St.

Joseph’s University Nursing Care Plan

Your Name: Guerlene Jerome Date:10/12/2023 Unit: 17w Instructor: Ms. Leonethia Room Number: 1727A
Students Name: Day of Care:

Patients Initials: _TS____ Ethnicity: Russian__ Age: 70 Birth Sex: Female Preferred Gender: Female Code Status: DNR/DNI
Weight: 84.8 kg Height: 5”5 Diet: thicken diet Isolation: No Glasses/Lenses: No
Hearing Aids: No Dentures: No Oriented: Person yes Place_yes___ Time_yes__
Admitting Diagnosis: Failure to Thrive, fell at home twice, low appetite
Surgical Procedure: Tummy tuck, appendectomy
PMHx/PSHx: Heart Failure, diabetes Mellitus, HTN, constipation, fatigue,and weakness on both lower extremeties.
Allergies: no
Vital Signs: T- 97.8 P -85 Rhythm NSR RR -20 O2 Sat% - 99% BP – 130/74
Tubes/Drainage: NGT N/A GT N/A Foley N/A JP N/A Chest Tube N/A Hemovac_N/A Drainage Type and amount: N/A
Recent Travel: NO
COVID Vaccination? Yes
Monkeypox exposure: No

Pediatrics

Birth weight:
Delivery type:
Complications at birth:
Maternal History:
Development appropriate for age:
Immunization Status:
Head Circumference:
Length:
Gross Motor assessment:
Fine Motor assessment:
Neonatal Reflexes:
PAIN SCALE: NIPS______________ FLACC:_______________ WONG BAKER FACES:__________ 0/10:___________________

Subjective Data:
70 y/o Russian female, English speaking.
Patient is alert, and oriented.

Objective Data:

PLEASE INCLUDE A COMPLETE HEAD TO TOE PHYSICAL ASSESSMENT FOR YOUR PATIENT. THE ASSESSMENT IS NOT
LIMITED TO THE ITEMS LISTED. THEY ARE IN ADDITION TO THE FINDINGS ON YOUR PHYSICAL ASSESSMENT

Neurological:
Seizure Precautions: No
Glasgow Coma Scale: 15
Ambulation/ Gait:_No
Fontanel (Pediatrics):______________
ROM:
Respiratory: No respiratory distsress noted, respiration rate 20, lungs clear upon asculataion bilaterally

Cardiovascular:
Telemetry: No

GI/GU: abdomen soft, nontender

Continent: Yes, patient wear primifeed
Indwelling catheter: No

Integumentary: skin break down noted on sacrum, warm to touch, discoloration noted

Wounds/Incisions: buttock sacrum wound.

Musculoskeletal: muscle weakness noted to upper and lower extremities bilaterally.

Psychosocial: depression
Family/ Parents/Support/Visitors at bedside: (daughter)

Erikson’s Stage of Development: Generativity VS Stagnation

Psychiatric Hx_depression

Safety:
ID Band: Yes
Assistive Devices: No
Restraints:_ No
Weight Bearing Status: NO
Wanderguard:_No
1:1 Observation: No

Fall Risk Assessment:

➢ See Attached Complete Morse Risk for Falls Score
➢ SCORE - 50
○ Fall Precautions: YES___X____ NO_______
Skin Risk Assessment: See attached Braden / BradenQ Assessment
➢ Complete Braden Score
○ SCORE -
Risk?_____18_______________

Pain Assessment:
➢ Pain Intensity (1-10) - 0
➢ Pain tolerable: YES_______ NO__X____
➢ FLACC Score -

Intravenous Lines:
➢ IV site assessment without noted redness, swelling or pain. YES____ NO_X___
PIV/ Location __N/A___ Date Inserted __N/A, Tubing Change_N/A , Central Line_ N/A Date Inserted____N/A_____, Tubing Change___N/A______, Dsg
Change__N/A_

Activity:
➢ BR. YES_ NO_X___
➢ OOB. YES__X__ NO___
➢ Dangle. YES____ NO___X_
➢ BRP. YES__ NO__X__
 ➢ Ambulate. ___ NO_X_
➢ Pediatrics: Rolls Over____ Sits Up:____ Crawls:_____ Walks:______
Independent: _____ Assist__X__
Diet:
Fingersticks: YES
Fluid Restriction: NO
Thickened Liquids:_ NO
Enteral Feeding: NO

Laboratory Findings:

Labs Client Values Expected Labs Client Values Expected Labs Client Expected
Values Values Values Values

RBC 41.2 4.7-6.1 M BUN 32 10-20 Alkaline N/A 44-147 U/L

4.2-5.4 F Phosphatase

Hgb 12.7 14-18 M Creatinine 0.50 0.6-1.2 Total Bilirubin N/A 0.3-1.0 mg/dL
12-16 F

Hct 37.9 42-52 M ABG N/A 7.35-7.45 Albumin N/A 3.4-5.4 g/dL
37-47 F

Platelets 60 150,000- U/A N/A Total Protein N/A 6.0-8.3 g/dL

400,000

WBC 4.41 5,000-10,000 pH N/A 4.6-8 (ALT) SGPT N/A 8-46 U/L

Sodium 139 135-145 Color N/A Amber (AST) SGOT N/A 12-32 U/L

Potassium 3.8 3.5-5 Sp.Gravity N/A 1.010-1.025 MCV 92.0 80-100 fl

Chloride 110 95-105 Protein N/A None MCH 30.8 27.5-33.2 pg

Glucose (FBS) 229 70-110 Glucose N/A None MCHC 33.5 30-34 gHb/100ml

CO2 - 17 35-45 Ketones N/A None NRBC% 0.0 0 nucleated

RBC/100WBC

Calcium 8.5-10.5 Blood 0-2 RBCs MPV 7.5-12.0 fl

Magnesium 1.8 to 2.4 PT N/A Phosphorus 10.1 2.5-4.5 mg/dL
mg/dL PTT/INR

Other Diagnostic Findings/ Tests Performed:

N/A

Additional Laboratory Findings:

N/A

Medications:

Generic/Trade Dose Route Frequency Reason Side effects Adverse Reactions Primary Nursing
Classification Considerations
KEPPRA 500MG IVPB Q12 SEIZURE HEADACHE ANAPHYLAXIS, STEVEM JOHNSON Observe for signs of adverse
(levetiracetam) INFECTION NASAL SYNDROME effects.
CONGESTION Monitor fluid balance closely

Lidocaine patch 2 patch transde daily pain Erythema, puritus Skin irritation, allergic reaction Use caution in patients with
(Derma lid) rmal hepatic disease. Effects
prolonged.

Ascorbic acid 250mg oral daily Anemia, HTN Pain, swelling Injection site pain, hemolysis, oxalate Taking more than 2000 mg
Vitamin C) nephropathy daily is possibly unsafe and
may cause kidney stones and
 severe diarrhea

Cetylpyridinium 20 ml oral q.i.d Oral wash mouth irritation and Site burns, lip swelling, burning, gingival pain. Brush your teeth at least twice
(cepal temporary staining of a day. Use fluoride toothpaste
mouthwash) the teeth or tongue and a soft-bristled toothbrush.

Dexamethasone 2mg IV Q!2 inflammation Cataracts, erythema, Body fluids, cushion syndrome Observe for signs of adverse
(Decadron) vertigo reactions.
Monitor blood pressure 2 - 3
times daily.

Insulin glargine 10 units SQ daily Diabetes Lipodystrophy, rash Edema, hypertensive Monitor nutritional status to
provide nutritional consultation
as needed.

➢ List (3) Priority Nursing Diagnosis: (use NANDA Diagnostic Statement)

➢ e.g. Impaired gas exchange related to ventilation perfusion imbalance as evidenced by decreased breath sounds, respiratory rate
28…
Write up and further develop the PRIORITY nursing diagnosis with as many interventions as needed to the care of the patient.
Please use APA format in the citations and provide a reference page.

Diagnosis #1: Risk for aspiration related to difficulty swallowing as evidence by coughing while eating and drinking
Diagnosis #2: Risk for imbalance nutrition related to loss of appetite by evidence of fatigue.
Diagnosis #3: Risk for falls related to muscle weakness as evidence by patient inability to bear weight.

Goals
 Short Term Goals Long Term Goals

Patient will be fall free Provide patient with ADL’s assistant to live a safe and functional life,
free of falls and safety prevention

Patient will have proper nutrition. Provide patient with high protein diet

Patient will be aspiration free Provide patient with everyday assistant to live a safe, functional life
due to stroke and non-verbal, with safety and prevention

Nursing Interventions for Priority Diagnosis Rationales for Interventions with APA Citations

1.) 1.)
a. design a plan of care preventing falls a.planning a fall prevention is establish to reduce risk of patient falling

b. provide wristband identification for patient high risk for falls to b.helps establish awareness for healthcare for condition of patient
remind healthcare worker to monitor fall precaution.

c. transfer patient to room near nursing station c.establish which patient most likely to fall, and provide more constant
observation and quick response
(Gulanick & Myers, 2021)

2.) 2.)
a. ascertain healthy body weight for age and height a. dietician can determine measure of patient nutritional status

b. if patient lacks strength, schedule rest periods before meals, open b. nursing assistance with activities of ADL’s will conserve patient
 packages and cut food for patients energy for activities patient values
c. provide companionship during mealtime c. attention to social perspectives of eating is important in hospital and
home setting
3.) (Gulanick & Myers, 2021)
a. alternative activity with periods of rest and uninterrupted sleep
a.to prevent excessive fatigue
b. teach the patient signs and symptoms of overexertion with activity
b.changes in HR, oxygen saturation, and respiratory rate will reflect the
c. increase confidence level. Self-esteem, and tolerance level patients tolerance for activity

c.increase confidence level, self-esteem, and tolerance level

(Gulanick & Myers, 2021)

Patient Responses to Interventions:

Evaluation (Identify outcome attainment with supportive data):

Patient showing progress in following care plans without complication.

Patient able to swallow due to changing diet to thicken diet. Patient
tolerates interventions well. Patient remains fall free through the shift.

Revision in Plan (Identify Outcomes that were not attained):

NO revision needed.

Nurses Note: Please write a detailed nurses note below

Patient is alert, disoriented, verbally responding to his name. No respiratory distress noted. Lungs are clear bilaterally upon auscultation, S1, and
S2 noted. Abdomen is soft, non-tender, with audible bowel sounds present in all four quadrants. Patient wears a primifeed in place. Patient has a
history of falls and failure to thrive. Patient has weakness bilaterally in extremities. Patient is also on aspiration precaution. Patient has a wound
on his sacrum, discoloration noted. Safety maintains. Continue current plan of care. Guerlene

References (In APA format):

1) Gulanick, M., & Meyers, J.L., (2021). Nursing care plans: Diagnoses, interventions, and outcomes. Elsevier
2) Jones & Bartlett Learning. (2021). 2022 Nurse’s Drug Handbook (Jones & Bartlett Learning, ED.) Jones & Bartlett Learning