Delaware Technical Community College

NUR 320 Health Assessment

RN to BSN program: Plan of Care Chart

STUDENT NAME: Lexi Leskovac DATE: Dec. 2, 2020

Nursing plan of care

Identified problem/need: Identified goal or Plan/ Interventions: Projected Evaluation/ Community Resources/
(include supporting outcome: (Provide rationale/ and Outcomes: (How will you Referrals: (Must be actual
subjective and objective cited evidence to justify measure that it worked?) resources from the
data) the rationale) client’s community.
Include Name, address,
web address, and phone
number)
Posterior urethral valves -Medication compliance Continue taking at home Lab studies should be LabCorp
 CKD stage 3  kidney -Adherence to diet medications - Rapamune, reviewed to assess 13900 Park Center Rd,
transplant  -Compliance with lab work Mychophenalic Acid, whether they are within Herndon, VA 20171
R/F AKI – blood studies and Oxybutynin, Olmesartan, expected ranges. (703) 742-3124
urinalysis Vitamin D and Amoxicillin https://www.labcorp.com/
-Exercise within limits as prescribed to prevent Evaluate food & exercise
-Keep a food & exercise rejection against journal to assess Eat Well Guru
journal transplant, treat compliance with plan of Dr. Dadkhah, Ph.D., RDN,
-Follow-up with PCP, neurogenic bladder, avoid care. CPT
nephrologist, and renal damage from HTN, 46165 Westlake Dr.
transplant team at Johns replete Vit D deficiency, No urinary tract Suite 200
Hopkins and prevent chronic UTIs. infections. Sterling, VA 20165
703-988-7402
Meet with registered Ensure prescriptions are https://www.eatwellguru.
 renal dietitian to review being refilled. Question com/services/renal-diet
lab work and evaluate patient about when they
proper amt of protein, take their medications.
potassium, phosphorous, U.S. Renal Care
sodium, and fluids to 12330 Pinecrest Rd
consume (NIDDK, 2014). Suite 200
Reston, VA 20191
30 minutes of exercise, 703-476-0605
minimum of 3 https://www.usrenalcare.
nonconsecutive days a com/living-with-kidney-
week consisting of low- disease/diet-and-
level strength exercise.html
conditioning and aerobic
exercises (NKF, 2020). Nephrology Associates of
Northern Virginia
13135 Lee Jackson
Memorial Highway
Suite 135
Fairfax, VA 22033
703-961-0488
https://www.nanvonline.com/

HTN -Medication compliance -Olmesartan daily – ARBs -Maintain SBP of 90-120 Town Center Family
-Monitor BP at home lower BP and help slow and DBP of 60-80 Medicine
-Adherence to diet progression of kidney 11800 Sunrise Valley Dr
regimen disease (NIDDK, 2014). -Review BP recordings #700
-Exercise within limits with PCP. Adjust Reston, VA 20191
-Record log of blood medications, diet, and 703-834-1473
pressure recordings exercise as needed to https://www.inova.org/lo
 (Mayo Clinic, 2020).
Neurogenic Bladder  -Utilize proper sterile -Educate to wash hands
frequent straight technique when with soap and water prior
catheterization  R/F catheterizing to procedure (National
chronic UTIs -Consistent Library of Medicine,
catheterization schedule 2019).
with appropriate
frequency -Educate to catheterize
-Medication compliance first thing in the morning,
before bed, and every 4-6
hours or 4 to 6 times a day
(National Library of
Medicine, 2019).
-Continue to take
prescribed Oxybutynin to
relax the bladder and
Amoxicillin as prophylaxis
for UTIs.
-Educate about UTI
symptoms and when to
call the provider (National
Library of Medicine,
2019).
Immunocompromised 2° -Adherence with routine -Schedule vaccinations
kidney transplant vaccinations
maintain stable BP.
-A urinalysis can be used
to evaluate for presence
of a UTI
-Ask the patient to talk
through their process of
catheterizing step-by-step
to ensure they are
performing it properly
-Assess/monitor patient
for presence of UTI
symptoms (fever, flank
pain, chills, burning upon
urination, N/V, odorous or
cloudy urine)
-Monitor patient for signs
of infection or rejection of
cations/primary-
care/town-center-family-
medicine
Town Center Family
Medicine
11800 Sunrise Valley Dr
#700
Reston, VA 20191
703-834-1473
https://www.inova.org/lo
cations/primary-
care/town-center-family-
medicine
CVS Pharmacy
12027 Town Square St,
-Medication compliance -Continue taking
-Strict COVID-19 Rapamune (Sirolimus) and
precautions Mychophenalic Acid
-Pt will not contract (CellCept) as prescribed.
COVID-19 Use a pill box organizer
and set an alarm to take
the medications at the
same time each day to
promote medication
compliance (National
Kidney Foundation,
2020a)
transplant: fever, urine Reston, VA 20190
output, fever, tenderness (703) 707-9787
near the kidney, bloody https://www.cvs.com/stor
urine, flu-like symptoms, e-locator/cvs-pharmacy-
or weight gain of more address/12027+Town+Squ
than three pounds in two are+Street-Reston-VA-
days 20190/storeid=10361?
WT.mc_id=LS_GOOGLE_F
S_10361

-Educate on what
medications,
supplements, and foods to
avoid while taking
immunosuppressants
(National Kidney
Foundation, 2020a)

-Practice social distancing,

wear a mask, wash hands
with soap and water, work
from home, and always
keep a 30-day supply of
prescriptions on hand in
case you need to
quarantine (Centers for
Disease Control and
Prevention, 2020)