NUR2115 Comprehensive Plan of Care Please see attached copy of the work. In this third and final submission lanofp your Course Project, you will  be comple

NUR2115 Comprehensive Plan of Care Please see attached copy of the work.
In this third and final submission lanofp your Course Project, you will  be completing a comprehensive care plan. This written assignment should  include the following:
Comprehensive Plan of Care
  Develop a comprehensive plan of care/treatment with short and long  term goals and include safety needs, special considerations regarding  personal needs, cultural/spiritual implications, and needed health  restoration, maintenance, and promotion.
Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates. Running Head: HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
Health History, Assessment, and Nursing Diagnosis
Student’s Name
Institutional Affiliation
1
HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
2
Clinical Site/ Unit: TCU
Patient Initials: S.D
Gender: Female
Age: 71
Weight: 287lbs
Height: 64.0
Baseline vitals (from the patient chart)
Date: 02/07/19; B/P: 127/52; Pulse: 85 bpm; RR: 16 bpm; T/mode: 98
(Tympanic)
Pulse ox: 98.0%
Vital Signs Assessment (Taken by me)
B/P: 143/58; HR: 72 bpm; RR: 19 bpm; T: 97 ; SpO2: 94%
Allergies: Amlodipine, Meperidine, Nitroglycerin, Polyethylene Glycol, Simvastatin, NSAIDs,
Penicillin, Sulfa Antibodies
Code Status: Full code
Social Health: Husband of 44 years; Daughter (EMT); Son (EMT Firefighter)
Marital Status: Married
Cultural Background: Caucasian
Primary Language: English
Past Medical/ Surgery History: Had depression in the past and is treated for it.
HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
Family Health History: Mental health problem, had depression in the past
Diet: Consistent carbohydrate diet, Regular Texture texture, Thin Liquid consistency
Special Instructions: Preferences for taking medications – water with ice, ice tea
Activity/Assistive Devices: No assistive devices required
Treatment Orders: Not required
Tubes/ Drains/ Ostomies: No Tubes/ Drains/ Ostomies required
Interdisciplinary Cares (OT/ PT/ ST) and frequency: No interdisciplinary cares noted
Dressings/ Wounds: (type & location): No Dressing/ Wounds noted
3
HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
4
ASSESSMENT SUMMARY
Body System
Pain Level (pain scale 0-10/
location):
Subjective: Patient’s Health
History
Patient reports pain of 6.5 out
of 10 (leaning forward) and 3
out of 10 (still sitting)
Objective: My assessment
findings
Pain rating: 0-10:
Characteristic: Temporal
Onset: When leaning forward
Location: Right shoulder
Description (dull, aching,
sharp): Sharp pain
Exacerbating factors
factor(s): Comes and go.
Orientation:
Head/Eyes/ Ears/ Nose/
Throat (HEENT):
Relieving factor(s): Pain
medications (oxyCODONE)
Patient reports no trauma to
Orientation (person, place,
the head. Does not experience time and situation): Patient
any headache.
alert and oriented X 4. Had
four (4) brain surgery to stop
Patient reports no problem
trimmers.
with vision, no eye pain, no
glasses or contact lenses, no
Speech (clear/appropriate):
history of an ocular problem, Speech is clear
no blurring, no blind spot.
PERL (pupils equal and
Patient reports no ear pain, no reactive to light): Pupils are
history of ear infections, no
equal and reactive to light.
ear discharge, and no hearing Had a cataract surgery.
loss.
Ears (clean/dry): No lesions,
Patient reports nose is always no drainage, CN8 intact, no
clogged. Patient reports no
hearing aids
experience of headaches and
trauma to the head.
Nose (clean/dry/intact):
Symmetrical no deformities,
no lesions, mucosa and
turbinate are pink, moist, no
exudates, no septal deviation,
no perforations.
Throat (pink, moist): Thrush
on her tongue from a fungal
HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
Musculoskeletal:
Patient reports arthritis in
fingers but does not have
rheumatoid arthritis
5
infection, has sore on the
mouth (lip), oral mucosa is
pink and moist, and the
patient has good dentition.
Good symmetrical
movement. The pharynx is
normal in appearance without
tonsillar or exudates. No
adenopathy is noted. CNS IXII (All intact).
MAE (moves lower
extremities very well, and left
upper extremity
Weakness: Right shoulder
Assist (transfers/ambulation):
Stand by assist with all
transfers and ambulation.
Respiratory:
Patient reports no cough, no
shortness of breath, no chest
pain, no smoking history, no
history of respiratory
infections, and no
environmental exposure.
Assistive device (walker,
cane): no use of any assistive
devices (walker or cane).
Respirations: 19 bpm
Rate: Regular
Lung sounds: quick deep on
inspiration and quick shallow
on expiration
Cough: No cough noted
Cardiac:
Patient reports no chest
tightness, no recent fatigue.
SOB: no shortness of breath
AP (apical pulse): 72 bpm
Rate (regular): Is regular.
Chest pain: No chest pain
Peripheral pulses: Brachial,
Carotid, Radial, Dorsal Pedis
Edema: Lower extremities –
4+ pitting edema
HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
Integument:
6
Capillary refill: Less than 3
seconds
Patient reports no leg pain, no Skin ( moist, intact): Skin is
leg cramps
moist and intact, not
dehydrated, warm to touch
Color (pink, pale, cyanotic):
Skin is pink
Wound(s): 2-3 inches red
bruise on left foot from
blister.
Gastrointestinal (GI):
Patient reports no bowel
problems. Patient reports
having a bowel a day before.
Dressing(s): No dressings on
any part of body.
Bowel sounds (x4): Bowel
sounds regular and present in
all 4 quadrant.
Nausea/vomiting: no nausea
or vomiting
Pain/tenderness with
palpation: No pain on
palpation
Last BM: 2 bowel
movements a day ago
(02/06/19)
Genitourinary (GU);
Patient reports no problem
with voiding. Patient reports
voiding 8-10 times a day
Continent: Continent of
bowels
Frequency of urination (q2h,
q4h, foley): 8-10 times a day.
Approximately q2h.
Color: Pale yellow
Dysuria (frequency, burning):
No pain or burning sensation
Endocrine;
Patient reports no abnormal
growth, no endocrine disease
or disorders, no abnormal
temperature
Continent: Continent
Diabetic/ Blood sugar: 193.0
HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
7
Diet: Consistent carbohydrate
diet, Regular Texture texture,
Thin Liquid consistency
Psychosocial/ Spiritual:
Patient reports associating
with Native American
Spirituality and is Buddhist.
Patient reports having a
strong family support.
Appetite (%): 75%
Good spirits/ Pleasant: Very
active and good spirit
Sad/ Tearful/ Anxious: She is
not sad, tearful or anxious
What is resident main
concern during their stay? To
walk 3-4 times a day to get
lower extremities working.
Main concern after they
discharge? To be able to go
back to work and go about
normal business.
HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
8
Medication Data Sheet
Drug Name
Trade and
generic name,
dose, route&
frequency
Drug
Classification
Expected
action and
indication for
use
It is used to
treat mild to
moderate
pain.
Medical
Diagnosis
Side Effects
and Adverse
Reactions
For pain
experiencing
in Right
shoulder.
Side effects:
Assess the
Nausea,
history of pain.
stomach pain,
loss of appetite,
itching, rash,
headache, dark
urine.
Adverse
reaction:
Difficulty
breathing or
swallowing,
swelling of the
face, lips,
throat or
tongue. Hives,
severe itching
Treatment or
prevention of
vitamin D
deficiency.
For Closed
Fracture off
the head of
the right
humerus
Gabapentin
Neuropathic
(Neurontin)
pain, diabetic
Capsule 300 mg.
For
neuropathic
pain
Side Effects:
Kidney stones,
confusion,
disorientation,
muscle
weakness,
frequent
urination,
nausea,
vomiting,
constipation.
Adverse
Effects:
Extremely
large doses can
cause toxicity.
Side effects:
sleepiness,
dizziness,
Acetaminophen
(Tylenol) Tablet
500 mg. Give 2
tablets by mouth
orally 3 times a
day. No more
than 4000 mg in
24 hours, also a
PRN dose of
1000 mg.
Vitamin D3
(Cholecalciferol)
tablet 5000
units. Give one
pill by mouth
two times a day.
Nursing
Administration
special
instructions and
assessments
Client
Education
Evaluation of
medication
effectiveness,
e.g., Pin Scale
Demonstration
of relieving of
pain on the
pain scale 010
I am assessing
patient carefully
for evidence of
hypocalcemia,
assessing for
symptoms of
vitamin
deficiency
before and
periodically.
Normalization
of serum
calcium and
parathyroid
hormone
levels.
Resolution of
prevention of
vitamin D
deficiency.
Assess the
location,
characteristics,
Decreased
intensity of
HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
Give 300 mg by
mouth two times
daily.
peripheral
neuropathy.
Wellbutrin
(buPROPion
HCL, ER) SR
Tablet Extended
Release. Every
12 hours 200
mg.
Give 1 tablet by
mouth two times
a day.
Treatment of
depression.
The patient
is taking for
depression
and has a
history of
depression.
Protonix
(Pantoprazole
Sodium) Tablets
Delayed-Release
40 mg.
Give 1 mg tablet
by mouth two
times a day.
Erosive
esophagitis
associated
with GERD.
Maintenance
of healing of
erosive
esophagitis.
The patient
is taking this
medication
for GERD.
9
fatigue,
clumsiness
while walking,
weight gain,
tremor
Adverse
effects: Skin
rash, unusual
bruising,
swollen glands,
muscle aches.
Side Effects:
dry mouth, sore
throat, nausea,
vomiting,
flushing,
headache,
abdominal
pain.
Adverse
Effects: mood
or behavior
changes,
anxiety,
depression,
panic attack.
and intensity of
pain
periodically
during therapy.
neuropathic
pain.
Assess mental
status and mood
changes, inform
health care
provider if the
patient
demonstrates a
significant
increase in
signs of
depression.
Increased
sense of wellbeing,
renewed
interest of
surroundings.
Side Effects:
headache,
nausea,
vomiting,
diarrhea,
stomach or
abdominal
pain, gas,
dizziness.
Adverse
Effects: Facial
edema,
hyperglycemia,
photosensitivity
I am assessing
patient
routinely for
epigastric or
abdominal pain.
Decreased in
abdominal
pain,
heartburn,
gastric
irritation and
bleeding in
patients with
GERD.
HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
Nursing Diagnosis
#1
Acute pain
Expected Outcomes
(S.M.A.R.T) Specific,
measurable, attainable,
realistic, & time oriented
(ID a future time or date
for reassessment/
evaluation
The patient will verbalize
relief of pain.
Short-term goal: Patient
verbalizes minimized or
Movement of bone fragments, controlled feeling of pain.
edema, and injury to the soft
tissue
Long-term goal: Patient is
free of pain on surgical site.
R.T.
10
Nursing Interventions
Maintain immobilization of
affected part by means of bed
rest, cast, splint, traction.
A.M.B.
Reports of pain
#2
Impaired Physical Mobility
R.T.
Neuromuscular skeletal
impairment; pain/discomfort;
restrictive therapies (limb
immobilization)
The patient maintain position
of function.
Short-term goal: After 4
days of nursing intervention,
the patient will be able to
demonstrate techniques and
behaviors that enables
resumptions of activities.
Instruct patient or assist with
active and passive ROM
exercises of affected and
unaffected extremities.
A.M.B.
Reluctance to attempt
movement; limited ROM
#3
Skin/Tissue Integrity,
impaired: actual/risk for
R.T.
Physical immobilization
A.M.B.
Reports of itching, pain,
numbness, pressure in
affected/surrounding area
Long-term goal: After 4
days of nursing intervention,
the patient will be able to
maintain or increase strength
and functions of affected
body part.
The patient verbalize relief of
discomfort.
Short-term goal: After 6-8
hours of nursing intervention
the patient will have reduced
risk of further impairment
of skin integrity.
Assess position of splint ring
of traction device.
HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
11
Long-term goal: After 3-4
days of nursing intervention
the patient will be able to
reduce risk of infections.
Which of your diagnoses are Priority using Maslow’s Hierarchy of Needs: Impaired Physical
Mobility according to Maslow’s Hierarchy of Needs, physiologic needs should satisfy first, so
that the patient should satisfy this to satisfy her physiologic needs.
Evaluation: Were any of your short term expected outcomes met during your shift? None of the
short-term expectations were met during my shift.
How might you revise your care plan next time to achieve at least one outcome during your
shift? I plan on improving my care plan next time by monitoring my patients’ recovery process
keenly and offering effective ways to have my patient be able to decrease edema and promotes
venous return.
Medical Diagnosis
1. The patient diagnosed with an Unspecified Displaced Fracture of Surgical Neck of Right
Humerus the pieces of bone at the fracture site are separated and shifted out of position.
This type of fracture typically requires surgery. Proximal humerus fractures are
diagnosed by a thorough physical examination and diagnostic imaging (Stanley, n.d.).
HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
12
2. Humerus fractures are caused by direct harm to the arm shoulder. About 20% of humerus
fractures are displaced and mostly occur in baseball games. Such type of fracture requires
a more intrusive treatment like surgery
3. A subsequent encounter is experienced when an active treatment of the patient’s injury
has been offered, and the patient is now receiving routine care for the injury in the
healing process (Deter, 2006). An example is medical ex-rays to monitor the healing
process of the fracture
4. Asthma is an inflammatory disease of the airway demonstrated by various recurring
symptoms and bronchospasm. Common symptoms of asthma include; coughing,
wheezing, short breaths, and chest tightness.
5. A major depressive disorder is a mental disorder demonstrated by two weeks or more of
low mood. It is accompanied by loss of interest in several things, low self-esteem, pain
with no clear cause and low energy. Patients with depression often hear or see things that
are unseen by other people. They affect patients negatively as some end up committing
suicide (Deter, 2006).
LAB RESULTS
DATE
LAB TEST
NORMAL
VALUE
CLIENT
VALUE
01/27/19
Sodium
135-145 mmol/L 134 (L)
01/27/19
BUN/Creatinine
Ratio
10-20 mg/DI
27 (H)
SIGNIFICANCE
OF
ABNORMAL
LAB VALUE
The significance
of abnormal
sodium lab value
is hyponatremia.
This mean the
patient may not
be getting
enough blood
flow to their
HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
01/27/19
Hemoglobin
12.0-16.0 g/DI
7.8 (L)
01/27/19
ALK Phosphate
50-136 IU/L
144 (H)
01/27/19
RBC
4.00-5.20 mil/cu
mm
2.95 (L)
13
kidneys, and
could have
conditions such
as congestive
heart failure,
dehydration, or
gastrointestinal
bleeding.
This mean that
there is a
nutritional
deficiencies such
as iron, folate or
B12 deficiency.
Elevated ALK
Phosphate is
most commonly
caused by liver
disease or bone
disorders.
This could
signify trauma in
the patient.
Diagnostic Tests
Tests
Results
Significance
US Venous Upper Extremity
Right Indication: Right
Humerus Fracture
The right arm veins are
negative of DVT
EKG 12- Lead
Interpretation: Artifact, Sinus
rhythm, right Atrial
enlargement, Abnormal ECQ
It enables the nurse to know
where exactly the fracture
happened and the intensity of
the fracture to administer
proper medication.
It directs the nurse on the
exact medication to use.
HEALTH HISTORY, ASSESSMENT AND NURSING DIAGNOSIS
14
References
Deter, L. L. (2006). Basic medication administration skills. Australia: Thomson Delmar
Learning.
Stanley, L. (n.d.). Moving Forward: Physical Therapy Brings Motion to Life.
https://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=937e6560
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