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NURSING CARE PLAN

Nursing Care Plan
NURSING (AS) Program
Student Name: Mabelys Blandy Instructor: Roberto Puga
Date: 07/07/2014 Clinical Site: Palmetto Rehabilitation Center
Patient Information
Initial: EF Sex: M / F Age: 61 Ethnic Group: White / AA / Hispanic / Asian
Date of Admission: 07/08/2014 . Allergy: IODINE Weight: 160 Diet: Low Fat Low NA
Admitting Diagnoses:
1) CVA
2) RHEUMATOID ARTHRITIS
3)
4)
Patient Past Medical History: TIA 2013,


Past Surgical History: CABG 2009

Social History: 59 YEAR OLD WHITE HISPANIC MALE. DIVORCED, LIVES ALONE. HAS 2 CHILDREN THAT LIVE IN ANOTHER STATE.
SMOKED 20 YEARS AGO 1 PACK OF CIGARRETES PER DAY. DENIES ALCOHOL USE.

History of Present Illness: (If additional Space is needed please continue on the back of this page)
PATIENT PRESENTED TO THE ER WITH FACIAL DROOP AND IMPAIRED MOBILITY TO RIGHT SIDE OF BODY.



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NURSING CARE PLAN

Subjective Findings
(If additional Space is needed please continue on the back of this page)
PATIENT STATES THAT HE FEELS HELPLESS AND DEPENDENT BECAUSE HE IS UNABLE TO DRESS INDEPENDENTLY AND
REPORTS DIFFICULTY SWALLOWING





Objective Finding
Vital Sign: BP: 129/83 HR: 84 RR: 18 Temp: 98.7



Physical Assessment Findings: SKIN; WARM AND DRY TO TOUCH NO OPEN OR REDDENED AREAS NOTED. ALERT ORIENTED TO
PLACE AND PERSON. FACIAL DROOP R SIDE HEMIPLEGIA. LUNGS CLEAR. BOWEL SOUNDS PRESENT X 4. ABNORMAL GAIT;
POOR COORDINATION; DIMINISHED SWALLOW AND COUGH REFLEXES. UNEQUAL HAND GRIPS; UNEQUAL PUPILS. INFLAMED
KNEE JOINTS

Laboratory Studies:
CBC LIPID PANEL Metabolic Panel Coagulation

RBC 4.32 CHOLESTEROL 241 CALCIUM 10.1 PROTHROMBIN TIME (PT) 12 SECONDS
HGB 13.8 HDL 38 CHLORIDE 118 INTERNATIONAL NORMALIZED RATIO (INR) 2.8
HCT 42.2 LDL 133 CREATININE 1.20
WBC 4.1 TRIGLYCERIDE 156 GLUCOSE 99
PLATELET 402 POTASSIUM 5.2
SODIUM 139
BUN 22

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Imaging Result: (X-Ray, CT scan, MRI, MRCP, ultrasound…….)

CT SCAN ; INCREASED INTRACRANIAL PRESSURE, CEREBRAL EDEMA, LEFT HEMISPHERIC CEREBRAL INFARCT
EEG; CBF 24




Endoscopic Result: (colonoscopy, EGD…..)







What is the relation between these diagnostic tests with the Patients Disease and or present illness?

CT SCAN (COMPUTED TOMOGRAPHY SCAN)
PROVIDES DETAILED VISUALIZATION OF SOFT TISSUE AND BLOOD VESSELS WITHIN THE BRAIN. A CT SCAN AIDS THE DOCTOR
IN PINPOINTING THE EXACT LOCATION OF THE CAUSATIVE FACTOR OF THE STROKE SUCH AS HEMORRHAGE OR BLOOD CLOT.

EEG (ELECTROENCEPHALOGRAM)
IS A USEFUL TOOL FOR ACUTE STROKE DETECTION AND FOR MONITORING AFFECTED TISSUE. OFFERS A CONTINOUS, REAL
TIME, NON INVASIVE MEASURE OF BRAIN FUNCTION. DECLINE IN CBF )CERBRAL BLOOD FLOW) CAN BE IDENTIFIED BY A
DECLINE IN THE FREQUENCIES OF THE EEG.


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NURSING CARE PLAN

Analysis:
What are the potential Complications / Problems for this patient?

PNEOMONIA DUE TO IMMOBILITY, PRESSURE ULCERS, ASPIRATION, HEMORRHAGE, INJURY RELATED TO RISK FOR FALLS






















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Medication List

Medication/Order Usage Usual Dose Side effects Nursing Intervention

HEPARIN IV 1X
ANTICOAGULANT
INITIAL BOLUS

5000 UNITS

HEMMORRHAGE
MONITOR VS ASSESS FOR
SIGNS OF BLEEDING

HEPARIN IV DAILY

ANTICOAGULANT
2000 UNITIS/HR X 48
HR

HEMMORRHAGE
MONITOR VS ASSESS FOR
SIGNS OF BLEEDING

COUMADIN PO DAILY

ANICOAGULANT

4 MG QD
NAUSEA, VOMITING,
BLATING, GAS
MONITOR VS ASSESS FOR
SIGNS OF BLEEDING

ASPIRIN PO DAILY

ANTICOAGULANT

81 MG QD
NAUSEA, HEARTBURN,
STOMACH CRAMPS
MONITOR VS ASSESS FOR
SIGNS OF BLEEDING
COLACE DAILY 1 TAB
PO

STOOL SOFTENER

100 MG
BLOATING, CRAMPING,
DIARRHEA
ASSESS BOWEL SOUNDS
DAILY

MANNITOL IV DAILY

DIURETIC

180 MG
DRY MOTH, THIRST,
HEADACHE, DIURESIS
MONITOR URINARY
OUTPUT AND VS

FUROSEMIDE PO DAILY

DIURETIC

20 MG PO
DRY MOTH, THIRST,
HEADACHE, DIURESIS
MONITOR URINARY
OUTPUT AND VS

OXYGEN VIA NC CONT.

2 ML/MIN

ASSESS LEVEL OF
CONSCIOUSNESS AND O2
SATURATION

TYLENOL #3 PO PRN
Q 4 HR AS NEEDED FOR
PAIN
1 TAB DRY MOUTH,
DIZZINESS, NAUSEA,
VOMITING
MONITOR PAIN LEVEL
BEFORE AND AFTER
MEDICATION
ADMINISTRATION

BENADRYL PRN
ANTIHISTAMINE PRESCRIBED
FOR IODINE ALLERGY DUE TO
CONTRAST USED IN CT SCAN
1 TAB
DROWSINESS, DIZZINESS,
BLURRED VISION,
CONSTIPATION


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NURSING CARE PLAN



Nursing Care Plan
Once evaluated patient’s past and present history, select at least three nursing diagnoses from highest to lowest priority. Give nursing interventions
(dependent/independent/collaborative) for each nursing diagnoses with rational for each intervention. Determine a short and long term goal for each nursing diagnoses.
Nursing Diagnoses
(…..related to…..secondary to ….evidenced
by…..)
Desired Outcome

Nursing Interventions / Rationales

RISK FOR BLEEDING RELATED TO
ANTICOAGULANT THERAPY
SECONDARY TO TREATMENT
POST CVA









DRESSING SELF CARE DEFICIT
RELATED TO HEMIPLEGIA
SECONDARY TO CVA EVIDENCED
BY IMPAIRED MOVEMENT ON
RIGHT SIDE OF BODY


PATIENT WILL BE FREE
OF BLEEDING DURING
THE TIME OF
HOSPITALIZATION









PATIENT WILL DRESS
AND UNDRESS IN A SAFE
WAY AND LEARN TO
PERFORM TASKS AS
INDEPENDENTLY AS
POSSIBLE WITH LEFT
HAND DURING
MONITOR PT/INR

ASSESS IV SITE Q SHIFT

IMPLEMENT FALL PRECAUTIONS

MONITOR FOR HEMATURIA

ASSESS SKIN FOR SIGNS OF BLEEDING SUCH AS HEMATOMA

MONITOR VITAL SIGNS


HAVE NURSING ASSISTANT HELP WITH DRESSING

REFER FOR OCCUPATIONAL THERAPY

PROVIDE CLOTHING THAT IS EASY TO PUT ON WITH ONE HAND

HAVE SOCIAL SERVICES REFER PATIENT FOR HOME CARE
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HOSPITAL STAY ASSISTANCE
Nursing Diagnoses
(…..related to…..secondary to ….evidenced
by…..)
Desired Outcome

Nursing Interventions / Rationales

RISK FOR ASPIRATION RELATED
TO DECREASED REFLEXES
SECONDARY TO CVA EVIDENCED
BY INABILITY TO COUGH AND
SWALLOW ADEQUATELY






CHRONIC PAIN RELATED TO
JOINT DESTRUCTION AND
ANKYLOSIS SECONDARY TO
RHEUMATOID ARTHRITIS
EVIDENCED BY FACIAL
GRIMACING AND GUARDING OF
AFFECTED AREA





PATIENT WILL BE FREE
OF S/S OF ASPIRATION
AND WILL VERBALIZE
UNDERSATNING OF
IMPORTANCE OF
ELEVATING HOB TO
PREVENT ASPIRATION




PATIENT WILL
VERBALIZE PAIN RELIEF
AND A LEVEL OF PAIN
OF 3 OR LESS ON THE
NUMERIC RATING PAIN
SCALE
MAINTAIN HOB ELEVATED

ASSESS LUNG SOUNDS

PROVIDE THICK FLUIDS OR THICKENER FOR THE FLUIDS

CRUSH PILLS AND ADMINISTER WITH PUDDING OR APPLE SAUCE

REFER FOR SPEECH THERAPY


ADMINISTER PRESCRIBED PAIN RELIEF MEDICATION PRIOR TO
ONSET OF PAIN

TEACH AND PROMOTE RELAXATION TECHNIQUES SUCH AS
DISTRACTION AND IMAGERY

APPLY ICE OR COLD PACKS DURING ACUTE EPISODES

PROVIDE PASSIVE ROM EXCERCISES
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Nursing Diagnoses
(…..related to…..secondary to ….evidenced
by…..)
Desired Outcome

Nursing Interventions / Rationales

























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Patient’s Care Plan Evaluation of Outcomes:

PATIENT REMAINED FREE OF SIGNS AND SYMPTOMS OF BLEEDING
DEMONSTRATES ABILITY TO DRESS UPPER BODY WITH LEFT ARM
REMAINED FREE OF S/S OF ASPIRATION
PATIENT VERBALIZED A PAIN LEVEL OF 2 AS MAXIMUM LEVEL OF PAIN EXPERIENCED




















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Student Evaluation
(To be completed by faculty only)

Comments:




Student Needs to Improve on:





FINAL GRADE: _____________________ Instructor’s Signature: _____________________________
Date of evaluation: _________________ Student’s Signature: _______________________________

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