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NRSG 3240 Fundamentals
Sleep Aid Use no List:
Alcohol use no Amount/day:Tobacco use no PPD: X Years: = Pack Years
Street drug use no History of use:
PAIN
Location knee and ankle
Chronology (onset,
duration)
tibial plateau fracture
Quality throbbing shooting stabbing sharp cramping dullburning stinging aching tender squeezing pressure
nagging radiating tiringFrequency brief/momentary/transient Intensity/Quantity 3 on scale of 0 to 10 Unable to verbalize
Client’s pain goal: What level of pain would you be comfortable with? 1 Unable to verbalize
Aggravating factors standing/moving
Alleviating factors sitting and meds.
OBJECTIVE DATA
NEUROLOGIC/MUSCULOSKELETAL/SENSORY
Mental status: Alert Oriented X 4 Drowsy Lethargic Disoriented
Confused Semi- comatose
Speech: Clear Unclear Slurred Garbled AphasicMotor: 0 – Flaccid; no evidence of contraction 1 – Evidence of slight contraction
2 – Complete ROM without gravity 3 – Complete ROM against gravity
4 – Complete ROM against gravity with someresistance
5 – Complete ROM against gravity with fullresistance
Gait: Stable Unstable Not observed High Risk for Falls? Yes NoPupils: PERRLA Non-reactive Dilated Constricted
Unequal (describe):Eyes: Redness Pain Discharge Glasses Contacts
Ears: No deficits Hearing loss Hearing aid(s) Right Left
Pain Right Left Drainage Right Left
RESPIRATORY
Breathing effort: Unlabored Labored Describe:Cough None Non-productive Productive Sputum:Breath Sounds: Clear over all lobes Adventitious sounds Location:
Type:
O2 use at home? no
CARDIOVASCULAR
Capillary refill < 2 seconds
Pacemaker no Insertion date:AICD: no Insertion date:Mucus membranes Pink Cyanotic Other Nail beds Pink Cyanotic Other Radial pulses 2+ NormalPedal pulses 2+ Normal
Heart sounds S1 S2 Extra heart sounds
Gross murmur (describe):
GASTROINTESTINAL/NUTRITION
Food allergies: Denies IBW: 100 lbs % of IBW: 77%Oral condition good
Difficulty chewing Difficulty swallowingTube feeding Not applicable Formula: Rate: cc/hour
Route: Nasogastric/nasoenteral Continuous IntermittentFeeding Feeds self Needs assist Total assist Loss of appetite (anorexia)
Abdomen Contour: Flat Rounded Obese Scaphoid
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NRSG 3240 Fundamentals
Palpation: Soft Firm Distended Tender
Bowel sounds RLQ Normal, active RUQ: Normal, active LUQ: Normal, active LLQ: Normal, activeNausea/vomiting None Frequency: Duration:
Bowel habits Usual frequency: 1 per day Last BM:Laxative use None Type & frequency:
Stool consistency: Soft formedStool frequency: n/a
Bowel problems: Rectal bleeding Tarry stools IncontinenceOstomy NoneGENITOURINARY
Urine Color yellow
Urine Appearance: Clear Urine Odor none
Bladder problems: Urgency Pain BurningIncontinence Bladder distention Retention
Catheter: Indwelling: Fr. Straight: Fr. X (# times this shift)Urinary diversion: None Suprapubic Ileal conduit Other Genitalia: Intact Lesions Discharge Itching PainFemale only Obstetrical Hx: G P A
Menses: LMP: Regular SKIN
Color Normal for ethnicity Pale Ashen Gray
Flushed Jaundiced Mottled CyanoticMoisture Dry DiaphoreticTemperature Warm Hot Cool ColdTurgor Good/elastic Fair Poor/ tenting
INDICATE LESIONS ON BODY
Directions: Using the drawing feature in Word, place a dot on affect areas, and then complete the table.
Location (specify) Code
Right tibial plateau fracture
Lesion Codes
1 Edema 6 Burn 11 Other ulcer
2 Rash 7 Incision 12 Central line
3 Ecchymosis 8 Scar 13 Peripheral I.V.
4 Abrasion 9 Dressing 14 5 laceration 10 Pressure ulcer 15
IMPACT OF HOSPITALIZATION:
Developmental stage1 Late adulthood: integrity vs. despair
Explanation: looking back on life and feeling both happiness and despair.
Sociocultural factorsnone
Explanation:
TEACHING/LEARNING:
Learning Needs: Activity Diet Disease/Self-carePre-Postop Equipment Hygiene/grooming
Medication Community resources Disease management
1 Erickson’s stages of growth and development are explained at: http://web.cortland.edu/andersmd/ERIK/welcome.HTML.Page 3 of 14
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NRSG 3240 Fundamentals
Other: n/a
Other: n/aReadiness to learn: yes Explanation: n/a
Learning Preferences ReadingBarriers to learning: Degree of illness Visual impairment Hearing impairment Age
Motor skills Comprehension Motivation Low literacyOther (explain) n/a
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NRSG 3240 Fundamentals
CLINICAL DATA BASECLIENT DATA:
Age: 55 Sex: female Height: 144.7 cm Weight: 58.97 kg IBW: 100 lbs
Admission Date: 4/12/10 Reason for admission: right tibial plateau infection
Allergies: co deine
MEDICAL DIAGNOSES:
Primary Medical
diagnosis: Righttibial plateau
fracture
Definition: Common Signs & Symptoms: pain,
impaired movement,
Usual treatment:
Secondary Medical
diagnosis: n/a
Definition: Common Signs & Symptoms: Usual treatment:
Chronic illnesses:
n/a
Definition: Common Signs & Symptoms: Usual treatment:
LABORATORY & DIAGNOSTIC DATA
HEMATOLOGY
CBC
Test Normal Most Recent Result
Date
Admission Result
Date
Clinical Significance
WBC 3.07-11.77 7.10 normal
RBC 3.76-5.20 3.98 normal
Hgb 11.6-15.6 11.7 normal
Hct 33.9-45.9 32.5 low; nutritionally deficit or fluid retention.
Platelets 129-355 539 high; acute infection
WBC DIFFERENTIAL
Test Normal Most Recent Result
Date
Admission Result
Date
Clinical Significance
PMN 40-80 69 normal
Bands n/a Lymphocyte
s15-40 18 normal
Monocytes 0-10 12 high; infection. Eosinophils 0-7 1 normal
Basophils 0-2 1 normal
COAGULATION STUDIES
Test Normal Most Recent Result
Date
Admission Result
Date
Clinical Significance
PT/PTT 12.2-41.6 n/a n/a INR 2.0-3.0 n/a n/a CHEMISTRY
SERUM CHEMISTRY
Test Normal Most Recent Result
Date
Admission Value Clinical Significance
Sodium 135-145 137 n/a normal Potassium 3.5-5.0 4.6 n/a normal
Chloride 99-109 99 n/a normal
CO2 22-32 29 n/a normal
Calcium 8.5-10.2 10 n/a normal
BUN 5-22 11 n/a normal
Creatinine 0.50-1.17 0.67 n/a normal
Total
Protein4.2-8.0 7.0 n/a normal
Albumin 3.5-5.0 3.3 n/a low; immobilization or infection
Glucose 70-99 99 n/a normal
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NRSG 3240 Fundamentals
Test Normal Most Recent Result
Date
Admission Value Clinical Significance
Phosphates n/a n/a n/a n/a
Uric Acid 2.5-7.7 3.6 n/a normal
Alkaline
Phosphatase
30-112 81 n/a normal
LDH 97-190 185 n/a normal
SGOT/AST 15-38 26 n/a normal
Bilirubin 0.2-1.3 0.7 n/a normalCholesterol 114-200 168 n/a normal
BACTERIOLOGY
CULTURES (Blood, Urine, Sputum, and/or Wound)
Specimen type Date/Value Clinical Significance
n/a n/a n/a URINALYSIS
Test Normal Most Recent Result
Date
Admission Result
Date
Clinical Significance
Specific gravity
n/a n/a n/a pH 7.35-
7.45n/a n/a
Glucose 70-99 99 n/a normal
Protein 6.0- 8.0 7.0 n/a normal
Blood/RBC 3.76-5.20 3.82 n/a normal
Bilirubin 0.3-1.2 n/a n/a Bacteria n/a n/a n/a WBC 3.07-
11.77
7.10 n/a normal
Ketones n/a n/a n/a Clarity n/a n/a n/a ARTERIAL BLOOD GAS (ABG)
Test Normal Most Recent Result
Date
Admission Result
Date
Clinical Significance
pH
PACO2
PAO2
HCO3
BE
OTHER LABORATORY STUDIES
THERAPEUTIC DRUG LEVELS (digoxin, theophylline, phenytoin, vancomycin)Drug Normal
Level
Most Recent Result
Date
Admission Result
Date
Clinical Significance
n/a CARDIAC MARKERS
Test Normal Most Recent Result
Date
Admission Result
Date
Clinical Significance
CK (CPK) n/a n/a CK-MB n/a n/a Troponin
(TRO)
n/a n/a Page 6 of 14
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NRSG 3240 Fundamentals
DIAGNOSTIC TEST RESULTS:
Test Summary of findings for this client Clinical Significance
Chest X-ray Ultrasound Echocardiogram Abdominal series KUB Cardiac cath report
Pathology EKG/ECG CT Scan Other: xray- knee ap lat right. no acute findings. screws in
place.
the screws are in place and no new findings.
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NRSG 3240 Fundamentals
MEDICATIONSDrug Name – Generic
(Trade)
Theragran M Colace Ancef
Client’s ordered dose,
frequency, times & route
1 tab PO Qday 100 mg cap PO Qday 1 g IVP Q8hr
Action/purpose of drug Side effects Nursing Implications Why is this client taking themedication?
What outcome did you
observe for this medication
Drug Name – Generic
(Trade)
Lovenox Crestor Client’s ordered dose,
frequency, times & route
40 mg/0.4 ml inj SC Q24 hr 1 tab PO SMWF Action/purpose of drug lipid lowering. decreses
cholesterol and triglycerides.
Side effects abdominal cramps, rashes
rhabdomyolysis, constipation,
flatus and heartburn.
Nursing Implications dietary hx, ck levels,
administer with magnesuim,
avoid grapefruit juice. limit
cholesterol, carbs and alcohol.
Why is this client taking the
medication?
to lower cholesterol What outcome did you
observe for this medication
n/a
Drug Name – Generic
(Trade)
Client’s ordered dose,
frequency, times & route
Action/purpose of drug Side effects Nursing Implications Why is this client taking the
medication?
What outcome did you
observe for this medication
NUTRITIONType of diet: regular Percentage taken: Bkfst 50 % Lunch n/a %
Calories needed: 1800 Calories consumed: n/a
Fluid intake past 24 hours: 1294 ml Output past 24 hours 1290 ml
Implications of currentnutritional pattern uponhealth outcome/client needs.
n/a
OTHER PRESCRIBED TREATMENTS, PROCEDURES PERFORMED –
ORDER OUTCOME NURSING IMPLICATIONS
n/a n/a n/a
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NRSG 3240 Fundamentals
ORDER OUTCOME NURSING IMPLICATIONS
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NRSG 3240 Fundamentals
NURSING CARE PLANList diagnoses in ORDER OF PRIORITY 2. Use a separate table for each diagnosis. Include diagnositic category, related factors
(“related to”) and defining characteristics (“as evidenced by”) for all actual diagnoses. Include diagnostic category and related factors
for all risk diagnoses. Cite references for both diagnosis and the nursing interventions and rationales.
NANDA Diagnosis # 1: Infection related to right tibial plateau fracture as evidenced by admitting diagnosis
Measurable Client Goals:
• Subject
•Verb
• Conditioner/time
frame
Therapeutic Nursing
Interventions with Rationales
Interdisciplinary Team Roles.
Consider PT, OT, RT, ST, SW,
Chaplain, Dietitian, and MD.
Evaluation of Client Goals
Long-term goal: The patients
infection will get better before
they are discharged from the
hospital. The patient will learn
to ambulate with assistive
devices upon discharge.
Short-term goal: The patients
infection will not worsen on
my shift.
Assessment:
• Assess the patients vital
signs to make sure they are
not elevated.
• Assess the the patientswound to see severity of
infection to monitor and
make sure the infection
does not get any worse.
• Assess the patients pain
level and tolerance tomake sure to treat the
patients pain as well as
infection.
• Assess the patient for fluidloss from the wound.
• Assess the patients ability
to learn so you can inform
them of how to keep the
wound clean and
uninfected.
• Physical therapist to help
client learn to ambulate
with assistive devices.
• Ocupational therapist to
help client keep movementin foot.
• RN-to administer meds.
• MD- to prescribe meds
and treatments
• Case manager to plan for
discharge.
The goal identified for the
client was partially met
Changes need to the plan of
care: n/a
Treatment:
• Clean the patients wound
to ensure no moreinfections.
• Wrap the patients woundto make sure bacteria
cannot get it.
• Change dressing
frequently to make sure it
stays clean, dry and intact.
• Give the patient
medications to treat
infections and to treat pain.
Teaching:
• Teach the client theimportance of keeping
their wound site clean and
covered.
• Teach the patient about
risks for future infections
to prevent future
infections.
• Teach the client and their family how to do dressing
2 See Prioritizing Nursing Diagnoses handout in the Clinical Learning folder of the course web site.Page 10 of 14
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NRSG 3240 Fundamentals
changes so they can
continue to keep their
wound clean when they
are discharged.
• Teach patient how to
ambulate with crutches or
other assistive devices.
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NRSG 3240 Fundamentals
NANDA Diagnosis # 3: Risk for falls related to decreased lower extremity strength as evidence by right tibial plateau fracture.
(NANDA PAGE 312-313)
Measurable Client Goals:
• Subject
• Verb
• Conditioner/time
frame
Therapeutic Nursing
Interventions with Rationales
Interdisciplinary Team Roles.
Consider PT, OT, RT, ST, SW,
Chaplain, Dietitian, and MD.
Evaluation of Client Goals
Client will understand their risk for falls during my shift.
Client will relay back the
importance of getting help toambulate or get out of bed
during my shift.
Assessment:• Assess patients affected
foot so you can document
any changes and assess
their ability to be mobile.
• Assess clients ability to
ambulate with help to
make sure they do not do
anything that will harm
them any farther.
• Take blood pressure to
make sure they are not
hypotensive before making
abrupt movements.
•Physical therapist to help
client learn to ambulate
with assistive devices.
• Ocupational therapist to
help client keep movementin foot.
• RN-to administer meds.
• MD- to prescribe meds
and treatments
• Case manager to plan for
discharge.
The goal identified for theclient was met
Changes need to the plan of
care: n/a
Treatment:
• Administer meds as
prescribed to ensure theclient is being well taken
care of and the doctors
orders are being carried
out properly.
• Encourage client to use
call light to call for help so
they do not injury
themselves while they are
trying to move on their
own.• Encourage client not to
attempt to get out of the
bed so they do not harm
themselves by trying to be
more mobile than they are
capable of..
Teaching:
• Teach patient importance
of fall precautions so they
understand and do not
attempt to do things that
might harm them.
• Teach patient importanceof only ambulating with
help so they realize the
risks related to falls.
• Teach patient importance
of heel protectors to
protect feet from bed sores
and ulcers.
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NRSG 3240 Fundamentals
References
Use APA format and list all references cited in the care plan.
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