Tuesday, June 29, 2010

Care Plan with Comments by Dr. A.

Morning Victoria,
See comments.
Dr. A
Sharon A. Aronovitch, PhD, RN
Faculty, ADN Program

Previous Message:
Mrs. Crow is a 70 year-old white female with a history of early Alzheimer's Disease. She is widowed and lives alone. She fell at home and fractured her right hip. She was brought to the E.D. two days after the fall with severe pain. An open reduction internal fixation was done two days ago. She experienced urinary retention 24 hours post-op and a 16 Fr Foley catheter was inserted. The urine was cloudy with several mucus plugs noted in the tubing. She is oriented to person and place, but not time. She has an order for Tylenol with codeine every 4 hours prn for pain. Her most recent dose was 2 hours ago.
Areas of Care:
* Fluid Management - I&O

* Vital Signs - BP, RR, HR (radial), T (oral)

* Safety/Other - SR X2 up at all times, TEDS continuously

* Mobility - Out of bed with therapy only; reposition X1

* Irrigation - Irrigate F/C with 50ml NS to a closed system

* Musculoskeletal Management - Abductor pillow at all times; AROM of bilateral upper extremities

* Comfort Management - 3 comfort measures

CP #1 – Impaired Physical Mobility r/t loss of integrity of bone structures aeb limited range of motion
Goal:
Pt will be {This is your assignment, which is a nursing intervention. A nursing intervention cannot be used as the patien toutcome. Think beyond your assignment and PCS time frame for the patient outcome.} repositioned once during PCS
Interventions:
1. Reposition the patient with abductor pillow maintained
2. Encourage patient to perform AROM exercises with upper extremities

CP#2 - Risk for Injury r/t confusion
Goal:
Patient will remain free of injury during PCS
Interventions
1. Maintain SR x2 at all times
2. Re-orient to time place and events

CP #1 Priority – rationale – {My first suggestion is to not write the rationale in 1 long sentence.} physical mobility is a basic physiology need according to Maslow,{stop here} if the patient is not able to mover herself, tissue perfusion will be impaired, muscular skeletal contractures or atrophy may develop, strength will diminish and patient will loss ability to perform ADLS. {OK, so why is all of this a problem for the patient?}

Documentation
Fluid management/irrigation:
Patient’s skin turgor on chest good, oral mucosa moist and pink, accepted 120 cc water during pcs. #6 French Foley catheter patent ; Irrigation: irrigated with 50 cc NS with cloudy dark amber urine returned to closed drainage system, no mucous plugs noted. Aseptic technique maintained. Patient tolerated without any complaints of discomfort.
Safety: {This would be documented in Other Observations.}
Bilateral side rails up, bed in low position, TEDS maintained Oriented patient to surroundings and instructed to use call light for assistance. Patient verbalized understanding.
Mobility/Musculoskeletal Management;

Physical Therapy not present during PCS. Repositioned on left side with pillows propping patient off buttock, Abduction pillow maintained. Good alignment maintained. Patient tolerated procedure with no distress noted or verbalized. {Missing narrative note for musculoskeletal management.} {All of this is for PVA: Wiggles toes, good capillary refill bilateral toes, sensation present to light touch. Pedal pulses strong bilaterally. Skin of bilateral lower extremities warm} and dry.
Comfort Management:
{What was initial assessment of comfort or patient needs?} Repositioned with patient verbalization of comfort, back rub given, and face washed. Patient verbalized appreciation and stated feels better and rated pain as 2 on a scale of 0-10.

Care Plan with comments by Dr. A.

Hi Victoria, Good work, see the few comments.

Dr. A

Sharon A. Aronovitch, PhD, RN
Faculty, ADN Program

Previous Message:
Please review the careplan and documentation. Thanks! Vickie

27 y/o male who, over the last year, has steadily gained weight, especially around his waist. After being diagnosed with Cushing’s Disease he attempted weight loss with a variety of OTC “remedies”. As a result he has liver failure and has been admitted for a liver biopsy. Has acute ascites, which is causing some dyspnea. Oxygen 2lpm NC. His extremities are atrophied. Has some abdominal pain, last rated 4/10 and constant. Fentanyl ordered PRN for pain. VS: AP, BP, R, oral temp, SpO2 IV: D5NS 65 ml/hr I&O: Restrict oral fluid to 300 ml during PCS Mobility: OOB to chair with assist, ambulate down hall x1 as tolerated with assist AOCs: Abdominal assessment – girth measured at level of umbilicus Respiratory management – IS x10 qhour PVA – lower extremities Comfort management

CP #1
Ineffective Breathing Pattern r/t decreased lung expansion AEB dyspnea
Goal:
Patient will report ability to breath comfortably during PCS
Interventions:
1. Administer oxygen as ordered at 2lpm NC
2. Encourage patient perform IS x10 per hour
CP #2
Excess Fluid Volume r/t compromised regulatory mechanism AEB ascites
Goal:
Patient will explain measures that are to be followed to treat excess fluid volume, especially fluid restrictions.
Interventions:
1. Restrict PO fluid intake to 300 ml uring PCS
2. Measure girth at umbilicus

CP # 1 – Rationale: According to Maslow adequate ventilation is a basic physiological need. With out effective breathing patterns oxygenation will be impaired and further complications can occur such as pneumonia .

Documentation:
Fluid management:
IV site right forearm without inflammation or edema, D5/NS infusing via pump at 65 ml/hour. Oral mucosa moist and pink, reviewed fluid restriction and I&O procedure with patient. Understanding verbalized.
Abdominal Assessment: {Abdominal girth is no longer a critical element.}
Curtain pulled for privacy, patent denied need to void, Head of bed at 30 degrees due to dyspnea and knees flexed 45 degrees. Abdominal girth 58 inches at umbilicus. Abdomen rounded and firm all quadrants. Bowel sounds active all 4 quadrants, Patient rates pain in ribs and general abdominal area at a constant 4 on a scale of 0-10. Not increased with palpation.
PVA:
{This is an assessment for musculoskeletal management: Bilateral lower extremities noticeably atrophied. } Pedal pulses palpated bilaterally, skin warm to touch, capillary refill <3 seconds on bilateral toes, wiggles toes bilaterally, acknowledges light touch on dorsal and planter aspects of bilateral feet.
Comfort:
Reported patient’s pain to RN and medicated with fentanyl by RN. Assisted patient to left side and provided back rub. Mouth care and facial wash accepted. Patient stated, “I feel better now”
Respiratory Management:
Oxygen maintained at 2 lpn via NC. Head of bed in semi-fowler’s position skin on nares and ears intact with no redness noted. Assisted patient to fowler’s position, Lung sounds decreased bilaterally posterior upper and lower lobes. Performed IS x 10 repetitions. Reassessed lungs with {The correct term is clear.} normal breath sound upper bilateral lobes and right lower lobe, left lobe remains abnormal. No sputum expectorated.
Mobility:
Assisted patient to side of bed and dangled x1 minute. Assisted with ambulation in hall 50 feet, with nasal o2 tank. Returned to room and sat in chair. Tolerated activity with slight dyspnea. Patient stated, “Boy that really takes a lot of effort”

Wednesday, June 23, 2010

Care Plan with corrections - Thanks Sherri!!

Below is a care plan I sent to Sherri Taylor - CPNEworkshop.com With corrections noted in red, bold font and yellow highlight. I went to the workshop in Atlanta in January - the wisest thing I could have done. The support doesn't end till I pass. Thanks Sherri!!
The scenario is courtesy of Chuck.


Mrs. Crow is a 70 year-old white female with a history of early Alzheimer's Disease. She is widowed and lives alone. She fell at home and fractured her right hip. She was brought to the E.D. two days after the fall with severe pain. An open reduction internal fixation was done two days ago. She experienced urinary retention 24 hours post-op and a 16 Fr Foley catheter was inserted. The urine was cloudy with several mucus plugs noted in the tubing. She is oriented to person and place, but not time. She has an order for Tylenol with codeine every 4 hours prn for pain. Her most recent dose was 2 hours ago.


Areas of Care:
* Fluid Management - I&O
* Vital Signs - BP, RR, HR (radial), T (oral)
* Safety/Other - SR X2 up at all times, TEDS continuously
* Mobility - Out of bed with therapy only; reposition X1
* Irrigation - Irrigate F/C with 50ml NS to a closed system
* Musculoskeletal Management - Abductor pillow at all times; AROM of bilateral upper extremities
* Comfort Management - 3 comfort measures

CP #1 – Impaired Physical Mobility r/t loss of integrity of bone structures aeb limited range of motion
Goal:
Pt will be repositioned once during PCS this is an intervention not a goal.....
Interventions:
1. Reposition the patient with abductor pillow maintained
2. Encourage patient to perform AROM exercises with upper extremities

CP#2 - Risk for Injury r/t confusion
Goal:
Patient will remain free of injury during PCS
Interventions:
1. Maintain SR x2 at all times
2. Re-orient to time place and events

CP #1 – choose as priority - rationale – physical mobility is a basic physiology need according to Maslow, if the patient is not able to move, tissue perfusion will be impaired, muscular skeletal contractures or atrophy may develop, strength will diminish and patient will lose ability to perform ADLS.

Documentation
Fluid management/irrigation:
Patient’s skin turgor on chest good what is good??? tinting or non tinting, oral mucosa moist and pink, accepted 120 cc water during pcs. #16 French Foley catheter patent ; irrigated with 50 cc mls...NS with cloudy dark amber urine returned to closed drainage system, no mucous plugs noted. Aseptic technique maintained. Patient tolerated without any complaints of discomfort.
Safety:
Bilateral side rails up, bed in low position, TEDS maintained Oriented patient to surroundings and instructed to use call light for assistance.but did you leave it in reach? Patient verbalized understanding.
Mobility/Musculoskeletal Management;
Physical Therapy not present during PCS. Repositioned on left side with pillows propping patient off buttock, Abduction pillow maintained. Good good???? proper alignment maintained. Patient tolerated procedure with no distress noted or verbalized. Wiggles toes, good good????? less than 3 seconds capillary refill bilateral toes, sensation present to light touch. Pedal pulses strong present or absent bilaterally. Skin of bilateral lower extremities warm and dry.
Comfort Management:
Repositioned with patient how, where??? verbalization of comfort, back rub given, and face washed. Patient verbalized appreciation and stated feels better .put what they say in quotes

Sunday, June 20, 2010

CPNE Study Guide 16th Edition page 472

JG DOB 9/14/37

DX unstable angina, DVT right leg

Information only: renal failure with kidney transplant, telemetry. Left arteriovenous shunt

Safety – siderails x2

No BP, IV, blood draws in Left arm

Mobility-

Bedrest with BRP

Reposition x 1 during PCS

Elevate legs on 1 pillow

Fluid Management-

I & O

Parenteral: 5% Dextrose in water 50 ml/hr ICD

Enteral: Fluids ad lib

Diet: regular with no added salt

Vital Signs: temporal artery temp, apical pulse, BP, Respiration, O2 Sat: report if <92% to primary RN

PVA – lower extemities

Skin assessment – lower legs

Medications:

Cellcept 250 mg po 0830

Protonix 40 mg po 0830

Lasix 40 mg po 0830

Potassium Chloride 40 meq po 0830

Comfort Management – comfort measures

K pad to right calf



Care Plan

#1 ND Ineffective Tissue Perfussion – peripheral venous r/t dx Deep venous thrombosis AEB edema, patient complaints of pain



Goal: patient will have palpable pulses during pcs.



Interventions: 1- peripheral vascular assessment

2- report any deviation form baseline to primary RN



#2 ND Impaired physical mobility r/t DVT AEB {This is a treatment and not a symptom (defining characteristic) of the nursing diagnosis.} forced bedrest



Goal: patient will assist with repositioning once during pcs



Interventions: 1- encourage patient to assist with repositioning

2- elevate legs on 1 pillow

CP for knee replacement

Hello Victoria, please excuse the late response. I do not regularly do the message center and I overlooked this request. Dr. A sent me a reminder..

Ms. Vicki Ledel is a 52 y/o female admitted four days ago for a right knee replacement due to aseptic necrosis of the lateral condyle. Her surgical procedure was uneventful. She is currently on a continuous passive range of motion machine (CPM). Ice is being applied to her right knee for 30 minutes three times a day. Her dressing remains intact with no new drainage. Her IV antibiotic has been discontinued and she is now receiving oral antibiotics. She is on a regular diet and tolerating food well. She is taking in adequate fluids and urinary output is quantity sufficient. She is presently having regular BMs, but her elimination is being monitored closely, as she is taking Lortabs 5mg po Q4 hours prn for pain (and has been taking them Q4 hours while awake). Physical therapy has made an initial assessment. Two-person transfer and limited weight-baring with a walker has been initiated.
Overriding/Required Areas of Care:
* Safety/Other (SR up X2, eyeglasses, dentures, TED hose bilateral lower extremities continuous)
* Mobility (Transfer OOB to chair with assist of 2 and walker, limited weight-bearing of right leg; elevate RLE while OOB)
* Vital Signs (BP, AP, RR, T, Pain)
Selected Areas of Care:
* Peripheral Vascular Assessment (lower extremities)
* Muskuloskeletal Management (AROM of LLE, PROM of RLE; CPM to bilat legs while in bed; Cold application to right knee X 20 minutes)
* Pain Management
* Respiratory Management (cough/deep breathing)

Care Plan:

#1 Ineffective Airway Clearance

R/t retained secretions this is a sign and symption - on page 174 under related factors, obstructed airway retained secretions is listed as r/t. Due to intubation a post op patient most likely has some retained secretions? I am confused as to why this is not acceptable.you have correctly stated this, and the text supports your choice

AEB ineffective cough this is a restatement of the NrDx review this diagnosis in the text( ackley) on page 174 defining characteristics “absent or ineffective cough” is written. Aren’t the defining characteristics the AEB? Abnormal breath sounds are the next grouping on that page. - What you are hearing is abnormal breath sound – which is the most objective data to support that the coughing is ineffective. And your interventions also support this as your evidence ( defining character istic) and your evaluation of the whether the coughing was effect would be if the breath sounds clear – otherwise there is no objective data.

Goal:

Patient will demonstrate effective cough during PCS this is anevaluation of the intervention not a goal that will assist the phyisological function of the patient. You would also have to measure “ effective”.. how would you do this? Thinking about this may actually give you your outcome. Once again on page 174 Client outcomes “demonstrate effective coughing and clear breath sounds” If I add the clear breath sounds would that suffice? As to how to measure effective? A strong vs weak cough?

Interventions:

1. Assess lungs

2. Have patient perform deep breathing and coughing exercised



#3 Impaired physical Mobility

R/t loss of integrity of bone structure

AEB limited range of motion

This one is stated correctly

Goal:

Patient will have complete ROM of lower extremities during PCS- not realistic for this patient/ what type of ROM/ how do you measure ‘complete” I intended to say - the patient will have the prescribed range of motion exercises completed during the PCS, poor wording

Interventions:

1. Encourage patient to perform AROM of LLE

2. Perform PROM of RLE



I selected #1 as my priority – this is good – as oxygen is important According to Maslow an effective airway clearance Oxygen exchange is a basic physiological need, effective airwary clearance is needed to support this exchange. Without adequate clearance of the air way the paitent may ...................with an effective airway the patient will progress towards healing as the tissue will have adequate oxygenation thus promoting regeneration.

PCS #1

This is one of the scenarios from Chuck. I am going to write out each step as though it were a real PCS. I will submit it to EC for evaluation and will post the feed back in a future post as well as an edit or possibly a comment.
36 year old female s/p cholecystectomy 2 days ago. Right abdominal incision with DSD. JP drain in place, being removed after lunch. Indwelling Foley catheter. Fluctuating pain levels 5-9 on a 0-10 scale and maintains morphine PCA at this time.

Siderails x2

VS - TPR, BP Pain level 0-10 scale

Fluids - IV D5LR @ 120ml/hr

I&O

Mobility - ambulate in hall x1 assist, OOB to chair ad lib

AOCs:

Respiratory Management - IS x 10 every hour

Abdominal assessment

Comfort Management

Wound Management - DSD to abdominal incision

CP
#1 Acute Pain r/t tissue trauma aeb pain rating of 5-9 on scale of 0-10
Goal:
 Patient will report pain level of 3 or less on a 0-10 scale
Interventions:
1- assess IV site and patentcy of PCA
2- report break though pain to RN

#2
Ineffective airway clearance r/t retained secretions aeb weak cough
Goal
Patient will perform IS 10x every hour during pcs
1-Assess lungs immediately before and after IS
2 Encourage patient to perform 10 reps of IS every hour

Saturday, June 19, 2010

Care Plan Scenarios by "Chuck"

This is an intro to a page of care plans I found on Dave's blog - It has numerous scenarios for practice care plan writing.

Greetings!

Below is a compilation of the practice scenarios I posted over the last few months. Please feel free to use these for practice. I wish you all the best in your preparation for the CPNE.

-Chuck

Care Plans are here -Click

Friday, June 18, 2010

De-Stress Kit for the Changing Times

We all know that millions of people are experiencing extra stress. Much outgoing care and compassion is needed to help ease the emotional pain that so many are increasingly experiencing. Doc Childre, founder of HeartMath, a leading stress research institute, has written a free booklet De-Stress Kit for the Changing Times that provides a few simple practices to help people intercept and manage stress during this period of challenge and uncertainty.

De-Stress Kit

The State of Ease

The State of Ease


There is a "state of ease" that each of us can access to help release emotional turbulence and help maintain coherent alignment between our heart, mind and emotions. Learning to access our personal space of "inner-ease" can be done with minimum practice and in just a little time. When operating in an ease-mode, it’s easier to choose less stressful perceptions and attitudes and re-create "flow" in our daily routines.
Click for free PDF Download

Tuesday, June 8, 2010

Apical Pulse

If you would like to know precisely where to place your stethoscope for an apical rate and would like some prctice counting irregular and infant apical rates try visting this link APICAL PULSE