PVD Nursing Care Plan

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.