Risk Factors: HolisticHolistic FactorsFactors Review of Systems – include use of Patient in unemployed which could result in Rectal cancer, renal Patient in unemployed which could result in CARE PLAN CONCEPT MAP therapeutic devices non-compliance of medication insufficiencies, hypertension non-compliance of medication NoNo familyfamily camecame toto visitvisit In and out hospital for cancer Respiratory Knowledge Knowledge deficit deficit of of whatwhat caused caused thethe fainting fainting Student_Lyndsey Duplessis_____ Date_5/9/13______Respirations 18 Regular and unlabored DevelopmentalDevelopmental Bilateral breath sounds clear Vitals BP P Resp Temp O2 % No problems swallowing IntegrityIntegrity vs.vs. despairdespair Admit 152/90 97 14 99.0 98 Cough absent Pre Clin. 147/73 98 18 97.9 98 Cardiovascular 0800 152/79 75 18 99.2 97 Regular Bilateral radial pulse palpable +2 Admitting Medical Diagnosis: 1200 126/79 70 16 98.1 98 Pedal pulse palpable +1 Syncopical episode * * Treatment Orders 1600 Capillary refill less than 3 secs Contact isolation No edema, extremities warm to touch Chief Complaint: Cardiac diet Pain Abdominal pain IV site observation every 4 hours Patient stated he had pain in his abdomen Vitals every 4 hours * that comes and goes at a rate of 6 out of 10 Mode of transport every 12 hours and a liitle discomfort from the tubes inserted Other Medical Dx. /Health Problems: Neurological C. Diff, Rectal Cancer, Renal insufficiency *, UTI Alert and oriented to person, place, and time hypertention MAE equally Speech clear Surgeries: Musculoskeletal Placement of cholestomy and urostomy Patient Strengths Gait unsteady Positive attitude Need slight assistance with ADLs Miscellaneous – include any other pertinent Compliant with medication regimen Gastrointestinal vitals, etc. Abdomen soft with hypoactive bowel sounds Tolerates cardiac diet Cholestomy bag in place with stools brow and paste like Labs: GreatFaculty job! comments: Way to go connecting things. RBC L 3.31 Surgical History: RememberGreat to cite references. You were Teaching/Learning Needs Hgb L 9.5 Genitourinary the ONLY student to include the concept Diet- cardiac low sodium diet Hct L 28.2 Able to void with Urostomy in place key as you should have. Fall Risk Interventions Segs H 91 Urine yellow and clear Side effects of new antibiotic CO2 L 21 Care for cholestomy and urostomy bags Creatine level H 1.76 Skin/Mucosa-include IV site assessment * Calcium L 7.5 Skin color appropriate to ethnicity Extremities warm and dry Concepts Key Turgor elastic Cognition/ perception Discharge Planning Needs IV site clear, patent and dry Mobility Continue antibiotic medications No redness, swelling or pain Psychosocial Nutrition/ elimination Follow up with physician Go to ER if conditions worsen Thinking is congruent with situation. Patient Perfusion stated he felt a little depressed due to the C. Protection/ Adaptation diff diagnosis but still had a positive attitude Great you were the ONLY one to do No support system was present this correctly!

Nursing Diagnoses Expected Outcomes Nursing Care/Interventions Evaluation Nursing Diagnoses Expected Outcomes Nursing Care/InterventionsRationale Evaluation Rationale

Skin Integrity Impairment related to Patient will be free from infection and skin break Incision care as ordered Patient was free from infection and showed cholestomyAcute pain related and urostomy to choletomy downPatient by will the have end aof decrease the shift. level of pain within Administer -This will medicationprevent incisions as ordered from noPatient signs stated of skin he break had adown decrease by the in end pain of placementand urostomy as evidenceplacement by as left two hours of administering pain medication. becoming -Pain medication infected will relieve the pain myrating shift. it 3 out of 10 one hour after upperevidence quad by cholestomy patient stated and he right has medication was administered. upperpain the quad comes urostomy and goes * rating it 6 ReportAssist patient redness, in changingswelling, andpositions out of 10 * drainage -This is a non-pharmacological pain relieving -proper methoddocumentation to show it was acted upon Reassess the patient after pain Teachmedication proper or woundrepositioning care and cleaning -This will to showthe patient if the interventions have -This worked is to prevent infection when patient is discharged.

Risk for Falls related to syncopical Patient will be free from falls the entire shift Place call light in reach The patient was free from falls this shift. episode -The light is used to call the nurse’s station id needed assistance to move

Collaborate with the doctor for physical therapy -The PT will evaluate the patients balance and transfer mobility to prevent falls

Fall preventions safety measures GreatHave atjob, least remember 3 prioritized to cite -PlacingHave the at bedrails least 3 upnursing to make references.Nursing Diagnoses Include at least 1 outcome per Nursing sureinterventions the patient is for safe each Nursing Include at leastDiagnoses 1 outcome per Nursing Diagnoses Diagnoses Have at least 3 nursing interventions for each Nursing Have at least 3 prioritized Diagnoses Nursing Diagnoses Admit Diagnosis-relate the Pathophysiology Clinical Diagnostic Studies – include your Complications diagnosis to a concept Manifestations patient’s results Assessment Objectives/Goals Content/Information Teaching Strategies Evaluation Syncopal episode * * Fainting, temporary Pale, increased CT scan- negative Depends on the underlying cause of the loss of consciousness, sweating, nauseated, Chest X-ray- negative fainting. Can lead to brain damage, heart Patient admitted to the hospital due to causedPatient by will not verbalize having understandingdizzy or light-headed, Information onBlood cholestomy Cultures- and positiveDemonstrate for C. diff how tocomplications, proper maintain tissuePatient damage, verbalized and death of the cholestomy and urostomy urostomy bags and demonstration of the bags understanding of the bags a syncopal episode. Patient has rectal enough blood flow to fatigue ECG- normal thebags brain and proper maintenance by the proper maintenance and proper maintenance at cancer with led to the placement of a end of teaching the end of teaching left upper quad cholestomy bag and a Patient will verbalized 3 signs and Information on the side effects of Teach/educate side effects of Patient verbalized 3 side right upper urostomy bag. Blood symptoms of medication to treat the antibiotics and prevention measures medication and what to do if it effects of medications by infection by the end of teaching happens the end of teaching culture test shows positive for C. diff. He states some pain and discomfort Patient will verbalize fall prevention Home assessment guide for fall Read over pamphlet and demonstrate activities by the end of teaching hazards pamphlet fall prevention techniques Patient verbalized fall in his abdomen and is at risk for falls. prevention activities by the Pertinent History (relate to a end of teaching concept):

Rectal Cancer Hypokalemia * Renal insufficiency *

Teaching Learning Plan Medications Sheet

Medication, Dose, Route, Classification and Action Rational for Administration Major Side Effects Nursing Implications Frequency (Explain why the patient is receiving the medication) Home Medications: Metoprolol 50 mg PO QD Antihypertensive- Lowers To maintain normal blood Hypotension, Assess ECG B/P by β-blocking effects; pressure levels bradycardia, insomnia, I&O which can indicate CHR, reduces elevated renin cardiac arrest, Hepatic and renal plasma levels pulmonary edema, NVD Turgor

Simvastatin 10 mg PO HS * Antilipemic- Inhibits Maintain normal cholesterol Liver dysfunction, Assess renal studies HMG-CoA reductase levels NVD, constipation, I&O, BUN, creatinine levels enzyme, which reduces muscle pain, respiratory Appropriate diet cholesterol synthesis tract infection

Hospital Medications: Linezolid 600mg/30 ml IVPB Anti-infective- preventing Used to treat bacterial infections Headache, dizziness, Monitor CBC levels, assessing for bacterial translation in NVD, lactic acidosis leukopenia, thrombocytopenia, anemias, AST Q12 hrs gram positive organisms and ALT

Meropenem 1gm IVPB q 12h Anti-infective- causes Used to treat bacterial infections Seizures, hepatitis, Assess for renal disease, may require a lower bactericidal NVD, PE, hypotension dose Make sure to reconstitute with sterile water

Enoxaporin 30mg SC QD Anticoagulant- Binds to Used to prevent blood clots that antithrombin III can result in DVT and PE Assess bleeding, renal studies, BUN, blood inactivating factors Xa/IIa, studies Hct/Hbg, thrombocytopenia thereby resulting in a higher ratio of anti-factor Xa to IIa