Nursing Care Plan Week 3
Student Initials_RMS
Occupation retired Religion/Culture Chris tian ALLERGIES anti-coagulants Medical Diagnoses Stage IV colorectal CA metastasized to vaginal mucosa, Diabetes Mellitus, Cataracts and retinopathy, CHF, Hypertension, Morbid obesity, Asthma, Anemia secondary to CA tx Surgery (if applicable) colon resection 3/08 Subjective and Objective Assessments Related Nursing Diagnosis
Patient Goals/Outcomes with measurable criteria
Interventions based on Goals/Outcomes Implemented with Rationale, including reference with page numbers
Assessed pt @ Assess s/s of dehydration pt reports hx of 0800 Patient will maintain \u2022 Poor skin Turgor diarrhea x 3 years post fluid balance within colon resection \u2022 Dry mucous membranes 200 ml while in \u2022 hospital Mental status changes S:
O: Pt incontinent of diarrhea 8 x QS; partial thickness radiation burns across panniculus, perineum and rectum; 2+ BL pitting edema Risk for Deficient Fluid Volume r/t active fluid loss
Evaluation based on Goals/Outcomes
Goal met: pt maintained adequate fluid balance
Rectal tube
Maintain strict I/O including stool inserted @ loss 1430 Insert rectal tube per MD order
\u2022
Maintain Foley catheter
\u2022
Encourage PO fluid intake
Made sure pitcher was kept full IV D/C\u2019d 1310
Administer IV fluid as ordered
Subjective and Objective Patient Goals/Outcomes Assessments with Related Nursing Diagnosis measurable criteria
S: pt reports 18 rounds Patient will exhibit no further breakdown of radiation tx; hx of during hospital stay DM neuropathy
Interventions based on Goals/Outcomes Implemented with Rationale, including reference with page numbers
Perform pericare Q one hour Rectal tube and PRN
\u2022
Treat existing breakdown wound gel and cover with
\u2022
inserted @ with1430; pericare gauze throughout shift
\u2022 Insert rectal tube per MD order O: large BL ulcers on bottom of feet; Pt incontinent of diarrhea 8 x QS; partial Dressing Patient\u2019s foot wounds thickness radiation changed @ \u2022 Change dressings QS will heal without burns across 1400 panniculus, perineum complications \u2022 Apply QS Accuzyme as ordered and rectum; Enzyme ointment dissolves necrotic tissue with little impact on intact skin Impaired Skin Patient\u2019s infection will
Integrity r/t radiation, be resolved incontinence and altered circulation AEB foot ulcers and destruction of pannicus and perineal epidermis
Evaluation based on Goals/Outcomes
Maintain CTI dressing between changes
\u2022
Maintenance of a clean wound site decreases number of organisms and reduces spread of infection. Preulent d/c
Monitor for signs of infection
\u2022
o
take temperature Q 4
noted at mediport site; reported to nurse/doctor
Goal partially met: pt skin was cleansed and dressed meticulously, but this nursing student is aware that such care will be impossible under normal hospital circumstanst
hours o
o
o
o
drainage or heat at any wound IV access insertion site urine for malodor or mucous oral cavity for white coating assess for cough, sputum production, or crackles in lungs; notify physician if any are noted.
A fever or systemic signs such as malaise may be the only sign of infection, as the patient is unable to produce the normal inflammatory response due to immunosuppression.
Ensure adequate rest, and hydration
\u2022
Patient had limited number of nutrition, visitors; diet was adequate
Encourage adequate nutritional intake, especially of protein, vitamin C, and iron.
\u2022
Rest and hydration are both needed for restoration of the body and to ; adequate nutrient intake, especially of vitamin C, protein, and iron, is required for healing and tissue repair.
Subjective and Objective Assessments Related Nursing Diagnosis
Patient Goals/Outcomes with Interventions based on Goals/Outcomes Implemented with Rationale, including reference measurable criteria with page numbers
Evaluation based on Goals/Outcomes
Assess for location, intensity, quality, and precipitating factors. Have the patient rate pain intensity Assessed Q 2 Pt’s pain will remain Goal not met: using a pain rating scale. hours and PRN S: pt reports hx of under control: Pt remained at 5/10 pain during peri-care diarrhea x 3 years post • The patient will Assess the status of affected level; jumped to 8/10 extremity, including pain at colon resection verbalize that pain has during skin care and operative site, tenderness to touch, been relieved 30 transfers temperature, and edema. minutes after O: Pt incontinent of interventions. diarrhea 8 x QS; Administered partial thickness Administer analgesics, as ordered, Vicodin q4 radiation burns across on a regular schedule, not allowing hours, panniculus, perineum pain to get intense. Keeping painOcycontin BID and rectum; 2+ BL medication at constant intervals pitting edema decreases pain level and keeps pain manageable. Acute Pain r/t radiation burns and skin ulcers
Assess effectiveness of interventions to relieve pain and modify tx as necessary D eter m ines whether interventions have been effective in relieving pain or whether new strategies need to be employed.
