Download BCIT Level 2 Nursing Care Plan - Alastair Thurley - VGH-care

BCIT Level 2 Nursing Care Plan
Date: March 4, 2011
Patient: Manning, B
Room: 200-1
Age: 51 F
PO1
Date of Surgery:
March 3, 2011
Type of Surgery:
MIS radical
nephrectomy
Potential
Problems
Diagnosis:
Right renal mass
PMHx:
Anxiety, bariatric, moderate smoker, HTN, arthritis, asthma, risk of OSA
Diet:
Treatments:
Nicotine replacement therapy
Activity:
AAT
PRN Medications:
Lorazepam, Ativan
VALIDATION PROCESS
ASSESSMENT
EVIDENCE
What are the
anticipated problems
for this patient and
what is potentially
causing these
problems. (due to or
related to)
Wednesday PM – How will I
assess each problem?
Epidural/Acute
Pain (Actual)
d/t surgery
d/t physiological
stress
1. Assess pt pain
behaviour. (grimacing,
guarding, wincing,
avoiding movement)
2. Assess pt pain level
on a scale of 1-10 &
LOTARP pain Q1hr
3. Assess pt’s last dose
of analgesic and
frequency
4. Monitor autonomic
responses (diaphoresis,
 HR,  RR, change in
BP, nausea, pallor, pupil
dilation)
5. Assess pt knowledge
or preference for the
array of pain relief
strategies available
6. Evaluate pt response
to meds/therapeutic
interventions
7. Careful monitoring of
therapeutic effect of
epidural. If her infusion
rate is increased, I will
(Adverse
cardiovascular
effects including
hypertension,
tachycardia and
increased cardiac
work may result
from
unrelieved pain.
Pain may also lead
to shallow
breathing and
cough suppression
increasing the risk
of retained
pulmonary
secretions and
atelectasis
potentially leading
to pneumonia)
Thursday PM – Data collected to indicate a valid
problem
Periphery:
Analgesics (NSAIDS,Gabapentin)
CNS:
Narcotics
Brain:
Anxiolytics (atrovan) or complimentary
therapy
Medications:
Salbutamol, ranitidine, heparin, cefazolin
INTERVENTIONS
EVALUATION/FOLLOW UP
Wednesday PM – What will I do for
each of the potential problems –
both nursing interventions and
medical interventions?
Thursday PM – What will I do Friday for each valid problem
Epidural interventions:
-Assess pain intensity Q1H
until pain controlled, then Q4H
-if pain control inadequate after
maximizing intervention- page
POPS
- BP/Pulse from start of
infusionQ30 minx3h; then
Q1Hx4
-Sensory level to temperature
Q8H while awake
-Monitor function Q4H while
awake ( ability to bend Knees)
-Postural BP/Pulse prior to
every ambulation (Assistance
with ambulation as required)
-Assess for local aesthetic
toxicity Q4H ( ringing ears,
peri-oral/tongue numbness,
dizziness, visual disturbances,
twitching)
Bupivacaine
- recommended for local or regional aesthetic. Ability
to separate sensory and motor blockage because its
affect on motor function varies with concentration.
With Bupivacaine admin Analgesia persists longer
than anaesthesia, postpones the need for post operative
narcotics. In combination with narcotics it is also used
in epidural patient – controlled analgesia.
Adult Max: 2mg/KG Onset: 1-10 min; Duration: 39; t1/2: 3.5
Standard Monitoring
RR&SS Q1Hx24h, then Q4H
Intensive Monitoring
( increased risk of respiratory
Hydromorphone:
Moderate to severe pain
Action: 7-10x more analgesic than morphine, shorter
duration of action
Less N&V than morphine although it induces
pronounced respiratory depression.
Onset: 15min (IM, SC); 30 min (PO)
Peak: 30-60 min; Duration: 4-5hr (IM< SC) t1/2:
2.6h. Metabolized in the liver and excreted in the urine
Plasma protein binding:60-80%
5 complications of an epidural
1.Resp Depression
Acute pain is
frequently
associated with
anxiety and
hyperactivity of the
sympathetic nervous
system
Pain has sensory
and emotional
components
Gate Control
Theory-Melzack
The interplay
among these
connections
determines when
painful stimuli go to
the brain:
1. When no input
comes in, the
inhibitory neuron
prevents the
projection neuron
from sending
signals to the brain
(gate is closed).
2. Normal
somatosensory input
happens when there
is more large-fiber
stimulation (or only
large-fiber
stimulation). Both
the inhibitory
neuron and the
projection neuron
are stimulated, but
the inhibitory
neuron prevents the
projection neuron
monitor her RR, SS, BP,
Pulse, Pain Intensity
Q1H X 5
depression)
RR & SS Q1Hx 48h, then Q4H
Following IV opiod bolus for
breakthrough pain assess:
-RR, SS, BP, Pulse, pain
intensity Q15 min x2 or until
stable
Following Epidural top- up
by pops anaesthesiologist
assess: ---RR, SS,BP, Pulse,
Pain Intensity Q15 minx 30
min or until stable
*Following increase in
Epidural Infusion Rate
Assess:*
-RR, SS, BP, Pulse, Pain
Intensity Q1Hx2, then resume
monitoring as previously
ordered
Notify pops and stop infusion
for the following:
-Systolic BP less than___mm
and or pulse less than ____ min
-RR less than 8/min
-Sedation scale greater than 2
-Numbness above nipples and
or inability to bend knees
After discontinuation of
Epidural infusion: Maintain
IV access for 24 h
After termination of epidural
infusion:
-assess pain intensity, -RR, and
SS Q4Hx 24h
-continue to hold any heparin
injections for 6 hours following
removal.
Guidelines for SS of 2:
-Check SS, RR, Pain level, O2
sat Q15 min x2
-Page POPS for orders
Acute pain interventions due to
incision and surgery
2.Hypotension
3.Urinary retention epidural
4.catheter migration to the intracellular or subdural
space
5. epidural haematoma and abscess formation
What is an epidural?
The epidural space lies just outside the special
covering or dura, which encloses the spinal
canal. An 'epidural' is a type of regional
anesthetic in which a needle is positioned
between the bones of the spine to allow the
anesthesiologist to insert a small plastic tube
(or catheter) into the epidural space. The
needle is then removed and local anesthetic is
injected through the catheter. This local
anesthetic moves (or diffuses) across the dura.
into the spinal canal, and temporarily stops
the spinal nerves from working, so that
sensation and movement in the area supplied
by the nerves does not occur. When the effect
of the local anesthetic wears off, sensation and
movement will return. If a weaker solution of
local anesthetic is used, then only painful
sensations will be blocked.
This is very useful for controlling pain and is
called epidural analgesia. Often continuous
infusions of local anesthetic solutions are
used, which allows the effect to be maintained
as long as required. The catheter may be
placed in the upper back (thoracic spine) or
the lower back (lumbar spine), depending on
where the effect is needed.
from sending
signals to the brain
(gate is closed).
3. Nociception (pain
reception) happens
when there is more
small-fiber
stimulation or only
small-fiber
stimulation. This
inactivates the
inhibitory neuron,
and the projection
neuron sends signals
to the brain
informing it of pain
(gate is open).
Cancer pain:
-Cancer cells
(tumours) that grow
and damage parts of
the body can cause
pain. This is the
most common cause
of pain in many
people with cancer.
-A tumour growing
within a bone or
muscle crowds out
healthy cells nearby,
and may cause pain.
-There may be pain
if a tumour is
growing against or
inside an organ,
such as the liver.
-Pain can also be
caused by a tumour
pressing on and
damaging a nerve
-cancer treatments
such as surgery,
radiation therapy,
* help pt into a comfortable
position. Provide pt with a
heating pad or warm blanket to
help alleviate pain.
*administer appropriate
analgesic if pt is due for next
dose. (Refer to pops list and
WHO pain scale). educate pt to
report pain, especially if it is
not controlled.
*evaluate the pt’s response to
pain and medication and
medications or therapies aimed
at relieving pain. (Q1hr)
* provide rest periods to
facilitate comfort, sleep and
relaxation. Can also provide
distractions such as
conversation
*Assess and document the
intensity of the pain and each
new report of pain at regular
intervals (systematic ongoing
assessment and documentation
provide the direction for pain
treatment plans and
adjustments based on the pt’s
response)
chemotherapy or
biological therapies
may cause pain.
o
Neuropathic pain
- pain in which the
underlying
pathology is
abnormal
processing of
stimuli in the
peripheral or CNS.
-Results of some
injuryto the
peripheral reseptors,
afferent fibers,
CNS, or an
impairment of the
nervous system.
-Can be described
as shooting,
burning, stabbing,
and follows a
radicular or
radiating pattern
-Caused by trauma,
inflammation of
metabolic disease (
diabetes), infections
such as herpes
zoster, toxins, and
neurologic disease
Risk of Electrolyte
Imbalance
d/t nephrectomy
d/t decreased
electrolyte uptake
due to decreased
kidney function
Pathophysiology:
Electrolytes are
substances that
become ions in
solutions and have
1. Assess for
hyper/hypoatremia
(sodium levels)
2. Assess for
hyper/hypokalemia
3. Assess for
hyper/hypomagnesemia
4. Assess for
hyper/hypocalcemia
5. Assess for
hyper/hypophosphatemai
6. Assess for change in
VS (BP, dysrithmia,
1. Administer/encourage small
frequent meals as tolerated. If
decreased due to discomfort,
small meals will be easier to
tolerate.
2. Administer appropriate
electrolyte if deficiency is
present (sodium, calcium,
potassium)
3. Administer diuretics for fluid
overload as ordered (note pt is
allergic to sulfas thus lasix
would not be an option)
the capacity to carry
positive or negative
electrical charges.
Electrolytes
maintain voltages
across cell
membranes, and
cells use electrolytes
to conduct electrical
impulses (nerve
impulses, muscle
contractions). The
kidneys work to
keep the electrolyte
concentrations in
the blood constant
despite changes in
the body.
An electrolyte
imbalance is present
whenever there is an
excess or deficit in
the plasma level of a
specific ion.
HR)
7. Assess for change in
LOC
8. Assess for any weight
gain (edema)
9. Assess ins and outs
4. Continue to monitor ins and
outs Q1hr
5. Consult a dietician
6. Monitor serum electrolytes
as prescribed, assessing for
electrolyte disturbances:
Hypokalemia (potassium
greater than 5.5 mEq/l):
 Electrocardiogram
changes (increased T
waves, widened QRS
segment, prolonged
PR interval
 Bradycardic
dysrhythmias
Hyponatremia (sodium less
than 115 mEq/l):
 Nausea and vomiting
 Lethargy, weakness
Hypocalcemia (calcium less
than 6 mg/100ml):
 Perioral paresthesia
 Twitching, tetany,
seizures
 Cardiac dysrhythmias
Risk for
hypervolemia/fluid
volume excess
d/t increased water
absorption
d/t nephrectomy
d/t electrolyte
imbalance
Pathophysiology:
Fluid volume excess
represents an
isotonic expansion
of the ECF
compartment with
increases in both
interstitial and
vascular volumes.
Isotonic fluid
volume excess
results from in
increase in total
body sodium that is
accompanied by a
proportionate
increase in body
water cause by a
decrease in sodium
and water
elimination by the
kidneys.
Atelectasis
(potential)
d/t hx: smoking
d/t risk for OSA
d/t surgery
d/t hx: asthma
d/t shallow breaths
d/t pain
d/t lack of
mobilization
smoking increases
mucus secretions
and damages cilia
1. Assess for increased
bp, decreased hr, edema,
decreased urine output,
tachycardia, crackles.
2. Monitor intake and
output.
3. Monitor serum
electrolytes and urine
osmolality and report
abnormal values.
Increased hemoglobin
and hematocrite and
decreased blood urea
nitrogen (BUN) suggest
fluid excess. Urinespecific gravity is
likewise decreased.
4. Assess color and
amount of urine. Report
urine output less than 30
ml/hr for 2 consecutive
hours.
5. Monitor temperature.
6. Auscultate breath
sounds and heart sounds
for signs of fluid
overload. (sob, dyspnea,
tachypnea, orthopnea)
1. Encourage oral intake of
clear fluids 200cc/hr. Provide
oral fluids patient prefers. Place
at bedside within easy reach.
Provide fresh water and a
straw. Be creative in selecting
fluid sources (e.g., flavored
gelatin, frozen juice bars, sports
drink).
2. Weigh pt. daily and record
findings.
3. Record intake and output in
pt. chart to ensure input =
output
4. Administer IV medications
in least amount of fluid
possible.
5. Administer diuretics as
prescribed.
6. If peripheral edema is
present, move the patient gently
and reposition often.
Edematous skin is more
susceptible to breakdown.
1. Assess for  wbc
count
2. Assess for 
temperature
3. Assess oxygen
saturation  95%
4. Auscultate lungs:
listen for presence of
adventitious sounds, sob,
mild or sharp stabbing
pain in the chest,
diaphoresis, cyanosis,
rapid irregular pulse
1. Administer 3-4 litres of
oxygen as ordered by physician
prn
2. Assist patient with coughing,
deep breathing, and splinting
q1h
- improves productivity of
cough
3. Encourage increased fluid
intake
200 cc per hour
-fluid are lost by diaphoresis,
fever, tachypnea and are
Pathophysiology:
-Atelectasis is the
collapse of alveoli
or lung tissue. It
develops when the
alveoli become
airless from
absorption of their
air without
replacement of the
air with breathing.
-refers to the
incomplete
expansion of a lung
or portion of a lung
and can be caused
by airway
obstruction, the
increased recoil of
the lung caused by
inadequate
pulmonary
surfactant or lung
compression.
-The danger of
obstructive
atelectasis increases
after surgery.
Anaesthesia, pain,
administration of
narcotics, and
immobility tend to
promote retention of
viscid bronchial
secretions and thus
airway obstruction.
-Compression of the
lung tissue occurs
when the pleural
cavity is partially or
completely filled
with fluid, exudate
or blood.
- Bronchial lung sounds
are commonly heard
over areas of lung
density or consolidation.
Crackles are heard when
fluid is present.
5. Assess vital signs bid
for irregularities in bp
and pulse
6. Assess cause of
pleuritic chest pain (if
present) ( pleura
membrane irritated, rub
together, nerve endings >
pain)
7. Assess past and
current respiratory
status. (asthma, smoker)
8. Assess cough for
effectiveness and
productivity.
9. Assess respirations,
noting rate, rhythm,
depth, and use of
accessory muscles.
needed to mobilize secretions
4. Incentive Spirometer –
improves deep breathing and
prevents atelectasis
5x hour
5. Pace activities for patient
with reduced energy
6. Provide oral care
Secretions may cause nausea
and vomiting
7. Consult respiratory therapist
for chest physiotherapy and
nebulizer treatment
8. Administer salbutamol as
prescribed in dr. orders.
9. Elevate head of bed to 45 or
as is comfortable for pt.
10. Maintain pain control as
listed above in order to aid
patient in taking deeper
breaths, though should be used
with caution to avoid
respiratory depression.
11. Continue to monitor
sedation levels and document to
observe the trend line.
12. Encourage ambulation
Discharge
Teaching
1. Assess pt. and
family’s prior
experiences with surgery
2. Assess potential
anxiety surrounding the
procedures, since pt.
does already suffer from
anxiety and panic attacks
for which she takes
Ativan as needed.
3. Assess need to talk
with a social
worker/counsellor
4. Assess for financial
stability
5. Ask pt. if she has a
thermometer at home to
ensure avoidance of
fever.
6. Assess if pt.
understands medications
and need to take them.
7. Ensure pt. knows
when it is necessary to
call the Dr. or go to the
ER (infection, fever,
dehydration, inadequate
pain control)
8. Assess if the pt. has
food in the house so to
ensure proper nutrition
9. Ask pt. if they have a
I will start out by asking the
patient of her knowledge of the
surgery she has just undergone
and answer any questions she
may have regarding her health
status so as to alleviate any
anxiety she may have
surrounding the procedure. Pt.
has 5 children at home to take
care of and does most of the
work around the house. I will
need to discuss if she has a
significant other or someone to
help her around the house once
she is discharged. I will also
discuss her financial situation
and find out what her working
situation is. I will also talk
about who will be able to cook
for her children and provide
other needs after her discharge.
Ms. Manning has a past
medical history of being
bariatric, but has lost a
significant amount of weight
due to health concerns. She is
rated a moderate smoker so she
smokes 10-20 cigarettes a day.
She also suffers from panic
attacks. I will discuss what she
has been doing to cope with
this anxiety. Her chart says it is
The Red Book:
http://www.bc211.ca/
Walking Club:
http://walkers.meetup.com/cities/ca/bc/vancouver/
to encourage regular physical activity via walking (also
encouraged by the heart and stroke foundation)
Asthma
d/t cold weather
d/t physical
exertion
d/t medications
d/t allergens
Pathophysiology:
Is a chronic
inflammatory
disorder that is
characterized by
airflow obstruction.
When a
hypersensitive
individual is
exposed to a trigger,
a rapid
inflammatory
response with
subsequent
bronchospasm
occurs.
Proinflammatroy
cells, primarily mast
cells, signalled by
immunoglobulin E,
release
inflammatory
mediators that
produce swelling
and spasm of the
bronchial tubes.
This causes
adventitious sounds
(wheezing),
coughing, increased
mucus production,
and feelings of
dyspnea.
Eosinophils and
neutrophils rush to
regular exercise routine
and/or get moderate
amounts of exercise.
due to the loss of her father last
year.
1. Assess respiratory rate
>20, rhythm, depth and
O2 saturation on RA
>94% bid unless
experiencing WOB.
2. Assess for
conversation dyspnea.
3. Assess for dyspnea,
retractioins, flaring of
nostrils, and use of
accessory muscles.
4. Assess breath sounds
(WOB), and note
wheezes or other
adventitious sounds.
5. Assess pt’s LOC.
Use sedation score on
flow sheet. Reduced
LOC could indicate
hypoxia or hypercapnia.
Initially bp, hr and RR
increase. As the hypoxia
and/or hypercapnia
progress, bp and hr drop
and respiratory failure
may ensue.
6. increased heart rate
<100
7. Monitor for increased
restlessness, anxiety,
lethargy and somnolence
which may indicate early
onset of hypoxia.
1. Administer or allow patient
to self administer the
bronchodilator Salmeterol 1
inhalation bid or as ordered by
physician.
2. Continue to monitor sedation
levels and document to observe
the trend and base-line.
3. Elevate the HOB (semifowlers – high fowlers)
4. Encourage patient to
mobilize tid or as tolerated.
5. If patient has an asthma
attack  respiratory depression
due to morphine, administer
Naloxone – opioid antagonist
(binds to all 3 opioid receptors,
with the strong binding to mu
receptor) – for the complete or
partial reversal of narcotic
depression (respiratory
depression induced by opioids),
or the reversal of the effects of
sedation, and hypotension and
urinary retention. (Initial dose
of 0.4 mg to 2 mg is
recommended, this dose may
be repeated every 2 – 3 minutes
until full reversal is achieved or
to a maximum of 10 mg)
6. Teach patient deep breathing
exercises. Encourage client to
take @ least 10 slow deep
breaths q1hr.On the 3rd breath,
get pt to cough.
the area, and
additional cytokines
are released, some
of which are long
acting and result in
epithelial damage,
late-phase airway
edema, continued
mucus
hypersecretion, and
additional
hyperresponsiveness
of the bronchial
smooth muscle.
Reversals of the
airflow obstruction
usually occurs
spontaneously or
with treatment.