Beruflich Dokumente
Kultur Dokumente
COLLEGE OF NURSING
Student: Lindsey Willis
1 PATIENT INFORMATION
Patient Initials: B.K.
Age: 59 y.o.
Gender: Female
Number/ages children/siblings:
Dyspnea 794.39
Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: 9/19/15 Procedure: cardiac
catheterization
1 CHIEF COMPLAINT:
Heart issues. I had a stress done Friday and was told to go to the hospital immediately.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
59 y.o. female with past medical history of diabetes mellitus, hypertension. Sent to the ER from her cardiologists office
that the patient had a stress test done showing that it was abnormal; so the patient was sent to the ER for further
evaluation. The patient denies any chest pain, but presented with dyspnea. No fever or chills, nausea, vomiting, headache.
OLDCARTS: Dyspnea. Onset: 9/19/15; Location: lungs/chest. Duration: 12-24 hours. Characteristics: shortness of breath.
Aggravating factors: exertion. Relieving factors: rest and oxygen administration. Treatment: oxygen. Severity: moderate
to severe difficulty in breathing.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date
Unknown Date
Unknown Date
Unknown Date
Unknown Date
Unknown Date
Unknown Date
Operation or Illness
Thoracic Outlet Syndrome
Diabetes Mellitus
Hypertension
Hyperlipidemia
Anxiety and depression
Incontinence Surgery
5
0
7
9
Father
Mother
Tumor
Stroke
Stomach Ulcers
Seizures
Mental
Problems
Health
Hypertension
Problems
Kidney
Gout
Heart Trouble
(angina, MI, DVT etc.)
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Anemia
Arthritis
Cause
of
Death
(if
applicab
le)
Environmental
Allergies
2
FAMILY
MEDICAL
HISTORY
Hysterectomy
Alcoholism
Unknown Date
CAD
Ovarian
cancer
Brother
5
6
Sister
relationship
relationship
relationship
Comments: Patient did not know age of onset for family medical history
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) Unknown
Adult Tetanus (Date) 2015
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS
Medications
Other (food, tape,
latex, dye, etc.)
NAME of
Causative Agent
YES
NO
No known allergies
No known allergies
5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Coronary artery disease (CAD) is part of a continuum of conditions affecting the coronary arteries, such as arteriosclerosis
and atherosclerosis. These conditions result in decreased oxygen and nutrients to the myocardium. The most common
cause of reduced myocardial blood flow is atherosclerosis (Osborn, Wraa, Watson, & Holleran, 2014, pp. 920).
Atherosclerosis is a type of arteriosclerosis that results in coronary artery luminal obstruction due to plaque buildup
infiltrating the lining of the arterial wall, which leads to a reduction of blood flow to the myocardium (Osborn et al.,
2014, pp. 920). A reduction in myocardial blood supply can lead to a variety of coronary syndromes: stable angina,
unstable angina, acute myocardial infarction, and sudden cardiac death (Osborn et al., 2014, pp. 920). These syndromes
represent a sequence of progressively worsening diseases, due to the increasing imbalance between myocardial oxygen
demand and oxygenated blood supply. To meet the myocardial oxygen demand, myocardial blood flow must be increased.
With CAD the arteries do not dilate properly, or at all, due to the plaque buildup and calcification within the artery walls
(Osborn et al., 2014, pp. 920). Additionally, due to decreased blood supply, the heart muscle has significant difficulty
increasing the force of contraction to increase cardiac output (Osborn et al., 2014, pp. 920). Overall the unmet oxygen
demand, leads to myocardial ischemia resulting in angina (Osborn et al., 2014, pp. 920). Risk factors for CAD are both
non-modifiable and modifiable. Non-modifiable risk factors include age, gender, and genetic predisposition. Genetics and
age, especially for women after menopause, are significant factors in the development of CAD. Modifiable risk factors
include metabolic syndrome, smoking, diabetes, sedentary lifestyle, and poor diet. Modifying these factors can lead to a
significant decrease in the potential to develop CAD (Huether & McCance, 2012, pp. 597-598). Evaluation and diagnosis
of CAD can be done through a variety of tests: stress testing, radionuclide imaging, positron-emission tomography or a
PET scan, multi-slice helical CT, multi-gated acquisition scan, cardiac MRI, intravascular ultrasound, cardiac
catheterization, and percutaneous coronary intervention (PCI) (Osborn et al., 2014, pp. 937). Diagnosis is also based on a
review of systems, and the patients medical/social/family history for associated diseases and risk factors (Osborn et al.,
2014, pp. 945). There is no cure for CAD but there is medical management for the disease through the use of
pharmaceuticals and lifestyle modification. Pharmaceutical management includes a variety of medications: beta-blockers,
ACE inhibitors, ARBS, vasodilators, thrombolytic agents, anticoagulants, and nitrates. When the arteries become severely
occlude a coronary artery bypass graph (CABG) may be performed. A CABG uses healthy arteries to bypass diseased
segments within the heart. CAD is a progressive disease and will lead to myocardial infarction and eventual heart failure
(Osborn et al., 2014, pp. 964-965).
5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN
medication. Give trade and generic name.]
Name: Elavil
(amitriptyline)
Concentration (mg/ml)
Route: Oral
Home
Hospital
or
Both
antidepressants
Indication: Management of depression.
Side effects/Nursing considerations: Suicidal thoughts, arrhythmias, torsade de pointes, sedation, hypotension, constipation,
blurred vision. Monitor for suicidal tendencies, frequent ECG monitoring for patients taking high doses or a history
of cardiovascular disease.
Name: Aspirin
Concentration
EC
Route: Oral
Frequency: Daily
Home
Hospital
or
Both
Indication: Prophylaxis
Name: Lipitor
(atorvastatin)
Concentration
Route: Oral
Frequency: Nightly
Home
Hospital
or
Both
inhibitors
Indication: Adjunctive management of primary hypercholesterolemia and mixed dyslipidemia. Primary prevention of
coronary artery disease.
Side effects/Nursing considerations: Rhabdomyolysis, angioneurotic edema, abdominal cramps, constipation, diarrhea, flatus,
dyspepsia. Monitor hepatic function. Instruct patient to notify a health care professional if unexplained muscle pain,
tenderness, or weakness occurs, especially accompanied by fever or malaise.
Concentration
Name: Dulcolax (colace)
Dosage Amount: 100mg
Route: Oral
Frequency: Twice
softeners
Home
Hospital
or
daily
Both
Indication: Prevention
of constipation.
Side effects/Nursing considerations: Mild cramps, diarrhea. Assess for abdominal distention, presence of bowel sounds, and
usual pattern of bowel function. Teach patients that laxatives should be used only for short-term therapy.
Name: Lovenox
(enoxaparin)
Concentration: 40mg/ml
Route: subcutaneous
Frequency: Daily
low molecular
Home
Hospital
or
Both
weight heparin
Indication: Prevention of venous thromboembolism (VTE).
Side effects/Nursing considerations: Bleeding, anemia, hyperkalemia, edema, dizziness, headache. Monitor for signs of
bleeding.
Name: Pepcid
Concentration
(famotidine)
Route: Oral
Name: Zestril
Concentration
(lisinopril)
Route: Oral
Frequency: Daily
Home
Hospital
or
Both
inhibitors
Indication: Alone or with other agents in the management of hypertension. Reduction of risk of death or development
of heart failure after myocardial infarction.
Side effects/Nursing considerations: Angioedema, cough, dizziness, hypotension, hyperkalemia. Monitor BP and pulse.
Monitor weight and assess patient routinely for resolution of fluid overload. Monitor for signs of angioedema.
Pharmaceutical class: Ace
Name: Glucophage
(metformin)
Concentration
Route: Oral
Frequency: Twice
Home
Hospital
or
daily
Both
Indication: Management
Name: Paxil
(paroxetine hydrochloride)
Concentration
Route: Oral
Frequency: Daily
serotonin reuptake
Home
Hospital
or
Both
inhibitors
Indication: Major depressive disorder, panic disorder, generalized anxiety disorder.
Side effects/Nursing considerations: Neuroleptic malignant syndrome, suicidal thoughts, Stevens-Johnson syndrome, anxiety,
dizziness, drowsiness, insomnia, weakness, dry mouth. Monitor for serotonin syndrome, neuroleptic malignant
syndrome, and rash. Assess for suicidal tendencies.
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? NPO
Analysis of home diet:
Diet pt follows at home? Regular
My patients diet was high in saturated fat, oils, and
sodium. In comparison with an average 2,000 calorie diet,
my patient was over her daily allowance by 200 calories.
The recommended daily allowance for grains is 6oz, and
my patient had consumed 0oz. Healthy examples of wholewheat grains include oatmeal, whole cornmeal, and brown
rice. The recommended daily allowance of vegetables is 2.5
cups, and my patient had consumed 5 cups. Most
vegetables are low in fat and calories, and most any type
can be eaten to reach your recommended daily value. It is
important to incorporate a variety of vegetables into your
diet: dark-green vegetables, starchy vegetables, red and
orange vegetables, and beans and peas. The recommended
daily allowance of fruits is 2 cups, and my patient had
consumed 0 cups. Like vegetables, most any type can be
eaten to reach your recommended daily value, but it is
important to avoid fruits in sugary syrups and juices. The
recommended daily allowance of dairy is 3 cups, and my
patient consumed 1.75 cups. Healthy examples of dairy
include fat-free or low-fat milk, yogurt, and cheese. The
recommended daily allowance of protein is 5.5oz, and my
patient consumed 8oz. Healthy examples of protein include
lean or low-fat meat, poultry, or fish rich in omega-3 fatty
acids. The recommended daily allowance of oils, saturated
fats, and sodium are 6tsp, 22g, and 2,300mg, respectively.
My patient consumed 7tsp of oil, 50g of saturated fats, and
4,29mg of sodium.
24 HR average home diet:
Breakfast: Bacon and eggs
Lunch: Does not eat lunch
Dinner: Pot roast with potatoes and steamed vegetables
Snacks: Cheese sticks, ice cream, crackers/chips
Liquids (include alcohol): Water (3 16oz. bottles/day) and
diet Dr. Pepper (3 12oz. cans/day)
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your
University of South Florida College of Nursing Revision August 2013
discussion)
Who helps you when you are ill?
My significant other.
How do you generally cope with stress? or What do you do when you are upset?
Rest and relax, play computer games, watch TV, listen to music.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Increased anxiety and depression.
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority
Identity vs.
Role Confusion/Diffusion
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
My patient is in stage 7: generativity vs. stagnation. The goal of this stage is to be creative and productive. Often this is
accomplished through work or relationships, such as raising healthy, functional children or contributing to society by
developing a distinguished career, for example in nursing. The person who fails to achieve generativity (the desire and
motivation to guide the next generation) may manifest stagnation in the form of superficial relationships and selfabsorption (Treas & Wilkinson, 2014, pp. 164).
I believe my patient has achieved generativity through a fulfilling career as a truck driver which she loved and is now
retired from and raising her 4 children. She also has had a long-term relationship for the past 6 years, which has given
her love and support.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of
life:
I believe my patients illness has had a significant effect on her life and her ability to enjoy her life as a retired adult. I
believe she may have developed a sense of stagnation as evidenced by her increased depression and anxiety in
conjunction with her progressively worsening condition. She is no longer to participate in activities that bring her
enjoyment or spend time with family and friends.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Genetics
+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?__Yes______________________________________________________________
Do you prefer women, men or both genders? ___Men_____________________________________________________
Are you aware of ever having a sexually transmitted infection? __No__________________________________________
Have you or a partner ever had an abnormal pap smear?___No_______________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___No_____________________________________
Are you currently sexually active? ___Yes___________________When sexually active, what measures do you take to
prevent acquiring a sexually transmitted disease or an unintended pregnancy? __in a monogamous relationship, patient
had a hysterectomy___________________
How long have you been with your current partner?____6 years_____________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? ___No____________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No
thru
56
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Beer, wine, kahlua and cream
(age 14
What?
Yes
No
For how many years? 42 years
Yes
No
(age 20s
thru
30s
22
thru
current
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No.
10 REVIEW OF SYSTEMS
General Constitution
Gastrointestinal
Integumentary
SPF:
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:
HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Genitourinary
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
10 x/day
Bladder or kidney infections
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Immunologic
Other:
Hematologic/Oncologic
Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:
Metabolic/Endocrine
2 x/day
Diabetes
Type: 2
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:
Vision screening
Other:
Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
irregular
Environmental allergies
last CXR? 9/19/15
Other:
WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam? 1992
menstrual cycle
regular
menarche
age? 13
menopause
age? 50-52
Date of last Mammogram &Result:
2015
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
9/19/15
Other:
Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:
Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:
Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No.
Any other questions or comments that your patient would like you to know?
No.
10
talkative
withdrawn
quiet
boisterous
aggressive
hostile
flat
loud
11
Pulmonary/Thorax:
Cardiovascular:
No lifts, heaves, or thrills PMI felt at: S5, 5th intercostal space mid-clavicular line
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
Unable to get ECG strip
No JVD
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:
Biceps:
Brachioradial:
Patellar:
Achilles:
Equipment unavailable to test CNs, Rombergs test, stereognosis, graphesthesia, proprioception, and DTR
10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Lab
WBC:
9.53
7.65
Normal: 4.6-10.2
Dates
9/19/15
9/22/15
Hemoglobin:
13.0
14.0
Normal: 12.2-16.2
9/19/15
9/22/15
Platelets:
302.0
260.0
Normal: 142.0-424.0
9/19/15
9/22/15
Trend
Upon admittance, the
patients WBCs were
slightly elevated but
within normal range.
WBCs were trending
down but within normal
range.
Analysis
WBCs exit in the blood
and help fight infection
within the body. Elevated
WBC levels is referred to
as leukocytosis and is a
response from the
immune system due to
infection or disease.
Decreased WBC levels is
referred to as leukopenia.
Leukopenia may be
caused by bone marrow
damage or disorders,
autoimmune disorders, or
diseases of the immune
system.
Hemoglobin is the ironcontaining protein in
RBCs, that allow them to
bind oxygen and carry it
throughout the body.
Hemoglobin levels may
be elevated due to
pulmonary disease,
congenital heart disease,
smoking, and
dehydration. Hemoglobin
levels may be decreased
due to excessive blood
loss, iron deficiency, bone
marrow disorders, or
kidney disease.
Platelets are fragments of
cells essential for normal
blood clotting. An
elevated platelet count is
referred to as
Hematocrit:
39.4
42.7
Normal: 37.7-47
9/19/15
9/22/15
Na+:
141.0
139.0
Normal: 135.0-148.0
9/19/15
9/22/15
K+:
4.0
4.2
Normal: 3.5-5.3
9/19/15
9/22/15
Cl-:
105.0
104.0
9/19/15
9/22/15
thrombocytosis and is
most often the result of an
existing condition. A
decreased platelet count is
referred to as
thrombocytopenia and is
most often caused by
bone marrow disorders
causing decreasing
production or conditions
where they are used up
faster than normal. For
example, heparin-induced
thrombocytopenia.
Hematocrit levels are
often used to test for
anemia, polycythemia,
hydration status, and to
monitor therapy. Elevated
hematocrit levels are
often a sign of
polycythemia. Decreased
hematocrit levels often
indicate anemia.
Sodium is an extracellular
cation, that is tested to
evaluate electrolyte
balance and hydration
levels. Hypernatremia is
most often due to
inadequate water intake
and dehydration.
Hyponatremia typically
due to excess sodium
loss, excess water intake
or retention, or edema.
Potassium is an
intracellular cation, that is
tested to evaluate fluid
and electrolyte balance.
Hyperkalemia is most
commonly due to kidney
disease. Hypokalemia
often occurs due to
electrolyte imbalance
from vomiting and
diarrhea.
Chloride is the most
abundant anion in the
extracellular fluid.
Normal: 98.0-107
HCO2:
22.0
27.0
Normal: 22.0-29.0
9/19/15
9/22/15
BUN:
19.0
22.0 H
Normal: 6.0-20.0
Creatinine:
0.9
0.9
Normal: 0.57-1.11
9/19/15
9/22/15
9/19/15
9/22/15
Chloride is tested to
evaluate electrolytes,
acid-base balance, and
hydration level.
Hyperchloremia typically
indicates dehydration.
Hypochloremia typically
occurs with disorders that
cause low sodium levels.
Bicarbonate is tested as
part of the electrolyte
panel to detect, monitor,
and evaluate electrolyte
imbalance. When
bicarbonate levels are
high or low, it indicates
the body is having trouble
maintaining acid-base
balance or something has
upset the electrolyte
imbalance. For example,
losing too much or
retaining too much fluid.
The blood urea nitrogen
test (BUN) is used to
measure kidney function.
Urea is a waste product
from the liver that results
from protein metabolism.
Urea travels in the blood
to the kidneys, where it is
filtered out of the blood
and eliminated in the
urine. BUN levels elevate
when there is disease or
damage to the kidneys.
Low BUN levels are less
common and are of
serious concern.
The creatinine test is used
to measure kidney
function. Creatinine is a
waste produced by
muscles from the
breakdown of creatine.
Creatinine travels in the
blood to the kidneys,
where it is filtered out of
the blood and eliminated
in the urine. Creatinine
15 CARE PLAN
Nursing Diagnosis: Decreased cardiac output r/t cardiac dysfunction AEB dyspnea, S-T segment change, elevated troponin levels, and low LVEF
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Patient will demonstrate adequate *Monitor for and report signs and
These are signs and symptoms
Patient showed no signs or
cardiac output as evidenced by
symptoms of fluid volume
consistent with heart failure and
symptoms of fluid volume overload
blood pressure, pulse rate and
overload, including the following:
decreased cardiac output (Ackley at end of shift. She did have mild
rhythm within normal parameters
dyspnea at rest, paroxysmal
& Ladwig, 2014, pp. 180)
dyspnea upon exertion but not
for client; strong peripheral pulses; nocturnal dyspnea, abdominal
while at rest.
maintained level of mentation.
distention, weakness and fatigue,
Lack of chest discomfort or
JVD, crackles, laterally displace
dyspnea, and adequate urinary
PMI, irregular heart beat, and
output; an ability to tolerate
diminished pulses (Ackley &
activity without symptoms of
Ladwig, 2014, pp. 180).
dyspnea, syncope, or chest pain
(Ackley & Ladwig, 2014, pp. 179).
Administer oxygen as needed per Supplemental oxygen increases
Patient was able to remain on room
physicians order (Ackley &
oxygen availability to the
air throughout the shift without any
Ladwig, 2014, pp. 180).
myocardium (Ackley & Ladwig,
difficulty in breathing. Oxygen at
2014, pp. 180).
2L via nasal cannula was available
if needed.
*Place client in semi-Fowlers or
Elevating the head of the bed and Patient remained in a semihigh-Fowlers position with legs
legs in down position may decrease Fowlers position for the majority
down or in a position of comfort
the work of breathing and may also of the shift without any difficulty in
(Ackley & Ladwig, 2014, pp. 180). decrease venous return and
breathing. Patient was also able to
preload (Ackley & Ladwig, 2014, rest in a supine position with two
pp. 180).
pillows without difficulty in
breathing for a few hours.
Check blood pressure, pulse, and
It is important that the nurse
The patients vitals were taken and
condition before administering
evaluate how well the client is
assessed prior to all medication
cardiac medications such as ACE
tolerating current medications
administration. The patients blood
inhibitors, ARBS, digoxin, and
before administering cardiac
pressure and heart rate were within
beta-blockers. Notify physician if
medications; do not hold
normal range.
heart rate or blood pressure is low
medications without physician
before holding medications
input. The physician may decide to
15 CARE PLAN
Nursing Diagnosis: Acute pain r/t myocardial ischemia AEB patient states pain, dyspnea, and anxiety
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Patient will report decreased pain
*Administer analgesics as
Pharmacological interventions are
level of less than 4 out of 10 by end prescribed by physician (Ackley first-line approaches to the
of shift.
& Ladwig, 2014, pp. 581).
management of pain (Ackley &
Ladwig, 2014, pp. 581)
Evaluation of Interventions on
Day care is Provided
The patient was assessed for pain
and asked if she needed her PRN
pain medication frequently
throughout the shift. Pain
medication was typically
administered when pain exceeded a
6 or 7 out of 10, per patients
request. Post-administration of pain
medication, patient reported pain at
a 2-3 out of 10.
The patient was taught how and
when to use sublingual
nitroglycerin. The patient
understood the teach, as she
modeled when and how the
nitroglycerin should be
administered.
I discussed with the patient her
experience with pain and how she
currently manages pain. The patient
has thorough experience with pain,
as she has suffered with thoracic
outlet syndrome the majority of her
adult life. Unfortunately, the patient
is unable to get pain medication
prescribed by her PCP and cannot
afford to see a pain management
physician. Therefore, the patient
self medicates with marijuana on a
regular basis. Her pain is managed
at a tolerable level at home. While
in the hospital, the patients pain
has been managed at a tolerable
DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
References:
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to
planning care (10th ed.). Maryland Heights, MO: Elsevier.
AACC: American Association for Clinical Chemistry. (2015). About Lab Tests Online. Retrieved
from https://labtestsonline.org/
Huether, S., & McCance, K. (2012). Understanding pathophysiology (5th ed.). St. Louis, MO:
Elsevier.
Osborn, K.S., Wraa, C.W., Watson, A.B., & Holleran, R. (2014). Medical-surgical nursing:
Preparation for practice (2nd ed.). Upper Saddle River, NJ: Pearson Education, Inc.
Treas, L., & Wilkinson, J. (2014). Basic nursing: Concepts, skills, & reasoning. Philadelphia,
PA: F.A. Davis Company.
Unbound Medicine, Inc. (2015). Nursing Central (Version 1.26). [Mobile application software].
Retrieved from http://itunes.apple.com
USDA: United States Department of Agriculture. (2015). Choose MyPlate. Retrieved from
http://www.choosemyplate.gov/about