Harry George 401 Care Plan.docx

NURSING CARE PLAN Harry George rm 401 Jaylloyd Dullas & Vanessa Andrade VN 110 Ms. Candy Martin & Mrs. Elinda Parkinson October 7th, 2019 Nursing Care Plan Patient’s Initials: __H.G.________________________________ Primary Diagnosis: ___Cellulitis left foot with osteomyelitis____ Secondary Diagnosis: __Type 2 Diabetes Mellitus, alcoholism__ Age 54 year old Gender Male Health State Disability due to cellulitis of the left foot with chronic diabetes mellitus. Developmental state Generativity vs. Self-absorption and stagnation. Sociocultural orientation No documentation of education, Caucasian Patterns of living Homeless Environment Areas in which are not suitable for clean leaving, ADL not easily achievable due to living conditions, no immediate access to medications for chronic medical problems. Resources Homeless shelter. Occasional friends. No contact with family. Summary: 54 year old patient arrived via stretcher from homeless shelter. Patient admitted with a 2 cm open wound on the left foot with redness, swelling, and serous drainage. Has decreased sensation and edema on both lower extremities. Difficulty distinguishing sharp vs. dull. Fractures with surgery 4 years ago. Divorced with 2 children, no local family. Part I: Routine Medication- Allergic to: Urinary anti-infective causes rash. Cefotaxime 1g/6hours IV- Antibiotics, bactericidal; fight severe infections, lowers serious respiratory tract, urinary tract, skin, bone, gonococcal infections. The patient is fighting an infection in his wound. Side effects are dark urine, weakness, stomach pain, vomiting, nausea and fever. Rashes and itchiness is another side effect. Nursing considerations assess lab reports to identify if infection has decreased or has not changed. Glyburide 1.25mg/day- Classification: sulfonylureas, lowers blood sugar by causing the pancreas to produce insulin. Patient has type 2 diabetes mellitus Side effects: Stomach pain, low grade fever, weight gain. Assess glucose levels every 4 hours. Gentamicin 20mg/8hours IV- Function class: Anti-infective; Chemical Class: aminoglycoside; It works by stopping the growth of bacteria. side effects are nausea, vomiting, upset stomach, muscle twitching, rash, hypotension and hypertension. Nursing considerations Assess patient for previous sensitivity reaction. assess patient for signs and symptoms. Thiamine 100mg/day PO/IM-Function class: Vitamin B1, chemical class: water soluble; need for pyruvate metabolism, carbohydrate metabolism. This was a routine medication for the patient e/b Poor appetite, which doesn’t help nutrition. Side effects: restless, weak, hypotension, nausea, diarrhea. Assess patient for anaphylaxis, and teach patients necessary foods to be included in diet. PRN Medication- Lorazepam 0.5mg/8hours IV- Function class: Sedative-hypnotic, antianxiety agent, Chemical Class: Benzodiazepine, short acting. Potentiates the actions of GABA is an inhibitory neurotransmitter, especially in the limbic system and reticular formation which depresses the CNS. Outcome decreased anxiety, relaxation. Some side effects dizziness, drowsiness, confusion, headaches, insomnia, orthostatic hypotension. Nursing considerations we should assess for alcohol withdrawal symptoms and monitor BP and RR if systolic number dops 20mm Hg, hold product, notify health provider. Oxycodone 5mg / acetaminophen 325mg 2tablets/3hours PO- Function class: opiate analgesic, Chemical Class: semisynthetic derivative. Inhibits ascending pain pathways in CNS, increase pain threshold, alters pain receptions. Outcome decreased pain. Patient is receiving this medication to relieve moderate to severe pain. Side effects: drowsiness, dizziness, confusion, headaches, sedation, constipation, rash, urinary retention. Nursing considerations is to assess the patient’s pain level and the intensity of it. give medication 1 hour before or 2 hours after food. Phenytoin sodium 100mg/8hours-function class: Anticonvulsant/ anaesthetic (class IB). Inhibits spread of seizure activity in motor cortex by altering ion transport. Increases AV conduction to decrease dysrhythmias. Outcome: decreased seizures, absence of dysrhythmias. Side effects are dizziness, insomnia, hypotension, nausea, vomiting, and constipation. Assess for blood dyscrasias assess fever, sore throat, bruising, rash. Teach patient to notify prescriber of unusual bleeding, bruising, petechiae, and clay colored stools. Trimethobenzamide hydrochloride 200mg/6 hours IM- Function Class: antiemetic, anticholinergic, Chemical class: Ethanolamine derivative. Acts centrally by blocking chemoreceptor trigger zone, which in turn acts on vomiting center. Outcome for patient absence of nausea and vomiting. Observe for drowsiness, dizziness, nausea, and vomiting. caution patient to avoid hazardous activities. advice patient to lay down after IM injection. Treatments: Foley Catheter- The patient states that he goes to the bathroom 6-8 times which could mean he is retaining urine, the medication he is taking is a hypnotic and sedative which reduces the ability to recognize and act on the urge to void. Patient is also ordered as bedrest voiding is a complication for the patient due to immobilization, which is a risk for an infection. Patient has a history of UTI treated with pills. Patient is responding well to treatment and urinalysis has been assessed documented an abnormal amount of protein and glucose found in the urine. Documented I&O every 8 hours. This is to determine how much urine he was retaining or voiding, emptying the bag when the bag is filled 1/3 or ½ of the bag. PT- Physician ordered PT evaluate the patient for mobility, they develop a plan of care to regain patient’s mobility, Patient is uncooperative to treatment and refused to see PT, also very agitated when bothered. Was not able to assess Psychiatric Evaluation Team- Assesses the patient’s mental health by asking presenting problems, personal relevant history, family history, mental and emotional status and doing a cognitive impairment test, patient is compliant. Patient states he has lost his family which puts him in depressive state where the person realizes the full impact of his loss. Diagnostic Tests: X-Ray- Date: Monday Type of exam: Anterior/posterior and lateral chest Findings: no abnormal bony prominences, heart of normal size; sharp costophrenic angles. Impression: normal anterior/posterior and lateral chest exam. Date: Monday Type of exam: Exam of the left foot Impression: Healed fractures of left metatarsals 1,2, and 3 and malleolus on left. Osteomyelitis of fracture sites. Date: Tuesday Type of exam: Bone Scan Impression: Osteomyelitis Labs: MON: Hematology- WNL (expect: WBC 19,200) Chemistry- WNL [except: Glucose 380mg/dL, Albumin 2.8gm/dL, AST (SGOT) 80 U/L] Urine- WNL (except: Dark Amber) TUE: Hematology- WNL (except WBC 14,000, Lipase- 310U/L, Amylase 280 U/L) Part II: Psycho-social: According to Erikson’s theory the patient is in developmental task of Generativity vs. Self-absorption and stagnation. The patient is battling the generativity, his main task is too care for his children and to be there for his family. His inability to fill that role has put him into a stagnation stage where he has a prolonged period of little or no growth in his developmental stages. He is currently homeless surviving by getting occasional care and meals. Receiving support from friends but mostly relies on shelter homes. Wife took his two sons and left him which affects his developmental stage and is also a major factor to his mental health. His primary motive is seeing his kids once he is discharged Mental-Health: Patient only has two concerns the loss of his family and the pain he is enduring due to his injury. He is coping with the loss of his job, family, and his role of being a father through negative coping mechanisms and has turned to alcohol to make him feel better. The realization of his is perceived loss of his wife and two sons put his in a depressive state therefore the reasoning of his alcohol abuse to help him cope with the loss. He has increased feelings of Depression, anxiety about his life situation,hopelessness, and suspiciousness. States “I’m sick and lost my family.” The coping mechanism is ineffective as it helps him relax, but can form an unhealthy habit leading to many problems down the road. Cultural-Ethnicity: Patient is a Caucasian Spirituality: Patient believes that there is a higher power but doesn’t attend church, has no spiritual or cultural practices that are important to him. Refused spiritual care and doesn want any contact with any spiritual advisor. Part III: Physical Assessment NEUROLOGICAL Alert Confused Lethargic Unresponsive Oriented: Person Place Event Time Verbalization: Appropriate Inappropriate Nonverbal Hand grasps: R__SE_____ L__SE____ Leg pushes: R___SE_____ L___W_____ (W-weak, S-strong, E-equal) PERRL R___Q__ L___Q___ (Q-quick, S-sluggish, N-nonreactive) Pupil size (mm): R___2mm___ L___2mm____ SKIN Temp: __99.7_____ Color: Normal Cyanotic Ashen Jaundice Pale Condition: Dry Moist Clammy Turgor: Brisk Slow to return Tenting Integrity: Intact Bruising Decubitus Rash Incision Describe/location: _____________________________________________________ IV/HL Central Line Location: ____Right forearm peripheral IV site____ Braden Score: ______17________ RESPIRATORY Rate ____29____ Regular Irregular SOB Labored Clear Wheezes Expiratory Inspiratory Rales Ronchi Diminished Location ___5th intercoastal space_______ Cough: Nonproductive Productive: ___________________ O2@ ______RA_______ L/min N/C Mask: _________________ Pulse Ox: _______93_____ Suction: ______________________________ CARDIOVASCULAR BP ______160/99__________ Cap refill _______sluggish at 4 sec_______ AP __110__ _ Regular Irregular Radial L ______2+________ Regular Irregular Radial R _______2+_______ Regular Irregular Pedal R ________2+_______ Normal Weak Absent Pedal L __1+ to doppler____ Normal Weak Absent Edema: Non-pitting Pitting _______________________________________________ URINARY Bladder: Distended Nondistended Clear Cloudy Pale Concentrated No Odor Amber Teat Bloody Sediment Continent Incontinent F/C: Size ___22___ Balloon____inflated___ AV Fistula: Thrill Bruit Location __________n/a____________________ GASTROINTESTINAL Abdomen: Soft Firm Hard Tender Mildly Distended Nondistended Bowel Sounds: RLQ RUQ LLQ LUQ Absent Continent Incontinent Characteristic of stool: Color _______N/A__________Consistency __”Normal”______ Appetite: Good Fair Poor NPO Emesis: N/A Frequency _______________ Characteristic_______________________ GT NGT Suction type __________________________________ ACTIVITY Bedrest Turn q2h Chair BRP Ab lib Restrictions: ___________________ Ambulate: Independent Assist Assistive Device _____________________ Self-care: Independent Assist: Min Mod Max Dependent Isolation: Type ___________________________________________________ MUSCULOSKELETAL Joint: WNL Swelling Redness Pain Limited ROM: Location ___________LLE_____________________________ Amputation Location: ___________________________________________ Cast: Type _______________ Location ____________________________ Nerve/Circulation distal of cast Pulse Cap refill _____sec Edema Warmth Sensation PAIN Intensity ___4/10_____ Location ______________LLE______________________ Duration ______Constant______________ Frequency ____________________ Radiation ___________N/A_______________ NANDA Diagnosis: Dx: ___Ineffective Coping_____ R/T: ___Inadequate confidence in ability to deal with a situation___ E/B: ___Substance abuse, Inability to meet role expectations, inability to ask for help____ STG: ___Patient will identify one appropriate coping strategy by 1200___ LTG: ___Patient will correctly implement one appropriate coping strategy by EOS___ Nursing Interventions: Nurse will determine patients degree of impairment in order to assess current functional capacity and wnote how it is affecting the individuals coping ability at 11/14/2019 @ 1200. Encourage identification and expression of feelings. Provides opportunity for client to learn about and accept self and feelings as normal. Encourage verbalization of fears and anxieties and expression of feelings of denial, depression, and anger. Let patients know these are normal reactions. Provide for gradual implementation and continuation of necessary behavior and lifestyle changes. STG: Patient identified journaling as an appropriate coping strategy by 1200. Goal met. LTG: Patient correctly implemented journaling by EOS. Goal met.