HOWARD COMMUNITY COLLEGE NURSE EDUCATION PROGRAM NURS-135 MEDICAL-SURGICAL NURSING I NURSING CARE PLAN

Student Name: Amanda Feather Patient Initia"&: 'F A(e)Se* +1 ,r -"d ma"e Date Submitted: Medi.a" Dia(n-&i& A!ri" 11#$%13 Dee! /ein 0hr-mb-&i&

Complete using your nursing text oo!s "#ite re$eren#es use%&' Un%erline t(e etiologies )n% #lini#)l m)ni$est)tions t()t rel)te to your #lient'

I'

*)t(op(ysiology+

Dee! 1ein thr-mb-&i&# a"&- 2n-3n a& D/0# i& 3hen a b"--d ."-t 4-rm& 3ithin the dee! 1ein& m-&t .-mm-n", in the "-3er e*tremitie& &u.h a& the 4em-ra" 1ein -r the i"ia. 1ein 5Le3i&# Dir2&en# 6eit2em!er# 7u.her# 8 Camera&# $%119

II'

Etiology+

0hree main 4a.t-r& .-ntribute t- the .au&ati-n -4 dee! 1ein thr-mb-&i&: 0he 4ir&t -ne i& 1en-u& &ta&i& 3hi.h re4er& t- the n-rma" b"--d 4"-3 3hi.h re"ie& -n the mu&."e& -4 the "-3er e*tremitie& &u.h a& the "e(& and !r-!er 4un.ti-n -n the 1a"1e& 3ithin the 1ein 3hi.h a""-3 b"--d t- -n", m-1e in -ne dire.ti-n: 0he ne*t .au&ati-n i& dama(e t- the end-the"ia" ti&&ue# 3hi.h i& a thin "a,er -4 .e""& 3ithin the 1ein: An, dama(e t- the&e .e""& 3i"" .au&e !"ate"et& t- .-me t- the &ite and be(in the !r-.e&& 4-r .-a(u"ati-n -r ."-ttin(: 0he 4ina" 4a.t-r t- .au&ati-n i& the h,!er.-a(u"abi"it, -4 the b"--d -r ra!id ."-ttin( -4 a !er&-n;& b"--d 3hi.h ma, be due t- b"--d di&-rder&# &e!&i& -r e1en !re(nan.,: 5Le3i&# Dir2&en# 6eit2em!er# 7u.her# 8 Camera&# $%119 III' Clini#)l M)ni$est)tions ",igns - ,ymptoms&+

-*)in in lo.er extremities /Ten%erness -er,thema /,.elling or e%em) in t(e )$$e#te% leg /He)t t(roug(out t(e e$$e#te% leg /In#re)se% me)surement o$ t(e )$$e#te% lim /*)in .(en .)l!ing -7e"-3 the area -4 the ."-t the e*tremit, ma, be .--"# !a"e and ha1e edema -Pr-minent &u!er4i.ia" 1ein& -Fun.ti-na" im!airment

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-,mo!ing /non use o$ mus#les /*)tient reports ) $eeling o$ (e)0iness I1' Tre)tment )n% Nursing M)n)gement+ Dru( 0hera!,Anti.-a(u"ant& &u.h a& he!arin -r C-umadin Indire.t thr-mbin inhibit-r& /itamin ? anta(-ni&t Dire.t thr-mbin inhibit-r& 7ed re&t M-nit-r !artia" thr-mbin time A&&e&& 1ita" &i(n& A&&e&& !ain A&&e&& &2in inte(rit,# edema and neur-1a&.u"ar &tatu& 0ea.h !atient ab-ut "imitati-n& t- ambu"ati-n# .-m!"i.ati-n& and medi.ati-n& Patient 3i"" re.ei1e a .a1a" 4i"ter due t- hi& .areer

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1'

Di)gnosti# ,tu%ies2L) An)lysis+ D)te 3)$= 3)$= 3)$@ Client3s Result A7C 11:1 6C0 B1:+ MC6 3$ R7C B:B1 GLUCCSE 15@ P00 115:1 C0/-&h-3ed an e*ten&i1e ."-t in the 4em-ra" and i"ia. 1ein Norm)l Result/ A7C- B:=-1%:= 6C0- B$-5$ MC6 $@-31:% R7C- B:@-+:1% GLUCCSE @5->> P00 $3:+-3@:1 C0/NEGA0I/E An)lysis A7C in.rea&e due tre&!-n&e t- 1ein trauma 6.t de.rea&e& due tde.rea&ed R7C MC6 i& in.rea&ed due t- the de.rea&e in R7C and n.han(e in hem-("-bin 3hi.h in.rea&e& the rati-: G"u.-&e i& mea&ured b, 4a&tin( "e1e" and the !atient 3a& n-t 4a&tin( .au&in( a hi(her readin( but it &ti"" remain& 3ithin n-rma" "e1e"& P00 i& in.rea&ed due t- the !atient re.ei1in( 6e!arin 3hi.h i& in.rea&in( the .-a(u"ati-n time

Test C7C C-a(u"ati-n C0/ 3ith .-ntra&t

1I'

Dis#()rge *l)nning )n% Client Te)#(ing+ /Me%i#)tions /A#ti0ity le0el /Nutrition /D1T pre0ention /,mo!ing #ess)tion Gro.t( - De0elopment+ According to Erickson: Stage: Adulthood Crisis: Generativity vs. Stagnation List )ll t)s!s t()t )re rel)te% to t(is %e0elopment)l st)ge+ A: De&.ribe ,-ur !atient;& abi"it, t- a.hie1e their (r-3th and de1e"-!menta" ta&2&: 6-3 i& thi& abi"it, a44e.ted b, the under",in( di&ea&e !r-.e&& and)-r the .urrent admi&&i-nD 0he !atient ha& an im!aired abi"it, t- a.hie1e hi& (-a" -4 .arin( 4-r hi& .hi"dren# the ne*t (enerati-n# due t- hi& "imitati-n& re"ated t- hi& dee! 1ein thr-mb-&i& 3hi.h a"&"imit& him 4r-m 3-r2in( due t- hi& .areer unti" the thr-mbu& i& re&-"1ed

1II'

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7: Li&t nur&in( a.ti-n& t- a&&i&t ,-ur ."ient in meetin( their (r-3th and de1e"-!menta" need&: -Gi1e the !atient !r-!er re&-ur.e& re"ated t- hi& dia(n-&e& and re"ated treatment& -Edu.ate the !atient -n the im!-rtan.e -4 4-""-3in( the re.-mmended treatment !"an hi& !h,&i.ian re.-mmended: - Gi1e the !atient re&-ur.e& -n &m-2in( .e&&ati-n and de&.ribe the im!-rtan.e: -Edu.ate the !atient -n the im!-rtan.e -4 !r-!er nutriti-n 1III' List in priority or%er all rele0)nt nursing %i)gnoses $or your p)tient' In."ude NANDA dia(n-&i&# eti-"-(, and &u!!-rtin( data: A.ute !ain r)t in4"ammat-r, !r-.e&& a:e:b edema and heat in a44e.ted "-3er e*tremit,: Ri&2 4-r Ine44e.ti1e ti&&ue !er4u&i-n r)t interru!ted 1en-u& 4"-3 a:e:b "-3er e*tremit, edema De4i.ient 2n-3"ed(e r)t un4ami"iarit, 3ith the di&ea&e !r-.e&& -4 a dee! 1ein thr-mb-&i& a:e:b the !atient& inabi"it, t- re.-(niEe the &e1erit, -4 the di&ea&e Ri&2 4-r b"eedin( r)t anti.-a(u"ant thera!, Ri&2 4-r im!aired &2in inte(rit, r)t a"tered !eri!hera" ti&&ue !er4u&i-n

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Assessment D)t)
Identify all data that support the priority nursing diagnosis.

Nursing Di)gnosis
(According to NANDA)

Nursing A#tions
List in order of priority. Label aspect of care.

R)tion)le
State the rationale for each nursing action. Cite reference and page number.

E0)lu)tion
E aluate the patient response to each nursing action pro iding ob!ecti e and sub!ecti e data. "e ise nursing actions as necessary.

,/ W(en I mo0e t(ere is ) s()rp p)in in my leg O/ *)in is ) 4 on ) s#)le o$ 5/65 O/ *)tient grim)#es %uring repositioning O/ Le$t #)l$ me)sures 7'4 in#(es l)rger t(en t(e p)tients rig(t #)l$ %ue to 89 e%em) O/ ,igni$i#)nt (e)t in le$t #)l$ ,/ During )m ul)tion p)tient ()s signi$i#)nt p)in

A.ute !ain re"ated tin4"ammat-r, !r-.e&& a& e1iden.e b, edema and heat in a44e.ted "-3er e*tremit,:

6'*sy#(ologi#)l Assess $or presen#e o$ p)in using t(e 5/65 p)in s#)le 7'*()rm)#ologi#)l A%minister )n)lgesi#s )s pres#ri e% )n% %o#ument me%i#)tion )n% relie$ o t)ine% using t(e me%i#)tion 8'Re() ilit)tion)l Ensure t()t p)tient m)int)ins e% rest: lim ele0)tion )n% %oes not #ross (is legs %uring t(e )#ute p()se'

6'E0)lu)tion o$ p)tients per#eption o$ p)in %etermines t(e most e$$e#ti0e )n)lgesi# 5S3earin(en# $%1$9 7'Do#umenting per#ei0e% p)in )n% p)in relie$ me)sures (elps %etermine )%e;u)te %osing $or e$$e#ti0e p)in relie$ 5S3earin(en# $%1$9 8'T(ese me)sures promote 0enous return: minimi<e engorgement )n% %e#re)se t(e potenti)l $or em oli<)tion' 5S3earin(en# $%1$9 ='A0oi%ing (ip or !nee $lexion minimi<es 0enous st)sis )n% %is#om$ort 5S3earin(en# $%1$9

6' ,/*)tient r)tes (is p)in )s ) 4 on ) 5/65 p)in s#)le 65 eing t(e .orst p)in 5 eing no p)in 7' O/*)tient re#ei0e% (y%ro#o%one ,/ An (our l)ter p)tient st)te% p)in )s = out o$ 4 O/ *)tient re#ei0e% Lort) ,/ *)tient r)te% p)in )s ) 7 out o$ 65 8' O/ 1eins %i% not e#ome engorge% ,/ p)tient %i% not report ,O>: %yspne) or #(est p)ins O/ *)tients re)t( soun%s rem)ine% norm)l )n% %i% not %ispl)y s2s o$ em olism =' ,/ *)tient reporte% t()t y not #rossing (is legs: $lexing (is !nees or (ips (e %i% experien#e )n% in#re)se% #om$ort le0el O/ *)tient %i% not %ispl)y %iminis(e% perip(er)l pulses )n% ()% ) (e)lt(y s!in #olor' 5

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Expe#te% Out#ome+

Sh-rt-0erm G-a" 5S0G9: Wit(in )n (our o$ inter0ention p)tient .ill ()0e ) %e#re)se o$ su ?e#ti0e per#eption o$ p)in on t(e 5/65 p)in s#)le' L-n(-0erm G-a" 5L0G9: >y %is#()rge t(e p)tient .ill e ) le to report p)in )s ) 6 or less on t(e 5/65 p)in s#)le
E0)lu)te e)#( expe#te% out#ome+

=' *(ysi#)l A0oi% $lexion o$ (ips )n% !nees

Sh-rt-0erm G-a" 5S0G9: Patient re!-rted !ain a& a 3 -n a %-1% !ain &.a"e L-n(-0erm G-a" 5L0G9: In !r-(re&&

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Assessment D)t)
Identify all data that support the priority nursing diagnosis.

Nursing Di)gnosis
(According to NANDA)

Nursing A#tions
List in order of priority. Label aspect of care.

R)tion)le
State the rationale for each nursing action. Cite reference and page number.

E0)lu)tion
E aluate the patient response to each nursing action pro iding ob!ecti e and sub!ecti e data. "e ise nursing actions as necessary.

O/ ,#)ns s(o. ) l)rge t(rom us in t(e $emor)l 0ein O/ Norm)l sens)tion o$ le$t $oot ,/*)tient reports pins )n% nee%le $eeling in (is le$t $oot O/ 89 e%em) in le$t #)l$ O/,igni$i#)nt (e)t is le$t #)l$

Ri&2 4-r Ine44e.ti1e !eri!hera" ti&&ue !er4u&i-n r)t interru!ted 1en-u& 4"-3 a:e:b "-3er e*tremit, edema

6'*(ysi#)l Assess $or p)in )n% #()nges in s!in temper)ture: #olor or motor sensory $un#tion' 7'Re() ilit)tion)l Ele0)te t(e p)tients legs 8' Re() ilit)tion En#our)ge %eep re)t(ing =' *(ysi#)l Assess perip(er)l pulses 4'*()rm)#ologi#)l A%minister )nti#o)gul)nts )s %ire#te%

6'Assessment (elps %etermine signs o$ in)%e;u)te perip(er)l per$usion 5S3earin(en# $%1$9 7'*romotes 0enous return )n% #)r%i)# output 5S3earin(en# $%1$9 8' Deep re)t(ing #re)tes )n% in#re)se% neg)ti0e pressure in t(e lungs )n% t(or)x to )ssist in emptying o$ l)rge 0eins' 5S3earin(en# $%1$9 =' Assessment o$ perip(er)l pulses ensures t(e loo% $lo. is still )%e;u)te to t(e lo.er extremities' 5S3earin(en# $%1$9 4' Anti#o)gul)nts (elp ensure t(ere is no $urt(er #lotting .(i#( #oul% $urt(er o stru#t loo% $lo.: 5S3earin(en# $%1$9

6' O/ *)tients s!in tone rem)ine% pin! )n% .)rm O/*)tient .)s ) le to mo0e (is toes ,/*)tient reporte% ) pins )n% nee%le $eeling in (is le$t $oot ut %i% not $eel li!e (is lim .)s #ol% 7' ,/ *)tient st)te% t()t ele0)ting t(e leg (elpe% (is #om$ort le0el 8' E0)lu)tion is ongoing =' O/*e%i)l: ti i)l )n% poplite)l pulses rem)ine% 79' @emor)l pulse .)s not $elt upon p)lp)tion 4' O/ *)tient %i% not ()0e )ny ot(er #lot $orm)tions ,/*)tient st)te% (e ()% no p)ins in )ny ot(er )re)s ex#ept le$t lo.er extremity'

Expe#te% Out#ome+

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Sh-rt-0erm G-a" 5S0G9: *)tient .ill $ollo. inter0entions )n% ()0e perip(er)l pulses rem)in )t 79 L-n(-0erm G-a" 5L0G9: >y (ospit)l %is#()rge p)tient .ill ()0e )%e;u)te tissue per$usion .(i#( .ill e e0)lu)te% y %iminis(e% %is#om$ort: norm)l extremity temper)ture: #olor )n% motor $un#tion )n% .ill )lso experien#e ) %e#re)se in s.elling'

E0)lu)te e)#( expe#te% out#ome+

Sh-rt-0erm G-a" 5S0G9: 7, the end -4 the &hi4t the !atient;& !eri!hera" !u"&e& remained at $F: L-n(-0erm G-a" 5L0G9: In !r-(re&&

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MEDICATION *RE*ARATION ,HEET Allergies+ Peni.i""in and a.e inhibit-r

Me% )s per MAR+ 6e!arin MD Or%er+ $5%%% unit& in 5G de*tr-&e 5%%m" in4u&i-n .-ntinu-u& I/ Time"s& Due+ .-ntinu-u& in4u&i-n Generi#2Tr)%e N)me+ Norm)l Dos)ge+ $%#%%%HB%#%%% unit& in4u&ed -1er $B hr Cl)ssi$i#)tion2A#tion+ Anti.-a(u"ant In%i#)tion $or *)tient+ Pre1enti-n -4 b"--d ."-t& M)?or ,i%e E$$e#ts+ 7"eedin( *)r)meters C(e#!e%+ 7P# 1ita" &i(n&# n-&e b"eed&# b"eedin( 4r-m I/ &ite# "e1e" -4 .-n&.i-u&ne&&# "ethar(, Me% )s per MAR+ 6,dr-.-d-ne MD Or%er+ 5m( IB PRN Time"s& Due+ 1%%% then IB Generi#2Tr)%e N)me+ /i.-din# N-r.-# L-rtab# J,d-ne# Ane*&ia Norm)l Dos)ge+ $:5H1% m( I 3H+ hr a& needed Cl)ssi$i#)tion2A#tion+ -!i-id a(-ni&t& n-n-!i-id ana"(e&i. .-mbinati-n& In%i#)tion $or *)tient+ Pain re"ie4 M)?or ,i%e E$$e#ts+ Sedati-n# diEEine&&# .-n&ti!ati-n# h,!-ten&i-n *)r)meters C(e#!e%+ 7P# Pain "e1e"# "e1e" -4 .-n&.i-u&ne&&# /ita" &i(n&# re&!irati-n rate and "un( &-und&: Me% )s per MAR+ 7eni.air MD Or%er+ $%m( dai", Time"s& Due+ 1%%% Generi#2Tr)%e N)me+ -"me&artan Norm)l Dos)ge+ $%m( dai", Cl)ssi$i#)tion2A#tion+ Anthi&tamine In%i#)tion $or *)tient+ Sea&-na" a""er(ie& M)?or ,i%e E$$e#ts+ Sedati-n# dr-3&ine&& *)r)meters C(e#!e%+ Le1e" -4 .-n&.i-u&ne&&# breath &-und& Me% )s per MAR+ Phener(an MD Or%er+ 15m( Time"s& Due+ e1er, B h-ur& Generi#2Tr)%e N)me+ !r-methaEine Norm)l Dos)ge+ 1$:5H$5 m( I B hr a& needed Cl)ssi$i#)tion2A#tion+ antiemeti. In%i#)tion $or *)tient+ de.rea&e nau&ea M)?or ,i%e E$$e#ts+ *)r)meters C(e#!e%+ A&&e&& 4-r nau&ea and 1-mitin( be4-re and a4ter admini&trati-n

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Me% )s per MAR+ 0ramad-" MD Or%er+ 5%m( Time"s& Due+ Generi#2Tr)%e N)me+ U"tram Norm)l Dos)ge+ Cl)ssi$i#)tion2A#tion+ ana"(e&i.& In%i#)tion $or *)tient+ Pain re"ie4 M)?or ,i%e E$$e#ts+ Sedati-n# re&!irat-r, de!re&&i-n# diEEine&&# heada.he *)r)meters C(e#!e%+ Re&!irati-n&# "e1e" -4 .-n&.i-u&ne&&# a&&e&& 4-r !ain -r heada.he& Me% )s per MAR+ MD Or%er+ Time"s& Due+ Generi#2Tr)%e N)me+ Norm)l Dos)ge+ Cl)ssi$i#)tion2A#tion+ In%i#)tion $or *)tient+ M)?or ,i%e E$$e#ts+ *)r)meters C(e#!e%+ Me% )s per MAR+ MD Or%er+ Time"s& Due+ Generi#2Tr)%e N)me+ Norm)l Dos)ge+ Cl)ssi$i#)tion2A#tion+ In%i#)tion $or *)tient+ M)?or ,i%e E$$e#ts+ *)r)meters C(e#!e%+ Me% )s per MAR+ MD Or%er+ Time"s& Due+ Generi#2Tr)%e N)me+ Norm)l Dos)ge+ Cl)ssi$i#)tion2A#tion+ In%i#)tion $or *)tient+ M)?or ,i%e E$$e#ts+ *)r)meters C(e#!e%+

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1%

INTERDI,CI*LINARY *ROGRE,, NOTE D)te Time Dis#ipline

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Student Name:

HCC ID#:

Date: HOWARD COMMUNITY COLLEGE NUR,E EDUCATION *ROGRAM Nursing C)re *l)n E0)lu)tion Tool
Y Assessment Data Collection A&&e&&ment (uide .-m!"ete and a..urate Path-!h,&i-"-(, adeIuate", di&.u&&ed and .-rre.t Gr-3th and de1e"-!ment .-m!"ete and a..urate U&e& mu"ti!"e &-ur.e& -4 data t- .-ntribute t- the !"an -4 .are 5i:e: &ubKe.ti1e# -bKe.ti1e# "ab# dia(n-&ti.# !ath-!h,&i-"-(,9 An)lysis Data Interpretation A..urate", inter!ret& a&&e&&ment data C-m!are& e*!e.ted 4indin(& t- ."ient 4indin(& Ana",Ee& "ab data# thera!ie& and !r-.edure& t- determine the im!a.t -n the ."ient Nursing Diagnoses F-""-3& !r-4e&&i-na" (uide"ine& 4-r 3ritin( nur&in( dia(n-&e& Identi4ie& ALL re"e1ant nur&in( dia(n-&e& 4-r the ."ient Li&t& nur&in( dia(n-&e& in !ri-rit, -rder Re"ate& &!e.i4i. and a..urate data t- the nur&in( dia(n-&i& *l)nning Expected Outcomes Stated in term& -4 !atient beha1i-r Cut.-me& are &!e.i4i.# mea&urab"e and ha1e a time 4rame Identi4ie& &h-rt term and "-n( term (-a"& Re"ate t- the eti-"-(, -4 the nur&in( dia(n-&i& Nursing Interventions Identi4ie& !ri-rit, nur&in( inter1enti-n& Inter1enti-n& &u!!-rt a.hie1ement -4 e*!e.ted -ut.-me& Inter1enti-n& are "abe"ed 3ith the .-rre.t a&!e.t -4 .are Cite& a!!r-!riate &.ienti4i. rati-na"e Implement)tion )n% E0)lu)tion E1a"uate& the &u..e&& -4 ea.h nur&in( inter1enti-n E1a"uate& ."ient !r-(re&& t-3ard a.hie1ement -4 e*!e.ted -ut.-me& Re1i&e& !"an -4 .are t- a.hie1e unmet -ut.-me& Mis#ell)neous Nur&in( .are !"an i& "e(ib"e C-m!-&iti-n 5"-(i.a" 4"-3 -4 idea&9 C-rre.t &!e""in( and (rammar Submitted -n time N I

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Y L Me&

N L N-

I L In.-n&i&tent

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