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Care Plan

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LIVING SITUATION/WITH WHOM: (home, assisted living, LTC, etc) Lives with daughter.

SOCIAL HISTORY: (tobacco, ETOH, illicit drugs, family dynamics) Quit smoking many years ago, no history of ETOH or drug use.


Client's principal admitting diagnosis was leukocytosis. Definition: (from Taber’s) “An increase in the number of leukocytes (usually above 10,000/mm3) in the blood. It occurs most commonly in disease processes involving infection, inflammation, trauma, or stress, but it also can result from the use of some medications” (Venes, 2009, p. 1327).
Etiology/pathophysiology: ( NOT from Taber’s or Wikipedia)

Etiology: Causes of leukocytosis are infection, inflammation, tissue damage, immune reaction, bone marrow problems, medications, and stress (Drug Information Online, 2011). Pathophysiology: “Leukocytosis can be a reaction to various infectious, inflammatory, and, in certain instances, physiologic processes (eg, stress, exercise). This reaction is mediated by several molecules, which are released or regulated in response to stimulatory events that include growth or survival factors (eg, granulocyte colony-stimulating factor, granulocyte-macrophage colony-stimulating factor, c-kit ligand), adhesion molecules (eg, CD11b/CD18), and various cytokines (eg, interleukin-1, interleukin-3, interleukin-6, interleukin-8, tumor necrosis factor)” (Medscape, 2010).

Common signs/symptoms:

Fever, bleeding, bruising, lethargic, dizziness, trouble breathing, weight loss, and sweating.

Potential complications:

Increased risk for infections.


SECONDARY MEDICAL DIAGNOSIS: (include pertinent preexisting diagnoses such as DM, COPD, etc)

Diabetes Type II, Non insulin dependent diabetes mellitus (NIDDM).


“A chronic metabolic disorder marked by hyperglycemia. Diabetes mellitus results from insulin resistance, with inadequate insulin secretion to sustain normal metabolism. Diabetes mellitus may damage blood vessels, nerves, kidneys, and the retina” (Venes, 2009, p. 630).


Etiology: “Risk factors for developing type II diabetes include the following: high blood pressure, high blood triglyceride levels, high-fat diet, high alcohol intake, sedentary lifestyle, obesity” (Diabetes, 2011). Pathophysiology: “The pathophysiology of Type 2 diabetes mellitus is characterized by peripheral insulin resistance (insulin insensitivity), impaired regulation of hepatic glucose production, and later on: declining beta (ß) cell function, eventually leading to possible ß-cell failure. The primary events are believed to be an initial insensitivity of insulin resulting in peripheral insulin resistance; and, later on, relative insulin deficiency” (Death to diabetes, 2010).
Common signs/symptoms:

Increased thirst, frequent urination. Increased hunger, weight loss, fatigue, blurred vision, slow healing sores, and frequent infections.
Potential complications:

Heart and blood vessel disease, neuropathy, eye damage, foot damage, more susceptible to skin problems.

Urinary tract infection


“Infection of the kidneys, ureters, or bladder by microorganisms that either ascend from the urethra or that spread to the kidney from the bloodstream” (Venes, 2009, p. 2413).

Etiology: “The urinary system is composed of the kidneys, ureters, bladder and urethra. All play a role in removing waste from your body. Urinary tract infections typically occur when bacteria enter the urinary tract through the urethra and begin to multiply in the bladder. Although the urinary system is designed to keep out such microscopic invaders, the defenses sometimes fail. When that happens, bacteria may take hold and grow into a full-blown infection in the urinary tract” (Mayo Clinic Staff, 2011). Pathophysiology: “Urinary tract infections occur when a bacterial organism enters the urinary tract. Although urine resists many types of bacteria, especially those living in or around the vagina area, gram negative rods (a specific type of bacteria) can grow rapidly in urine. Most urinary tract infections are caused by gram negative rods that normally inhabit the gastrointestinal tract, which consists of the stomach and intestines. The most common strain found in urinary tract infections is E. Coli” (Chandler, 2011).

Common signs/symptoms:

No symptoms, burning on urination, frequency, urgency, nocturia, incontinence, pelvic pain, hematuria, back pain.
Potential complications:

Infection can become chronic and cause permanent damage to renal system.


When I cared for this client his reason for visit was complaint of abdominal pain and distention. He presented with large ascites and had peritoneal catheter in place.


Client has history of Non-Hodgkin lymphoma, anemia, chronic back pain, diabetes mellitus type II, chronic renal insufficiency, hypertension, herpes zoster, hard of hearing. Past surgical history includes peritoneal catheter placement, February 2011.

VI. SURGERIES/MEDICAL PROCEDURES THIS ADMISSION: (include date performed and explanation)

On 6/17/11 client had placement of peripherally inserted central venous access device, 5 french dual lumen catheter from right arm. Peripherally inserted central catheters are frequently used to obtain central venous access for patients in acute care.


No complications r/t placement of PICC line.

VIII. CONSULTS: ( type, include date and reason for consult)

Client had consultation on 6/13/11 for liver cirrhosis and recommendation for hospice.

IX. DIAGNOSTIC TESTS: (CT, MRI, CXR, U/S, EKG, etc.; include date, reason for test, and results)

Client did not have any diagnostic tests performed.

X. LABS: Lab Test Purpose Normal Values Client Results Interpretation of Abnormal Labs


“To determine the presence of an infection” (Kee, 2005, p. 435). “To monitor the hemoglobin value in RBCs” (Kee, 2005, p. 222).

3.4 – 10.7 K/mcL 13.5-18 g/dL males

34.4 K/mcL 10.8 g/dL

Increased level due to infection. Decreased level due to anemia and cirrhosis of liver.


“To monitor the volume of RBCs in 40-54% blood during a debilitating illness” (Kee, males 2005, p. 220). “To check the blood glucose level” (Kee, 2005, p 208). “To detect renal disorder or dehydration associated with increased BUN levels” (Kee, 2005, p. 84-5). “To diagnose renal dysfunction” (Kee, 2005, p. 149) 60-110 mg/dL 5-25 mg/dL 0.5-1.5 mg/dL


Decreased level due to anemia, cirrhosis of lever, and previous course of antineoplastic agents. Increased level due to diabetes mellitus and stress from hospital stay. Increased level due to diabetes mellitus, renal insufficiency, and medications. Increased level due to diabetic nephropathy and renal failure.


143 mg/dL 34 mg/dL

Creatinine (serum)

2.03 mg/dL

XI. MEDS: Medication (Brand and Generic Names) Classification Prescribed Dose, Freq, Route Mechanism of Action Patient Specific Indications Side effects and Nursing Implications

Allopurinol Zyloprim

Antigout agent

100 mg PO daily

Calcium Carbonate Os-Cal

Fluid and electrolytic replacement; antacid.

500 mg PO BID

“Allopurinol reduces endogenous uric acid by selectively ingibiting action of xanthine oxidase, the enzyme responsible for converting hypoxanthine to xanthine and xanthine to uric acid” (Wilson, Shannon, & Shields). “Calcium carbonate is a rapid-acting antacid with high neutralizing capacity and relatively prolonged duration of action” (Wilson, Shannon, & Shields ). “Lowers blood glucose levels by stimulating the release of insulin

Prevent flare up of gouty attack.

Drowsiness, headache, vertigo, vomiting, diarrhea, malaise. Monitor for effectiveness, gouty attack, lab tests, report onset of rash or fever to physician immediately. Check for return of lab results as ordered during shift.

Relief of heartburn or calcium supplement.

Constipation, hypercalcemia. Note consistency of stools, monitor lab tests, observe for S&S of hypercalcemia. Client bedridden wearing diapers so assess during change after any BM. Monitor any returned lab results during shift. Back pain, dizziness, diarrhea, hypoglycemia Assess lab tests results and monitor for hypoglycemia

Nateglinide Starlix

Hormone; Antidiabetic

60 mg PO TID

Treatment of NIDDM.

Midodrine HCL ProAmantine


5 mg PO BID

from the pancreatic cells of a type 2 diabetic” (Wilson, Shannon, & Shields) “Vasopressor and alpha1 agonist that activates the alphaadrenergic receptors of the arteries and veins, resulting in increased vascular tone and elevation in blood pressure” (Wilson, Shannon, & Shields).

during shift.

Treatment of symptomatic orthostatic hypotension.

Chills, pain, facial flushing, anxiety, dry mouth, pruritus. Monitor supine and standing BP during VS checks q 4 hrs.





XIII. IV SITE(S): ( location, gauge) PICC line right upper arm, 5 french lumen catheter inserted 6/17/11. XIV. PT/OT: None XV. RESP TX: None Frequency Type Rationale

XVI. NURSING INTERVENTIONS: (frequency, type, description, and/or N/A) Drain ascitic fluid via Denver catheter VS q 4 hours accucheck AC and HS Offload heels off mattress with pillows VS: DATE/TIME TEMP /ROUTE 6/23/11 at 1036 97.4 Oral 106/58




72 bpm


Pain level:

0-10 scale 0



Neuro checks:

Client is alert and oriented times three. Pupils are equal and reactive to light. Responds appropriately to requests. Normal grip strength in both hands.

Cardiac monitor: None Oxygenation: None Vent settings: None
ABGs: (results) N/A

Pacemaker/ICD: None Method of Delivery N/A Mode N/A TV N/A Flow N/A FiO2 N/A
Suctioning: N/A

Hemodynamic monitoring: None Rate N/A Rate N/A
Method N/A Frequency N/A

Pulse Oximetry N/A PEEP/CPAP N/A
Result N/A

Nutrition: Weight: 140 lbs




Wt gain/loss


Regular Route N/A

Good Indication N/A

Tolerates with no GI upset Formula N/A

Zero Rate N/A


Chewing/ Swallowing

Intact Tolerance N/A Glucose (FS or lab) N/A

Enteral feeding: None

BOWEL/BLADDER ELIMINATION: Last bowel movement was 6/22/11

I&O: Not being monitored

Foley None

NG None

Ostomy None

Drains Denver drain left ABD

Other tubes None

Dressing/wound care: Clear bandage over PICC line MOBILITY: BEDREST Ortho: (traction, cast, etc) None Safety considerations: None Sleep/rest: No complaints

Location Right upper arm

Appearance Clean and dry

Activity/assistive aids: Bed rest Restraints: (date, type and justification) None Hours Approximately 8 hours per night Quality Good Aides None

Head to Toe Assignment Summary
Vital signs: BP Pulse radial pedal apical Respiration 18 Temperature 97.4 F Oxygen Saturation N/A Pain Assessment (scale 1-10) Note presence, onset, location, intensity Frequency, duration. Radiation Precipitating factors, facial appearance Guarding, inability to focus, change in VS Must narrate all abnormal findings. None Ego Integrity: Integrity vs Despair Patient denies any pain 6/23/11 at 1045 106/58 Radial 72 bpm

Physical Appearance Client appeared awake and alert. Clean and resting comfortably in bed.

Behavior- verbalize appropriate to situation Yes Normal thought processes Yes Memory intact Yes Affective appropriate Yes Tobacco Previous smoker Alcohol No use of ETOH Substance abuse No history

Skin- Note and describe on chart any of the following: rashes, wounds, pressure ulcers, ecchymotic areas Healing skin tear R lower arm, bruises bilaterally arms, Pressure ulcer on sacrum, redness bilaterally buttocks. Hygiene (participation in ADLs) (assistance required) Color Turgor Peripheral edema sites Degree of edematous areas (Use Scale Below) Nail beds (color and angle) Capillary refill (seconds) Neurosensory:
1+ =barely detectable 2+ =indentation of less than 5 mm 3+ =indentation of 5 to 10 mm 4+ =indentation > 10mm

Client needs assistance with ADLs. Acyanotic Good skin turgor Moderate edema bilateral lower extremities, 1+ No clubbing, pink 2 seconds

ORIENTED: PUPILS: PEERLA Pupil Size Prosthetic Devices

Person Alert Equal R: 4 mm Glasses None


Time Reactive

L: 4 mm Hearing Aids None Present Dry A= Absent

Other N/A

Circulation: Weak Edema Perfusion Warm S= Strong W=Weak Respiratory Lung CTA Pattern Breath Sounds Even Normal

Site Bilaterally LE D= Doppler



Cough None SOB @rest or exertion None Sputum amount and color None Hemoptysis None Orthopnea None O2 Therapy (type/amount) N/A

Peripheral and or central cyanosis None Color of mucous membranes Pink Use of accessory muscles No Pain on Inspiration and Expiration None Other treatments

Activity/ Sleep (list any assistive devices) Activity Bedrest


ROM Full Joint Swelling None Steady Gait Not observed Quality & Quantity of Sleep Well, approximately 8 hours

Activity Restriction Bedrest Stiffness None PT/OT Assessment

Contractures None Ambulation with rolling walker Rest/Sleep No complaints


Code: 4= normal strength, grip strong or good pressure resistance can move, lift and and hold extremity 3= grip weak and/or poor pressure resistance lifts and holds, can move, lift and hold extremity 2= weak grip or pressure resistance lifts and falls back, can move and lift extremity but cannot hold position 1= little or no grip or pressure resistance moves on bed, cannot lift or hold 0= no movement ELIMINATION: Note any of the following food intolerance or allergies, N or V, change of bowel habits, rectal bleeding or black tarry stools, use of laxative and type Oral mucosa Bowel sounds Bowel movement Ostomy ( type) Normal See Below Last BM 6/22/11 None Other Frequency 3-4 x/week Character Loose brown

Note any abnormalities on the chart: bowel sounds; absent, hypoactive, hyperactive, areas of tenderness or pain, location of ostomy.

RUQ Present

LUQ Present

Present RLQ

Present LLQ

Urine Last Voided

Frequency Pt wearing diapers. Changed at 1045.

Normal Catheter Type Sexuality:

FEMALE CLIENT Last menstrual period: Menopause: Yes Vaginal discharge: Last PAP smear: No

MALE CLIENT Urethral discharge pain:


Hx of prostatic hypertrophy: No Self-testicular exam: Unknown Surgical hx:

PAP results


sexual activity current Hx of STD's Surgical hx: Self breast exam contraception

Hx of STD's No Circumcision: Yes X Sexual activity current Contraception

Not active


XIX. NURSING CARE PLAN: Directions: 1. Formulate a NCP using (3) nursing diagnoses: a. Two (2) are the priority nursing diagnoses. b. The 3rd nursing diagnosis can be Knowledge Deficit or At Risk. c. Write full nursing diagnoses statements. Example: Ineffective airway clearance R/T increased sputum production as evidenced by ineffective cough and coarse rhonchi. Note: if nursing diagnosis is “Risk for” there is no evidence to report. d. Include client’s level on Maslow’s Hierarchy. 2. Outcomes: a. Include Nursing Outcome Classification (NOC). b. State (2) STGs and (1) LTG. c. Goals must be client-centered, specific, measurable, realistic, and have a time frame for achievement. Examples: STG: Lungs will be clear in 8 hours. LTG: Client will demonstrate colostomy care by time of D/C. Note: Sometimes it is more appropriate for LTGs to extend beyond D/C. 3. Interventions: a. Include Nursing Intervention Classification (NIC). b. Prioritize interventions in order of performance. c. Must be individualized/specific/with frequencies/and be directly related to goals. d. Cite work for all interventions Example: 1. Observe/assess resp status for rate, depth, and chest wall movement Q4 hrs and PRN (Lemone & Burke, 2004) 4. Rationales: Specific to each intervention listed and scientific. Example: 1. Tachypnea, shallow resp, and asymmetric chest movement may be indicative of resp compromise (Lemone & Burke, 2004). Note: Use nursing textbooks and scholarly journals only. No medical dictionaries or health-related internet web sites are to be used. Cite work for all rationales. Note: Last page of NCP must include APA formatted reference page for all works cited in interventions and rationales. 5. Documentation: Document your interventions as you would in written nurse notes. Example: 0800 RR shallow at 24/min, even, non-labored. 6. Evaluation: Evaluate each STG as met, partially met, or not met and care plan status as D/C, continue, or revise. Example: Goal not met. Revise care plan. Note for teaching care plan: In order for learning to have taken place, the client must verbalize or demonstrate something. Example: Verbalized how to read labels on canned goods for sodium content.

Analysis of Client’s Assessment Data: Formation of Nursing Diagnoses Based on the data base, identify objective and subjective data that may lead to actual and potential nursing diagnoses.

Nursing Diagnosis #1 Impaired skin integrity R/T physical immobilization AEB erythema on sacrum area.
Objective Data: Erythema on sacrum area. Beginning Stage 1 pressure ulcers. Subjective Data: Pt. complained of discomfort on buttocks.

Nursing Diagnosis #2 Deficient knowledge R/T condition and treatment AEB inaccurate perceptions of health status and failure to correctly perform prescribed health behaviors. Objective Data: Subjective Data: Urinary tract infection Pt acutely ill and referred to hospice and discontinue chemotherapy but family not accepting. Elevated WBCs Elevated blood glucose Elevated BUN and creatinine

Nursing Diagnosis #3 At risk for infection R/T acute illness
Objective Data: Subjective Data:







Impaired skin integrity R/T physical immobilization AEB erythema on sacrum area.

STG-1 Client will report any altered sensation or pain at site of skin impairment during shift. STG-2 Client/family will demonstrate understanding of plan to heal skin and prevent reinjury before end of shift. LTG Client will regain integrity of skin surface.

1a. Nurse will monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection (Ackley & Ladwig, 2009). 1b. Nurse will not position client on site of skin impairment to help reduce pain. If consistent with overall client management goals, turn and position client at least every 2 hours (Ackley & Ladwig, 2009). 2a. Nurse will monitor client's skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin skin cleansing (Ackley & Ladwig, 2009).

1a. Systematic inspection can identify impending problems early (Ackley & Ladwig, 2009). 1b. Do not position an individual directly on a pressure ulcer. Continue to turn/reposition the individual regardless of the support surface in use (Ackley & Ladwig, 2009). 2a. Cleansing should not compromise the skin (Ackley & Ladwig, 2009). 2b. Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently (Ackley & Ladwig, 2009). 3a. Moisture from incontinence

Maslow’s Hierarchy Level:


0845 client alert and oriented times three. Client eating breakfast and comfortable. 0950 Checked on client and he stated he felt wet. Client bedridden and wearing diapers so assisted him in changing. Noticed redness on buttocks area of pressure points. Cleaned pt thoroughly and applied topical ointment for moisture barrier. Spoke with client and daughter about repositioning every 2 hrs, keeping area dry to prevent further skin breakdown.

STG-1 Goal met, client expressed discomfort from pressure ulcers. STG-2 Goal met, client and family demonstrated interventions to prevent further breakdown of skin. LTG Goal not met. Client still receiving care to improve skin integrity.

2b. Nurse will individualize plan according to client's skin condition, needs, and preferences (Ackley & Ladwig, 2009). 3a. Nurse will monitor client's continence status, and minimize exposure of skin impairment and other areas of moisture from incontinence, perspiration, or wound drainage (Ackley & Ladwig, 2009). 3b. Nurse will teach client and family to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury (Ackley & Ladwig, 2009).

contributes to pressure ulcer development by macerating the skin (Ackley & Ladwig, 2009). 3b. The use of effective pressurereducing seat cushions significantly prevents sitting/laying acquired pressure ulcers (Ackley & Ladwig, 2009).







Deficient knowledge R/T condition and treatment AEB inaccurate perceptions of health status and failure to correctly perform prescribed health behaviors.

STG-1 Client/family will demonstrate how to perform healthrelated procedures satisfactorily before end of shift (Ackley & Ludwig, 2009). STG-2 Client will state confidence in one's ability to manage health situation and remain in control of life in 24 hours (Ackley & Ludwig, 2009). LTG Client/family will list resources that can be used for more information or support after discharge (Ackley & Ludwig, 2009).

1a. Nurse will adapt the teaching process for the physical constraints of the aging process (Ackley & Ladwig, 2009). 1b. Nurse will offer opportunities for the practice of psychomotor skills (Ackley & Ladwig, 2009). 2a. Nurse will engage client as a partner in the educational process (Ackley & Ladwig, 2009). 2b. Discuss healthy lifestyle changes that promote wellness for the older adult (Ackley & Ladwig, 2009). 3a. Help the client appropriate follow-up resources for continuing information

1a. Adults are capable of learning at any age. Age modifies but does not inhibit learning (Ackley & Ladwig, 2009) 1b. Older adults indicate a preference for hands-on learning (Ackley & Ladwig, 2009). 2a. A nursing approach that is collaborative and that uses encouragement and support to increase selfefficacy resulted in client satisfaction, empowerment, and confidence (Ackley & Ladwig, 2009). 2b. Greater efforts must be made both to improve preventive health care and enhance quality-of-life interventions for older

1030 Family informed of discontinuation of upcoming chemotherapy and referral for hospice for client.

STG-1 Goal met with family assisting in client care. STG-2 Goal not met, continue care plan. LTG Goal not met, continue care plan.

Maslow’s Hierarchy Level:


and support (Ackley & Ladwig, 2009). 3b. Refer elderly clients for postdischarge follow-up as they transition from hospital to home/hospice in regards to their treatment and medication regimens.

people (Ackley & Ladwig, 2009). 3a. Advocating for client's participation using a communitybased case management program has demonstrated improved clinical and financial outcomes for clients with complex chronic conditions (Ackley & Ladwig, 2009). 3b. Extended followup and social support may prevent relapses and readmissions in older, vulnerable clients (Ackley & Ladwig, 2009).







At risk for infection R/T acute illness

STG-1 Client will demonstrate appropriate care of infection prone site by end of shift. STG-2 Client/family will demonstrate appropriate hygienic measures such as handwashing, oral care, and perineal care by end of shift. LTG Client will remain free from symptoms of infection prior to discharge.

1a. Nurse will recognize that chronically ill geriatric clients have an increased susceptibility to infection; practice meticulous care of all invasive sites (Ackley & Ladwig, 2009). 1b. Carefully wash and pat dry skin, including skinfold areas. Use hydration and moisturization on all atrisk surfaces (Ackley & Ladwig, 2009). 2a. Use appropriate “hand hygiene” (Ackley & Ladwig, 2009). 2b. Ensure the client's appropriate hygienic care with handwashing; bathing; oral care; and hair, nail, and perineal care performed by either the nurse or the

1a. A successful infection prevention program can provide the foundation for expanding performance improvement throughout the facility (Ackley & Ladwig, 2009). 1b. Atopic dermatitis is a common, chronic skin condition that can be managed in most clients by prescribing avoidance measures, good skin care, antihistamines, and conservative topical medications (Ackley & Ladwig, 2009). 2a. Meticulous infection prevention precautions are required to prevent health care-associated infection (Ackley & Ladwig, 2009).

0845 Checked lab values for any abnormal findings. Assessed Denver cath for signs of infection. Monitored VS.

STG-1 Goal not met. Client needs assistance with proper care of infection prone sites. STG-2 Goal met. Family assisted with care and used proper technique. LTG Goal not met. Client still having abnormal lab values r/t acute illness.

Maslow’s Hierarchy Level:


client/family (Ackley & Ladwig, 2009).

2b. Daily showers or baths can help to reduce the number of 3a. Nurse will note and bacteria on the client's report laboratory values skin (Ackley & (Ackley & Ladwig, Ladwig, 2009). 2009). 3a. The WBC count 3b. Nurse will observe and the automated and report signs of absolute neutrophil infection such as count are good redness, warmth, diagnostic tests discharge, and (Ackley & Ladwig, increased body 2009). temperature (Ackley & Ladwig, 2009). 3b. Prospective surveillance study for health care acquired infection should include fever of unknown origin as the single most common and clinically important entity (Ackley & Ladwig, 2009).

Maslow’s Hierarchy Level:








Maslow’s Hierarchy Level:








Maslow’s Hierarchy Level:


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