Nursing Care Plan Week 3

Student Initials_RMS

Occupation retired Religion/Culture Christian ALLERGIES anti-coagulants Medical Diagnoses Stage IV colorectal CA metastasized to vaginal mucosa, Diabetes Mellitus, Cataracts and retinopathy, CHF, Hypertension, Morbid obesity, Asthma, Anemia secondary to CA tx Surgery (if applicable) colon resection 3/08
Subjective and Objective Assessments Related Nursing Diagnosis S: pt Patient Goals/Outcomes with measurable criteria Interventions based on Goals/Outcomes with Rationale, including reference with page numbers Implemented Evaluation based on Goals/Outcomes

reports hx of diarrhea x 3 years post colon resection O: Pt incontinent of diarrhea 8 x QS; partial thickness radiation burns across panniculus, perineum and rectum; 2+ BL pitting edema Risk for Deficient Fluid Volume r/t active fluid loss

Patient will maintain fluid balance within 200 ml while in hospital

Assess s/s of dehydration • Poor skin Turgor • Dry mucous membranes • Mental status changes

Assessed pt @ 0800

Goal met: pt maintained adequate fluid balance

Maintain strict I/O including stool loss • Insert rectal tube per MD order • Maintain Foley catheter

Rectal tube inserted @ 1430

Encourage PO fluid intake

Made sure pitcher was kept full IV D/C’d 1310

Administer IV fluid as ordered

Subjective and Objective Assessments Related Nursing Diagnosis

Patient Goals/Outcomes with measurable criteria

Interventions based on Goals/Outcomes with Rationale, including reference with page numbers

Implemented

Evaluation based on Goals/Outcomes

S: pt reports 18 rounds of radiation tx; hx of DM neuropathy O: large BL ulcers on bottom of feet; Pt incontinent of diarrhea 8 x QS; partial thickness radiation burns across panniculus, perineum and rectum; Impaired Skin Integrity r/t radiation, incontinence and altered circulation AEB foot ulcers and destruction of pannicus and perineal epidermis

Patient will exhibit no further breakdown during hospital stay

• • •

Perform pericare Q one hour and PRN Treat existing breakdown with wound gel and cover with gauze Insert rectal tube per MD order

Rectal tube inserted @ 1430; pericare throughout shift

Patient’s foot wounds will heal without complications

Patient’s infection will be resolved

• Change dressings QS • Apply QS Accuzyme as ordered Enzyme ointment dissolves necrotic tissue with little impact on intact skin • Maintain CTI dressing between changes Maintenance of a clean wound site decreases number of organisms and reduces spread of infection.

Dressing changed @ 1400

Goal partially met: pt skin was cleansed and dressed meticulously, but this nursing student is aware that such care will be impossible under normal hospital circumstanst

Monitor for signs of infection o take temperature Q 4

Preulent d/c noted at mediport site; reported to nurse/doctor

hours o drainage or heat at any wound IV access insertion site o urine for malodor or mucous o oral cavity for white coating o assess for cough, sputum production, or crackles in lungs; notify physician if any are noted. A fever or systemic signs such as malaise may be the only sign of infection, as the patient is unable to produce the normal inflammatory response due to immunosuppression.
Patient had limited number of visitors; diet was adequate

Ensure adequate rest, nutrition, and hydration • Encourage adequate nutritional intake, especially of protein, vitamin C, and iron. Rest and hydration are both needed for restoration of the body and to ; adequate nutrient intake, especially of vitamin C, protein, and iron, is required for healing and tissue repair.

Subjective and Objective Assessments Related Nursing Diagnosis

Patient Goals/Outcomes with measurable criteria

Interventions based on Goals/Outcomes with Rationale, including reference with page numbers

Implemented

Evaluation based on Goals/Outcomes

S: pt

reports hx of diarrhea x 3 years post colon resection O: Pt incontinent of diarrhea 8 x QS; partial thickness radiation burns across panniculus, perineum and rectum; 2+ BL pitting edema Acute Pain r/t radiation burns and skin ulcers

Pt’s pain will remain under control: • The patient will verbalize that pain has been relieved 30 minutes after interventions.

Assess for location, intensity, quality, and precipitating factors. Have the patient rate pain intensity using a pain rating scale. Assess the status of affected extremity, including pain at operative site, tenderness to touch, temperature, and edema.

Assessed Q 2 hours and PRN during peri-care

Goal not met: Pt remained at 5/10 pain level; jumped to 8/10 during skin care and transfers

Administer analgesics, as ordered, on a regular schedule, not allowing pain to get intense. Keeping pain medication at constant intervals decreases pain level and keeps pain manageable.

Administered Vicodin q4 hours, Ocycontin BID

Assess effectiveness of interventions to relieve pain and modify tx as necessary Determines whether interventions have been effective in relieving pain or whether new strategies need to be employed.

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