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Download BCIT Level 2 Nursing Care Plan - Alastair Thurley - VGH-care
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BCIT Level 2 Nursing Care Plan Date: Jan 27 PO DAY3 Patient: c Room: 400-1 Age: 24 Date of Surgery: Jan 24 post op day 4 Diagnosis: Testicular Cancer Treatments: chemotherapy/orchidectomy/PLND PMHx: Post Bleomycin chemo/Peripheral neuropathy/orchidectomy Medications: POPS/celecoxib/ Diet: CF<FF PRN Medications: Activity: AAT Type of Surgery:Right PLND Potential Problems What are the anticipated problems for this patient and what is potentially causing these problems. (due to or related to) Risk of Atlectesis D/T: Anaesthesia|:causes impaired gas exchange and muscle paralysis and lungs can collapse Narcotics: can depress breathing Bleomyocin chemotherapy can produce lung problems Stress response: pain from surgery can prevent patient from breathing deeply VALIDATION PROCESS ASSESSMENT EVIDENCE Wednesday PM – How will I assess each problem? Thursday PM – Data collected to indicate a valid problem Ausclate lung sounds in the back Low Air Entry to lung bases Assess O2 SAT and WOB Patient on bleomycin therapy Assess pain and rate pain on scale of 1-10 Patient complaining of pain Assess is patient knows deep breathing and coughing and Patient is on oral narcotics how effective it is Assess if patient knows how to use spirometer Asses if patient is ambulating Assess for chest pain/SOB/cyanosis/rapid irregular pulse/anxiety INTERVENTIONS Wednesday PM – What will I do for each of the potential problems – both nursing interventions and medical interventions? Keep head of bed at 30 degrees Encourage deep breathing and coughing 10 times q our using spirometer Place spirometer at hand Encourage position changes in bed and ambulation Control pain with analgesics and narcotics to reduce the stress response Splint the incision when coughing to help reduce pain during breathing and coughing exercises Maintain adequate hydration 200cc per hour Administer 02 if necessary Get doctors orders for inhalers if necessary X-ray or ct scan of the lungs or chest if necessary EVALUATION/FOLLOW UP Thursday PM – What will I do Friday for each valid problem Pain due to: Surgery incision Peripheral Neuropathy IV, Catheter, and Epidural insertions Edema and swelling from removal of lymph nodes from groin area Removal of epidural and weaning of PO meds Ask patient to rate pain on scale of 1-10 Patient complained of pain of 4/10 Teach patient how to use PCA if provided Patient said that pain was decreased Perform LOTARP Assess for discomfort due to edema in the legs Patient expressed difficulty in ambulating due to pain Teach patient how to ambulate in order to prevent further pain Ask patient if the analgesics/narcotics are working Patient asked for pain killers Teach patient deep breathing for relaxation Risk of infection D/T: Low WBC count from chemotherapy and immunosuppressant Risk of infection at the incision site due to mechanical disruption of tissue and skin IV,Catheter,Epidural sites of insertion Stress response Monitor input and output every hour Continue to monitor pain every hour Administer narcotics/analgesics as prescribed Administer PRN narcotics/analgesics Assess Vitals for tachycardia, increased respiration, and high BP Assess acid reflux/ GI bleed Place legs on pillow and apply TED stockings to relieve discomfort from swelling Patient had slight fever the night before Provide ice packs Notify physician if output is less than 30 cc per hour or if urine is amber and has odour Monitor color/clarity/odour of urine Assess lab results for WBC count Assess for signs of fever with regards to last dose of analgesic(time/dose)/take Temp at start of shift and twice a day Assess IV,Catheter, Incision sites for signs of infection: Purulent, swelling, redness Notify physician if WBC count is low and/or fever is present Get doctors orders for C+S if purulent is present or for urine sample Chest X-ray if coughing/low AE to bases/crackling Sputum sample if yellow sputum present Stool sample if diarrhea is present Assess all dressings to see if dry and intact Osculate the lungs for signs of infection: crackles, low AE Assess for coughing Assess for diarrheal Administer antibiotics as ordered (bleomycin ?) Maintain gravity drainage for catheter Maintain surgical asepsis for surgical site and IV,epidural, and Catheter sites Assess patients orientation for signs of UTI Encourage fluid intake 200cc q hr Provide thorough peri care and catheter care Provide Tylenol if fever is present Provide patient teaching o catheter care Risk of N&V due to: Anaesthetics Narcotics Assess for sign of gagging and welching Assess for paleness/cool and clammy skin Assess appetite NPO until BS return (or full fluids) No signs of fever Temp was normal Wbc count is normal Lungs are clear No swelling/redness around insertion sites and incision site Catheter draining clear/odourless fluid Ingestion of fluids or food before peristalsis returns Chemotherapy Assess bowel sounds Assess output due to vomiting Start on clear fluid with IV until patient can tolerate fluids then remove IV Administer antiemetic as prescribed Metoclopramide (maxeran), Gravol, Prochlorperazine,ondanterin Provide mouth care Assess for BS regularly Apply cold cloth to head Dim the lights Discharge Assess marital status Assess if he has a place to stay at Assess if he is staying with someone or someone is staying with him Ask if someone will be accompanying him at time of discharge Ask if patient needs transportation Assess if patient has money If patient had food at home If patient has thermometer at home Provide ginger ale Maintain active listening with patient Sit down when asking questions Ask for family members or friends to accompany patient at time of discharge Provide patient and family teachings on risk factors,priscriptions and follow-ups
