While utilizing the provided care plan template, which was given to you in week one, write a care plan on a newly admitted patient with a
1. Tracheostomy and a ventilator
PLEASE NO PLAGIARISM FROM OTHER STUDENTS PAPER ONLINE OR FROM ONLINE SOURCES. PAPER WILL BE CHECKED FOR PLAGIARISM WHEN SUBMITTED.(Tracheostomy and ventilator CAREPLAN Sample)
Tracheostomy and ventilator CAREPLAN Sample-Solution
| SEATTLE CENTRAL COLLEGE REGISTERED NURSE PROGRAM
NURS 142 BEHAVIORAL HEALTH CARE PLAN FORM |
DATE: | STUDENT: | Page 1 | ||||||
| RELEVANT LABORATORY VALUES | |||||||||
| PATIENT DATA | DIAGNOSES | Date | Test | Result | Normal/
Abnormal: |
Significance | |||
| Pt Initials: GP
Age: 80 years
Gender: Male
Admit Date:
Precautions: Risk of fall, harm to self
Level/Privileges: 3
Ethnicity: Unknown Reason for Admission:
Psychiatric History: Neurocognitive decline, Alzheimer’s type. |
Depression | ||||||||
| PATHOPHYSIOLOGY OF DIAGNOSES
Depression is common, but a serious medical illness that affects how people feel, think, and act negatively. Depression is associated with a depletion of the neurotransmitters serotonin, norepinephrine or dopamine in the central nervous system. This depletion or reduction contributes to the development of depressive symptoms in subjects at elevated risk of depression, especially people with MDD in full remission or individuals from a family with a history of depression. The reduction is also linked to mood congruent memory bias, altered reward-related behaviors, and inhibitory affective processing disruption. Depression leads to feelings of extreme sadness and loss of interest in activities once enjoyed.(Tracheostomy and ventilator CAREPLAN Sample) |
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| STUDENT PLAN FOR DAY | |||||||||
| Instruct the patient and family about depression, including the genetic and environmental links to the disorder. Teach them how to deal with grieve and hopelessness. Educate them about the need for the patient to continue taking prescribed medications, even if the patient feels better. Ensure that the family have contact information for the patient’s health care team, including the psychiatric practitioner and the patient can easily reach out to the care team at the facility. Document the patient’s behaviors, including signs of self-harm, sadness, grief, isolation, and eating and hygiene patterns. Record medication given and any adverse reactions. Document teaching provided to the patient and family, their understanding of that teaching, and any need for follow-up teaching.(Tracheostomy and ventilator CAREPLAN Sample) | |||||||||
| NURS 142 BEHAVIORAL HEALTH CARE PLAN FORM | Page 2 | ||||
| NURSING DIAGNOSIS #1
Grieving Related to: Actual loss
As evidenced by: Changes in activity level, detachment, disorganization, emotional distress, giving meaning of the loss, psychological distress
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EXPECTED OUTCOME/PLAN (SMART)
(List only 1 )
Patient will engage in self-care activities at his own pace. (Tracheostomy and ventilator CAREPLAN Sample) |
NURSING INTERVENTIONS
1. Ask the client about the losses that have happened in his life and how he views them
2. Allow the patient to recognize and express feelings and establish a connection between the feelings and the loss(Tracheostomy and ventilator CAREPLAN Sample)
3. Discuss with and educate the patient about the normal stages of grief and accepting the reality of related feelings, such as powerlessness(Tracheostomy and ventilator CAREPLAN Sample) |
RATIONALE/SOURCE
(for each intervention) 1. People tend to not recognize the significance of the loss and are often in a state of denial
2. Expressing feelings in a safe environment can help the patient handle unresolved issues somehow responsible for the depression. It also helps the client relate the feelings to the loss or event(Tracheostomy and ventilator CAREPLAN Sample)
3. It allows the individual to acknowledge these normal feelings and remove the negative effects, including guilt, caused by these feelings
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| NURSING DIAGNOSIS #2
Hopelessness Related to: burdensome depression symptoms, losses, and stressors
As evidenced by: loss of interest in life, inability to establish goals, negative ruminations, suicidal thoughts, and decreased verbalization
|
EXPECTED OUTCOME/PLAN (SMART)
(List only 1 )
Client will express feelings and acceptance of life events over which he has not control.(Tracheostomy and ventilator CAREPLAN Sample)
|
NURSING INTERVENTIONS
1. Assess client signs of hopelessness
2. Allow the patient to express feelings and perceptions
3. Express hope to the client with realistic comments regarding his strengths and resources(Tracheostomy and ventilator CAREPLAN Sample)
|
RATIONALE/SOURCE
(for each intervention)
1. It will help focus attention on aspects of the client’s needs
2. Recognizing feelings that underlie and facilitate behaviors allows the client to begin taking control of their lives
3. Clients can feel hopeless, but it is helpful to hear others express positively(Tracheostomy and ventilator CAREPLAN Sample) |
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| NURSING DIAGNOSIS #1 | NURSING DIAGNOSIS #2 | RATIONALE/SOURCE | |||
| Evaluation: | Evaluation: | ||||
| Met, the patient has embarked on self-care activities, including eating well and bathing. Allowing the patient to recognize and express feelings, establish a connection between the feelings and the loss, and educating the patient about normal stages of grief were effective interventions.(Tracheostomy and ventilator CAREPLAN Sample)
(Describe if and how expected outcome/goal was met or not met, and which interventions were effective in meeting the goal) Goal Met Yes:___ No:___ In Process:____ |
Met, the client expresses feelings and acceptance of life events that he cannot control, death in particular. Examining the patient’s signs of hopelessness, allowing him to express feelings and perception, and sharing positive expressions were effective in achieving the desired outcome.(Tracheostomy and ventilator CAREPLAN Sample)
(Describe if and how expected outcome/goal was met or not met, and which interventions were effective in meeting the goal) Goal Met Yes:___ No:___ In Process:____ |
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| NURS142 BEHAVIORAL HEALTH CLINICAL NURSING PROCESS FORM | Page 3 | ||||||
| MEDICATION LIST | |||||||
| TIME DUE | MEDICATION, DOSE,
ROUTE, FREQUENCY |
NORMAL DOSE | DRUG ACTION | SPECIFIC RATIONALE FOR PT | ADVERSE REACTIONS/ | NURSING RESPONSIBILITIES | |
| Galantamine | 8 mg PO qAM | It is a reversible inhibitor of acetylcholine esterase and amplifies the intrinsic action of acetylcholine on nicotinic receptors, causing enhanced cholinergic neurotransmission in the CNS.(Tracheostomy and ventilator CAREPLAN Sample) | Reduce memory loss or forgetfulness | Chest pain or discomfort, lightheadedness, dizziness, or fainting, shakiness in the legs, arms, hands, or feet, shortness of breath, slow or irregular heartbeat, and unusual tiredness. | Assess cardiovascular status, including baseline and periodic EKG and BP readings.
Monitor respiratory status, and reporting worsening COPD. Monitor drug interaction, especially with other cholinesterase inhibitors. Monitor appetite and food intake. Educate patient about side effects, possible adverse events, and when to report. Advise patient to report urinary retention, chest pains, difficulty breathing, dark stools, blood in urine, fainting, and/or palpitations.(Tracheostomy and ventilator CAREPLAN Sample) |
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Mental Status Examination – Using Memory Aid “OLA SAMI PAT JIM”
Orientation –
Oriented x3/4
Level of Consciousness –
oriented, awake, conscious, not alert
Appearance –
Dressed appropriately for age, wearing pajamas in the afternoon, slouched, head in hands, lacks eye-contact
Speech –
Steady, hesitates periodically when asked to remember something, slow
Affect –
Blunted, disinterested, preoccupied
Mood –
Sad, frustrated, anxious, depressed
Intelligence –
Able to answer questions
Posture –
Slouched, hunched
Attention Span –
Intact, engages in conversation without distractions
Thought content & process –
Organized,
Judgment –
Intact
Insight –
Intact, clear
Memory
Impaired, hesitates periodo when asked to pull from long or short-term memory
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