APPENDIX A Care Plan

STUDENT NAME:

JULIA BROWN DATE: 10/12/2020

CLIENT DEMOGRAPHIC INFORMATION

Allergies: NKA
Client’s Initials: AB DOB: 09/06/2006 Age: 14 Wt: 110lb
Date(s) cared for: 10/12/2020

SECTION I: PHYSIOLOGICAL ASSESSMENT & NURSING DIAGNOSES

MEDICAL HISTORY:
Reason for Admission
ATV ACCIDENT

Medical History
NO PMHX GIVEN

Current Medical Problems

FRACTURED TIBIA AND FIBULA

Surgeries/Procedures
SKELETAL TRACTION

PATHOPHYSIOLOGY
Current Medical Diagnoses/ Problems How this relates to this patient
BROKEN TIBIA AND FIBULA AS A YOUNGER PATIENT, CARE MUST BE
MAINTAINED SO NORMAL GROWTH AND
DEVELOPMENT CAN OCCUR. THE BROKEN
BONES CAN HEAL UNEVENLY IF NOT PROPERLY
CARED FOR.
THE BROKEN BONES CAN IMPAIR THE
PATIENT’S ABILITY TO AMBULATE

RELEVANT LABORATORY FINDINGS

Date of Test Name Patient’s Normal Range How does the value related to
Test Lab Finding this patient? (Analyze trend)
N/A
RELEVANT LABORATORY FINDINGS
VITAL SIGNS ADMISSION FIRST READING SECCOND
READING
Temperature 98.6^F / 37.0^C 102.4^F 100.9^F

Heart Rate 87 75 93

Respiratory Rate 18 16 12

Blood Pressure 11/72 120/69 108/80

SaO2 97% RA

Pain/ Scale Used SEVERE NONE

REVIEW OF SYSTEMS
NEUROLOGICAL N/A

CARDIOVASCULAR N/A

PULMONARY N/A

GASTROINTESTINAL N/A

GENITOURINARY/REPRODUCTIVE N/A

MUSCULOSKELETAL IMPAIRED ABILITY TO AMBULATE

INTEGUMENTARY IMPAIRED SKIN INTEGRITY FROM THE CAST AND PINS

SECTION II: DEVELOPMENT & PSYCHOSOCIAL ASSESSMENT

DEVELOPMENTAL ASSESSMENT

Expected Developmental Milestones Actual Stage of Development

(How does this patient compare to expected

milestones)

1. Nutrition NORMAL

2. Elimination NORMAL
 3. Gross Motor WALKING IMPAIRED DUE TO INJURY

4. Fine Motor NORMAL

5. Language NORMAL

6. Cognitive Development NORMAL

7. Self-Concept AT RISK FOR IMPAIRMENT DUE TO INJURY

8. Roles and Relationships NORMAL

9. Coping and Resiliency NORMAL

FAMILY ASSESSMENT

PARENTS MENTIONED

PROBLEM 1: RISK FOR INFECTION RELATED TO SURGICAL PROCEDURE

RISK FACTORS: POST-SURGERY, INCREASED TEMPERATURE
GOAL: PATIENT WILL REMAIN INFECTION FREE
SECTION III: NURSING PROCESS:
Nursing Strategies /Interventions Patient Responses

1. MAINTAIN STRICT ASEPTIC TECHNIQUE FOR N/A

DRESSING CHANGES AND WOUND CARE
2. HAND WASHING AND HYGIENE, PPE N/A

3. EDUCATE PATIENT ABOUT HOW TO N/A

PROPERLY CLEAN AREA
4. ENCOURAGE NUTRIENT-DENSE MEALS N/A

5. TEACH TO AVOID THOSE THAT MAY BE SICK N/A

6. PRESCRIBE ANTIBIOTICS IF NEEDED N/A

PROBLEM 2: AT RISK FOR IMPAIRED SKIN INTEGRITY

RISK FACTORS: CAST, BED REST, SURGICAL INCISIONS
GOAL: PATIENT WILL HEAL AND HAVE UNREMARKABLE SKIN

Nursing Strategies /Interventions Patient Responses

 1. ASSESS SKIN FOR CHANGES AROUND N/A
CAST AREA AND SURGICAL SITE
2. FREQUENT POSITION CHANGES PATIENT RE-PO Q2HR WITH PILLOW
SUPPORT
3. HIGH-PROTEIN HIGH-CALORIE DIET N/A
WITH INCREASED FLUIDS
4. PROPER PLACEMENT OF IV TUBING N/A
AND OTHER DEVICES
5. TEACH HOW TO ASSESS WOUND N/A
HEALING
6. KEEP THE BED FLAT TO REDUCE PT HAS SKELETAL TRACTION AND GRAB
FRICTION AND PRESSURE BAR

PROBLEM 3: IMPAIRED MOBILITY

RISK FACTORS: BROKEN TIBIA, BROKEN FIBULA, SKELETAL TRACTION, CRUTCHES
GOAL
Nursing Strategies /Interventions Patient Responses

1. ASSIST PT WITH AROM AND PROM N/A

2. PRESENT A SAFE ENVIORNMENT N/A

3. PROMOTE EARLY AMBULATION AS SOON N/A

AS POSSIBLE
4. ALLOW PT TO ACCOMPLISH TASKS AT THEIR N/A
OWN PACE
5. GIVE MEDICATIONS AS NEEDED N/A

6. HELP PT BALANCE AND TRANSFER WEIGHT N/A

Document ALL regularly scheduled medications given during the clinical shift, attach additional sheets if necessary.
 PRN MEDICATIONS (ADMINISTERED IN LAST 24 HOURS)
Drug / Drug Target Dose/Range Dose, Route, Why Ordered for Priority Assessments
Class for your patient Frequency this Patient & Interventions for
this patient
PAIN INJ 75MG FOR MOD-SEVERE PAIN LEVEL
MEDICATION PAIN DECREASES AFTER
ADMINISTRATION
ANTI-NAUSEA INJ 25MG/1ML FOR NAUSEA NAUSEA
MEDICATION DECREASED AND
ABSENT AFTER
ADMINISTRATION

CONTINUOUS INFUSIONS
Infusion Name Target Dose/Range Why Ordered for this Patient Priority Assessments &
for your patient Interventions for this patient
N/A

What are the relationships between the pathophysiology, psychosocial assessment, medications, labs,
and treatments? (You may draw a concept map – relationships between above items must be clear and
detailed)
A BROKEN BONE CAN BE PAINFUL. HAVING TWO BONES BROKEN IN THE SAME LEG CAN
NOT ONLY BE PAINFUL, BUT ALSO SEVERLY IMPAIR THE PATIENT’S ABILITY TO WALK AND
MOVE EFFICIENTLY. THE PATIENT WILL NEED TO LEARN HOW TO USE CRUTCHES AND BE
REMINDED THAT THEIR BONES ARE STILL HEALING AND THAT THEY NEED TO TAKE IT
EASY AND KNOW LIMITATIONS.

SECTION V: ADDITIONAL INFORMATION

DISCHARGE PLANNING: (What goals must be met before pt is discharged):

COMMUNITY/TEACHING RESOURCES
S – PATIENT WILL HAVE SURGICAL WOUND HEAL WITHOUT INFECTION
M – PATIENT WILL GAIN STRENGTH WITH EVERY VISIT TO PT/OT
A – PATIENT WILL REPORT ANY SSX OF INFECTION OR CHANGE IN HEALTH
R – PATIENT WILL EFFECTIVELY USE CRUTCHES
T – PATIENT WILL REGAIN STRENGTH OVER THE COURSE OF 6 MONTHS
What is the nursing course outcome for Teamwork and Collaboration?
The successful student completing NURS 2201 will be able to: Identify concepts within nursing and in
interdisciplinary teams that foster open communication and mutual respect. Identify the parameters of
effective relationships with patients and members of the health care team (ASN PO#-3).
2 List your strengths, limitations, and values in functioning as a member of the healthcare team.
Strengths Limitations Values Readiness to learn Hands on learner Empathetic Competent Hard worker Good
communication skills Willing to work with others Limited experience
Online clinical- no hands on learning Honesty Responsibility Trustworthy Loyalty
3. Describe one example of how you functioned as an effective member of the healthcare team during
your clinical experience this week.
I arrived to preconference on time ready and willing to learn.
I performed the simulations in a timely manner and attended post conference to discuss patient care provided
4. List (by title, not name) the members of the healthcare team, including yourself, for one of the
patients you cared for this week. Include the patient and family in this listing; identify family role (i.e.,
parent, spouse, sibling, or child). Provide one example of how each team member contributed to the
achievement of patient care outcomes. Healthcare Team Member Contribution to the Achievement of
Patient Care Outcomes Clinical instructor
Student nurse - Helped me understand the simulation and what was expected of me. Performed the simulation
in a timely manner
“patient” Came in with an acute asthma exacerbation
“family members” - educated on how to prevent asthma attacks and cessation of smoking, were cooperative
with team
5. Write a short summary that supports your achievement of the course clinical learning outcomes for
teamwork and collaboration. Refer to the clinical learning outcomes listed on the course clinical
evaluation tool, and provide specific examples of how you met the learning outcome.
I believed I worked well with others this week because despite being online and not having face to face
interaction with members of the healthcare team, I was able to communicate well with my instructor via zoom
in which she was available to help with any questions I had. I was also able to help other classmates that were
also struggling when they reached out to me for advice.