Answered step-by-stepI need nursing care plan 2. this is sce
Answered step-by-stepI need nursing care plan 2. this is scenario, and then I’m done…I need nursing care plan 2. this is scenario, and then I’m done nursing care plan1. So, you can make nursing care plan 2 by referring to the scenario and nursing care plan 1. Nursing Care Plan Assignment Case Study – Bacterial Pneumonia Linda Cerullo is a 56-year-old female who was brought to the hospital by ambulance on January 25, 2021. She presented to the emergency department and was diagnosed with left sided bacterial pneumonia. She has a history of iron deficiency, high cholesterol and hypertension. Past surgical history includes a caesarian section. She is taking ramipril 10mg PO, daily, atorvastatin 20 mg PO, daily and ferrous fumarate, 300 mg, PO BID. She has an IV of 2/3 & 1/3 running at TKVO in her left hand and is currently on IV ceftriaxone 1gm q24 hours plus Tylenol 1g, PO q6H prn for fever or pain. Linda is currently a secretary at a dental office. She lives at home with her husband and her adult daughter. She is Italian by birth and attends Roman Catholic mass weekly. At home the family speaks Italian but she is fluent in English. She is a full code status and has allergies to penicillin and vancomycin. Linda wears reading glasses. Today is the second day of her admission and you are the nurse caring for her on the medical unit. Upon your assessment her vital signs are temp 38.9 degrees Celsius, pulse (radial) 99 beats/min, RR 24/min, BP 118/79 and O2 sat 92% on 2L of oxygen via nasal prongs. You use your stethoscope to auscultate her chest and note decreased breath sounds to the LLL. She has a productive cough still and complains of being short of breath frequently. You ask her to sit up in the bed and notice that she becomes increasingly short of breath with bed mobilization. There is evidence of accessory muscle use (abdominal breathing). When asked if she has any pain the patient states “Yes I have pain when I breathe deeply or cough.” She rates her pain as 2/10 at rest and 6/10 when breathing deeply or coughing. You ask Linda when she first noticed the pain, “I first noticed the pain at 5am today”. Linda explains to you that she is feeling “unwell and tired”. She expresses frustration with her inability to sleep due to noise in the hallway at night. She also reports difficulty in getting into a comfortable position to rest as she normally sleeps on her side at home but gets very short of breath when lying down now. You notice she is short of breath during the interview. She can get no more than two words out before having to stop talking and rest.You compare that to the blood pressure that the previous nurse had obtained overnight from the patient. Her blood pressure overnight was 99/69. You recognize that this was lower than normal and ask her if she gets dizzy or lightheaded. She tells you that she is not now but sometimes when she gets up suddenly she does get dizzy and lightheaded. Linda also expresses frustration to you about being constipated, “I think I need some bran flakes. I haven’t had a bowel movement in 2 days”. She says that her medication makes her constipated but at home she is active and drinks more fluid to assist with this. Her abdomen does appear distended. You auscultate for bowel sounds and note that they are hypoactive in all 4 quadrants. You palpate all four of her abdominal quadrants and note they are slightly firm. She tells you that a month ago she was 135lbs but when came to the ER she was only 128 lbs. You ask her why she thinks she has lost weight and she says, “I haven’t eaten well since I started to get sick almost 2 weeks ago. I haven’t had an appetite and it takes a lot of effort to eat due to my shortness of breath.” Linda eats a low cholesterol, regular diet at home. Her bloodwork showed a WBC is 16.2 and her CXR shows consolidation to the left lower lung. Explanation:1. Patient information and assessment data collectionName Linda CeruloDOB/Age 56 yearsDate of Admission 25/1/2021Date of Assessment 26/1/2021Gender Identification FemaleAllergies Penicillin and VancomycinCode Status FullReligion Roman CatholicAdmitting Diagnosis Left-sided bacterial pneumoniaPast Medical History (diagnosis and date of diagnosis if possible) Iron deficiencyHigh cholesterolHypertensionPast Surgical History (diagnosis and date of diagnosis if possible) Caesarian sectionMedication Dose Route Frequency Reason YOUR patient is takingRamipril 10mg PO Daily To treat hypertensionAtorvastatin 20mg PO Daily Due to high cholesterol levelsFerrous fumarate 300mg PO BID Due to iron deficiencyCeftriaxone 1gm IV q24hours Bacterial pneumonia Tyenol 1g PO q6H PRN For fever or pain Vital SignsTemp HR (Pulse)BPRRO2Sat on R/A or amount of O2 38.999bpm118/79mmHg24breaths/min92%PainO = OnsetP = Provocation/Palliation Q = Quantity/ QualityR = Region/Radiation S = Associated S&ST = TimingU = UnderstandingLast Pain Medication?Effect? Pain began at 5am on day of assessment. Breathing deeply, coughing or sittingSharp Chest2/10 when resting and 6/10 when provokedPain started on day of assessment at 5amCaused by bacterial pneumoniaTyenolFor pain management Sleep & RestSleeping patterns(#h/d)NapsUse of sedationFeeling rested? Inability to sleep due to noise in the hallway at night Feeling “unwell and tired”MobilityGait, balanceIndependently ambulatoryW/C, Walker, Cane, CrutchesBed ridden Level of assistance required for movement (transferring, getting out of bed, walking) She has no immobility problemsShe can walk but feels lightheaded and dizzy when she gets upNoneNo NeurologicalLevel of ConsciousnessOrientationMental StatusGCS NumberCommunicationLanguageVision Hearing ConsciousCoherentFrustrated She can get no more thatn two words outSpeaks ltalian but sheis fluent in EnglishWears reading glassesNo abnormalitiesCardiovascular Radial pulse – rate, rhythm, strengthApical pulse – rate, rhythm Heart valve characteristicsCapillary RefillPeripheral Pulses X 4 BPEdema – description, extent, pitting or non-pitting Hypertension99 beats/min –118/79mmHg-Respiratory Respirations – Rate, Rhythm, Depth,Characteristics, Adventitious SoundsCough (productive or non-productive)SecretionsSuction RequirementO2 SaturationOxygen Therapy Bacterial Pneumonia24breaths/minDecreased breath sounds to the LLL, can get no more than two words Productive– 92% 2L of Oxygen via nasal prangGastrointestinal Abdomen shape, Scars, LesionsBowel soundsAbdominal palpation BM – last one, usual bowel patternsBristol bowel movement descriptionContinent/incontinent stoolHeightWeightBMIDietAmount consumedAbility to eat, physically and psychologically Frustraion about being constipatedDistendedHypoactiveSlightly firm2 days ago, abnormally slowHardContinent-128lbs, but 135lbs prior to admission-Eats low cholesterolRegular dietLoss of appetite due to shortness of breathGenitourinary Continent/incontinent urineCatheterCondition of Perineal SkinDischarge/odorUrine Assessment – characteristics, amount no information Musculoskeletal Upper body strengthLower body strengthROM Contractures/abnormalities no information Integumentary ColourTemperatureSkin TextureSkin TurgorLesions/woundsScarsBraden scale Ability to manage hygiene need no infromation except 38.9 38.9 *S-Selp-Esteem * E-Energy Level *L-Lifestyle*F-Family System*A-Affect*C-Culture*N-Needs: As expressed by the patient *G-Goals: As expressed by the patient -Emotional distress due to shortness of breath-She has lost weight: I haven’t eaten well since arriving to this hospital-I have no appetite and it seems to take a lot of effort to eat-Frustration about constipated, sleep-Worried about bowel movement-Feeling unwell and tired-Inability to perform ADLS-She works as a secretary at a dental office-She lives with her husband and adult daughter-Stressed by shortness of breath-She is italian and attends roman catholic weekly-She needs some bran flakes and water for constipation-To manage shortness of breath and constipationLab Values & Diagnostic Tests WBC 16.2CXR shows consolidation to the left lower lung Jan 25,2021 Jan 25,2021 Normal value4.5-11.0Tubes Insitu -IV ceftriaxone 1gm q24-left hand, 2/3+1/3 running af TKVO Safety Falls RiskSafety Measures – call bells, bed rails, seatbelts, lap trayPsychological Security Discharge Plans/CareDischarge teachingCare on discharge Risk for falls when she gets up due to lightheadedness and dizzinessAssist to get up and support when ambulating No information 2. Clustering of Data: priority 1- Respiratory BACTERIAL PNEUMONIArr 24/mindecreased breath sound to lllcan get no more than two words out before having to stop talking and restproductive cougho2: 92%oxygen THERAPY: 2l of oxygen via nasal prongs priority 2-Painpain when breath deeply or coughpain of 2/10 at restpain of 6/10 when breathing deeply or coughingchestsharpfirst noticed the pain at 5 am todayfor pain management takes tylenol priority 3-gastrointestinalconstipatedhypoactive bowel movementabdominal distensionslightly firmhard, continent stool128lbs, but 135lbs prior to admission priority 4-psychosocialaffect-worried about bowel moment, constipatedinability to perform adlsfeeling unwell and tiredwork as a secretary at a dental officelive with husband and daughterstress by shortness of breathattend roman catholic 3. Identifying priorityDifficulty breathingPain managementConstipationRisk for fallsFrom this I need nursing care plan 2Nursing Care Plan Part 2 (10%) Worksheet?* Nursing diagnosis/problem ? * 1 short term SMART goal/expected outcome ? * 4 nursing interventions with cited rationale ? * Evaluation 1.Nursing Diagnosis/Problem: Review the priority cluster and select the priority nursing diagnosis/problem. 2. List the signs and symptoms from your data collection that support the chosen diagnosis/problem.1)2)3)4)5)3. Priority Nursing Diagnosis/Problem Statement: 4. Short Term SMART Goal/Expected Outcome:S-M-A-R-T-5. Nursing Interventions: 6. Identify four appropriate Nursing Interventions with cited rationale Nursing Intervention Research-Based Rationale 7. Evaluation: Because you cannot truly evaluate the outcomes it will be important to provide an explanation about what, when and how would you evaluate the nursing interventions. 8. final care plan on the template belowNursing Care Plan Part 2 TemplateAssessment Nursing Diagnosis/ Problem Short Term SMART Goal/ Outcome Nursing Interventions Rationale Evaluation Health ScienceScienceNursingPNC 121Share
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