CLIENTS NURSING CARE PLAN FORM

Student: Brandi Rambeau

Client Initials: GP
A!e: "# Medi$al %ia!n&sis: 'em&(t)sis and Anemia
Nursin! %ia!n&sti$ Statement Rati&nale *&r Nursin! %ia!n&sis Client G&als
+Ris, *&r bleedin! r-t irritati&n
&* air.a) se$&ndar) t&
lar)n!eal mass/ anti$&a!ulati&n
t0era()/ and ir&n de*i$ien$)
se$&ndar) t& anemia
1
Literature1based Rati&nale *&r Nursin! %ia!n&sis Client Situati&n Rati&nale *&r Nursin! %ia!n&sis
T0e nurse .ill mana!e and
minimi2e bleedin! e(is&des
3T0e (rin$i(le $&m(li$ati&n &*
anti$&a!ulant t0era() is s(&ntane&us
bleedin! an).0ere in t0e b&d)4 5%a) et
al/ +66#/ ( 7879
T0e m&st $&mm&n and (&tentiall)
de:astatin! $&m(li$ati&n &*
.ar*arin t0era() is 0aem&rr0a!e
An INR;86 (la$es t0e (atient at a
!reater ris, &* a bleed Older (atients
.0& in$ur an e(is&de &*
&:eranti$&a!ulati&n ta,e l&n!er t&
return t& a sa*e le:el/ e<(&sin! t0em t&
(&tential bleedin! $&m(li$ati&ns
P&&r $&ntr&l &* =ar*arin ma) lead
t& in$reased m&rbidit) and m&rtalit)/
*re>uent d&$t&r :isits/ l&n!er
and m&re *re>uent 0&s(ital sta)s
and resultant in$reased 0ealt0 and
0&s(ital $&sts 5=esta.a)/ Crui$,s0an,/
R&berts/ ? Esterman/ +6@69
3Anemia is a $&nditi&n in .0i$0 t0e
0em&!l&bin $&ntent &* t0e bl&&d is
insu**i$ient t& satis*) b&dil) demands
T0e $&nditi&n usuall) is due t& a de$rease
in t0e number &* $ir$ulatin! RBCs4
5Lem&ne ? Bur,e/ +666 ( @+"79
3Treatment &* t0e $lient .it0 anemia is
dire$ted t&.ard ensurin! ade>uate tissue
&<)!enati&n C&mm&n treatments *&r
$lients .it0 anemia in$lude
(0arma$&l&!i$ t0era()/ dietar)
GP is a "# )ear &ld male .0& $ame t&
t0e 0&s(ital :ia E'S &n Aanuar) 6B/ +6@C
.it0 0em&(t)sis and anemia Ditals .ere
C"8 C 569/ "E b(m/ @+@-E7mm'! F
bra$0ial/ and Sa6+ BBG &n r&&m air &n
admissi&n T0e (t 0as been $&u!0in! u(
bl&&d *&r se:eral m&nt0s and 0as se:ere
di**i$ult) s.all&.in! and $&nsistent (ain
in 0is t0r&at A br&n$0&s$&() and CT
ne$, e<am .as (er*&rmed Feb @@/ +6@C/
s0&.in! a 8 $m mass &n t0e le*t side &*
t0e (atients lar)n< Patient 0as multi(le
lesi&ns and masses/ e<$essi:e mu$&us
se$reti&ns/ and in*lammati&n in t0e
t0r&at T0e (atients in$rease in $&u!0in!
and lar)n!eal lesi&n is $ausin! m&derate
am&unt &* 0em&(t)sis T0e (t .as ta,in!
=ar*arin " m! PO dail)/ but be$ause &*
0is 0i!0 ris, *&r bleedin! t0e d&$t&r 0eld
t0is medi$ati&n T0e (t is n&. &n E666
units Fra!min s-$ dail)
Client Out$&mes
@Client .ill remain *ree *r&m
e(is&des &* a$ti:e bleedin! b)
@7-@-@C
1 S,in *&r bruisin!
1'em&(t)sis
1 Bl&&d in st&&l
1 N&se bleeds
1 'ematuria
+ Clients :ital si!ns remain at
baseline b) @7-@-@C
C %is(la) lab&rat&r) results *&r
$l&ttin! times and *a$t&rs .it0in
n&rmal ran!e *&r indi:idual b)
m&di*i$ati&ns/ bl&&d re(la$ement
t0era()/ &r su((&rti:e inter:enti&ns4
5Lem&ne ? Bur,e/ +666 ( @+769
@7-@-@C
8 Client .ill be edu$ated ab&ut
a$ti&n and e**e$ts &*
anti$&a!ulati&n t0era() b)
@7-@-@C b) s0&.in! an
understandin! &* t0e reas&n 0e is
&n t0e medi$ati&n 5treatment9
and (&ssible bleedin!
abn&rmalities 5side e**e$ts9 su$0
as bleedin! *r&m !ums/
0em&(t)sis/ bl&&d in st&&l/
0ematuria/ n&se bleeds
Inter:enti&ns Literature1based Rati&nale *&r Inter:enti&ns E:aluati&n
Client Nursin!
N1@: 3Care*ul m&nit&rin! $an dete$t earl)
$0an!es in bl&&d :&lume4 5Car(enit&1M&)et
+6@6/ ( B@+9
N1+: 3All&.s *&r earl) dete$ti&nH t0ese s)m(t&ms
indi$ate t0at t0e b&d) is unable t& $l&t e**e$ti:el)
and *urt0er e<aminati&n and inter:enti&ns ma) be
.arranted t& (re:ent 0em&rr0a!e4 5R&d!ers/ +667
( #@89
N1C: 3T0e t0era(euti$ ran!e *&r t0e INR is +61
C64 5Car(enit&1M&)et/ +6@6 ( BC+9
N:8 3In&.led!e en0an$es an<iet) redu$ti&n and
all&.s t0e (atient t& understand 0ealt0 status and
im(lement 0ealt01(r&m&tin! be0a:i&rs4
5R&d!ers/ +667 ( #@89
N1E/ C1+: 3T0e (atient is at 0i!0 ris, *&r bleedin!H
sim(l) bum(in! int& &bJe$ts (la$es t0e (t at ris,
*&r bruisin! &r *ran, bleedin! *r&m sim(le
inJuries4 5R&d!ers/ +667 ( #@89
C1@: T0e (atient .0& 0as re$ei:ed t0r&mb&l)ti$
t0era() &r .0& is re$ei:in! anti$&a!ulant t0era()
is at ris, *&r 0em&rr0a!e due t& alterati&n &*
n&rmal $l&ttin! me$0anisms It is im(&rtant *&r
t0e (atient t& remain alert *&r e:iden$e &*
bleedin! 5Lem&ne ? Bur,e/ +6669
C1C: T0e le:el &* ,n&.led!e &* t0e main side
e**e$t &* .ar*arin and t0e si!ns and s)m(t&ms &*
bleedin! b) (atients is (&&r/ indi$atin! t0e
maJ&rit) &* (atients bein! dis$0ar!ed 0&me
a*ter bein! $&mmen$ed &n .ar*arin/ la$,ed
a.areness &* ,e) as(e$ts &* t0eir .ar*arin
Out$&me @: Partially MET
T0e (t did remain *ree *r&m a$ti:e bleedin!
e(is&des T0e (atient still e<(erien$es *re>uent
e(is&des &* 0em&(t)sis/ 0&.e:er But t0is
bleedin! .as &nl) a m&derate am&unt t0r&u!0&ut
t0e da)
Out$&me +: MET
Clients :ital si!ns remained stable >8 0rs
T C"8 C 5O9 P "E b(m/ .ea, BP @+@-E7 mm'!
F bra$0ial/ su(ine/ R +8-min lab&red/ Sa6+ B7G
&n r&&m air
Out$&me C: NO DATA AVAILABLE
T0e last INR lab data .as &n @"-@-@C at @+/
.0i$0 is .it0in n&rmal limits
@7-@-@C RBC 88# 5L9/ '!b @@C 5L9/ '$T C7 5L9
Out$&me 8: MET
I 0ad a dis$ussi&n .it0 t0e (atient ab&ut 0is
anti$&a!ulant medi$ati&ns 'e said t0e d&$t&r
s(&,e t& 0im &n @#-@-@C t& e<(lain .0) 0is
=ar*arin .as bein! 0eld =e dis$ussed t0e side
e**e$ts &* anti$&a!ulati&n t0era() and 0e
underst&&d t0at 0is medi$ati&n .as 0eld be$ause
0e .as at a 0i!0 ris, *&r bleedin! =e als&
dis$ussed sa*et) (re$auti&ns t& ta,e t& (re:ent
bleedin! e(is&des/ and t0in!s t& .at$0 *&r/ su$0
as: bleedin! *r&m !ums/ bleedin! in urine &r st&&l/
n&se bleeds/ and $&u!0in! u( bl&&d t0at .as m&re
t0an usual *&r t0e (t
Overall Goal: N& seri&us bleedin! e(is&des
&$$urred .0ile I .as .it0 m) (t 'e did 0a:e
@Client .ill re(&rt t&
nurse and bleedin!
e(is&des su$0 as
1bleedin! *r&m !ums
10em&(t)sis
1bl&&d in st&&l
10ematuria
1n&se bleeds
+ Pt .ill a:&id
a$ti:ities t0at in$rease
t0e ris, *&r bleedin!
and ambulate $are*ull)
1s0a:in!
1m&bili2in!
1usin! a s&*t bristled
t&&t0 brus0
1 trimmin!
*in!ernail-t&es
CClient .ill e<(ress an
understandin! &*
treatments/
medi$ati&ns/ and side
e**e$ts &*
anti$&a!ulati&n t0era()
@Nurse .ill m&nit&r
:ital si!ns *&r baseline
:alues
+Nurse .ill m&nit&r
*&r indi$ati&ns &*
bleedin! abn&rmalities
1 S,in *&r bruisin!
1'em&(t)sis
1 Bl&&d in st&&l
1 N&se bleeds
1 'ematuria
CM&nit&r lab&rat&r)
:alues: INR/ CBC
8Tea$0 t0e (atient and
e:aluate 0is
understandin! &* t0e
*&ll&.in!: Treatments/
medi$ati&ns/ and side
e**e$ts &*
anti$&a!ulati&n
t0era()
E En$&ura!e t0e (t t&
ambulate $are*ull) and
re*rain *r&m 0i!0 ris,1
a$ti:ities
treatment It is essential *&r (atients t& 0a:e
$lear ,n&.led!e &n t0e si!ns &*
bleedin! 5=esta.a)/ Crui$,s0an,/ R&berts/ ?
Esterman/ +6@69
0em&(t)sis but t0is is usual *&r t0e (t T0e
0em&(t)sis .as &nl) a m&derate am&unt and I
in*&rmed t0e (t t& n&ti*) me i* t0e am&unt &*
bleedin! in$reased durin! t0e da)