Nursing Care Plan

MS Care Plan Client Initials:

JBA

Allergies: NKA Code Status: Full code

Room #: 5131 Wt: 80 kg (176 lbs.)

Age: 70

Gender:

Ht: 172.2 cm (5’6”)

M

BMI: 27

Admit Date: 11-05-11 Admitting Diagnosis/Symptoms: Lower left extremity DVT (Left knee to groin) DVT can occur as the result of several combined events, including venous stasis, injury to the vessel wall, and the coagulation rate is altered. These conditions cause the formation of a blood clot, which becomes dangerous when the clot fragments and occlude the vessel. Complications of DVT include increased venous pressure, increased distal pressure, fluid stasis, and edema. (Smeltzer 2008) Current Medical Dx: LLE DVT w/ IVC filter placement An IVF filter (or umbrella filter) is inserted to prevent recurring pulmonary embolisms. The device is inserted through the internal jugular vein and advanced into the inferior vena cava, where it is opened and operates as a filter for the bloodstream that prevents large thrombi from passing through. (Smeltzer 2008) good explanations here and with PMH PMH/PSH: Polycythemia vera: (Bone marrow disease that leads to an abnormal increase in the number of blood cells. WBS and platelets are also increased. Thrombosis is a complication of this disease.) RLE DVT in 2008: (Formation of a blood clot in a vein. This is the pt’s current issue, though now in the opposite leg. PMH of past DVT and polycythemia identify pt is at higher risk for venous stasis, vessel wall injury, and hypercoagulability. ) Prostatectomy: (Total removal of prostate gland in 2006. Denies complications from surgery.) Appendectomy: (Total removal of appendix in 1990s. Denies complications from surgery. History of abdominal surgery is associated with thrombus/emboli). Social history (ethnicity, occupation, marital status, family support, living situation): White; married w/ grown children; retired; financially independent and fully mobile.

Relevant Medical Orders VS freq: q4h Diet: Coumadin diet Blood sugars: N/A diet what would this be? Activity: No restrictions Oxygen: RA Respiratory Tx: N/A Dressing Changes: q4d Other relevant orders: Continuous telemetry (baseline HR 87 & sinus rhythm with no ectopy, meaning all heart beats originate from the proper place in the heart.

Safety & Communication Primary Language: English Special Communications Communications Needs:

None

Translator required: N Hearing aids at BS: N

Sign Language Interpreter Required: N Isolation: N/A Falls Risk Score : Min. fall risk Aspiration Risk : N/A Bleeding Precautions: Yes. No aspirin; soft toothbrush; electric razor only; report constipation.

Assessment Physical Assessment Findings VS BP 131/76 HR: 83  T: 98.5 O2 Sat: 98% on RA

Analysis of Findings (Normal (Normal or not? What is is the significance of abnormal findings?) Normal, though BP is high, when compared to baseline BP of 140/80 and no history of HTN.

General appearance Well groomed and pleasant Behavior and speech appropriate Pain Pt reports pain at 0 on a scale from 0-10 Neuro/Psych A & O x 3 to person, place, and time Moves all extremities Reports no dizziness CV Venous thromboembolism Anticoagulation therapy: Heparin IV +1 edema on LLE; no edema present elsewhere on body HR 83 BPM, Rhythm regular No S3, no S4 or other extra sounds, no murmurs No visible pulsations, no heave or lift. Palpated apical impulse in 5th ICS and MCL, no thrill Capillary refill >3 seconds Respiratory RR 18, even and unlabored BS CTA, no adventitious sounds O2 Sat: 98% on RA

Normal Weight appears normal though BMI slightly high Normal

GI Abdomen soft and NT, BS present in all four quadrants. No bruits. Abdomen flat and symmetric with no apparent masses. Reports 0 abdominal pain on 1-10 scale.

Normal

GU Continent, no catheter

Normal

MS Full ROM, no pain with walking. Can walk without assistance. Full mobility. Integumentary Purple bruise approx. 4 in. x 2 in on RU arm

Normal

Normal

Pt monitored for improvement of edema in LLE; monitored for response to anticoagulant therapy.

Normal

Monitor IV sites. Monitor bruises for progression; risk for

Pink-red bruise on center thorax, 3 in. x 3 in. Pt reports “I bruise easily.” Skin WD and intact except in IV therapy sites IV Central line with 1 lumen, RT int. jugular Peripheral IV in right antecube Skin around both insertions WDI. Dressings on neck and RU extremity CDI.

impaired skin integrity or pressure ulcers.

Care should include dressing changes according to hospital protocol, which includes strict sterile technique. If  dressings become saturated with blood r/t to patient’s treatment with anticoagulants, notify physician.

Laboratory Tests Lab Test

Normal Values

Partial  Thromboplastin  Time (PTT) BID

60-70 seconds

Prothrombin  Time

PT: 11-12.5 seconds; INR: 0.81.1

Patien Significance of Result t Result 92.3 Used to determine how long it second takes for the blood to clot. s (MedLine Plus) Monitors the effects of treatment with Heparin, an anticoagulant. PTT level used to determine dosage of Heparin, according to a sliding scale. The sliding scale states that if the PTT is >90, it should be held for 1 hour and then restarted at a reduced rate. If the PTT is 60-70, the medication should be held. PT: PT is used to evaluate the 19.71 adequacy of the extrinsic system second and common pathway (factor 1: s; INR: fibrinogen, factor 2: prothrombinin, 1.61 and factors 5, 7 and 10) in the clotting mechanism. This is a common test for people with thromboembolic disease and being treated with Coumadin. PT is used with PTT to determine the function of coagulation factors. (Pagana p. 448)

Diagnostic Tests Test

Reason for test Venogram. This Suspected is a contrast DVT enhanced x-ray study of the venous system of an extremity. (Pagana p. 1139) Telemetry Monitor continuous HR r/t DX of  DVT

Results/ Findings DVT knee to groin in LLE.

Significance of  Results Pt should begin anticoaglulation therapy

Sinus rhythm with no ectopy.

Pt has no new CV problems related to current medical DX of  DVT.

Drug

Dose

MEDICATIONS Freq Rte INDICATIONS and Nursing Considerations (side effects, adverse reactions, interactions)

Oxycodone

5/325 mg

q4h PRN

PO

Heparin/D5W

Coumadin

25,000 units/5 mL (500 mL) 5 mg

q8h

PO

Protonix

40 mg

BID

PO

Ambien

10 mg

PRN

PO

Opio pioid anal analge gesi sic c use used d for for mo modera derate te to severe pain. Action unknown, binds with opioid receptors in the CNS, altering perception of and emotional response to pain. Adverse effects include bradycardia, respiratory depression, constipation, nausea, vomiting. Do not use with products containing aspirin, or MAO inhibitors. Nursing considerations include reassessing patient’s level of  pain at least 15 and 30 minutes after administration. Drug is potentially addictive. Instruct patient to take drug before pain is intense. (Nursing Drug Handbook pp 1017-1019) Draw blood to determine baseline coagulation levels. What is heparin actually used for? Anticoagulant for deep vein thrombosis. Adverse reactions include fever, hemorrhage, hepatitis, rash, and anaphylactic reactions. Draw blood to determine baseline coagulation levels. Drug interactions include many medications, including anabolic steroids, NSAIDs, salicylates, and thyroid drugs. Provide teaching to patient about foods to avoid. Patient must monitor the daily intake of vitamin K. Avoid all IM injections. (Nursing Drug Handbook pp. 14031406) Antiulcer and proton pump inhibitor for gastroesophageal reflux disease. Give drug without regard for food. Don’t crush or split tablets. Drug inhibits proton pump activity by binding to hydrogen-potassium adenosine triphosphase, located at the secretory surface of parietal cells. Adverse Reactions include hyperglycemia, hyperlipemia. Drug interactions include St. John’s Wort. Patient may be more sensitive to sunlight. Instruct patient to take exactly as prescribed and at about the same time every day. (Nursing Drug Handbook pp 1040-1041) Hypnotic and controlled substance schedule IV. For the short-term management of insomnia. For rapid

*Ordered mid-shift to begin the patient’s discharge process. Patient was taken off Heparin drip two hours after the Lovenox shot was administered.

Nursing Diagnosis #1: Ineffective tissue perfusion (peripheral) (LWW pp. 608-614) R/T: In I nterruption of venous flow AEB: DV D VT in LLE +1 edema in LLE PTT lab values abnormal Overall goal (measurable) (measurable): By the end of shift, patient will demonstrate increased perfusion AEB lab results WNL; decreased swelling in LLE according to measurements and assessment; pt free of pain and a nd discomfort according to 0-10 scale. Interventions:

Rationale for Intervention:

Administer medication as ordered by physician and monitor effectiveness.

Medications will help the patient return to baseline levels, but need to be monitored due to serious side effects. Monitor lab values to assess Lab values reflect progress of  effect of anticoagulant therapy the patient’s venous flow and and report lab values outside the peripheral tissue perfusion. desired range. HB/Hct

Educate patient on avoiding activities that could cause bruising and bleeding.

Bleeding can become a medical emergency due to anticoagulant therapy.

Monitor swelling in LLE and check for pedal pulses. Monitor pain associated with edema (per pt’s earlier report of feeling pain in LLE with the onset of edema, before treatment).

Leg measurement measurement discrepancies of more than 2 cm warrant further investigation. Swelling or lack of swelling indicates whether venous flow is efficient.

Education (pt/family): Discuss relevant risk factors.

Discuss care of LLE with regard to DVT and edema.

Educate client about reportable symptoms, including any changes in pain level, difficulty walking, etc.

Discharge Planning:

Expected Outcome: (Measurable) Medications will work effectively and improve the patient’s condition, with no notable side effects. Patient’s PTT levels will be within the normal range. Other related lab values (PT and INR, HCT/HB) also within normal range. Patient will verbalize an understanding of  precautionary measures. Pt reports no pain, and there is no tenderness or swelling on the lower extremities.

Rationale: Information necessary for client to make informed choices about remedial risk factors and lifestyle changes.

Expected Outcome: Discussion regarding risk factors will continue until patient demonstrates accurate knowledge of risk factors. When circulation is Client will recognize impaired, changes in how to care for sensation place client at risk affected extremity. for injury. Reporting symptoms will Pt will verbalize an provide opportunity for understanding of the timely evaluation and importance of early intervention. interventions. Rationale:

Expected Outcome:

What is anticipated length of stay? Where is pt being discharged to? What support do they have and/or need? Patient was discharged on 11-7-11, the day I was in the hospital  with him. Work toward discontinuation of  With lab values within Heparin treatment Heparin drip so that client can be normal ranges, the client will be successfully discharged, per physician order. should have the option of  discontinued with no treatment with a method complications. that is convenient for life after discharge.

Nursing Diagnosis #2: Readiness for enhanced self health management (LWW pp. 425428) R/T: Prevention of DVT recurrence AEB: Pt expresses desire to manage the illness. Verbalizes no difficulty w/ prescribed regimens. Describes reduction of risk factors. Overall goal (measurable) (measurable): Before being discharged, patient will demonstrate proactive management by anticipating and planning for eventualities of condition or potential complications. Interventions: Identify individual’s expectations of  long-term treatment needs and anticipated changes.

Identify any concerns or underlying issues related to the patient’s health or mental status.

Education (pt/family): Explore with patient areas of health over which each individual has control and discuss barriers to healthy practices.

Rationale for Intervention:  This allows the nurse to evaluate whether the patient’s expectations of  long-term treatment are accurate, or if he needs further teaching. Secondary issues could have an effect on the patient’s ability to follow a medication or therapeutic regimen.

Rationale:  This education will help the client plan to improve health practices.

Verify client’s level of knowledge and  This provides the understanding of therapeutic patient/nurse an regimen. opportunity to ensure accuracy and competency competency for future learning.

Expected Outcome: (Measurable) Patient will express accurate knowledge of what to expect from long-term treatment. Patient will report no secondary problems that could interfere with the success of a therapeutic regimen.

Expected Outcome: Patient will verbalize foods and activities that could interfere with a full recovery or that could cause a recurrence. Patient will provide a high level of  knowledge about the therapeutic regimen.

Discharge Planning: Rationale: Expected Outcome: What is anticipated length of stay? Where is pt being discharged to? What support do they have and/or need? Patient was discharged 11-5-11 with medication orders. He was discharged due to a PTT value within normal limits. Patient still had +1 edema on LLE but reported 0 pain on 0-10 scale. His wife was with him at discharge and drove him back to their home. Provide teaching on medications Patient must follow Patient will ordered by clinician; including medication regiment and demonstrate adverse effects; precautions; report and side effects such proactive

dosages; routes; and when to take the medication.

as bleeding, immediately to physician.

Provide teaching on any special diets related to the medications ordered.

With Coumadin therapy, the patient must monitor daily intake of vitamin K; no more than 120 mcg of vitamin K  should be ingested per day. Also, avoid cranberry juice, as it might increase the risk of bleeding.

management by anticipating and planning. Patient will verbalize how to properly follow the restricted diet.

References

Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. (2008). 23 & 31. Brunner 31. Brunner & Suddarth's textbook of medical-surgical nursing (11th nursing (11th ed., p. 666 p. 1005). Philadelphia: Lippincott Williams & Wilkins. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nurse's (2010). Nurse's pocket guide diagnoses,  prioritized interventions, and rationales (12th ed.). Philadelphia: F.A. Davis.  Lippincott's nursing drug handbook 2012. 2012. (2012). Philadelphia, Pa.: Lippincott Williams & Wilkins. Pagana, K. D., & Pagana, T. J. (2010). Mosby's (2010). Mosby's manual of diagnostic and laboratory tests (4th ed.). St. Louis, Mo.: Mosby Elsevier. Partial thromboplastin time (PTT): MedlinePlus Medical Encyclopedia. National Encyclopedia. National Library of Medicine - National Institutes of Health. Health. Retrieved November 10, 2011, from http://www.nlm.nih.gov/medlineplus/ency/article/003653.htm Polycythemia vera - PubMed Health. National Health. National Center for Biotechnology Information. Information. Retrieved November 10, 2011, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001615/