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
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
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
Patient will remain free of injury during PCS
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?}

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.

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