TRodriguez_D2Careplan_12082017.doc - Nursing 150 Clinical Packet Patient Assessment And Care Plan Instructions to student 1 Bring one copy of this

TRodriguez_D2Careplan_12082017.doc - Nursing 150 Clinical...

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Nursing 150 Clinical Packet Patient Assessment And Care Plan Instructions to student: 1) Bring one copy of this packet with you to clinical each week. 2) You will turn in a completed packet as assigned by your instructor. 3) Read the rubric! Each packet is Pass/Fail. You must meet the requirements listed to receive a Pass.
NURSING 150 CLINICAL ROTATION CLIENT ASSESSMENT AND CARE PLAN Client Initials: C.P. Room # D213 DOB: 08/15/1956 Age: 61 Years Gender: Male Admitted to facility Date: 11/28/2017 Resuscitation Status: Full Allergies: NKDA- Demerol intolerance (nausea and vomiting) Reason for Admission: Laparoscopic Gastric Bypass _______________________________________________________________________________ Social: M W S D Significant other, Next of Kin or POA for Health Care: Debra Parker ________________________________________ Occupation or former occupation: ___________________________________________________________________________ Primary Health Care Provider(s): Christina Tecarro Consultants/Specialists: Igal Breitman Medical Diagnoses: Diabetes Mellitus Type II, Sleep Apnea, Esophageal Reflux, heart murmur ______________________________________________________________________________________________________ Surgeries/Procedures and Dates: 11/28/2017: Laparoscopic Gastric Bypass ____________________________________________________________________________ _________________________________________________________________________________________________________ Current Physician/Health Care Provider Orders (Prescriptions for Care) ITEM TYPE THIS RESIDENT’S ORDERS RATIONALE Diet NPO To avoid stomach and intestines stretching and avoid ripping of stiches post gastric bypass Activity 1 assist with walker, up in chair at least twice a day Post : Laparoscopic Gastric Bypass I/O Monitored Monitor fluid and electrolyte balance VS Every 4 hours To identify possible complications after surgery such as perfussion Accu-Cheks 4 times a day- AC and HS Maintain control of glucose levels Foley indwelling urinary catheter To keep the bladder empty during surgery and to monitor output for the 1 st 24 hours after procedure NG N/A N/A STUDENT: Tonia Rodriguez Date of Care: 12/07/2017_________________
PEG/PEJ tube N/A N/A Wound Care / Dressing Change 1 st dressing change to be done by physician and change daily thereafter using clean gauze and steri strip To prevent infection and promote wound healing. Respiratory Treatments Incentive spirometer 10x per hour To keep the air moving and keep the lungs health post-surgery- prevention of atelectasis Tracheostomy n/a Suctioning n/a Chest Tube n/a Special Equipment Jackson Pratt Drain to remove fluids that build up in surgical area Lab orders Last checked 11/08/2017 to be checked again on 11/29/2017 in the A.M. Monitor blood loss, monitor electrolyte levels and blood glucose levels, kidney and liver function Other Sequential Compression Device (SCD) to be worn for 1 st 24 hours even when up in chair – per Dr Breitman DVT prevention and promote blood flow Rehab Services Activity or Treatment Plan & Schedule Rationale Physical Therapy Evaluation scheduled for 11/29/2017 to reduce pain, assess patients ability to perform daily activities, range of motion, function, and strength following procedure Speech Therapy n/a n/a Occupational Therapy N/A IV Access: Type Peripheral Site: left hand Last Dressing Change 11/28/2017 Last Tubing Change: Reason for IV access Venous access for fluid and medication administration IV fluids and meds Normal saline 0.9%, Cleocin 900 mg (once) Most recent Imaging Findings: (CXR? CT? MRI?)

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