AZUSA PACIFIC UNIVERSITY
SCHOOL OF NURSING
GNRS 588: ADVANCED NURSING CARE FOR ADULTS
COMPREHENSIVE CARE PLAN #: ___#2
Student: Yliana M Penalosa
Instructor: Tayag
Date of Care: 7/10/2015
Date of Submission: 7/17/2015
Nursing Clinical Worksheet
Student Name: Yliana M Penalosa
Patient Initials:
Age:
Sex: F
G.D.M
69
Allergies: Diet: Low
Fall Risk:
NKA
Carbohydrates
11
Isolation and Type: None
Braden
Score:14
Activity:Level
1 bed bound
Code Status:
Full
LOC:
A&Ox4
Date:
Admit Date: 6/29/2015
Primary MD: Dr. Bandyl
Consulting MD: Dr. Brandyl
Admitting Diagnosis: Bilateral lower extremities non-healing after transmetarsal amputation.
Secondary Diagnosis (Past Medical Hx and surgical Hx): Diabetes mellitus, hypothyroidism, hypertension,
hyperlipidemia, chronic back pain, and peripheral artery disease.
Patient’s Hospital Course (refer to progress notes): Patient went to the emergency department the week prior to
the current admission for increased pain and redness in the left foot. She was placed in antibiotics (bacterium and
Keflex). She stopped taking the antibiotics on 7/5/15 but continues to have left foot pain, denies pain in the right
foot. She is being cared for in a skilled nursing facility where she is not walking due to pain on the left foot. The
pain on her left foot remains rating it at an 8 on a ten point numerical pain scale.
Prioritized To Do List (refer to patient’s orders): Vital signs every 4 hours, wound dress check, keep wound
clean, continue on a low carbohydrate diet, follow safety protocols due to high fall risk, use incentive spirometer,
maintain patient’s glucose levels within targeted ranges, provide patient with a quite environment and good
personal hygiene including oral hygiene. Education is essential in this patient regarding glucose levels, diabetes
control, safety including rails up (2/4) and light call within reach. Also educating patient regarding spirometer, side
effects of medications and reporting any symptoms or changes or level of consciousness or discomfort.
Diagnostic tests and procedures
Results
Tests (Date completed)
Foot x-ray (6/30/15)
Chest x-ray (6/30/15)
Myocardial at perfusion stress and rest
test
Test
Range
RBC
4.6-10
Hbg
13.7-17.3
Hct
35-45
Glucose
70-110
Left foot has minimal amount of bone fragmentation at and near the first metatarsal
and diffuse soft tissue swelling, vascular calcifications present. The right foot has
bone fragmentation at and near first metatarsal; reason for x-ray was patient had
transmetarsal amputation.
Right transjugular central venous catheter; no pneumothorax; reason for x-ray patient
had a central venous catheter because peripheral IV catheter was not possible.
No evidence of inducible ischemic; normal activity; reason for test patient was
experiencing sinus tachycardia.
Abnormal / Pertinent Lab Values
Value at
Recent value Why this test was ordered and what is the significance
Admission
(date)
of the value?
4.07
3.20 (7/9/15)
Patient was bleeding from wound site which can lead to
low levels of RBC and become anemic, weak, and
fatigue.
11.7
9.6 (7/9/15)
Patient was bleeding which decreases RBC count and
Hbg count; which can lead to anemia.
35.6
26.7 (7/9/15)
Patient was bleeding which decreases RBC count and
Hct count; which can lead to anemia
153
177 (7/9/15)
Patient has diabetes and find it challenging to control
her glucose levels.
Doc Flowsheet Data
Vital Signs
Noninvasive Blood
Pressure (NIBP)
0800
113/55
1200
1600
111/55
117/56
Ventilator Settings
IV Fluids
Type
Piperacillin in
Rate/ Site
12.5mL/hr IV 8 h.q
Mean Arterial Blood
Pressure (MAP)
Pulse Rate
Respiration Rate (RR)
% O2 Saturation (SpO2)
Temperature
Hemodynamic Monitoring
Arterial Blood
Pressure (ABP)
Central Venus
Pressure (CVP)
Pulmonary Artery Pressure
(PAP)
Pulmonary Artery
Occlusion Pressure (PAOP)
Cardiac Index
Cardiac Output (CO)
69
71
74
99
19
96
98.3
0800
N/A
95
22
99
98.8
0900
95
15
96
98.6
1000
Mode: N/A
sodium
chloride 0.9%
50mL solution
Rate: N/A
1100
1200
TV: N/A
N/A
FiO2: N/A
N/A
N/A
PEEP: N/A
N/A
PS: N/A
N/A
Other
Intracranial Pressure (ICP)
Blood Glucose (POC)
Pain Level
Intake/Output
N/A
166
8
Intake ( ml per shift)
Enteral
IV
Oral
Shift Total
474
175
8
0
TOTAL
250
724
Urine
Output
1,250
Output (ml per shift)
Emesis
Drains
BM
Not
measured
0
0
TOTAL
1,250
Please state why there is a significant difference in the I/O (if any): The difference between intake and output can be due to patient
receiving diuretics.
PLACE ECG STRIP HERE
HR
94
Rhythm
Sinus
P wave
PR
QRS
P:Q ratio
ST segment
T-wave
Q-T
Ectopy
Rhythm
Interpretation: Patient has sinus rhythm all waves are within normal findings.
Complete Head-To-Toe Assessment
General
Survey
Neurologic
Physical
Appearance:
Mood:
Signs of Acute
Distress:
Orientation
Speech
Pupil (L)
Pupil (R)
Obese
Appropriate for situation, friendly, polite, compliant
Present, dull pain on the left lower extremity, rating pain at 8 using a numerical pain scale
A&Ox4
Clear and understanding
PERRLA
PERRLA
Pain
Assessment
GCS score
Abnormal
Muscles
Provocation/
palliation
Quality
Region/
Radiation
Severity
Time
Oxygenation
Respiration
Pulmonary
Cardiovascular
Gastrointestinal
R. Lung
L. Lung
Capillary Refill
Skin Color/
Temp
Apical Pulse
Heart Sounds
Peripheral
Pulses
Oral Mucosa
Tongue
Abdomen
Nutrition
Tube Feeding
Genitourinary
Bowel Sounds
Bowel
Movement
Urination
Urine Color
Urine
Character
Urine (ml)
Skin
(wounds)
Urinary
Catheter
Skin Color
Skin Integrity
Musculoskeletal
Wound/
Ostomy
Insertion Site(s)
IV Assessment
IV Fluids
Describe
abnormalities:
Psychosocial
15
Location: None
Strength: Transmetarsal amputation on both feet.
Pain related to wounds not healing.
Dull throbbing pain
Left lower extremity (including entire leg and foot)
8
Continuous (entire shift)
X Room Air ☐ Device
Flow rate: ___________ L/min
Quality: clear to auscultate, unlabored, symmetrical bilateral chest expansion
Rate:
18 bpm
Rhythm: Regular
Clear to auscultate
Clear to auscultate
≤2 seconds
Appropriate for ethnicity, warm to touch.
2+ Short rate and rhythm at fifth intercostal space left midclavicular line.
S1 & S2 normal sounds, no murmurs or gallop.
Radial equally bilateral 2+ regular rhythms except on lower extremities (feet are 1+ using a
Doppler)
Pink and moist, no lesions present.
Pink and moist, no lesions present.
Soft, non-distended, tender.
Low carbohydrates
Current Rate: N/A Goal Rate:
Residuals: _____________ Type: ☐ N/A ☐ NGT ☐PEG ☐ J-tube
Present normoactive
Last BM date: 7/10/2015
Frequent
Amber yellow
Clear
1,250
Insertion date: 7/2/2015
Appropriate for ethnicity
Wounds related to amputation on feet and left leg has a laceration related to surgery and trace
of edema on bilateral lower extremities.
N/A
Right upper extremity and right external jugular vein.
No phlebitis or infiltration
IV flush 3mL Q8hr with sodium chloride 0.9%
Lower extremities are weak related to patient not ambulating.
Marital status
Psychosocial Assessment
Widow
History
Education level
Social resources
Spiritual resources
Occupation
Employment
Smoking
Alcohol
Recreational Drugs
High school
Family
Catholic
Retired
None
No
No
No
Spiritual Assessment
Spiritual
Integrity
Presence of…..
X
X
X
X
X
X
1)
Look: (Signs of Meaning, Relationships, Hope and Joy)
Spiritual
Distress
Absence of….
Provide checkmark in either box for each criteria
Family, friends, visitors, wedding ring, photographs
Cards, letters, phone calls, flowers, pets
Attention to personal care and appearance
Work, projects, hobbies, music, books, tapes
Newspapers, magazines, television, radio
Special dress, prayer cap, head scarf, cross
X
Articles of faith, pictures, statues, rosary, star
X
Books of faith, Bible, Koran, Torah prayers
X
Smiles, motivation, coping skills, healthy lifestyle
Uses the observations listed above to begin your Spiritual Assessment
Acknowledge and inquire about photographs, cards, flowers, visitors
Acknowledge and inquire about hobbies, books, television/newspaper content
Acknowledge strength and inquire about profession
Acknowledge and inquire about articles of faith & religious preference
Acknowledge and inquire about mood (physical and psychological)
With your client as your guide, and after a sense of trust and connectedness have been established, continue with
the assessment. Phrase your questions and indirect statement in ways that convey your genuineness, style, and
comfort.
I would like to hear more about your life and/or your family.
When you return home, will there be someone available to help you?
What brings you joy, makes you happy, or makes you laugh?
What has brought you the greatest sense of pride and accomplishment to date?
What is your next goal?
What give you such strength?
Who do you turn to in tough times?
Would you like me to pray for you or with you?
Spiritual Integrity
Listen: (Actively listen for signs of meaning, relationships, hope, and joy) Spiritual Distress
Pt verbalizes...
**Provide checkmark in each box that is applicable
Pt verbalizes…
X Sense of purpose and meaning
My life has no meaning
X Source of pride & accomplishment
Guilt, if only….I should have
X Source of joy & happiness
Sense of sadness and despair
Future Goals and desires
Lack of motivation
X Hope and Courage
Hopelessness “What is the use?”
X Interest in world & concern for others
Lack of concern for others
X Personal Strengths
Powerlessness I am useless.
X Connection to others
Loneliness and isolation
Connection to a higher source
Helplessness, anxiety, fear
X Religious affiliation
“This is not fair. Why me?”
Request for special diets, clergy
“Why am I being punished?”
X Appreciation for nature
Apathy
X Ability to adapt to changes
Inflexibility
2. Nursing Diagnosis: Analyze the data, and if appropriate, select one of the following nursing diagnoses.
Potential for Enhanced Spiritual Well-Being
Spiritual Distress
Hopelessness
X Other
3. Plan: Develop a short-term goal and a long term goal for your client.
ST Goal: The Client will
LT Goal: The Client will
4. Interventions: Identify the specific nursing interventions you will use with your client.
X Be present.
X Establish a therapeutic relationship conveying respect, warmth, empathy and genuineness
X Active listening.
X Assist client to identify strengths, supports, and interconnections.
X Instill hope.
X Use of touch, if client is comfortable with closeness.
X Provide an environment conductive to reflection, prayer, and spiritual growth.
X Provide an environment conductive to client’s beliefs (food, ceremonies.)
Provide religious articles as requested.
X Support client in search for meaning and purpose in life, illness, and death
Support client in search for a relationship with a higher power.
Pray with the client.
X Pray for the client.
X Promote private time with people who are significant in client’s life.
X Be available and approachable to assist client with meeting spiritual needs, and making spiritual choices.
Collaborate with chaplain or spiritual leader.
Other:
Other:
5. Evaluation: Evaluate the client’s progress towards the goals.
(Note: Each person’s spirituality is highly variable, individual, and ever changing!)
ST Goal: try to meet with the priest to talk about spirituality and pray for her recovery for tomorrow.
LT Goal: continue to pray and not lose faith throughout her spiritual journey.
**This Client Spiritual Assessment Tool (CSAT) was adapted from: Hoffert, D., Henshaw, C., & Mvududu, N. (2007). Enhancing the
ability of nursing students to perform a spiritual assessment. Nurse Educator, 32(2), 66-72.
Scheduled Medications and PRN Medication Given
(please also include all saline flushes and IVFs)
Generic Name: Furosemide
Classification : Loop diuretic
Pt. Specific Indications: Treat patient’s edema.
Dose: 40mg
Trade Name : Lasix
Route: oral
Frequency/ Rate: Daily
Mechanism of Action: Rapid-acting loop diuretic and antihypertensive. Inhibits reabsorption of sodium and chloride primarily in loop
of Henle and in proximal and distal end tubules.
Contraindications: history of hypersensitivity to furosemide, increasing oliguria, anuria, fluid and electrolyte depletion states.
Side Effects: postural hypotension, dizziness with exercise.
Adverse Effects: acute hypotensive episode, hypovolemia
Patient Family Education: patient should intake potassium-rich foods including bananas and oranges to reduce/prevent low potassium
levels. Educate patient about hypokalemia including symptoms of cramps or weakness to physician. Reposition slowly to reduce
likelihood of dizziness or imbalances.
Generic Name : Insulin Lispro
Classification : Antidiabetic, fast acting insulin
Dose: 3 units
Trade Name : Humalog
Route:
Frequency/ Rate: Before meals
Subcutaneous
Pt. Specific Indications: Patient has DM type 2
Mechanism of Action: Fast-acting insulin, enhances trans-membrane passage of glucose across cell membranes in muscle and
adipose tissue. Promotes conversion of glucose to glycogen in the liver.
Contraindications: Hypersensitivity to insulin.
Side Effects: localized allergic reactions at injection site;
generalized urticarial or bullae, hypoglycemia, hyperinsulinemia
(profuse sweating, hunger, headache, nausea, tremors,
palpitations, tachycardia, weakness
Adverse Effects: Edema, Heart failure, DKA, Severe
Hypoglycemia, Hypokalemia, Anaphylaxis
Patient Family Education: Notify physician of local reactions at injection site.
Generic Name: Famotidine
Trade Name : Pepcid
Classification : H-2 blockers
Dose: 20mg
Route: Oral
Frequency/ Rate: BID
Pt. Specific Indications: reduce amount of acid in the stomach
Mechanism of Action: inhibits histamine at histamine H2-receptor site, decreasing gastric secretion while pepsin remains at a stable
level.
Contraindications: kidney problems, liver problems
Side Effects: constipation, diarrhea, feeling dizzy, headaches
Adverse Effects: chest tightness, jaundice, pneumonia
Patient Family Education: avoid irritating foods, alcohol, aspirin, extreme-temperature foods that may irritate GI system.
Trade Name : Zosyn
Generic Name : Piperracillin/tazobactam
Classification: Antiinfective, broad spectrum
Dose: 3375mcg Route:IV
Pt. Specific Indications: Patient appears to be positive for MRSA on lower left foot.
Mechanism of Action: Interferes with cell-wall replication of susceptible organisms.
Frequency/ Rate: 12.5mL/hr
Contraindications: hypersensitivity to penicillin, neonates, carbapenem allergy.
Side Effects: lethargy, hallucinations, anxiety, depression,
Adverse Effects: seizures, cardiac toxicity, pancreatitis, oliguria,
twitching, insomnia, headache, fever, dizziness, vertigo.
hematuria, renal failure, bone marrow depression.
Patient Family Education: Report sore throat, fever, fatigue, anxiety, depression, hallucinations and seizures.
Trade Name : Roxicode
Generic Name : Oxycodone
Classification : Opiod
Dose: 5mg
Route: oral
Frequency/ Rate: QID
Pt. Specific Indications: treat patient’s moderate to severe pain.
Mechanism of Action: inhibits ascending pain pathways in CNS, increases pain threshold, alters pain perception.
Contraindications: hypersensitivity, addiction (opiate), asthma, ileus.
Side Effects: drowsiness, dizziness, confusion, headache, sedation,
Adverse Effects: “black box warning” respiration depression
euphoria, fatigue, abnormal dreams/thoughts, hallucinations.
Patient Family Education: Report any difficulties in breathing, allergies, changes to CNS, avoid alcohol, driving operating machinery if
drowsiness occurs.
Present History and Relevant Past History: (Provide a synopsis of patient’s history leading to hospitalization)
Patient is a 69 year old woman who went to the emergency department the week prior to the current admission for
increased pain and redness in the left foot. She was placed in antibiotics (bacterium and Keflex). She stopped taking
the antibiotics on 7/5/15 but continues to have left foot pain, denies pain in the right foot. She is being cared for in a
skilled nursing facility where she is not walking due to pain on the left foot. The pain on her left foot remains rating it
at an 8 on a ten point numerical pain scale.
Pathophysiology of Admitting Diagnosis:(Describe pathophysiology as you would explain it to the patient. Provide
general reference.)
GDM returned to the hospital approximately a week after being admitted to the emergency department and
receiving antibiotics. Her pain persisted then decided to return to the hospital. Cultures were done on both lower
extremities to test for MRSA which returned positive for the left foot. Yet she is not in isolation precaution. The
slow wound healing can be related to the presence of MRSA on her left foot in which she currently continues to
have pain “8” on a numerical scale. In addition the patient is diabetic which can also result in slow wound healing.
At the moment she is receiving antibiotics, oxycodone and Lasix to treat the infection, pain and swelling lower leg
extremity.
Patient’s Plan of Care: (Briefly describe patient’s current plan of care during hospitalization, discuss relevant
procedures, therapies, tests, etc.)
The patient will continue to take her antibiotics IV, Lasix and opioids to care for the infection, swelling and pain of
her lower leg extremity. Her intake and output are being measure to confirm the Lasix are working. Also daily labs
are being withdrawn to monitor her electrolytes, WBC, RBC, BUN, and Creatinine. Physical therapy will visit her on
Monday to begin both upper and lower body exercises. Patient will also receive education regarding controlling her
blood glucose levels.
List 4 Nursing Diagnosis In Order Of Highest Priority:
(Based on your patient’s specific needs, identify three nursing diagnosis and rank them in order of importance,
be sure to include at least one physiologic and one psychosocial diagnosis)
1. Chronic pain related to ineffective pain management as evidence by patient reported 8/10 in a numerical pain
scale.
2. Risk for electrolyte imbalance related to receiving Lasix intravenous as evidence by tracing of edema on
lower extremities.
3. Impaired physical mobility related to limited range of motion, bed bound and as evidence by amputation in
left and right lower extremities (transmetarsal amputation).
4. Impaired tissue integrity related to ineffective healing of wound as evidence by red, swollen, purulent
wound on the left lower extremity (transmetarsal amputation).
Select one physiologic and one psychosocial nursing diagnosis listed above and create a nursing care plan for each selection:
(For each nursing diagnosis provide 1 goal, 3 interventions with rationales, and indicate if goal was met, not met or in progress)
List of Real/ Potential Nursing Problems (NANDA)
NSG DX #2
NSG DX #1
Chronic pain related to
ineffective pain
management as evidence by
patient reported 8/10 in a
numerical pain scale.
1. Chronic pain related to ineffective pain management
as evidence by patient reported 8/10 in a numerical
pain scale.
2. Risk for electrolyte imbalance related to receiving
Lasix intravenous as evidence by tracing of edema on
lower extremities.
3. Impaired physical mobility related to limited range of
motion, bed bound and as evidence by amputation in
left and right lower extremities (transmetarsal
amputation).
4. Impaired tissue integrity related to ineffective
healing of wound as evidence by red, swollen,
purulent wound on the left lower extremity
(transmetarsal amputation).
Risk for electrolyte
imbalance related to
receiving Lasix
intravenous as evidence
by tracing of edema on
lower extremities.
Related Assessment
NSG DX #1: Chronic pain related to ineffective pain management
as evidence by patient reported 8/10 in a numerical pain scale.

Vital signs including respiration
rate.

Reassessed for pain 60 minutes
after oral pain medication.

Patient indicates pain 8/10 the
majority of the day although
pain medication had been
administered.
Relevant Labs and Tests


Arterial blood gases
Complete blood count
Outcome Parameters/Goal

Patient will verbalize lower
pain levels after 60 minutes
of each administration of
pain medication; full
understanding of how long
medication takes to work
before 9am this morning.

Patient will feel comfortable
asking for pain medication
before 9am this morning.
Interventions & Rationales
1)
Patient will be educated about pain reassessment after
60 minutes of oral pain medication.
Rationale: Patient needs to be educated about the
importance in reassessing pain, confirming that
oxycodone helped diminished pain levels.
2)
Patient will be educated about the side effects of
oxycodone including respiration depression, drowsiness,
possible allergic reactions and changes in level of
consciousness or present hallucinations.
Evaluation

Rationale: Oxycodone is a “black box warning” drug it is
essential for the patient to report any side effects to
physicians and nurses immediately.
Relevant Meds

Oxycodone
3) Patient will report any discomfort or pain in lower
abdomen or feelings of bloated lower abdomen to
nurses and physicians immediately upon appearance of
symptoms.
Rationale: Intake and output must be monitored for
decrease output which may indicate urinary retention as
a possible side effect opiates.


Patient verbalized a
decreased in pain levels
within 60 minutes after
pain medication was
administered, however
patient continued to
experience pain 5/10.
Patient’s pain
diminished to 5 then
return to 8 in a
numerical pain scale.
Patient verbalized
sleeping helped
managed with pain.
Related Assessment

Patient indicates pain 8/10 the
majority of the day although
pain medication had been
administered.
Lasix intravenous as evidence by tracing of edema on lower
extremities.

Interventions & Rationales

Patient appears to have
responded to Lasix urine output
has been greater than her
intake.
Outcome Parameters
NSG DX # 2: Risk for electrolyte imbalance related to receiving
1) Patient will receive a nutritious meal high in potassium
including food options of bananas, peaches, oranges and
potatoes.
 Patient will verbalize an
understanding of appropriate
food options maintain
adequate potassium levels
before noon/lunch. (Goal
met)
 Patient will verbalize the
symptoms of hypokalemia
before noon (goal met).
Rationale: Patient should intake potassium-rich foods to
reduce/prevent low potassium levels.
Relevant Labs and Tests



2) Patient will be educated about hypokalemia including
Evaluation
symptoms of cramps or weakness to physician.
Arterial blood gases
Complete blood count
Urine analysis
Relevant Meds
 Furosemide

Patient verbalizes an
understanding of the side effects
of Lasix including orthostatic
hypotension and the need to
intake foods rich in potassium;
she had a banana for lunch and
not fall incidences occur during
the shift.

Patient verbalizes that she feels
comfortable reporting symptoms
of cramps or weakness to her
physician if present; no current
symptoms present.

Potassium levels are within
normal limits.
Rationale: Patients who receive Lasix are at risk of
hypokalemia which can lead to dysrhythmias due to Lasix
getting rid of sodium and potassium through urine
output.
3) Patient will reposition slowly to reduce likelihood of dizziness
or imbalances.
Rationale: Orthostatic hypotension may occur as a side
effect of Lasix.
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