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Nursing Care Plan

Nursing Care Plan

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Published by zsazsageorge
Nursing Care Plan - Medical Surgical Nursing
Nursing Care Plan - Medical Surgical Nursing

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Published by: zsazsageorge on Mar 22, 2012
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06/18/2014

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MS Care Plan
Client Initials
: JBA
Room #: 513-1Age
: 70
Gender: MAllergies
: NKA
Code Status
: Full code
Wt
: 80 kg (176lbs.)
Ht
: 172.2 cm(5’6”)BMI: 27
Admit Date
: 11-05-11
Admitting Diagnosis/Symptoms
:Lower left extremity DVT (Left knee to groin)DVT can occur as the result of several combined events, including venous stasis,injury to the vessel wall, and the coagulation rate is altered. These conditionscause the formation of a blood clot, which becomes dangerous when the clotfragments and occlude the vessel. Complications of DVT include increased venouspressure, increased distal pressure, fluid stasis, and edema. (Smeltzer 2008)
Current Medical Dx
: LLE DVT w/ IVC filter placementAn IVF filter (or umbrella filter) is inserted to prevent recurring pulmonaryembolisms. The device is inserted through the internal jugular vein and advancedinto the inferior vena cava, where it is opened and operates as a filter for thebloodstream that prevents large thrombi from passing through. (Smeltzer 2008)good explanations here and with PMH
PMH/PSH
:
Polycythemia vera
: (Bone marrow disease that leads to an abnormal increase inthe number of blood cells. WBS and platelets are also increased. Thrombosis is acomplication of this disease.)
RLE DVT in 2008:
(Formation of a blood clot in a vein. This is the pt’s currentissue, though now in the opposite leg. PMH of past DVT and polycythemia identifypt is at higher risk for venous stasis, vessel wall injury, and hypercoagulability. )
Prostatectomy:
(Total removal of prostate gland in 2006. Denies complicationsfrom surgery.)
Appendectomy:
(Total removal of appendix in 1990s. Denies complications fromsurgery. History of abdominal surgery is associated with thrombus/emboli).
Social history (ethnicity, occupation, marital status, family support, livingsituation)
:White; married w/ grown children; retired; financially independent and fully mobile.
Relevant Medical Orders
VS freq
: q4h
Diet
: Coumadin diet what would this be?
Blood sugars
: N/A
Activity
: No restrictions
Oxygen
: RA
Respiratory Tx
: N/A
Dressing Changes
: q4d
Other relevant orders
:Continuous telemetry (baseline HR 87 & sinus rhythm with no ectopy, meaning allheart beats originate from the proper place in the heart.
Safety & Communication
Primary Language: English Translator required: NSpecial Communications Needs: None Hearing aids at BS: N
 
Sign Language Interpreter Required: NIsolation
: N/A
Falls Risk Score
: Min. fall risk
Aspiration Risk 
: N/A
Bleeding Precautions
: Yes. No aspirin; soft toothbrush; electric razor only; reportconstipation.
 
Assessment
Physical Assessment FindingsAnalysis of Findings(Normal or not? What is thesignificance of abnormal findings?)VS
BP 131/76HR: 83 T: 98.5O2 Sat: 98% on RANormal, though BP is high, whencompared to baseline BP of 140/80 andno history of HTN.
General appearance
Well groomed and pleasantBehavior and speech appropriateNormalWeight appears normal though BMIslightly high
Pain
Pt reports pain at 0 on a scale from 0-10Normal
Neuro/Psych
A & O x 3 to person, place, and timeMoves all extremitiesReports no dizzinessNormal
CV
Venous thromboembolismAnticoagulation therapy: Heparin IV+1 edema on LLE; no edema presentelsewhere on bodyHR 83 BPM, Rhythm regularNo S3, no S4 or other extra sounds, nomurmursNo visible pulsations, no heave or lift.Palpated apical impulse in 5
th
ICS and MCL,no thrillCapillary refill >3 secondsPt monitored for improvement of edemain LLE; monitored for response toanticoagulant therapy.
Respiratory
RR 18, even and unlaboredBS CTA, no adventitious soundsO2 Sat: 98% on RANormalGIAbdomen soft and NT, BS present in all fourquadrants. No bruits.Abdomen flat and symmetric with noapparent masses.Reports 0 abdominal pain on 1-10 scale.NormalGUContinent, no catheterNormalMSFull ROM, no pain with walking.Can walk without assistance. Full mobility.NormalIntegumentaryPurple bruise approx. 4 in. x 2 in on RU armMonitor IV sites.Monitor bruises for progression; risk for

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