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 care plan Essay

п»їNUR 412

PLAN OF TREATMENT

Nursing Trouble

Interventions (Minimum of 3)

(with rationales)

Evaluation

Issue statement: Hope precaution.

Associated with: Feeding/trach

Because manifested by: PEG conduit and tracheostomy

Expected Outcome: Pt. will never experience any kind of aspiration attacks while in the hospital.

Problem statement: Risk for illness

Related to: Foley cath

While manifested by simply: erosion to urethral internet site

Expected Outcome: Pt. won't have infection whilst in the hospital

.. HOB elevated thirty five degrees. (gravity will help keep food down).. Check recurring. (Tells if the medication/food will be passed... Hold feed pertaining to care and turning. (laying the pt. flat improvements gravity plus the stomach articles ability to aspirate)

.. Monitor WBC. (rise in WBC may possibly indicate infection and early on intervention can be taken).. Apply Bacitracin ointment as buy (Bacitracin is employed as a prophylactic to prevent illness at site).. Keep site clean and dry out. (Wet and dirty areas can be a reservoir for bacterial growth) Pt. did not encounter any episode of hope.

Pt. would not experience virtually any infection whilst in the hospital.

LEDIGLICH 412

REGULAR PATIENT EXAMINATION GUIDE (include your head to toe physical assessment in addition to data obtained from patient and medical record) Nerve status/ physical status/ pain/ orientation/ educating learning readiness/ communication style

Pt. is usually alert however, not oriented. Pt. is does not respond to spoken response although respond to responsive stimuli. Rehabilitation. is nonverbal and cannot express soreness level, interaction is tough. Oxygenation level/ respiratory assessment/ aspiration risk

Pt. o2 level is 100%, pt. has tracheostomy. Pt. seems to have difficulty deep breathing as confirmed by thick mucus creation and rhoni noted bilaterally Pt. has high desire risk because of feeding/trach. Heart failure Rhythm /Circulation & pulses/ IV's/ liquid volume position

Pt. is usually on heart monitor, B/P=138/48 and pulse 86. Signal noted to be 2+. RRR, no gallops, no present edema Belly assessment Nutrition/ oral health, dentures/ weight & BMI/ diet amt consumed/emesis

BS within all four quadrants, rehabilitation. is about diabetic diet, wt. sixty-eight. 6kg. PEG tube, spending intact. There is not any evidence of emesis and rehabilitation. is tolerating tube feeding well, in 18hrs isosource. Elimination/ continence/ urine & stool color, amt, odor/ drains result color, smell

Urine end result: 300 light yellow and clear, no odor uncommon via Foley cath, intestinal movement x2. No drains noted. Mobility/ Activity

Workout

Rehabilitation. is unmoving, stationary and cannot participate in effective nor unaggressive ROM with out assistance Skin/Wound care/ Dressings/Protection/ Safety

Rehabilitation. has a level two sacral ulcer and a recovery stage two ulcer in left ankle joint. Duaderm is definitely intact and no sign of drainage mentioned. Psychosocial/spiritual/ expansion & creation level/ sleep- wake style

Pt. can be nonverbal - cannot support psychosocial or spiritual, sleep wake pattern details. Consumer Data Sheet (Weekly)

WIRKLICH 412

MEDICINAL RECORD (Weekly)

Medications:

Generic/Brand Name

Dose

Route

Frequency

Reason this kind of client getting med

Assessment of response to med

Toprol XL

25mg

PEG

Q10am

Treat hypertension

No adverse reaction mentioned

Atrovent HFA

1 PUF

Inhalation

Q6h

Assist with breathing

No negative reaction noted

Ferrous sulfate

300mg

PEG

Q8h

Take care of anemia

Zero adverse response noted

Folic acid

1mg

PEG

Q10am

Treat anemia

No unfavorable reaction mentioned

Zinc sulfate

220mg

PEG

Q12h

Take care of zinc insufficiency

No unfavorable reaction known

Carafate

1gm

PEG

Q8h

Prevent ulcers

No unfavorable reaction mentioned

Colace

100mg

PEG

Q8h

Relieve obstipation

No unfavorable reaction observed

Bacitracin ointment

1 apl

Affected location

Q12h

Prevent infection in urethral erosion

No adverse reaction known

Ascorbic acid

250mg

PEG

10A-10P

Lower severity of colds

Zero adverse response noted

Multivitamin-mineral

1 tabs

PEG

Q10am

Vitamin...

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