Course Number And Namecourse Nurs 101lnursing Care Plan Templatenurs ✓ Solved

Course Number and Name Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L Student Elisia Silva Goncalves Date 03/09/2020 Instructor Molina Course NURS 101L Patient Initial SC Unit/ Room# 303 DOB 03/09/1968 Code Status Full Code Height/Weight 4’11â€, 190 lbs Allergies Demerol (rash) Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale .6°F (axillary) 75 bpm (not noted) 20 bpm 100% (room air) 125/96 (supine) 3 (no non-pharmacologic interventions noted) History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with Evidence Based Citations Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations Chief Complaint: abdominal pain Patient complained of generalized abdominal pain that was constant, sharp, cramping, and tender when palpated.

Patient was observed to be crying, and rated pain 10/10 upon admission. Patient had performed a self-enema to relieve constipation and reported experiencing pain 15 minutes prior to going to the Emergency Department via ambulance. Admission Diagnosis: bowel perforation · colostomy performed in LUQ, 2.8 cm stoma Bowel perforations may occur as a result of damage or breakdown to the mucosal layers of the gastrointestinal tract. This develops an opening along the organ, leading to leakage of digestive contents (e.g. stomach acid or fecal matter) into the peritoneum. Can result from inflammation/infection, obstruction, invasive surgeries/procedures, or trauma (Jones & Zabbo, 2019).

A colostomy is a surgically created opening (stoma), diverting bowel elimination from the colon through the abdominal wall, and into an external pouching system for collection. This surgery can be temporary or permanent. Can be located in the ascending, transverse, descending, or sigmoid portion of the colon. Performed when elimination of stool through the rectum is prevented due to disease, or obstruction/damage to the colon (Johns Hopkins Medicine, n.d.-b). CNS: Patient fully conscious, oriented x4.

Head n ormocephalic , with full range of motion. Deep tendon reflexes +2/normal. EENT: Face, eyes, ears symmetrical. Pupil size 4mm each, bilaterally reactive. Oral mucosa moist and intact.

SKIN: intact, color appropriate for ethnicity, skin turgor - recoils immediately MS: upper and lower extremities full ROM, vascular perfusion WNL CV: heart rhythm and sound WNL, no signs of cardiac symptoms RESP: pattern/effort WNL, no cough, patient currently on room air GI: abdomen soft, bowel sound present x4, passing flatus. Colostomy bag LUQ, semi-formed stool; stoma intact, red, moist GU: urine yellow, no odor, symptoms WNL (Taylor et al., 2018) Pain Assessment: 3 – mild; abdomen – LUQ (Taylor et al., 2018) Glasgow Coma Scale: eye response – 4/spontaneous eye opening; motor response – 6/obeys commands fully; verbal response – 5/alert and oriented · total score – 15/15 · patient fully awake, alert, and oriented (Taylor et al., 2018) Braden Scale for Predicting Pressure Sore Risk: sensory perception – 4/no impairment; moisture – 4/rarely; activity – 4/walks frequently; mobility – 4/no limitation; nutrition – 4/excellent; friction and shear – 3/no apparent problem · total score – 23/23 · not at risk for developing pressure injuries (Taylor et al., 2018) Morse Fall Scale: no history of falling – 0; no secondary diagnosis – 0; IV access – 20; normal gait, bedrest, wheelchair – 0; orientated to own ability – 0 · MFS score – 20 · no risk, no fall interventions needed (Morse Fall Scale, n.d.) Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges), include dates and rationales supported with Evidence Based Citations Past Medical & Surgical History, Pathophysiology of medical diagnoses (include dates, if not found state so) Supported with Evidence Based Citations Diagnostic Procedures: 3/7/20 · abdominal x-ray: large amount of intraperitoneal air and multiple bowel fluid levels suggest bowel perforation Lab Results: 3/9/20 · Hematology: WNL, blood type B+ · Chemistry: potassium, calcium borderline low · patient not eating, insufficient nutrient intake · PTT, PT, INR: WNL · Urinalysis: yellow, no odor · All other lab results not stated are normal/WNL (Taylor et al., 2018) Past Surgical History: 5 years ago – appendectomy · An emergency surgical procedure to remove the appendix due to inflammation/infection, known as an appendicitis (Johns Hopkins Medicine, n.d.-a).

6 years ago – right inguinal hernial repair · Surgical process of moving a hernia (tissue protruding though a weakened area in the abdominal wall) from the groin area and back into the abdominal cavity. The weak abdominal wall muscles where incision is made are closed with sutures and reinforced with synthetic mesh (UCSF Department of Surgery, n.d.). 9 years ago – cholecystectomy · The surgical removal of the gallbladder typically to treat gallstones, or inflammation in the gallbladder or pancreas (Mayo Clinic, 2019). Past Medical History: All immunizations up to date (Centers for Disease Control and Prevention, 2020). Erikson’s Developmental Stage with Rationale And supported by Evidence Based Citations Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations Generativity vs.

Stagnation Occurs during middle adulthood, ages 40-65 years. Developmental stage with focused on care and the sense of productively contributing to the continuity of society (generatively) vs. the trivialization of one’s activities (stagnation). Is the person making their life meaningful by guiding future generations? Activities include working, teaching/mentoring others, volunteering in the community, and raising children (Feldman, 2016). Religion/Spirituality: Catholic Economic Background: bank teller with a bachelor’s degree Social Background: white male, primary language English; widowed, father of three (3) adult children (one son and daughter listed as emergency contacts), lives alone · potential for low self-esteem and social isolation · anxiety or fear of asking children for help · failure to thrive from loss of spouse, or living alone Safety Screening: patient did not mention concern for personal safety; no physical signs of abuse or neglect Substance use: patient consumes alcoholic drinks twice (2) a week No advanced directives listed (Taylor et al., 2018) Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each (“At Risk for…†nursing dx) Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale supported with Evidence Based Citations At risk for impaired skin integrity · cut out 1/8-inch margin in adhesive backing for ostomy pouch to prevent trauma to stoma tissue · monitor healing during ostomy care by inspecting skin for redness, inflammation, texture changes · clean area with warm water, pat dry, use a skin moisturizer to hydrate skin and prevent breakdown At risk for constipation or diarrhea · assess usual defecation pattern · determine presence of bowel activity through auscultation · review diet and fluid intake – fiber can provide bulk, fluids determine stool consistency · encourage daily physical activity, exercise (Ladwig et al., 2020) Consults & Discharge Referrals: · psychiatrist consult - patient expressed negative feelings about body image and lack of desire to thrive · social worker - if patient refuses to be compliant with colostomy care, may need to discharge to rehabilitative facility since they live alone Orders: Vital Signs every 4 hours Labs – CBC, BMP in the morning · check WBC, if elevated could indicate infection · BMP to check for fluid/electrolyte imbalances while adjusting to diet after surgery Diet – as tolerated · as patient recovers from surgery, normal bowel activity will return · want to promote balanced diet for metabolism and reduce risk for diarrhea and constipation Colostomy Care – ostomy assessment every shift, monitor for potential complications; change ostomy bag when soiled and prior to discharge · regular care reduces risk of skin integrity and monitors for infection Provide Patient Education – colostomy care · encourages sense of control for patient · prepares patient for self-care when discharge Continuous Activity – up ad lib · to prevent pressure injuries/maintain skin integrity · promote bowel movement/decrease risk for constipation (Ladwig et al., 2020; Taylor et al., 2018) Diagnostic Label Related to Contributing Factors As evidenced by Signs and Symptoms Priority Nursing Diagnosis (at least 2) Written in three-part statement Planning (outcome/goal) Measurable goal during your shift (at least 1 per Nursing diagnosis) Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) Rationale Each must be supported with Evidence Based Citations Evaluation Goal Met, Partially Met, or Not Met & Explanation Disturbed body image related to daily care of fecal material, as evidenced by verbalization of negative opinions of having a “poop bag†attached to person. (Ladwig et al., 2020) Patient will demonstrate social involvement and begin to accept situation by observing care of, or touching colostomy bag.

Ask patient psychosocial questions related to medical situation during nursing assessment. Consideration of providing counseling. Review the medical necessity behind surgical procedure, maintain positive approach during care. Assess patient’s level of social support. Verbalization of patient’s feelings can help identify the patient’s progress and risk for body image disturbance.

Can assist patient with acceptance of a temporary medical situation and promote will to thrive. Supporting patient can help develop strategies to cope with the emotional stress. A determent of patient’s speed of recovery and emotional health. Goal not met: · patient refused to open eyes or listen to any positive outlooks on situation. Patient used vulgar language about their perception of themselves.

Patient asked to be left alone. Deficient knowledge related to lack of exposure to new ostomy, as evidenced by lack of participation. (Ladwig et al., 2020) Patient able to explain the purpose of the colostomy procedure. Patient able to explain and perform colostomy care on self satisfactorily. Assess and evaluate patient’s emotional/cognitive/physical wellbeing. Use client-centered approach.

Have patient participate during ostomy care. Consider use of printed material (e.g. brochures) and electronic methods (e.g. videos, images, diagrams) during teaching. Repeat education and practice frequently. Patient must be willing to cooperate in order to learn effectively. Engages with client as an active learner.

Promotes sense of control. Serves as additional sources of information. Alternative formats of patient education may resonate with patient better. Reinforces learning. Goal partially met · patient was able to verbally explain why they received a colostomy and its purpose.

Patient acknowledge that they knew the colostomy bag is a temporary procedure, however expressed that they felt cursed by this event. Patient consequently was unwilling to participate during care and wished for the nurse to leave as soon as possible. MEDICATION LIST Medications (with APA citations Class/Purpose Route Frequency Dose (& range) If out of range, why? Mechanism of action Onset of action Common side effects Nursing considerations specific to this patient docusate (Jones & Bartlett Learning, 2020) Pharmacologic class: stool softener, surfactant Therapeutic class: laxative Oral Daily 50 mg capsule 1) acts as surfactant that softens stool by decreasing surface tension between oil and water in feces 2) increases electrolyte and water secretion into colon, forming a softer fecal mass syncope, abdominal cramps, distension, nausea/vomiting, diarrhea, perianal irritation increase fiber intake, hydration ketorolac tromethamine (Jones & Bartlett Learning, 2020) Pharmacologic class: NSAID Therapeutic class: analgesic IV Every 8 hours, PRN 30 mg blocks cyclooxygenase and inhibits prostaglandin synthesis, thus reducing inflammation and relieves pain GI bleeding, prolonged bleeding time, hepatic failure, renal failure, exfoliative dermatitis 1) take with food, remain upright for 30 minutes to decrease irritation of lower esophagus 2) avoid alcohol, increases stomach irritation ondansetron hydrochloride (Jones & Bartlett Learning, 2020) Pharmacologic class: selective serotonin (5-HT3) receptor antagonist Therapeutic class: antiemetic Oral Every 6 hours, PRN 4 mg tablet blocks serotonin receptors in the chemoreceptor trigger zone (CTZ) in the CNS and peripherally at vagal nerve terminals in the intestine, thus reducing nausea and vomiting headache, fatigue, diarrhea/constipation, abdominal pain, arrhythmias monitor nausea, bowel sounds/activity, gastric distention References Centers for Disease Control and Prevention. (2020, February 03).

Recommended child and adolescent immunization schedule for ages 18 years or younger, United States, 2020. Feldman, R. S. (2016). Development across the life span, 8th edition . Pearson Education.

Johns Hopkins Medicine. (n.d.-a). Appendectomy . Johns Hopkins Medicine. (n.d.-b). Colostomy . Jones & Bartlett Learning. (2020).

Nurse’s drug handbook, 19th edition . Burlington, MA. Jones, M. W., & Zabbo, C. P. (2019, October 11).

Bowel perforation. StatPearls . Ladwig, G. B., Ackley, B. J., Makic, M.

B. F., Martinez-Kratz, M., & Zanotti, M. (2020). Mosby's guide to nursing diagnosis, 6th edition . St. Louis, MO: Elsevier.

Mayo Clinic. (2019, August 09). Cholecystectomy (gallbladder removal) . Morse Fall Scale . (n.d.). Network of Care. Retrieved March 9, 2020, from Taylor, C., Lynn, P., & Bartlett, J.

L. (2018). Fundamentals of nursing: The art and science of person-centered nursing care , 9th edition . Philadelphia, PA: Wolters Kluwer. UCSF Department of Surgery. (n.d.). Inguinal hernia .

Revision Date: Month, Year (i.e. February, 2010) Page 1

Paper for above instructions

Nursing Care Plan for Patient SC

Patient Information:

- Name: SC
- DOB: 03/09/1968
- Date of Assessment: 03/09/2020
- Instructor: Molina
- Course: NURS 101L
- Patient Initial: SC
- Unit/ Room: 303
- Height/Weight: 4’11”, 190 lbs
- Code Status: Full Code
- Allergies: Demerol (rash)

Vital Signs:

- Temperature: 6°F (axillary)
- Pulse: 75 bpm (not noted)
- Respiration: 20 bpm
- Pulse Ox: 100% (room air)
- Blood Pressure: 125/96 (supine)
- Pain Scale: 3 (no non-pharmacologic interventions noted)

History of Present Illness:

Chief Complaint: The patient presented with generalized abdominal pain, described as sharp and cramping, particularly in the left upper quadrant (LUQ), with a pain rating of 10/10 upon admission. The patient self-administered an enema prior to visiting the emergency department, experiencing acute pain shortly after.
Admission Diagnosis: Bowel perforation, with subsequent colostomy creation in LUQ, and a stoma measuring 2.8 cm.
Bowel perforations are openings that develop in the digestive tract, resulting from a variety of causes such as infection or obstruction (Jones & Zabbo, 2019). A colostomy is a procedure that diverts the passage of fecal matter to the exterior of the abdomen via a stoma.

Physical Assessment Findings:

Patient is fully conscious and oriented x4 with no notable deficits in neurological (CNS) or cardiovascular (CV) systems. Areas of examination include:
- CNS: Alert, normal responses
- EENT: Symmetrical features, moist oral mucosa
- Skin: Intact, adequate turgor
- Musculoskeletal: Full range of motion in all extremities
- Respiratory: Normal respiratory pattern, no distress
- Gastrointestinal (GI): Bowel sounds present with stoma showing semi-formed stool
- Urinary: Clear yellow urine

Relevant Diagnostic Procedures/Results:

- Diagnostic Procedures:
- Abdominal X-ray (03/07/20): Showed significant amounts of intraperitoneal air, indicating bowel perforation.
- Lab Results:
- Hematology: WNL, blood type B+
- Chemistry: Borderline low potassium and calcium due to poor intake (Taylor et al., 2018).

Past Medical/Surgical History:

- Appendectomy (5 years ago)
- Right Inguinal Hernial Repair (6 years ago)
- Cholecystectomy (9 years ago)
- Immunizations are reported up to date (Centers for Disease Control and Prevention, 2020).

Developmental Stage (Erikson’s Theory):

- Generativity vs. Stagnation: The patient represents middle adulthood (ages 40-65) where contributions to society and guidance over future generations are key (Feldman, 2016).

Socioeconomic/Cultural and Psychosocial Considerations:

The patient is a widowed white male bank teller, financially stable with a bachelor’s degree. Concerns around personal safety and feelings of isolation may impact his emotional state; a potential risk for low self-esteem or anxiety has been identified (Taylor et al., 2018).

Nursing Diagnoses and Goals:

1. Disturbed Body Image related to stoma management and fecal elimination, manifested by negative verbalization regarding condition.
Goal: Patient will express understanding of the colostomy process and participate in colostomy care by the end of the shift.
Interventions:
- Engage the patient in educational discussions about ostomy care.
- Encourage the patient to express fears or concerns.
- Provide written and video materials for better understanding.
- Involve a counselor for support (Ladwig et al., 2020).
2. Deficient Knowledge regarding colostomy care as evidenced by lack of participation in care and inability to explain procedure.
Goal: Patient will demonstrate accurate knowledge regarding colostomy care before discharge.
Interventions:
- Teach the procedure step-by-step with hands-on involvement.
- Assess understanding by asking the patient to recount steps back to the nurse.
- Use teaching aids such as diagrams.
- Schedule follow-up visits with a colorectal nurse specialist.

Discharge Plan:

- Consults:
- Referral to a Psychiatrist to support emotional needs.
- Social Worker for community resources since the patient lives alone.
- Medications:
- Docusate: To prevent constipation post-surgery (Jones & Bartlett Learning, 2020).
- Ketorolac: For pain management (Jones & Bartlett Learning, 2020).
- Ondansetron: As needed for nausea management (Jones & Bartlett Learning, 2020).

Conclusion and Evaluation:

After implementing specific strategies and objectives, the patient demonstrated partial progress. He acknowledged the necessity of the colostomy but struggled to accept the changing body image, expressing a need for emotional support.
References:
1. Centers for Disease Control and Prevention. (2020). Recommended child and adolescent immunization schedule.
2. Feldman, R. S. (2016). Development across the life span (8th ed.). Pearson Education.
3. Johns Hopkins Medicine. (n.d.-a). Appendectomy.
4. Johns Hopkins Medicine. (n.d.-b). Colostomy.
5. Jones, M. W., & Zabbo, C. P. (2019). Bowel perforation. StatPearls.
6. Jones & Bartlett Learning. (2020). Nurse’s drug handbook (19th ed.). Burlington, MA.
7. Ladwig, G. B., et al. (2020). Mosby’s guide to nursing diagnosis (6th ed.). Elsevier.
8. Mayo Clinic. (2019). Cholecystectomy (gallbladder removal).
9. Morse Fall Scale. (n.d.). Network of Care.
10. Taylor, C., Lynn, P., & Bartlett, J. L. (2018). Fundamentals of nursing (9th ed.). Wolters Kluwer.
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This nursing care plan for SC has utilized current evidence-based practices and guidelines to ensure comprehensive patient-centered care focusing on both the physical and emotional dimensions of recovery.