Nursing Care Plan: Preventing Accidents and Injuries

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.

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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).

 

 

Nursing Assessment

 

 

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.

 

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
°C)

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

 

 

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.

 

 

 

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

 

˜      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

 

 

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

 

 

˜      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: ______________________

 

 

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

 

 

Generic & Trade name

 

Drug Class

 

Action

Dose, Route, Frequency  

Adverse Effects

 

Nursing Considerations

(Why is this patient receiving this drug?)
 

Treprostinil (Remodulin)

Vasodilators Decreases exercise-associated symptoms in patients with pulmonary arterial hypertension. Drip 67.1 nanograms/kg/min SQ Continuous Infusion

 

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)
 

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)

 

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.

 

Nursing Interventions

(3 for each Nursing Diagnosis)

 

 

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)

 

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:

 

Patient Teaching: Identify the most important learning need Describe the content of teaching:

Verbal, Motor skills

List one desired outcome & whether patient achieved it.
 

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.

 

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