Nursing Care Plan Week 3

Student Initials_RMS
Occupation retired Religion/Culture Christian
ALLERGIES anti-coagulants
Medical Diagnoses Stage IV colorectal CA metastasized to vaginal mucosa, Diabetes Mellitus, Cataracts and retinopathy, CHF,
Hypertension, Morbid obesity, Asthma, Anemia secondary to CA tx
Surgery (if applicable) colon resection 3/08

Subjective and Objective Patient Goals/Outcomes Interventions based on Goals/Outcomes Implemented Evaluation based on
Assessments with with Rationale, including reference Goals/Outcomes
Related Nursing Diagnosis measurable criteria with page numbers

Assessed pt @ Goal met: pt maintained

S: ptreports hx of Assess s/s of dehydration
Patient will maintain 0800 adequate fluid balance
diarrhea x 3 years post • Poor skin Turgor
fluid balance within
colon resection 200 ml while in • Dry mucous membranes
hospital • Mental status changes
O: Pt incontinent of
diarrhea 8 x QS; partial
Rectal tube
thickness radiation burns Maintain strict I/O including stool inserted @
across panniculus, loss 1430
perineum and rectum; 2+ • Insert rectal tube per MD order
BL pitting edema
• Maintain Foley catheter

Risk for Deficient Fluid Made sure

pitcher was
Volume r/t active fluid
Encourage PO fluid intake kept full
loss
IV D/C’d 1310
 Administer IV fluid as ordered

Subjective and Objective Patient Goals/Outcomes Interventions based on Goals/Outcomes Implemented Evaluation based on
Assessments with with Rationale, including reference with Goals/Outcomes
Related Nursing Diagnosis measurable criteria page numbers

• Perform pericare Q one hour

S: pt reports 18 rounds Patient will exhibit no Rectal tube
and PRN Goal partially met: pt
of radiation tx; hx of further breakdown inserted @
• Treat existing breakdown with skin was cleansed and
DM neuropathy during hospital stay 1430; pericare
wound gel and cover with gauze throughout
dressed meticulously,
shift but this nursing student
O: large BL ulcers on • Insert rectal tube per MD order is aware that such care
bottom of feet; Pt will be impossible under
incontinent of diarrhea normal hospital
8 x QS; partial circumstanst
thickness radiation Patient’s foot wounds Dressing
• Change dressings QS changed @
burns across will heal without
1400
panniculus, perineum complications • Apply QS Accuzyme as ordered
and rectum; Enzyme ointment dissolves necrotic
tissue with little impact on intact
Impaired Skin Patient’s infection will skin
Integrity r/t radiation, be resolved • Maintain CTI dressing between
incontinence and changes
altered circulation Maintenance of a clean wound site
AEB foot ulcers and decreases number of organisms
destruction of and reduces spread of infection. Preulent d/c
pannicus and perineal noted at medi-
epidermis port site;
reported to
nurse/doctor
• Monitor for signs of infection
o take temperature Q 4
 hours
o drainage or heat at any
wound IV access
insertion site
o urine for malodor or
mucous
o oral cavity for white
coating
o assess for cough, sputum
production, or crackles
in lungs; notify
physician if any are
noted.
A fever or systemic signs such as
malaise may be the only sign of
infection, as the patient is unable to
produce the normal inflammatory
response due to
immunosuppression.
Patient had
limited
number of
• Ensure adequate rest, nutrition, visitors; diet
and hydration was adequate
• Encourage adequate nutritional
intake, especially of protein,
vitamin C, and iron.
Rest and hydration are both needed
for restoration of the body and to ;
adequate nutrient intake, especially
of vitamin C, protein, and iron, is
required for healing and tissue
repair.
Subjective and Objective Patient Goals/Outcomes with Interventions based on Goals/Outcomes Implemented Evaluation based on
Assessments measurable criteria with Rationale, including reference Goals/Outcomes
Related Nursing with page numbers
Diagnosis

Pt’s pain will remain
S: ptreports hx of under control:
diarrhea x 3 years post
colon resection
O: Pt incontinent of
diarrhea 8 x QS;
partial thickness
radiation burns across
panniculus, perineum
and rectum; 2+ BL
pitting edema
Acute Pain r/t
radiation burns and
skin ulcers
Assess for location, intensity,
quality, and precipitating factors.
Have the patient rate pain intensity Assessed Q 2 Goal not met:
using a pain rating scale. hours and PRN
during peri-care
Pt remained at 5/10 pain
Assess the status of affected
• The patient will level; jumped to 8/10
extremity, including pain at
verbalize that pain has during skin care and
operative site, tenderness to touch,
been relieved 30 transfers
temperature, and edema.
minutes after
interventions.
Administered
Administer analgesics, as ordered, Vicodin q4
on a regular schedule, not allowing hours,
pain to get intense. Keeping pain Ocycontin BID
medication at constant intervals
decreases pain level and keeps
pain manageable.
Assess effectiveness of
interventions to relieve pain and
modify tx as necessary Determines
whether interventions have been
effective in relieving pain or
whether new strategies need to be
employed.