1 page/≈275 words
Health, Medicine, Nursing
Nursing Care Plan for a patient with PVD (Essay Sample)
INSTRUCTIONS. As the receiving RN, you receive the nursing report organized in the SBAR (Situation, Background, Assessment, Recommendation) format for Mr. Damon Patel, a 62-year-old who transferred from the intensive care unit to the post-surgical unit following an abdominal aortic repair performed two days ago. Review the recommendation section of Mr. Damon's SBAR report and then using the Nursing Process Overview and information from your textbooks, develop a Nursing Care Plan for the above patient. Your Nursing Care Plan (NCP) must include: One (1) priority nursing diagnostic statement (must be an actual nursing diagnosis) based on the information presented in the Recommendation section of the SBAR report. One (1) measurable patient outcome. Four (4) nursing interventions that will help the patient achieve the desired outcome. Identify criteria that will be used to establish the patient outcome has been met. Complete your nursing care plan using the Nursing Care Plan Form (you must save the file to your computer before completing the form). When you're ready to submit your work, click Browse My Computer and find your file. Once you've located your file click Open and, if successful, the file name will appear under the Attached files heading. Scroll to the bottom of the page, click Submit and you're done. Be sure to check your work and correct any spelling or grammatical errors before you post it. This activity will be assessed according to the AD Nursing: Nursing Process Rubric. THE SBAR report OF THE PT. Standardized Hand-Off: Situation Background Assessment Recommendation (SBAR) Patient Name: Damon Patel MRN: 9876 Room: 520 Date of Birth: 112/06/1950 (62 years) Gender: Male Height: 70 in. (178 cm) Weight:160Lbs(72.6kg)BMI:22.9 Physician: Dr. Mehta Allergies: None known Date of SBAR: today Time of SBAR:On transfer to nursing unit Situation Background Diagnosis: Abdominal aortic aneurysm High alert Meds:None Admitting Date: yesterday POD# 2 Surgical Procedure: Abdominal Aortic repair Reason for admission: 7 cm aortic aneurysm on CT scan New Meds: Atenolol; Enalapril; Atorvastatin Pertinent history:Hypertension; benign prostatic hyperplasia; smokes cigarettes (30 year pack history) Family/support/lifestyle issues: Lives with wife. Wife at bedside. Code Status: Full resuscitation Cultural Needs: Hindu; very modest. Diet: Cardiac prudent; vegetarian Skin Assessment: Every 8 hours Activity Level: Ambulate in hall 4 times daily; no sitting for more than 2 hours. Sequential compression devices on when in bed. Fall Risk:No. Able to rise from chair in a single movement Precautions:None Baseline Data Frequency: Intake/output: Every 8 hours Vital signs: Every 4 hours with peripheral vascular assessment to lower extremities Oximetry: Every 4 hours Other: Incentive spirometry every hour while awake Assessment Recommendation Neurological/mental status: Awake/alert/orientated Priorities/goals for next shift: Pain control Incentive spirometry every hour Ambulate twice in hall Wound/dressing : Abdominal dressing dry/intact Cardiovascular: BP 110/80; Pulse 76 regular; Pedal pulses strong/equal, toes warm, capillary refill less than 3 seconds; equal movement and sensation in feet present. Patient educational needs: Reinforce need for incentive spirometry New medications Reducing risk factors for peripheral artery disease. Respiratory: Respiratory rate 24; breath sounds crackles in bilateral bases; small amount white sputum; pulse oximetry 94% on room air. Genitourinary: clear yellow urine; Needs to stand to void. Pending orders:None Gastrointestinal: Appetite: ate ½ lunch tray. IV/Central line & fluids: Intermittent venous access device inserted in left forearm yesterday Pending tests: Blood work and chest x-ray tomorrow morning Tubes/catheters/drains (date inserted):None Pending consults:None Abnormal VS: vital signs stable for 24 hours. Discharge Needs: Estimated discharge date in 3 days Educational Needs Pain (value; tx and response): 2 to 8 on 0-10 verbal scale sharp pain located at abdominal incision area. Relieved by hydrocodone 5 mg every 4 to 6 hours. Last pain medication 1 hour ago. Blood sugar: Has been within normal range Comments: The care plan needs to be updated. Abnormal lab and tests: None. Nursing Care Plan Form- Priority nursing diagnostic statement (must be an actual nursing diagnosis): Measurable patient outcome: Nursing interventions: 1. 2. 3. 4. Criteria that will be used to establish the patient outcome has been met: ADDITIONAL INSTRUCTIONS: Overview of the Nursing Process: Steps, Description and Nursing Activities. Assessment: This step focuses on the gathering of patient information. The RN collects and validates the patient data. Communication of this data to the relevant care providers is also the RN's responsibility. The patient's medical history must be recorded accurately. Physically assessing the patient, reviewing the patient's medical records, and going through the nursing literature are all activities that the RN carries out during this portion of the process. The RN may also consult with the patient's family and friends (with the patient's permission) or with other health care professionals. All the data that has been collected is validated and continuously updated. Analysis: This step focuses on development of a prioritized list of nursing diagnoses and nursing diagnosis statements. The RN analyzes the patient data in order to identify any health problems. After interpreting all the available data the RN creates a prioritized list of nursing diagnoses. The nursing diagnoses are classified as actual (the patient has defining characteristics which support the nursing diagnosis) or risk* (the patient does not have defining characteristics but is vulnerable to develop the nursing diagnosis). The nursing diagnosis statement includes the following: - Nursing diagnosis(problem) - Etiology - Defining characteristics* *For risk nursing diagnoses, there are no defining characteristics. Planning: This step focuses on development of expected measurable patient outcomes and related nursing interventions. Once the nursing diagnosis statement has been formulated, the RN must develop: - A measurable patient outcome that prevents, reduces, or resolves the identified patient health problem (nursing diagnosis). - Nursing interventions which the RN performs to aid the patient in achieving the outcome specific to the nursing diagnosis statement. Implementation: This step focuses on carrying out the plan of care. The nursing care plan is implemented. The RN continuously collects and documents relevant data about the patient's health and modifies the plan of care as required. Evaluation: This step focuses on evaluating the effectiveness of the nursing interventions, the outcomes achieved by the patient, and revising the plan of care, if necessary. The RN assesses the patient's response to the care received. Factors that influence the achievement of the outcomes listed in the implementation stage are identified and the plan of care is revised as required. source..
Nursing Care Plan for a Patient with PVD Name: Institution: Nursing Diagnostic Statement (Actual) Having undergone the abdominal aortic repair surgery two days ago, the patient’s blood pressure needs to be updated frequently. This is especially crucial given the fact that the patient has had a history of hypertension diagnosis before, in their medical history. Given the high blood pressure history the patient needs to be assessed regularly for any of the signs that would indicate the same. The Abdominal Aortic Aneurysm is most of time related to hypertension, both of which the patient has had previous medical cases. Measurable patient outcome With the current condition of the patient, it is crucial that his heart condition is also checked to assert that they have not developed any form of coronary disease. Given that the patient has had a pack history of taking cigarettes for more than 30 years, as well as the hypertension cases, they may fall victim to the condition. As such the patient should be medically assessed for coronary diseases using the echocardiograph, where they are assessed through the various stress levels. All the medical conditions that the patient has had in the past, such as hypertension and Abdominal Aortic Aneurysm plus the fact that they have been smoking cigarettes can lead to the heart condition. Nursing interventions that will help the patient achieve thedesired outcome To help the patient achieve the level of health status that is safe from the coronary diseases, there are a couple of interventions, that carefully carried out by the nurse wi...
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