Nursing care plan for below case studies

Question 2. Marie Perez, a 53-year-old patient, is day 1 after a gastric bypass. She complains of shortness of breath; her respiratory rate is 30 breaths/min, heart rate is 110 bpm, pulse oximetry 89% on room air, temperature is 100°F, and her blood pressure is 90/50 mm Hg. She complains of feeling anxious and having stabbing chest pain which gets worse with inspiration. She complains that she feels like she is going to pass out or possibly die.

Chapter 34, Management of Patients With Hematologic Neoplasms

2. Susan Clare, age 38, is admitted to the medical oncology unit with acute myeloid leukemia (AML). She has many areas of ecchymosis and petechiae on her skin, as well as generalized pallor. She states she has lost 15 pounds in the last 2 months, and often has a low-grade fever. On physical assessment, you find her liver and spleen to be enlarged on palpation. (Learning Objective 3)

NURSING CARE PLAN RUBRIC

Include the case study in your document.

Do not write the NCP using a grid format… use an essay format/ bullet point using the numbers of this rubric.

All NCP will be graded according to the following rubric.

Format: New Times Roman, 12 point font double spaced. Include the case study.

NCP are to be written using the included Rubric. Do NOT use a grid format… use an “essay” style format or bullet point using the included Grading Rubric.

1) Definition of the medical diagnosis__________10

etiology/pathophysiology

2) Common signs and symptoms___________5

3) Potential complications___________5

4) Head to toe physical assessment you are to write one….use the data in the case if there is none you create it as if this was your patient. ____________10

5) Diagnostic and lab studies___________5

normal values

expected abnormalities

6) ALL NANDA Nursing diagnoses__________10

www.deanza.edu/faculty/hrycykcatherine/NANDA_2015-…

7) Develop 3 NANDA priority nursing diagnoses__________10

8) State a patient plan/goal for each of the __________10

priority nursing diagnosis

9) Write interventions for each of __________10

priority nursing diagnosis

10) Write scientific rationales for you you ___________5

interventions

11) Write evaluation of your interventions__________10

or make changes

12) List of typical medications__________10

category

usual dosage

side effects

patient teaching

HEAD TO TOE ASSESSMENT as part of your NCP

Watch www.youtube.com/watch?v=gG8kh8MfnGY

HOW TO WRITE: YOU ARE TO CREATE A PICTURE OF YOUR PATIENT

These are topics for you to consider documenting as applies to your client.

General appearance:

• Affect/behaviour/anxiety
• Level of hygiene
• Body position
• Patient mobility
• Speech pattern and articulation

This is not a specific step. Evaluating the skin, hair, and nails is an ongoing element of a full body assessment as you work through steps 3-9.

2. Skin, hair, and nails:

• Inspect for lesions, bruising, and rashes.
• Palpate skin for temperature, moisture, and texture.
• Inspect for pressure areas.
• Inspect skin for edema.
• Inspect scalp for lesions and hair and scalp for presence of lice and/or nits.
• Inspect nails for consistency, colour, and capillary refill.

Head and neck:

• Inspect eyes for drainage.
• Inspect eyes for pupillary reaction to light.
• Inspect mouth, tongue, and teeth for moisture, colour, dentures.
• Inspect for facial symmetry.

4. Chest:

• Inspect:
  • Expansion/retraction of chest wall/work of breathing and/or accessory muscle use
  • Jugular distension
• Auscultate:
  • For breath sounds anteriorly and posteriorly
  • Apices and bases for any adventitious sounds
  • Apical heart rate/rhythm
• Palpate:
  • For symmetrical lung expansion
• Breasts

Abdomen/GI:

• Inspect:
  • Abdomen for distension, asymmetry
• Auscultate:
  • Bowel sounds (RLQ)
• Palpate:
  • Four quadrants for pain and bladder/bowel distension (light palpation only)
• Check urine output for frequency, colour, odour.
• Determine frequency and type of bowel movements.

Genitourinary:

Check urine output for frequency, colour, odour.

Female: vaginal discharge

Male: circumcision, discharge

Musculoskeletal:

• Check if full or partial weight-bearing.
• Determine gait/balance.
• Determine need for and use of assistive devices.

Inspect:

• • Arms and legs for pain, deformity, edema, pressure areas, bruises
  • Compare bilaterally
• Palpate:
  • Radial pulses
  • Pedal pulses: dorsalis pedis and posterior tibial
  • CWMS and capillary refill (hands and feet)
• Assess handgrip strength and equality.
• Assess dorsiflex and plantarflex feet against resistance (note strength and equality).

Back area (turn patient to side or ask to sit up or lean forward):

• Inspect back and spine.
• Inspect coccyx/buttocks.

Tubes, drains, dressings, and IVs:

• Inspect for drainage, position, and function.
• Assess wounds for unusual drainage.

Sample format for documentation:

General Status

Vital signs

Head, Ears, Eyes, Nose, Throat

Neck

Respiratory

Cardiac

Abdomen/GI

GU

Pulses

Extremities

Skin

Neurological