Nursing Care Plan: Preventing Accidents and Injuries
Nursing care plan: Preventing Accidents and Injuries
NURS 360 Nursing Care Plan Sample
Name: S .F Date: 11/05/19 NCP #: 2 Patient Initials: E.Z.
Age: 59 y.o. Gender: F Code Status: Full Code Fall Risk? Yes (high risk) Precautions? Type: None
Allergies & Type of Reaction: Poison Ivy, Lisinopril, Nitrofurantoin Height: 5’ 4” (64cm) Weight: 139. 1 lbs. (63.1 kg)
Patient’s Admitting Diagnosis : Idiopathic pulmonary arterial hypertension (PAH) (WHO Group 1), chronic hypersensitivity pneumonitis secondary to Macrobid
Medical /Surgical History: Gastrointestinal arteriovenous malformations (GI AVMs), distant atrial fibrillation, acute on chronic hypoxic respiratory failure, awaiting lung transplant (listed 1/19 at Columbia University Hospital), hypothyroidism, pre-hypertension
Social History: Significant patient data which may affect patient’s ability to participate in interventions & patient outcomes. To be incorporated
in the Nursing Diagnosis section (p. 8) – Patient is a mother of 2 adult children, lives with her husband in Harrison, NY and used to work as a teacher and has never smoked.
After listening to the change of shift report, what is the most important patient problem to be addressed today? – Maintain adequate O2 saturation levels of high 90s with a high flow nasal cannula, and wait for a lung transplant by continuing ordered medications and encouraging physical therapy.
Pathophysiology of admitting diagnosis with APA reference: How did your pt. come to be diagnosed & what events up to this admission? –
Idiopathic pulmonary arterial hypertension (PAH) (WHO Group 1) narrows and blocks pulmonary arterioles and capillaries making it hard for blood to flow through the lungs. As a result, the heart works harder to pump blood through the lungs, thus weakening heart muscles (Oudiz, 2018). The patient presented symptoms of PAH, feeling pre-syncopal with an SBP in the 70s. The patient’s chronic hypersensitivity pneumonitis is secondary to Macrobid after the patient was diagnosed with a urinary tract infection by her primary doctor and prescribed Macrobid. The patient experienced adverse effects to Macrobid resulting in inflammation of interstitial lung (Hsieh, 2018).
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Nursing Assessment
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Laboratory & Procedural Diagnostic (CBC, serum levels, Culture & Sensitivity, CT scan, EKGs)
Review, record and identify abnormal results. Explain the reason why they are abnormal for this patient. |
Identify specific equipment:
(i. e Foley, wound care, ostomy care, oxygen requirements, NGT, chest tube.) Please include drainage amount and color. If your patient has an IV in place note condition, site, & type of IV fluid.
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| Subjective Data:
Statements in the EHR & what the patient tell you, including chief complaint (cc). Pay particular attention to subjective symptoms of pain.
Weakness Tired Lightheaded Dizziness
Objective Data: Data based on what can be determined by the 5 senses & by measurement. Include focused head-to-toe physical & mental status assessment in the following pages. Indicate any change in vital signs. Time #1: BP: 88/55 HR (Apical): 81 Respirations: 17 Pulse ox: 96% on HFNC Temperature: 98.4°F (36.9°C)
Time #2: BP: 80s – 100s HR (Apical): 70s Respirations: 17 Pulse ox: 96% on HFNC Temperature: 97.7°F (36.5 |
Na:
K: BUN: Cr: Ca: Mg: WBC: Hgb: Plt:
Chest X-Ray on Oct 1st, 2019 |
Room Air
ü Supplemental Oxygen ü Type: High Flow Nasal Cannula FiO2 ü L/minute: 30L 68% Tracheostomy Condition of tracheal stoma IVF: Rate: PCA: Type pf Venus Access Device: Peripheral saline lock ü PICC on right upper extremity Subclavian ü Other: Remodulin pump (rate 0.05mL/hr)
Diet: Regular
Tube Feeds: formula and rate
N/G tube
Other feeding tube
Wound care
Frequency of wound care
Drains
SCD’s
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| Head-to-Toe Assessment | Head-to-Toe Assessment | Head-to-Toe Assessment |
| Neurological: | Respiratory: | Cardiovascular: |
| LOC:
ü Alert Drowsy Lethargic Stuporous Coma
Orientation: ü Person ü Place ü Time ü Situation Communication: ü WNL Dysarthria Non-verbal Aphasia Expressive Receptive Global Pain: Location Rating 0 to 10: 0 Acute Chronic Constant Intermittent Head:
R pupil PERRLA: 4mm L pupil PERRLA: 4mm
Reaction to light: ü Brisk Sluggish No reaction right No reaction left Cataract Prosthesis
Visual/Hearing: ü WNL Visual Deficit: ____________________________ Hearing Deficit: ___________________________
Head: Note any abnormalities in hair, nose, ears. Note mouth: midline tongue, lesions, moisture, dentition.
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Respiratory Effort:
Normal, relaxed, regular rate Labored Dyspnea at rest Dyspnea with minimal effort (talking, eating) ü Dyspnea with moderate effort (dressing, walking) Respiratory rhythm: ü WNL Tachypnea Bradypnea Breath sounds: BS clear bilateral, no cough, no SOB ü Anterior clear throughout ü Posterior clear throughout ü Lateral clear throughout Adventitious sounds: Decreased (atelectasis?) Absent (pneumothorax?) Crackles Fine (popping sounds like hair rubbing) Coarse (Moist) Rhonchi (gurgles, snoring) Wheezes: Inspiratory Expiratory Pleural Friction rub (occurs with respiratory motion, sounds like rubbing leather) ü Other: SOB during moderate exertion
Cough: ü None Productive Non-productive Sputum: ü None Consistency: thin, thick Color: clear, foamy
Chest tube: Location Negative pressure set at: Drainage amount Drainage color Air leak Dressing change
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WNL No chest pain, HRR, + Peripheral Pulses, no edema, no syncope
Chest Pain ü Dizziness Syncope
Neck: carotid pulse________ JVD? : none Trachea midline
Chest: ü Apical pulse regular Pericardial friction rub (sounds like leather rubbing, fluctuates with heart rate) If on telemetry: rhythm
Overall Skin Color: ü WNL Pale Jaundice Dusky Cyanotic
Upper Extremities: ü Radial pulses: equal, 2-3 + Other: Capillary refill < 3 seconds Other: Grip equal & strong Skin temperature WNL Braden score Other
Lower Extremities: ü Hair present. Dorsalis pedis pulses: equal, 2-3+ Other: Posterior tibialis pulses: equal 2-3+ Other: Edema Location Non-pitting Pitting x # seconds) ü Foot strength equal & strong Positive Homan’s sign
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| Gastrointestinal: | Genitourinary: | Musculoskeletal: |
| Abdomen:
Inspection: ü WNL: soft, non-tender Distended Firm Ascites Abdominal incision ü Last BM: 10/21 ü Characteristics: Loose Continence: ü Yes No Nausea/Vomiting Y N Amount: ________________ Color: ___________________
Auscultation: (active, WNL), hypoactive, hyperactive, absent (for full 5 minutes) RUQ LUQ RLL LLQ
Nutritional Status: ü Adequate by mouth Inadequate: address in care plan Feeding Tube: Type of tube Insertion site
Condition of insertion site Checked placement Type of feeding Rate of infusion Amount of Residuals HOB elevated Stoma present Colostomy Ileostomy Condition of stoma: pink, viable OR Redness Dusky Retracted below skin S & Sx of Infection
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Urination
ü WNL: voiding, clear, yellow urine ü On commode Other: Burning Frequency Pain Retention Bladder scan amount Distention Incontinence Amount: ______________________
Urine Quality: ü Yellow Cloudy Concentrated Bright Red Blood Clots Other: ______________________
Foley Present: Y N Insertion Date: _______________________ Urine Quality: ü Yellow Cloudy Concentrated Bright Red Blood Clots Other: ______________________
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ROM Active:
ü Upper Right ü Upper Left ü Lower Right ü Lower Left
ROM Passive Only: Upper Right Upper Left Lower Right Lower Left
Extremity Strength: strong, moderate, weak, or absent Upper Right: strong Upper Left: strong Lower Right: moderate Lower Left: moderate
Gait: Steady without assistance ü Steady with assistance Unsteady with assistance Assistive devices:
Amputation: ______________ Prosthetics:________________ |
| Nursing Care Plan: Preventing Accidents and Injuries |
List all STANDING and PRN medications and rationale for why this patient is receiving these meds.
| MEDICATION | RATIONALE
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Generic & Trade name |
Drug Class |
Action |
Dose, Route, Frequency |
Adverse Effects |
Nursing Considerations |
(Why is this patient receiving this drug?) |
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Treprostinil (Remodulin) |
Vasodilators | Decreases exercise-associated symptoms in patients with pulmonary arterial hypertension. | Drip 67.1 nanograms/kg/min SQ Continuous Infusion
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Headache, vasodilation, diarrhea. Nausea. Rash. Infusion site pain/reaction, jaw pain | Monitor patient for signs of improvement in pulmonary arterial hypertension (decrease in dyspnea, increased exercise tolerance) periodically during therapy | Tx PAH (WHO Group 1) |
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Ambrisentan Oral (Letairis) |
Antihypertensives | Antagonizes endogenous endothelin, resulting in vasodilation. | 10mg oral daily 9am | Headache, peripheral edema. Decreased hemoglobin | Assess for signs and symptoms of primary pulmonary hypertension Monitor for symptoms of acute pulmonary edema (dyspnea, cough with
frothy sputum, anxiety, restlessness, palpitations) during initiation of therapy. Consider the possibility of pulmonary veno-occlusive disease; if confirmed discontinue ambrisentan. |
Tx PAH (WHO Group 1) |
| Digoxin (Lanoxin) | antiarrhythmics | Increases the force of myocardial contraction. Prolongs refractory period of the AV node. Decreases conduction through the SA and AV nodes. | 250 microgram oral qweek Sunday
250 microgram oral tiwk Tu/Th/Sat
125 microgram oral twik M/W/F |
Fatigue, bradycardia, anorexia, nausea, vomiting | Monitor ECG throughout IV administration and 6 hr after each dose. Notify health care professional if bradycardia or new arrhythmias occur. | Tx for Atrial fibrillation and atrial flutte |
| Furosemide (Lasix) | diuretics | Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal
renal tubule. Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium. |
80mg oral daily 9am
40mg oral q24h |
blurred vision, dizziness, headache, vertigo, hearing loss, tinnitus, dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis | Monitor BP and pulse before and during administration. Monitor frequency of
prescription refills to determine compliance in patients treated for hypertension. Assess patient for skin rash frequently during therapy. Discontinue furosemide at first sign of rash; may be life-threatening. Stevens-Johnson syndrome, toxic epidermal necrolysis, or erythema multiforme may develop. Treat symptomatically; may recur once treatment is stopped. |
Tx for hypertension |
| Midodrine | Vasopressors | Increase in vascular tone and BP. | 10mg oral q8hr | Supine hypertension, : urinary urge/retention/frequency, dysuria, piloerection, pruritus, paresthesia | Monitor supine and sitting BP prior to and during therapy. Assess pattern of urinary output prior to and during treatment for incontinence. Monitor renal and hepatic function with lab test. | Tx for symptomatic management of refractory orthostatic hypotension in patients |
| Alprazolam | (Xanax)
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Acts at many levels in the CNS to produce anxiolytic effect. May produce CNS depression. | 0.25mg oral PRN q12hr | Dizziness, drowsiness, lethargy | Assess degree and manifestations of anxiety and mental status (orientation, mood, behavior) prior to and periodically during therapy ( | Tx for generalized anxiety disorder |
Reference: Wolters Kluwer. (2019). Drug Handbook. Philadelphia: Wolters Kluwer.
Nursing Care Plan: Preventing Accidents and Injuries
| Priority Nursing Diagnoses (2)
Personal/Social History data should be incorporated in the nursing process. So if the goal is to teach a patient how to check capillary glucose, but the patient has substance abuse, the nurse will need to consider this in the plan of care.
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Nursing Interventions
(3 for each Nursing Diagnosis)
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Rationale: Why this intervention?
(3 for each Nursing Diagnosis), Each intervention must include a reference source in APA format |
Goals/Outcomes for the day
(1 for each Dx) Individualized to Patient Evaluation (whether outcome met) |
| Risk for activity intolerance related to compromised oxygen transport as evidence by exertional dyspnea
Risk for ineffective airway clearance secondary to hypersensitive pneumonitis as evidence by dyspnea |
1. Assess the physical activity level and mobility of the patient by monitoring the resting pulse, blood pressure, respirations, and O2 saturation levels during the patient’s physical therapy session. (Carpenito, 2017).
2. Assess the need for ambulation aids such as a walker for ADLs. (Carpenito, 2017)
3. Gradually increase activity with exercises in bed, sitting, and standing. (Carpenito, 2017)
1. Elevate head of bed and change the patients position frequently. (Carpenito, 2017)
2. Teach proper deep breathing exercises by demonstrating effective coughing in an upright position. (Carpenito, 2017)
3. Promote adequate hydration by setting a goal of 2500mL/day and monitor all fluid patients’ intakes and outputs. (Carpenito, 2017)
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1. Activity should be discontinued if the patient feels dizzy and/or O2 saturation levels decrease.
Assessing physical activity can determine if treatment is helping with exertional dyspnea 2. Assistive device may enhance the mobility of the patient by allowing the patient to reach levels of activity tolerance. 3. Gradual progression of activity prevents overexertion
1. Promotes chest expansion and expelling secretions.
2. Coughing helps to maintain clear patient airways and deep breathing exercises promote lung expansion and cough productivity.
3. Fluids aid in expelling secretions by thinning the secretions so they are easier to cough up. |
1. Patient will exhibit tolerance to exerting activity by displaying O2 saturation levels above 93%, and normal vital signs.
2. Patient will identify behaviors to achieve clear airways such demonstrating effective coughing. |
| Discharge Plan:
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Patient Teaching: Identify the most important learning need | Describe the content of teaching:
Verbal, Motor skills |
List one desired outcome & whether patient achieved it. |
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Upon receiving a lung transplant, encourage the patient to take part in rehabilitation programs to promote activity tolerance. The patient will also continue taking prescribed immunosuppressants to prevent the transplant lungs from rejecting and reduce infection. |
Symptoms of taking immunosuppressants are mood changes, insomnia, convulsions, and dizziness. Signs of infection include fever, inflammation, headaches, and purulent excretions and redness at site of incision. | Review with patient a diagram showing signs & symptoms of transplant rejection and infection. | Patient will state the signs & symptoms of infection and transplant rejection. The patient teaches back her understanding of her prescribed medications and good hygiene to prevent infection and maintain adequate health. |
Bibliography (Sources) in APA Format:
Carpenito, L.J. (2017). Nursing diagnosis: application to clinical practice.(15th ed.) Philadelphia: Wolter Kluwer
Hsieh, C. (2018, July 24). Hypersensitivity Pneumonitis. https://emedicine.medscape.com/article/299174-overview#a4
Oudiz, R. J. (2018, Jun 21). Idiopathic Pulmonary Arterial Hypertension. https://emedicine.medscape.com/article/301450-overview
Wolters Kluwer. (2019). Drug Handbook. Philadelphia: Wolters Kluwer.
Nursing Care Plan: Preventing Accidents and Injuries Assignment
Develop a teaching plan for prevention of accidents and injuries in either children or the elderly. Include the main elements of your presentation to a group of parents or elderly or their caregivers. This is a PowerPoint presentation of between 8-10 slides.
Preventing Accidents and Injuries –
For this Application Assignment, develop a teaching plan for prevention of accidents and injuries in either children or the elderly. Include the main elements of your presentation to a group of parents or elderly or their caregivers. This is a PowerPoint presentation of between 8–10 slides. Use a minimum of three references from the professional nursing literature in the assigned course readings and other references in the Walden Library. If they are relevant, you may use one or two professional Web sites in addition to the literature references.
- Overview – 20 pointsAfter your title slide, include a brief overview of the purpose of your presentation. This should be at least 1 slide.
- Statistics of the selected accident or injury – 30 points Describe the significance of your selected accident or injury. Include data about its rate of occurrence and references. This should be at least 1 slide.
- Prevention strategies / Teaching plan – 80 pointsOutline your teaching plan. This should include the main elements of your presentation to a group of parents or elderly or their caregivers and be based on best practices. This should be approximately 4–5 slides.
- Summary – 20 pointsEnd the presentation with a one-paragraph summary of the main points of the teaching plan/presentation.
Format/Style
Proofread the paper as described in the tips for success in this course and correct any typos, grammar, spelling, punctuation, syntax, or APA format errors before submitting your paper in the Dropbox. Up to 40 points can be deducted from the grade for this assignment for these types of errors, or for not using at least the minimum number of required
Total points for assignment = 150 points.
