Wednesday, June 23, 2010

Care Plan with corrections - Thanks Sherri!!

Below is a care plan I sent to Sherri Taylor - 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
Pt will be repositioned once during PCS this is an intervention not a goal.....
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 – 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.

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.
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

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