Nursing Care Plan template-W23 (1) (2)
Nursing Care Plan
Student(s) Name: Uvbi Osatohangbon Date:
Medical Diagnosis: Confusion/Intra-abdominal abscess
| Assessment Data | Nursing Diagnosis and Related Goals | Nursing Interventions and Rationale | Evaluation |
| Objective
Alert & Oriented x2 (recognizes she is hospital but not city location, is able to tell the month and can follow simple commands sometimes, cannot recall DOB)
No known allergies
Independent mobility
Experiences nausea
Clear breaths on all sides Non-productive cough Symmetrical chest expansion Regular heart sounds Capillary refill less than/equal to 2s No impaired sensory perception Rarely moist Walks occasionally. Bowels sounds present and active on all quadrants. No incontinence Abdomen soft and non-tender No lines, drains or wounds Skin complexion appropriate for ethnicity
History of Alzheimer’s dementia, anxiety, cataract, depression, diplopia, glaucoma, hearing loss, stroke, diverticulitis.
Vital Signs Hr – 75 Regular, Monitor Rr – 16 BP – 93/62 LA, Automatic, Lying Temperature – 36.8 Oral Spo2 – 94% RA Pain – on and off on LLQ Pedal pulses present Brachial and radial pulses are equal.
MEDICATIONS – Acetylsalicylic acid (ASA) TAB chewable 80mg, oral, daily – Amoxicillin – clavulanate (clavulin) 875-125 mg per TAB1, oral, daily – Cholecalciferol (Vitamin D3) tab 4000 units, oral, daily – Duloxetine (Cymbalta) delayed release capsule 30mg, oral, daily. – Enoxaparin prefilled syringe 40mgMagnesium (Tecta), delayed release, tab 40mg, Subcut, Nightly – Mirtazapine (REMERON) TAB 15mg, oral, Nightly – Pantoprazole magnesium (TECTA) delayed released tablet 40mg, oral, daily. – Potassium chloride (K-10) solution 40 mmol, oral, daily
PRN – Acetaminophen (Tylenol) suppository 650mg, rect, q4h – Acetaminophen (Tylenol) suppository 650mg, oral, q4h – Acetaminophen (Tylenol) suppository 650mg, EN, q4h – Melatonin sublingual (SL) TAB 3mg, nightly – Melatonin sublingual (EN) TAB 3mg, nightly – Ondansetron (Zofran) 2mg/mL injection Subcut, 4mg, q8h – Ondansetron TAB 4mg, oral, q8h – Ondansetron TAB 4mg, EN, q8h
Subjective”
“I don’t remember.”
“It was hurting before, it stopped but now it’s hurting again.”
“Looking at the food makes me want vomit.”
“I can’t eat, or I’ll vomit.”
“If I rest it will go away” |
Nursing Diagnosis
Risk for falls as evidenced by history of anxiety and depression, nausea and ability to follow or understand simple commands only sometimes.
Risk for impaired skin integrity as evidenced by Intra-abdominal abscess.
Goal Short term – Review home safety and free from hazards that could increase falls risk, educate patient about what does hazards could be and how to minimize or remove altogether to reduce fall risk by the day prior to discharge date.
Long term – Encourage movement of the patient after sitting and lying for hours muscles and improve balance. Review with other healthcare professionals’ medications that could be increasing patients fall risk.
|
Nursing Interventi