

                 

Nursing Diagnoses (3. prioritized)

1. Risk for infection r/t tissue destruction ABE breakdown on the sacrum
2. Risk for impaired skin integrity r/t diabetes AEB lesions and sores on lower extremities

3. Risk for ineffective tissue perfusion r/t impaired arterial circulation AEB 2+ edema bilateral on lower extremities

4. Risk for fall r/t impaired mobility AEB weight bearing pain on bilateral lower extremities

5. Risk for toileting self-care deficit r/t impaired mobility AEB need for assistance when ambulating

NOT APPLICABLE

Previous Surgeries                 When?

Tonsillectomy                      23 years old

   

Circumcision                        24 years old

                 

    Med. › albuterol › atrovent 

                *other Combvient Inhaler

Allergies:

                 

Glucometer:  Type II Diabetes

X ac/hs

X sliding scale insulin

No Known Allergies

                 

                 

                 

                 

Other: 

Discharge Plan/ Long Term Goals:

                 

                 

Regain strength to walk with out a walker

                 

                 



Describe pathophysiology of primary illnesses

Acute Cellulitis: it is an infection of the dermis and subcutaneous tissue. It is an infected area that is warm, erythermatous, swollen, and painful. The infection is usually in the lower extremities and responds to systematic antibiotics. To help with pain, Burow soaks is implemented (Huether, 2008).   

Hyponatremia: develops when the serum sodium concentration falls below 135 mEq/L. Sodium deflects usually causes hypoosolality with movement of water into the cells. Pure sodium deficits usually are caused by extrarenal losses, such as vomiting and diarrhea. This alters the cells ability to depolarize and repolarize normally. Pure sodium loss can be accompanied by loss of extra cellular fluid which can cause isotonic hypovolemia (Huether, 2009)

                 

                 

Name/Dose

Why does resident receive?

Major Side Effects

Nursing Implications

Acetaminaophen

500 mg tablets

2 tablets PO Q4

          

                 

Mild pain and if temp reaches over 101 degrees

rash, acute poisoning, anorexia, nausea, vomiting, dizziness, lethargy, hepatotoxcity, hepatic coma, acute renal failure

monitor for signs and symptoms of hepatoxcity even with moderate acetaminophen doses, especially in individuals with poor nutrition or who have ingested alcohol over prolonged periods.

          

Lotrimin Cream

One application to feet BID

          

          

Acute Cellulites to bilateral feet

                 

urogenial: vulvovaginal burning, itching, or irritation; maceration, allergic contact dermatitis

expect clinical improvement from topical application in 1-2 weeks.

Senna Plus

8.6-50 mg tablets

1 tablet PO BID

PRN

          

          

Constipation

abnormal cramps, flatulence, nausea, watery diarrhea, excessive loss of water and electrolytes

reduce dose in patients who experience considerable abdominal cramping.

the drug may alter your urine and feces color.

          

Glucotrol (XL)

5 mg PO Q day

          

          

          

Diabetis Mellitus Type 2

hypersensitivity to sulfonylureas, diabetic ketoacidosis,

observe response to initial dose, lab test to monitor liver function, check urine for sugar and ketone bodies, hypoglycemia maybe hard to detect at first.

Lasix

80 mg PO Q day

          

          

          

Diuetic

postural hypotension, dizziness, circulatory collapse, hypovolemia, dehydration, hyponatremia

closely and monitor blood pressure and vital signs, monitory s/s of hypokalemia, with older adults: observe periods of brisk diuresis, sudden alteration with fluid and electrolyte imbalance, lab test for frequent blood count, monitor I&O, monitor urine blood glucose in urine

          

Coumadin

2.5 mg PO Q day

                 

                 

          

A-fib and prophylactic

major or minor hemmerages form any organ and tissue, anorexia, nausea, vomiting, abdominal cramps,

determine PT/INP prior to initiation of therapy, obtain careful medication history prior to start of therapy, lab test for PT/INR,

Trazodone

50 mg 1 tablet PO Q bedtime

                 

                 

  

depression

drowsiness, dizziness, insomnia, headaches, agitation, hypotension, dry mouth, weight gain and loss

monitor pulse rate, monitor for change in behavior, observe patients level on activity, check for s/s of hypotension,

          

Uroxatral

10 mg 1 tablet PO Q day

                 

                 

          

Antispasmodic

fatigue, pain, dizziness, headache, abdomen pain, sinusitis, upper respiratory infection

monitor CV status and blood pressure, check postural vital signs to evaluate for orthostatic hypotension, check labs for baseline and periodic LFT's

Lipitor

10 mg 1 tablet PO Q day

                 

                 

          

Hyperlipidemia

back pain, asthenia, headache, constipation, diarrhea, increased liver function, rash

monitor therapeutic effectiveness which is indicated by reduction in the level of LDL-C, check labs for lipids levels, asses for muscle pain, monitor for digoxin toxicity with current digoxin use.

Toprol XL

50 mg PO Q day

                 

                 

          

Hypertension

red rash, fever, headaches, muscle aches, sore throat, dizziness, fatigue, insomnia, bradycardia, heartburn, shortness or air.

apical pulse and blood pressure because admin of drug, take several blood pressure readings, monitor I&O, daily weight,

Potassium Chloride

20 mcg 1 tablet PO BID

                 

                 

          

Hypokalemia

nausea, vomiting, diarrhea, abdominal distension, pain, mental confusion, irritability


     

monitor I&O ratio, check lab for serum, electrolytes are warranted, monitor for and report signs of GI ulceration, monitor potassium, , also patient has a risk of hyperkalemia.

                 

          

All information from the: Prentice Hall Nurse’s Drug Guide 2009, By: Wilson, Shannon, Shields


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Data Gathered:  [date]

Nursing Diagnosis:  5 Prioritized

          

1. Risk for infection r/t tissue destruction ABE breakdown on the sacrum

2. Risk for impaired skin integrity r/t diabetes AEB lesions and sores on lower extremities

                 

3. Risk for ineffective tissue perfusion r/t impaired arterial circulation AEB 2+ edema bilateral on lower extremities

                 

4. Risk for fall r/t impaired mobility AEB weight bearing pain on bilateral lower extremities

                 

5. Risk for toileting self-care deficit r/t impaired mobility AEB need for assistance when ambulating

                 

                 


 Your Assessment of Resident

Pertinent Lab/Diagnostic Test Results and date of exam:  

November  2008

Test

His Value

Normal Value

Na

138

136-146 mEq/L

K

3.3

3.5-5.0 mEq/L

Cl

105

98-106 mEq/L

Glucose

150 mg/dl

70-110 mg/dl

BUN

45 mg/dl

10-20 mg/dl

Creatine

0.7mg/dL

0.6-1.2 mg/dl

Calcium

5.4mg/dL

4.5-5.6 mg/dl

Bilirubin

0.5mg/dL

0.3-1.0nmg/dl

Albumin

3.7g/dL

3.5-5.0 g/dl

WBC

5,500 mm3

5,000-10,000 mm3

Hemoglobin

15 g/dl

14-18 g/dl

Hematocrit

0.48 SI units

0.42-0.52 SI units

Platelet ct

200,000 mm3

150,000-400,000 mm3

                 

                 

VS: BP: 135/ 85  heart rate: 86   Temperature 97.6   Respirations: 18

                 

                 

Musculoskeletal Activity: unsteady gait and able to perform tandem walk with assistance of walker, negative Romburg sign. Joints and muscles symmetric; no swelling or deformity; normal spinal curvature with slight kyphosis; no tenderness to palpation of joints; heat with swelling in both legs and feet. ROM: smooth movement except right shoulder, left knee- tenderness and limited movement and decrease flexion of them. Rest of ROM are smooth movement, no tenderness, no creptius, muscle strength- able to maintain flexion against resistance and without tenderness.

                 

Skin : warm and dry and has excessive bruising due to diagnosis of diabetes, breakdown on sacrum, good skin hygiene everyday. Skin is pallor with no clubbing, moles on arms, legs, and chest bilaterally, very few lesions on lower extremities.

                 

Cardiac: No lifts, heaves, or thrills, the cardiac apical impulses, it is located in the 5th ICS, MCL with a short genital tap with the measures of 1cmx2cm. S1 and S2 are present in all five cardiac areas with no extra beats or sounds, but with a slight irregular beat. Client is negative for JVD. Pulses: 2+ radial, 2+ ulnar, 2+ brachial, 1+ femoral, 1+ popliteal, 1+ posterior tibialis, 1+ dorsalis pedis. Client has 2+ edema on right foot and 1+ on left foot with warmth to touch.

                 

Pulmonary: Client has a dry productive cough with transferring, no pain with breathing and smoked for about 50 plus years and quit due to medical reasons; no history of lung disease. No bulging or retraction and symmetric with expansion. Resonance heard throughout, no adventurous sounds or crack or wheezes. The right shoulder is slightly higher than the left shoulder with pallor skin. No tenderness or creptius, a positive tactile fremitus. Chest expands posterior symmetrical with a resonance of the lungs with percussion. No adventurous sounds, cracks, or wheezes. His respiratory rate was 16.

                 

GI / Nutritional Status: Client states no changes in appetite, difficulty swallowing, abdomen pain, nausea or vomiting, or past histories of abdominal surgeries or diseases. With inspection on the abdomen, pallor, no lesions, midline and inverted umbilicus with no signs of discoloration or inflammation and no hernias, no bruits, bowel sounds positive in all four quadrants.

                 

                 


Nursing

Care Plan

                 

          

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

. Client states that he is weak and tired all the time. Client states that he has pain when walking around and that his legs stay swollen and that there are cracks/sores on both feet.

                 

Objective

 Cellulitis with necrosis bilaterally to lower extremities.

3+ edema in left lower extremities and 2+ edema in the right lower extremities.

Type II Diabetes,.

Lesions on bilateral lower extremities.


 
 

Problem:

Risk for impaired skin integrity

Long Term:

Verbalize a personal plan for preventing impairs skin integrity on [date] at 1130.

                 

For a client with limited mobility, monitor condition of skin covering bony prominences.

Rationale: pressure ulcers usually occur over bony prominences, such as the sacrum, coccyx, and heels. This is a result of unrelieved pressure between the prominences and support surface (Maklebust & Sieggreen, 2001; WOCN, 2003).

                 

Teach the client skin assessment and ways to monitor for skin breakdown.

Rationale: early assessment and intervention helps prevent the development of serious problems. Basic elements of a skin assessment are assessment of temperature, color, moisture, and intact skin (Baranoski & Ayello, 2003).

  

          

Client will be taught what a part of his body is at most risk for skin break down. He will also be taught how to do a simplified skin assessment and what to look for if there is a breakdown or change in skin.

Nursing student observes the material being taught and made sure it was taught in a simple manner so that it was not to complex for the client. Nursing student will observe the client doing his own simplified skin assessment.

R/T

Diabetes

                 

                 

Short Term:

Client will be able to report any altered sensations or pain on bilateral lower extremities after teaching on [date] at 1630.

Monitor skin conditions at least once a day for color or texture changes, or lesions. Determine whether the client is experiences loss of sensation or pain.

Rationale: systematic inspection can identify  impending problems early (Ayello & Braden, 2002; Krasner, Rodeheaver & Sibbald, 2001).

                 

Limit the number complete baths to two or three per week, and alternate them with partial baths. Use a tepid water temperature (90 and 105 degrees) for bathing.

Rationale: excessive bathing, especially in hot water, depletes again skin of moisture and increases dryness. The ability to retain moisture is decreased in the skin and starts to diminished amounts of dermal proteins. One of the most common age-related changes to the skin is damage to the stratum corneum (Baranoski, 2000; Ayello & Braden, 2003).

I

Client will be taught what to look for and how to inspect his own legs and will be able to demonstrate a self inspection of his lower extremities and be able to report is pain on a scale from 0-10.


  

Nursing student observes the client in doing a self inspection of his lower extremities. Client was able to report his findings and knows to report is there are any new ones.

Client also understood the importance of a pain scale and new how to implement it on a scale from 0-10.

                 

                 

AEB

Lesions and sores on bilateral lower extremities




References.

Ayello EA, Braden B (2002). How and why to do pressure ulcer risk assessment. Adv Skin Wound Care. 15(3), pg. 125

Baranoski S, Ayello EA (2003). Skin an essential organ. Wound care essentials: practice principles.

Bently DW, Bradley S, High K (2000). Practice Guidelines for Evaluation of fever and infection in long-term care facilities. Clin Infect Dis. 31(3), pp. 640-653.

Englehard S, Glasmacher A, Exner M (2002). Surveillance for nosocomial infection and fever of unknown origin among adult hematology-oncology patients. Infect Control Hosp. Epidemiol. 23(5), pg. 244.

Girou E, Oppein F (2001). Handwashing compliance in a French university hospital: new perspective with the introduction of hand-rubbing with a waterless alcohol-based solution. J Hosp Infect 48. pg. S55.

Holtzclaw BJ (2003). Use of thermoregulatory principles in patient care: fever management. Online J Clin Innovat. 5(5), pp. 1-23.

Wujcik D (1993). Infection control in oncology patients. Nurs Clin North Am. pg. 24S.

Huther SE (2008). Structure, Function, and Disorders of the Integument. Understanding Pathophysiology, Fourth Edition. 39, pg. 1103.

 Huther SE (2008). Structure, Function, and Disorders of the Integument. Understanding Pathophysiology, Fourth Edition. 4, pp. 107-8.

Baranoski S (2000). Skin tears: the enemy of frail skin. Adv Skin Wound Car. 13(2 Pt 1), pp. 123-126.

Krasner S (1999). Moving beyond the AHCPR guideline: wound care evolution over the last five years. Ostomy Wound Manag. 45(1A), pg. 1ss

Maklebust J, Sieggreen M (2001). Pressure ulcers: guideline for prevention and nursing management. Springhouse, Penn.

Wound, Ostomy, and Continence Nurse Society (2003). Guidelines for prevention and management of pressure ulcers. WOCN clinical practice guidelines series no 2. Glenview, Ill , The society.


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