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Care Plan Med Surg 1 Theresa Richardson TGH SBN

Nursing Diagnosis: Knowledge deficit r/t unfamiliarity with information AEB request for more information Nursing Interventions to Achieve Goal Rationale for Interventions Evaluation of Interventions on Day care Provide References is Provided 1.Increase Knowledge of breast cancer, 1. Assess readiness to learn 1&2- To increase knowledge about the Patient was willing to learn and was given recognize need for treatment, and 2.Provide information regarding disease disease it is important to know that each pad and pencil to write down any understand treatments by the end of shift process, medication, and treatment. patient is unique and their values and questions she had when either the nurse or beliefs influence learning. Knowing this doctor were in the room so that she could will help understand how to provide the remember. Even after being explained the best information to the patient treatment and diagnosis she still did not fully understand what type of breast cancer she had. She will still need further teaching. Patient Goals/Outcomes 2. List resources that can be used for more information or support after discharge. 1. Provide patient with resource information on breast cancer 2. Provide the patient with her doctors information, support groups and any other information needed before discharge. 1&2- advocating for patients participation using community based case management has demonstrated improved clinical and financial outcomes for clients with complex chronic conditions The patient will be given a binder with a lot of information in it. Most of the information that was provided was her doctors information, breast cancer, and her treatment. It even had nutrition information in to. The binder has plenty of room in it so that when she meets with other disciplinary she can add to it. That way she has all her resources together. She will be receiving the binder later today.

Nursing Diagnosis: Risk for infection r/t immunosuppression AEB Chemo treatment Patient Goals/Outcomes Nursing Interventions to Achieve Goal Demonstrate appropriate hygiene measures by the end of shift 1. Use appropriate hand hygiene 2. Follow standard precautions and wear gloves during contact with blood, mucous membranes, non intact skin, or other bodily substances 1.Note and report lab values 2. Ensure patient is performing daily hygienic care

Rationale for Interventions Provide References 1. Infection prevention precautions are required to prevent health care associated infection 2. Prevent transfer of infection from one area to another 1. WBC can indicate infection 2. Daily showers or baths can help reduce the number of bacteria on the patient and oral cavity is a common site for infection 1. Widespread use of certain antibiotics have been shown to develop resistance. 2. UTIs account for almost half of all health care related infections 3. Fever, redness, warmth discharge are all signs of infection. The quicker the infection is identified the quicker it can be treated

Evaluation of Interventions on Day care is Provided 1. Proper hand hygiene was done bye nursing staff day of intervention 2. Gloved were worn for procedures that called for it.

Avoidance of infections by discharge

1. Labs were drawn and WBC was actually WNL 2. Patient was able to bathe herself independently 1,2,3- These are patient teachings that I did not observe to be done the day of care.

Prevent further metastasis

1. If infection occurs use antibiotics responsibly, use sparingly 2. Use alternatives to indwelling catheters whenever possible/ Use of sterile technique 3. Observe and report and signs or infection

Nursing Diagnosis:
Patient Goals/Outcomes Identify Nutritional requirements by the end of shift

Imbalanced Nutrition less than body requirement r/t side effect of chemotherapy
Rationale for Interventions Provide References 1. Omission of entire food group increases risk of deficiency

Nursing Interventions to Achieve Goal 1. Compare usual food intake with food guide pyramid noting slightly omitted food (My Plate)

Evaluation of Interventions on Day care is Provided


1. Patient was able to tell me her daily food intake at home compared to how she had been eating in the hospital. She recognized where she was missing things such as fruits from her diet and was skipping meals. 2. At this point in time the patient is able to eat on her own and does so.

Recognize factors contributing to underweight by the end of shift

2. If patient is able to eat make sure they a lot themselves enough time. If they are unable to feed them selves the are susceptible to protein- calorie malnutrition Be free from signs of Malnutrition by 3. Determine time of day when clients 3. The presence of nausea or vomiting can 3. At this time the patient does not discharge appetite is greatest and lowest. When low decrease appetite have any nausea or vomiting and is administer antiemetics 4. Signs are brittle hair, bruises. Dry skin, eating 3 meals a day. 4. Monitor for Signs of malnutrition pale skin, muscle wasting, rash, dis orientation, ect. These can be indicators of malnutrition Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching) 1. *Nutrition Teaching Staying Nourished Help patient identify the areas to change that will make the greatest contribution to improve nutrition and help her through her chemo treatments 2. *Chemotherapy information adherence By having the pharmasist come and talk to the patient about her specific chemo treatments. She can begin to prepare for the side effects of what may be to come. 3. Community Support Groups Social Support The patient did not seem to have to much of a familial support at home. During treatment and after it is important to have support outside of the hospital 4. Breast Cancer Information Increase Knowledge By giving the patient the binder with information. She will be able to look back on it if she has further questions and does not have a Nurse or Doctor with her. 5. Good Hygiene and Avoiding Crowds Infection prevention It will be important for her to understand that with the medications and chemotherapy that she will be taking her immune system may be weak and she will have to make sure to do these things as a preventative measure so that she does not get more sick.

2.Observe patient ability to eat