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Nursing Care Plan 1

Nursing Care Plan


Student Shari Aguilera Course Nrsg 211 L Date 8/15/08
Instructor Sheryl Abelew
Patient IN M.H. DOB 5/8/1942 Age 64
DOA 7/21/08 Ht 5’7 Wt 158
Unit 7-East Room# 781-A

Admission Diagnosis Diagnostic Procedures/Surgeries (include dates) Discharge Referrals


Pancytopenia Only Lab Values were obtained for this patient, on N/A
the chart.

Erickson’s Developmental Stage Socioeconomic/Cultural Orientation Psychosocial Considerations


Mr. M.H. is in the Generativity vs. Mr. MH and his wife live at the home of his Mr. MH would need a translator to
Stagnation stage, which ranges between daughter and her family. He used to be a kitchen communicate with English
the ages of 30-64. In this stage, the chef while he was working. He is Spanish speaking speaking individuals.
middle-age adult seeks satisfaction only.
through productivity in career, family,
and civic interests. (Feldman, R., 2008, p.
365). In Mr. M.H.’s case, he is in the
stagnation stage because his health is
failing rapidly at age 64.

History of Present Illness Past Medical History Pertinent lab test (normal
(presenting signs & Past Surgical History ranges in parentheses) &
symptoms/diagnostic reports (Concurrent, onset, dates) diagnostic reports (with dates)
Patient was at home when he experienced Mr. MH has no prior illnesses except for Non- WBC- 1.4 (normal 4-10)
signs and symptoms of weakness. His Hodgkin’s lymphoma, which was diagnosed in RBC- 2.19 (normal 12-15)
wife brought him to the emergency room 2004. Platelets- 23
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where it was there that they found out


that his blood cell count was abnormal.
He was admitted to the medical surgical
floor and placed under reverse isolation
because of his WBC count of 1.4.

Pathophysiology of admitting and/or Collaborative Problems Rationale


related medical diagnosis Current Prescriber’s Order (with APA citations)
(with APA citations) (include meds, diet, test, and treatments)
Pancytopenia is the reduction in the The physician ordered reverse isolation for this Reverse isolation is used to
number of erythrocytes, all types of white patient to prevent infection related to the prevent the patient from attaining
blood cells, and the blood platelets in the pancytopenia. PRN medications for pain ordered. infection from an outside source.
circulating blood. (Miller 2006, p. 763) Patient is also on D51/2 NS + 20meq KCL IV Pain medications were given for
fluids. The patient is also on 02 2L NC, saturating the patient’s complaints of pain.
@ 96%. Since the patient has very poor
appetite, the physician ordered D5
½ NS + 20meq KCL to prevent
dehydration and electrolyte
imbalances. (Carpenito-Moyet,
2008 p. 873). Oxygen and Hand-
Held nebulizer treatments were
ordered to loosen lung secretions
and to promote adequate oxygen
saturation (Carpenito-Moyet, 2008
p 826).

Identify Potential Health Deviations Signs & Symptoms Interventions (at least two each)
(include Collaborative Problems) (Independent Nursing Functions)
The patient has potential for electrolyte -Patient hasn’t been having adequate fluid -Assess patient for any electrolyte
imbalances. intake orally, and had 2 episodes of disturbances, such as skin turgor, any
diarrhea. muscle contraction, blurred vision, and
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weakness.
-Monitor lab values as ordered, and notify
the physician if there are any electrolyte
imbalances.
- Hydrate the patient

The patient can have a potential infection -The patient has a WBC count of 1.4, RBC -Place the patient in reverse isolation
related to pancytopenia. count of 2.19, and Platelet count of 23. room.
-Instruct family that no outside fresh fruits
of flowers can be given to the patient
because it can cause infection.
-Monitor lab values as ordered
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Diagnostic Contributing Signs and


Label Related to As evidenced by
Factors Symptoms

Implementations
Independent
Functional Health Planning Rationale
Nursing Diagnosis nursing functions, Evaluations
Pattern (outcome/goal) (use APA citations)
minimum two, &
prioritized)
Health Perception- Ineffective Patient will have a -Encourage -Lying flat causes -Goal was met due
Health Management Respiratory respiratory rate ambulation as soon the abdominal to the patient having
Pattern function related to within normal limits as consistent with organs to shift an oxygen
weakness as compared with medical plan of toward the chest, saturation of 97%.
manifested by baseline in 3 days. care. thereby crowding
patient exhibiting -Assist client to the lungs and
Shortness of breath reposition, turning making it more
on exertion. frequently from side difficult to breathe.
to side (hourly if -Exercises and
possible). movement promote
-Encourage deep- lung expansion and
breathing and mobilization of
controlled-coughing secretions.
exercises five times -Adequate hydration
every hour. and humidity
--Ensure optimal liquefy secretions,
hydration status and enabling easier
nutritional intake. expectoration and
preventing stasis of
secretion.
(Carpenito-Moyet
2006 p.528)
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Health Perception- Risk for infection Patient will have -Place patient in -Prevents patient -Goat was met,
Health Management related to normal lab values reverse isolation from obtaining patients WBC count
Pattern pancytopenia as within 2 days. room infection coming was rechecked and
manifested by -Monitor vital signs. from an outside moved from 1.4 to
abnormal blood Note onset of fever, source. 3.9. Reverse
counts on lab draw. chills, diaphoresis, -Provides for early isolation was
and changes in detection of discontinued.
mentation. developing
-Assess lab values infectious process.
Doenges, 2006., p.
352).
- Suggestive of
presence of
infection/developing
sepsis, (Doenges,
2006)

Medication Information Sheet


Temp Pulse Respiration Blood Pressure Pain
98.4 84 16 102/63 2/10

Medications Mechanism of
Dose Common side Nursing
(with APA Class/Purpose Route Time action Onset of
(& range) effects considerations
citations action
Tylenol Nonnarcotic P.O. Every 4 hours 650mg – If Produces Anorexia, -Monitor s/s of
650mg Analgesic, As needed. temperature analgesia by vomiting, hepatotoxicity,
Antipyretic (Q4h PRN). >100.0 or for unknown dizziness, even with
If mild pain mechanism, but lethargy, moderate
temperature it is ventrally diaphoresis, acetaminophen
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>100.0, or for acting in the chills, tinnitus. doses,


mild pain. CNS by (Wilson, 2008,. especially in
increasing the P. 10) individuals
pain threshold with poor
by inhibiting nutrition, or
cyclooxygenase. have ingested
Reduces fever alcohol over
by direct action prolong
on periods of
hypothalamus time,
heat-regulating poisoning,
center with usually from
consequent accidental
peripheral ingestion or
vasodilatation, suicidal
sweating, and attempts;
dissipation of potential abuse
heat. (Wilson, from
2008, p 9). psychological
dependence.
(Wilson, 2008,
p. 10)
Morphine Analgesic; IVP Every 4 hours 4mg – For Natural opium Toxic -Obtain
Sulfate Narcotic as needed, for mild to severe alkaloid with psychosis, baseline
(opiate) mild to severe pain. agonist activity arrhythmias, respiratory rate
agonist pain. by binding with respiratory -Observe
the same depression, patient closely
receptors as hypersensitivity to be certain
endogenous rash, edema, pain relief is
opioid peptides. urticaria, deep achieved
(Wilson, 2008,. sleep, - Be alert to
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P. 1023) dizziness. elevated pulse


(Wilson, 2008., of respiratory
p. 1024) rate
-Monitor for
respiratory
depression,
-Assess ital
signs at regular
intervals
-Encourage
changes in
position
-Be alert for
nausea and
orthostatic
hypotension.
Monitor I&O
ratio and
pattern
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References

Doenges, M. E, Moorhouse, M. R, & Gessler-Murr, Alice C. (2005). Nursing diagnosis manual:

Planning, individualizing, and documenting client care. Philadelphia, PA: EA. Davis.

Carpenito-Moyet, L. J. (2008). Nursing diagnosis: Application to clinical practice, (11th ed.).

Philadelphia: Lippincott Williams & Wilkins.

Wilson, B. A., Shannon, M. T., & Stang, C. L. (2008). Nurse’s Drug Guide 2007. Upper Saddle

River, NJ: Pearson Education, Inc.

Lifespan Feldman, R.,(2008) Human Development (11th ed.). Boston: McGraw Hill.

Miller-Keane. (2006), Encyclopedia & dictionary of medicine, nursing, and allied health – 7th
edition.Philadelphia, PA: Darlene Como
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Nursing Care Plan


Grading Criteria
Criteria Possible Points Points Earned
Ericson’s Appropriate for patient
Developmental Sufficient rationale for stage
5
Stage
(5 points)
Related to patient’s
Pathophysiology admission diagnosis and
10
(10 points) history of present illness

Stated correctly
Nursing Diagnosis Sufficient data to support 10
(20 points) diagnosis 10

Dated
5
Measurable
Goals 5
Realistic
(20 points) 5
Relates to ND
5
Relates to the etiology
Nursing Orders Individualized
8
Interventions Appropriate
8
(20 points) Includes assessment and
4
teaching interventions

Each intervention, abnormal


lab result, and prescriber’s
Rationale 5
order have a rationale
(10 points) 5
(at least 3 are used)

Goal met or not met


Evaluation 5
Data to support
(10 points) 5
Organization
Format (Care Plan is complete)
5
(5 points) Spelling

Total