Nursing Care Plan: Preventing Accidents and Injuries

Nursing Assessment

Review, record and identify abnormal results.  Explain the reason why they are abnormal for this patient.

(i. e Foley, wound care, ostomy care, oxygen requirements, NGT, chest tube.) Please include drainage amount and color.  If your patient has an IV in place note condition, site, & type of IV fluid.

Statements in the EHR & what the patient tell you, including chief complaint (cc).  Pay particular attention to subjective symptoms of pain.

Weakness

Tired

Lightheaded

Dizziness

Objective Data:

Data based on what can be determined by the 5 senses & by measurement.  Include focused head-to-toe physical & mental status assessment in the following pages. Indicate any change in vital signs.

Time #1:

BP: 88/55

HR (Apical): 81

Respirations: 17

Pulse ox: 96% on HFNC

Temperature: 98.4°F (36.9°C)

Time #2:

 BP: 80s – 100s

HR (Apical): 70s

Respirations: 17

Pulse ox: 96% on HFNC

Temperature: 97.7°F (36.5
°C)

K:

BUN:

Cr:

Ca:

Mg:

WBC:

Hgb:

Plt:

Chest X-Ray on Oct 1^st, 2019

ü  Supplemental Oxygen

ü  Type: High Flow Nasal Cannula

?      FiO2

ü  L/minute: 30L 68%

?      Tracheostomy

?      Condition of tracheal stoma

?      IVF:

?      Rate:

?      PCA:

Type pf Venus Access Device:

?      Peripheral saline lock

ü  PICC on right upper extremity

?      Subclavian

ü  Other: Remodulin pump (rate 0.05mL/hr)

Diet: Regular

?      Tube Feeds:  formula and rate

?      N/G tube

?      Other feeding tube

?      Wound care

?      Frequency of wound care

?      Drains

?      SCD’s

ü  Alert

?       Drowsy

?       Lethargic

?       Stuporous

?       Coma

Orientation:

ü  Person

ü  Place

ü  Time

ü  Situation

Communication:

ü  WNL

?      Dysarthria

?      Non-verbal

?      Aphasia

?      Expressive

?      Receptive

?      Global

Pain:

?      Location

?      Rating 0 to 10: 0

?      Acute

?      Chronic

?      Constant

?      Intermittent

Head:

R pupil PERRLA: 4mm

L pupil PERRLA: 4mm

Reaction to light:

ü  Brisk

?       Sluggish

?       No reaction right

?       No reaction left

?      Cataract

?      Prosthesis

Visual/Hearing:

ü  WNL

?      Visual Deficit: ____________________________

?      Hearing Deficit: ___________________________

Head:

Note any abnormalities in hair, nose, ears. Note mouth: midline tongue, lesions, moisture, dentition.

?      Normal, relaxed, regular rate

?      Labored

?      Dyspnea at rest

?      Dyspnea with minimal effort (talking, eating)

ü  Dyspnea with moderate effort (dressing, walking)

Respiratory rhythm:

ü  WNL

?      Tachypnea

?      Bradypnea

Breath sounds:

?      BS clear bilateral, no cough, no SOB

ü  Anterior clear throughout

ü  Posterior clear throughout

ü  Lateral clear throughout

?      Adventitious sounds:

?      Decreased (atelectasis?)

?      Absent (pneumothorax?)

?      Crackles

?      Fine (popping sounds like hair rubbing)

?      Coarse (Moist)

?      Rhonchi (gurgles, snoring)

?      Wheezes:

?      Inspiratory

?      Expiratory

?      Pleural Friction rub (occurs with respiratory motion, sounds

like rubbing leather)

ü  Other: SOB during moderate exertion

Cough:

ü  None

?      Productive

?      Non-productive

Sputum:

ü  None

?      Consistency: thin, thick

?      Color: clear, foamy

Chest tube:

?      Location

?      Negative pressure set at:

?      Drainage amount

?      Drainage color

?      Air leak

?      Dressing change

?      Chest Pain

ü  Dizziness

?      Syncope

Neck:

?       carotid pulse________

?       JVD? : none

?       Trachea midline

Chest:

ü  Apical pulse regular

?       Pericardial friction rub (sounds like leather rubbing, fluctuates with heart rate)

?       If on telemetry: rhythm

Overall Skin Color:

ü  WNL

?      Pale

?      Jaundice

?      Dusky

?      Cyanotic

Upper Extremities:

ü  Radial pulses: equal, 2-3 +

?       Other:

?       Capillary refill < 3 seconds

?       Other:

?       Grip equal & strong

?       Skin temperature WNL

?       Braden score

?       Other

Lower Extremities:

ü  Hair present.

?       Dorsalis pedis pulses: equal, 2-3+

?       Other:

?       Posterior tibialis pulses: equal 2-3+

?       Other:

?       Edema

?      Location

?      Non-pitting

?      Pitting x # seconds)

ü  Foot strength equal & strong

?    Positive Homan’s sign

Inspection:

ü  WNL: soft, non-tender

?       Distended

?       Firm

?       Ascites

?       Abdominal incision

ü  Last BM: 10/21

ü  Characteristics: Loose

?       Continence:

ü  Yes

?      No

?       Nausea/Vomiting   Y    N

?      Amount: ________________

?      Color: ___________________

Auscultation: (active, WNL), hypoactive, hyperactive, absent (for full 5 minutes)

?       RUQ

?       LUQ

?       RLL

?       LLQ

Nutritional Status:

ü  Adequate by mouth

?       Inadequate: address in care plan

?       Feeding Tube:

?      Type of tube

?      Insertion site

?      Condition of insertion site

?      Checked placement

?      Type of feeding

?      Rate of infusion

?      Amount of Residuals

?      HOB elevated

?       Stoma present

?      Colostomy

?      Ileostomy

?      Condition of stoma: pink, viable OR

?      Redness

?      Dusky

?      Retracted below skin

?      S & Sx of Infection

ü  WNL:  voiding, clear, yellow urine

ü  On commode

?      Other:

?      Burning

?      Frequency

?      Pain

?      Retention

?      Bladder scan amount

?      Distention

?      Incontinence

?      Amount: ______________________

?      Urine Quality:

ü  Yellow

?      Cloudy

?      Concentrated

?      Bright Red

?      Blood Clots

?      Other: ______________________

?      Foley Present:   Y      N

Insertion Date: _______________________

?      Urine Quality:

ü  Yellow

?      Cloudy

?      Concentrated

?      Bright Red

?      Blood Clots

?      Other: ______________________

ü  Upper Right

ü  Upper Left

ü  Lower Right

ü  Lower Left

ROM Passive Only:

?      Upper Right

?      Upper Left

?      Lower Right

?      Lower Left

Extremity Strength:

strong, moderate, weak, or absent

?      Upper Right: strong

?      Upper Left: strong

?      Lower Right: moderate

?      Lower Left: moderate

Gait:

?      Steady without assistance

ü  Steady with assistance

?      Unsteady with assistance

?      Assistive devices:

?      Amputation: ______________

?      Prosthetics:________________

Generic & Trade name

Drug Class

Action

Adverse Effects

Nursing Considerations

Treprostinil (Remodulin)

Ambrisentan Oral (Letairis)

frothy sputum, anxiety, restlessness, palpitations) during initiation of

therapy. Consider the possibility of pulmonary veno-occlusive disease;

if confirmed discontinue ambrisentan.

250 microgram oral tiwk Tu/Th/Sat

125 microgram oral twik M/W/F

renal tubule. Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium.

40mg oral q24h

prescription refills to determine compliance in patients treated for hypertension. Assess patient for skin rash frequently during therapy. Discontinue furosemide at first sign of rash; may be life-threatening. Stevens-Johnson

syndrome, toxic epidermal necrolysis, or erythema multiforme may develop. Treat symptomatically; may recur once treatment is stopped.

Personal/Social History data should be incorporated in the nursing process.

So if the goal is to teach a patient how

 to check capillary glucose, but the

patient has substance abuse, the nurse will need to consider this in the plan of

care.

(3 for each Nursing Diagnosis)

(3 for each Nursing Diagnosis),

Each intervention must include a reference source in APA format

(1 for each Dx) Individualized to Patient Evaluation (whether outcome met)

Risk for ineffective airway clearance secondary to hypersensitive pneumonitis

as evidence by dyspnea

2.     Assess the need for ambulation aids such as a walker for ADLs. (Carpenito, 2017)

3.     Gradually increase activity with exercises in bed, sitting, and standing. (Carpenito, 2017)

1.     Elevate head of bed and change the patients position frequently. (Carpenito, 2017)

2.     Teach proper deep breathing exercises by demonstrating effective coughing in an upright position. (Carpenito, 2017)

3.     Promote adequate hydration by setting a goal of 2500mL/day and monitor all fluid patients’ intakes and outputs. (Carpenito, 2017)

Assessing physical activity can determine if treatment is helping with exertional dyspnea

2.     Assistive device may enhance the mobility of the patient by allowing the patient to reach levels of activity tolerance.

3.     Gradual progression of activity prevents overexertion

1.     Promotes chest expansion and expelling secretions.

2.     Coughing helps to maintain clear patient airways and deep breathing exercises promote lung expansion and cough productivity.

3.     Fluids aid in expelling secretions by thinning the secretions so they are easier to cough up.

2.     Patient will identify behaviors to achieve clear airways such demonstrating effective coughing.

Verbal, Motor skills

Upon receiving a lung transplant, encourage the patient to take part in rehabilitation programs to promote activity tolerance. The patient will also continue taking prescribed immunosuppressants to prevent the transplant lungs from rejecting and reduce infection.