Short Form Care Planning Tool: RAM Assessment of Behaviors & Stimuli Student Name: Maria J. Rios Date Assignment Completed: 12/27/2022 Client (Code) JM Age 80 Primary MD: Alvin Hernandez Primary Diagnosis: Venous Stasis Ulcer on right medial malleolus Past Medical History Past Surgical History COPD N/A CODE Status: Full Vital Signs: Every shift Time 1200 T (route) ORALLY 97F CHRONIC VENOUS INSUFFICIENCY AP 96 DEEP VEIN THROMBOSIS (5 years ago) B/P R 95 120/80 Arm position ____Left_______ Daughter reports that JM has had trouble with her mobility, an unhealth eating habit, and cannot care for herself successfully on her own. R 20 O2 Sat 94% ___ Y _ Room air __N/A____ Oxygen therapy N/A Devise __N/A__ l/ min Comments: N/A Seizures Stomach Ulcers Stroke Mental Health Problems Kidney Problems Hypertension Heart Trouble Gout Glaucoma Diabetes Cancer Bleeds Easily Asthma Arthritis Environmental Allergies Anemia Relationship Cause of Death (if applicable) Alcoholism Family Medical History Age (in years) Pain: (0-10) No Pain Reported=0 Current Medications (Including Herbal & Over the Counter) Medication Route Dosage Frequency Multivitamin Orally One Tablet Once Daily Aspirin Orally 81mg Once Daily Albuterol Inhaler 360mg PRN Acetaminophen Orally 650mg Q 6 Hours Immunization History: Up to date Height: 5ft 3 inches Admission date: Weight: 90kg (obese) 12/27/2022 BMI: n/a (date completed) Allergies: (Including environmental, food and medications) Yes Name of Agent Reaction Penicillin Rash Fatigue System Review Findings GI/Nutrition Diet: Unhealthy diet, and unhealthy portions. Pt. is overweight. - - Normal Findings: Bowel sounds active in all quadrants Abdomen soft, non-distended, non-tender Receives and tolerates nutrition and fluids Absence of nausea, vomiting, cramping, diarrhea or Constipation No complaints of nausea, vomiting, or abdomen pain with palpation Feeding tube (include size and type) Assess barriers to accessing nutritional food How did you assist the client with their diet? Educated the patient on the proper food choices, including My Plate. JM was provided with healthy meal options, that include all food groups including the right amount of protein. Describe your Findings: After assessing the patient, it was noted that she was overweight for her size and age. She also appeared as though she neglected choosing the right food choices with each meal. Bowel sounds are noted in all 4 quadrants. Abdomen is soft and non-tender, no complaints. Intake: 460ml Neurological Normal Findings: Alert and oriented x 3 Speech is clear Memory intact Follows commands and converses Absence of seizures Behavior appropriate to situation When upright: Balance steady Gross motor coordination intact Hand grasps strong/equal PERRLA, Foot presses and pulls strong and equal Gag, cough, blink reflexes intact Patient denies numbness tingling or other paresthesia of extremities Respiratory Normal Findings: Breath sounds clear and equal in all lobes. Respirations regular, non-labored, without use of accessory muscles Mucous membranes pink Chest excursion symmetrical Trachea midline If cough present, non-productive Sputum clear or absent Cardiovascular Normal Findings: Regular rhythm, heart sounds S1 S2 present Blood pressure baseline Denies chest pain Periorbital, sacral, pedal & generalized edema absent Skin warm & dry to slightly moist Nail beds pink, capillary refill< 3 sec Peripheral pulses palpable or present with doppler Skin Normal Findings: Color normal for ethnicity Temperature warm, dry to slightly moist Describe your findings: Alert and oriented x 3, but is often forgetful Speech is clear JM follows commands but can be a bit stubborn with complying No seizures noted Behavior is appropriate for situation JM is dressed appropriately for the weather Gait is unsteady Pt. requires assistance with positioning and ambulation currently Gag, cough, and blink reflexes are intact Patient denies numbness and tingling in all extremities, but it is noted that that patient has edema on the lower extremities Describe your findings: Breath sounds are regular and equal bilaterally. S1 and S2 noted. Describe your findings: Skin is warm and dry. All areas of skin are intact except for the right ankle. Cap refill is less than 2 seconds BP is 120/80 Pulse is 95+ radial and pedal Denies any pain currently Describe your findings: Temperature is 97.1 F Skin color is appropriate to ethnicity - Turgor normal, mucous membranes moist Skin intact without breakdown, rash, redness Wounds Normal Findings: Edges approximated and clean Surrounding tissues free from signs & symptoms of infection Dressing dry & intact: drainage absent IV Site (If applicable) Peripheral IV: Site Size Date Inserted Fluids infusing yes/ no • Type • Amount If no fluid, last time flushed Central Access Device: • Type of Device • Date inserted Fluids infusing- yes/no Type Amount Mobility/Functional Ability Normal Findings: Active ROM of all extremities within physical limitations Tolerates prescribed activity order If ambulatory, gait steady Able to complete ADL's Able to transfer (with/without assistance) List assistive device(s) Determine if assistive devices are used correctly Neurovascular assessment for client with cast or traction Elasticity is normal Skin is intact except for the right ankle Ulcer noted right medial malleolus Wounds: (yes/no?) Findings: Yes, right medial malleolus (venous statis ulcer) Wound measures at 1 inch deep Wound is pink and serous drainage is present No necrosis Hydrocolloid dressing replaces, dry and intact currently IV/ Central line (yes/no?) Describe your findings: No IV access No IV fluids currently Describe your findings: All extremities function appropriately for age Completes ADLs with assistance Requires assistance for turning JM is a 1 person assist when entering and leaving the bed Gait is unsteady Fatigue GU/Elimination Normal Findings: Urine clear, straw to amber no unusual odor Urine output within established parameters Bladder non distended Continent or incontinent of urine If urinary devise is used, list (indwelling urinary catheter, external female catheter, condom catheter, suprapubic catheter, straight catheter) Describe your findings: Urine is clear- straw colored No foley catheter in place Output: 240ml Psycho-Social Normal Findings: Participates in two way conversation, care and treatment plan JM is alert and answers all questions accordingly. Able to communicate his/her needs JM understands why she is in the hospital. Coping mechanisms intact (client and family) JM lives alone, but her daughter is present. Mood/affect/behavior appropriate to situation Assess client’s definition of health Assess client’s understanding of current illness What are the client’s resources for healthcare access, access to housing and food, ability to afford medications/ services and transportation to follow-up and future healthcare visits? Pain, Comfort, Rest and Sleep Normal Findings: Rates pain ( may use numeric scale 1-10, WongBaker faces pain scale, FLACC scale, CRIES scale, color analog scale, etc) States and appears rested Rests/sleeps during shift Slept well during night Obstetrics (If applicable) Assess Maternal status Description of uterine activity Assessment of Fetal status Description of findings on vaginal exam, if performed, including cervical dilation and effacement, fetal station, change in status of membranes, and progress since last exam Postpartum (If applicable) Assess Postpartum status Assess the breasts Assess Uterus (firm or boggy) What is the fundal height Is there bleeding (color and presence of clots) Inspect the dressing and incision if C- Section Assess Lochia (color, amount, number of pads used) Inspect the episiotomy ( redness or drainage) Has the client voided (amount, color) Has the client had a bowel movement Assess bonding Newborn Assessment (If applicable) Describe your findings: Describe your findings and identify the scale used: Pain is currently 0/10 Slight leg pain on admission but has since subsided. Comfortable otherwise, will reassess pain level at the next time of vitals. Describe your findings: N/A Describe your findings: N/A Describe your findings: Assess Newborn status APGAR ( Appearance, pulse, grimace, activity and respirations) N/A Weight/Length Head and abdominal circumference Skin (color, texture, nails, presence of rashes) Head and neck (molding) Fontanels Genitals and anus (passage of urine and stool) Pediatric Assessment (If applicable) Assess Pediatric status Assessment triangle (general appearance, work of breathing and circulation of the skin) Psychological, psychosocial and physical development aligned with age Safety: Describe your findings: Normal Findings: The physical environment is safe. • Physical layout of client area • Alarms • Bed, IV Describe your findings: N/A If Restraints used : Describe care Environment is safe, no electric cords or machines misplaced. Room is free of clutter. No restraints noted Patients bed is in lowest position and call bell is in reach. (N/A) Current order for restraints Identify Focal Stimuli (Focal stimuli, according to Roy (1983) are those stimuli that immediately confront the individual in a particular situation. Example: Individual needs, the level of family adaptation, and changes in the family environment. 1. 2. 3. 4. Ulcer presents on skin Skin break (right ankle) Ulcer on right medial malleolus Right leg ulcer Identify Contextual Stimuli (Contextual stimuli, according to Roy (1983) are internal or external factors that influence the ability to respond to the focal stimulus and contribute directly to adaptation but are not the focus of attention and energy.) Example: Other stimuli that may influence the situation- Coping mechanisms, diagnosis, symptom severity and co-morbidities. 1. 2. 3. 4. Decreased movement Obesity, age, and medical history Edema in lower extremities Poor nutrition Identify Residual Stimuli (Residual stimuli, according to Roy (1983) are the additional environmental factors present within the situation but whose effect on the client is unclear. Example: Beliefs, behaviors and personal experiences. 1. 2. 3. 4. Ineffective coping Impaired mobility Infection Stress/Depression Diagnostic Testing/Laboratory Data (CBC, UA, Chemistry, Drug levels, Cultures, X-Rays, CT, MRI, etc.) Albumin: Low Prealbumin- Low CBC- Normal BMP- Normal Teaching Needs Identified during the assessment (Behavior & Stimuli): Assessment of readiness to learn will be completed as part of the Teaching Plan. It is evident that JM needs further teaching in wound care, wearing of compression stockings and an appropriate diet plan. What teaching was reinforced during interactions with the client? Wound education, dressing changes, compliance, diet changes, application of compression stockings, home safety measures. SBAR Report Situation JM is an 80-year-old female that was admitted to the hospital on December 27th, 2022, for a wound on her right medial malleolus (venous stasis ulcer). JM lives alone, and it is evident that she needs assistance. Her daughter is present currently. Background JM has a history of COPD, chronic venous insufficiency, and deep vein thrombosis. JM has a history of ulcers as she notes that she has had trouble with her legs and needs assistance. She is up to date on all immunizations. JM has a habit of poor eating and is overweight for her current age and height. Assessment Upon assessment, vital signs are as followed BP: 120/80 RR: 20 HR: 80 SP02: 95% T: Orally 97.1F Patient is alert and oriented x3, and sometimes forgetful. She is pleasant and her mood is appropriate for the situation. JM has a clear respiratory assessment as well as cardiovascular. Upon assessing her skin, it was noted that a wound was present on the right ankle. Otherwise, the rest of her body is dry and intact. No infestations noted. JM does not give a definite number on the pain scale, but mentions her legs are swollen and hurt without assistance. Upon further assessment, it was noted that JM has moderate edema present and hyper pigmentation of the skin on the lower extremities. Currently, compression stocking is in place and her wound dressing is dry and intact. Recommendation It is recommended that JM receive proper education to prevent further wounds from happening, as well as education on proper nutrition. During her stay, it is recommended that JM be repositioned Q2H, with vitals taken each shift. Continue compression therapy and monitor for signs of infection as a wound is present. Educate JM on fall risks, as she is unsteady. Professional Nursing Care Plan The following table provides information to utilize in developing your nursing care plans. Each column in the care plan form should include the appropriate information related to the Nursing Diagnosis. You are expected to develop 3 Nursing Diagnoses with the supporting documentation as noted on the page below. The Nursing Diagnoses are then labeled in priority order where 1 would be the highest priority. (Nursing Diagnosis Priority # ) Any questions that you have concerning the nursing care plans should be directed to your instructor. (I) Data Collection Related to the Nursing Diagnosis Subjective (Nonobservable) Objective (Observable) Subjective data should be clear, concise and specific to the Nursing Diagnosis Objective data should be clear, concise and specific to the Nursing Diagnosis Subjective Data: Objective Data : What the patient or family relates, states, or reports. (Nonobservable) What is observed or measured. May include the client’s behavior, vital signs, lung sounds, urine output, laboratory data, diagnostic testing (etc.) as related to the specific nursing diagnosis. (Observable) 1. 2. 3. 4. (II) Complete NANDA Nursing Diagnosis (IV) Nursing Interventions (V) Scientific Rationales Best Evidence with References (VI) Evaluation of Patient Goals/ Outcomes Choose a NANDA approved diagnosis. The statement should list only one diagnosis and listed in the following format, i.e., problem followed by "Related to (R/T) the disease process Manifested by: (signs and symptoms) is not part of nursing diagnoses and should be written as a separate line. Example: Coping, ineffective family: R/T Temporary family disorganization and role changes. Manifested by significant other's limited personal communication with client. Each statement should be supported by a rationale Should be: 1. Concise 2. Clear 3. Specific 4. Individualized 5. Accomplishable to client and/or family, significant other. 1. Rationale should address how interventions are going to solve the problem and/or attain the outcomes. 2. Rationale should be specific to the interventions, i.e., why giving morphine 10 mg IV, why the client is being turned and positioned in proper alignment every 4 hours. 3. Rationale can be summarized in own words and/or quoted verbatim from sources. 4. For every nursing intervention, there needs to be a rationale. Should address: 1. If the expected revised, state how would revise intervention. 2. What was the client's response to interventions? (III) Goals/Outcomes (Long and Short term) Including timelines/timeframes 1. Could have both short term and long term outcomes throughout Nursing Care Plan (NCP), but each client should have one long term goal as part of the NCP. Definitions: Short-term goals: Those goals that are usually met before discharge or before transfer to a less acute level of care. Long-term goals: Those goals that may not be achieved before discharge but require continued attention by client and/or significant others as indicated. 2. Each diagnosis, if appropriate, could have short-term goals and long-term goals. 3. Statements: Specific - relates to nursing diagnosis. Measurable - tells what to see, hear, or smell. Achievable - realistic for patient. Clear and Concise - don't use “increase” or “decrease” without giving baseline range of data. 4. Timelines (timeframes) for achievement of goals: Should be realistic and specific. Give a date or time at which the expected outcome and nursing interventions are achieved and/or evaluated. Should specific as "by discharge date" or "on going." Student Name: Maria J Rios Client Code: JM Instructor: ________________________________ Date: Nursing Diagnosis Priority # DX 1 Grade: Professional Nursing Care Plan (I) Data Collection Related to the Nursing Diagnosis (II) Complete NANDA Nursing Diagnosis Subjective Objective (Non-observable) (Observable) JM states she has had slight Unsteady gait upon review DX1: Impaired physical leg pain while at home but not mobility related to the currently. Requires assistance with patient’s current state, as ambulation as well as evidenced by the patient's JM states she needs helps with positioning weight. her legs as they are swollen. Obese DX2: Impaired self-care JM’s daughter has related to the current state, as communicated that her current Braden scale 16 evidenced by an ulcer on her state reflects an unhealthy right medial malleolus. diet, and the inability to care Brown hyperpigmentation and for herself on her own. moderate edema present on DX3: At risk for skin both legs breakdown/infection The daughter states JM is forgetful Ulcer present on the bottom of the right heel (IV) Nursing Interventions DX1: Ensure the environment is always free from clutter and safe for the patient (initiate fall precautions) Ensure the patient is repositioned Q2 hours. Elevate legs appropriately Perform wound care as ordered to prevent further ulcers from forming. (V) Scientific Rationales Best Evidence with References R1: Identify barriers to mobility, (in this case, JM has a venous stasis ulcer), optimal treatment plan is in place https://nurseslabs.com/impaire d-physical-mobility/ R2: Monitor nutritional needs in relation to immobility (JM is obese and needs an appropriate nutrition plan to guide her back to being and feeling healthy https://nurseslabs.com/impaire d-physical-mobility/ (III) Goals/Outcomes Perform application of R3: Reassess the skin each (Long and Short term) compression stockings. shift ensuring treatment is Including Practice proper hygiene when going as planned. Skin timelines/timeframes caring for this patient, G1: Patient can care for especially with wound care. herself, in preventing further ulcers Educate the patient on medication adherence and G2: Patient continues self-examination. compression therapy and wound changes as scheduled G3: Patient verbalizes an understanding Monitor for infection and maintain asepsis technique. Encourage an appropriate diet G4: Patient sticks to a healthy to ensure adequate protein diet and eventually intake is met for wound participates in light exercise to healing. manage her weight breakdown is related to several risk factors (ie. Obesity, poor venous return, and inability to ambulate/reposition by self) https://nurseslabs.com/riskfor-impaired-skinintegrity/#:~:text=The%20gre atest%20risk%20factor%20in, high%2Drisk%20of%20skin% 20breakdown. (VI) Evaluation of Patient Goals/ Outcomes 1. 2. 3. JM has been accepting to allow assistance with ambulation as well as repositioning. JM has had no falls and has complied with current orders regarding assistive care. Goal met. JM understood the purpose of wearing the compression stockings and compliance with wound care. Goal met. JM’s long-term goal is to improve her diet and have a full venous return, thus avoiding these complications soon. The goal is in progress.
