Transition to Associate Degree Nursing Nursing Care Plan Activity Directions: Read each scenario and use this

information to formulate an individualized care plan for each patient. Follow the format provided; choose two scenarios and write two nursing diagnoses for each scenario in their order of priority. Remember an actual uses 3 parts, risk for uses 2 parts. Include a goal statement with all the parts and 4 interventions with all parts and rationale. This assignment is worth 10 points. 1. Patient is a 54 year old male who presents to the ER complaining of severe abdominal pain, nausea and vomiting for 3 days, inability to keep anything down. VS: T 100.0, BP 90/52, AP 98, R 16. Lab values: WBC 12,000, HGB 8.5, HCT 29, Lipase 400, ALT 135. Patient has a history of daily alcohol consumption of 6 beers/day. Other history includes HTN. 2. Patient is an 86 year old female who presents to ER complaining of shortness of breath, non-productive cough, swelling of feet. VS: T 98.6, BP 150/90, AP 92, R 32 and labored. Lung sounds harsh throughout, pitting edema 2+ to bilat feet, O2 sat 86% on room air. Lab values: WBC 8,700, HGB 10.0, HCT 30, BNP 900. Patient has a history of CHF, cardiomyopathy, and noncompliance with medications. 3. Patient is a 25 year old female who presents to the ER complaining of RLQ abdominal pain and fever. She has been nauseated. Any movement makes the pain worse. VS: T 100.5, BP 106/52, AP 100, R 18. Lab values: WBC 13,000, HGB 10.8, HCT 31. Doctors suspect appendicitis. The patient is apprehensive about impending surgery and is anxious. 4. Patient is a 36 year old male who presents to the ER complaining of pain in his left lower leg after falling off the top rung of a ladder. The lower leg is deformed and patient has not put any weight on it. Its broke. Bruising is noted to the mid calf area of the LLE. X-ray confirms the tibia has a clean break and the patient will be casted. After the casting, you give him crutches with some instructions and he is able to demonstrate how to use the crutches, but has difficulty doing stairs. Scenario chosen: Nursing Diagnosis #1 #1 Deficient Fluid Volume

r/t vomiting, fever, decreased fluid volume

AEB temperature of 100.0 F, B/P 90/52, AP 98 Goal #1 Patient will: stop vomiting to maintain hydration by 2/4/12 at 2000 and sustain until discharge. Intervention #1 Nurse will monitor pulse, respirations, and blood pressure every hour for until 2/14/12 at 2000 (24 hours from now) to monitor changes in vital signs. Rationale: Worsening vital sign changes, including tachycardia, tachypnea, hypotension, and elevated temperature, could include worsening condition of fluid volume deficit. Intervention #2 Nurse will monitor total fluid intake and output every 8 hours until discharge to monitor urine output. Rationale: Urine output of less than 30 ml/hour is insufficient for normal kidney function and indicated hypovolemia. Intervention #3 Nurse will provide fresh water and oral fluids every 2 hours until discharge to promote fluid intake. Rationale: Using dilated sports replacement drinks are tolerated better and help with fluid and electrolyte loss. Intervention #4 Nurse will monitor BUN/creatinine ratio every day until discharge to monitor dehydration. Rationale: High BUN/creatinine ratio can be sign of dehydration. Nursing Diagnosis #2 Acute pain r/t irritation and edema of inflamed pancreas AEB patients rating of 8 on a pain scale of 1 to 10, AP 98 Goal #1 Patient will: report acceptable pain level within 4 hours of admittance into ER and maintain until discharge.

Intervention #1 Nurse will assess for pain every 30 minutes until patient reports tolerable level of pain to monitor current pain level. Rationale: Knowing patients current level of pain helps nurse monitor and control their pain. Intervention #2 Nurse will administer opioid as ordered until discharge to control pain. Rationale: Administering medications as ordered helps patients pain get to an acceptable level and prevent future breakthrough pain. Intervention #3 Nurse will teach and implement 5 nonpharmalogical interventions once pain is controlled every shift until discharge to control pain. Rationale: Nonpharmalogical interventions can be used to supplement pharmacological interventions to control pain. Intervention #4 Nurse will demonstrate and teach medication administration and use of supplies every day until discharge to reinforce discharge teaching. Rationale: Teaching patient to stay on top of pain and prevent it from getting out of control will improve ability to accomplish goals of recovery. Scenario Chosen: #3 Nursing Diagnosis #1 Risk for Infection r/t possible perforation of appendix. Goal #1 Patient will: remain free of signs and symptoms of infection, such as warmth, redness, and elevated temperature, until discharge. Intervention #1 Nurse will monitor patient temperature every 30 minutes until surgical procedure to identify any elevations.

Rationale: Sudden rise in temperature could indicate infection and possible perforation of appendix. Intervention #2 Nurse will monitor lab values daily until discharge to monitor for an elevation in WBCs. Rationale: Elevated WBC count may indicate infection. Intervention #3 Nurse will use sterile technique during every dressing change until discharge postsurgical procedure to prevent bacterial infection. Rationale: Using sterile gloves during dressing change helps reduce bacteria and possible infection of wound. Intervention #4 Nurse will encourage high protein meals postsurgical procedure three times a day until discharge to promote proper dietary habits. Rationale: Adequate protein intake promotes wound healing and infection healing. Nursing Diagnosis #2 Anxiety r/t impending surgery AEB patients statements of being apprehensive. Goal #1 Patient will: demonstrate 1 ability to reassure self before surgery. Intervention #1 Nurse will offer client accurate information and encourage patient to talk about feelings as often as needed until surgical procedure to reduce anxiety. Rationale: Providing psychological and social support can reduce symptoms of anxiety. Intervention #2 Nurse will explain all procedures and issues with client using nonmedical terms and slow calm speech before surgical procedure to reduce anxiety.

Rationale: Effective nurse-client communication is critical to efficient care provision. Intervention #3 Nurse will use guided imagery as needed to decrease anxiety until surgical procedure. Rationale: Anxiety may decrease with use of guided imagery. Intervention #4 Nurse will administer antianxiety medications as prescribed 30 minutes before surgical procedure to decrease anxiety. Rationale: Antianxiety medications may help control anxiety prior to patients surgical procedure.