CNL Care Plan: Primary Medical Diagnosis Definition

CNL Care Plan

Primary Medical Diagnosis Definition (1-2 sentences):

Pleural Effusion

Pathophysiology (2-3 sentences):

Signs and Symptoms of  Pleural Effusion (minimum of 4):

  DyspneaCrackles on auscultation
  Orthopnea 
  Chest pain 
  Tachycardia( Honan, 2019)
                        

Secondary Medical Diagnoses– Minimum of 4 required; all must be listed. Include definitions (1-2 sentences), pathophysiology (2-3 sentences each), and signs and symptoms (4 for each):

Even though this patient came to the hospital following discomfort from the clinical signs of pneumoperitoneum, the patient also.

Suffers from secondary ailments such as

Secondary Medical DiagnosisDefinitionsPathophysiologySigns and Symptoms
Anemia             
  Atrial FibrillationAtrial fibrillation is an irregular and rapid heart rhythm that can lead to blood clots, stroke, and heart failure (Honan, 2019).  In atrial fibrillation the upper chambers of the heart(atria) contract irregularly or quiver instead of beating effectively to move blood into the ventricles. Blood pools because of this, and the heart’s beat becomes rapidly erratic (Honan, 2019).● tachycardia  ● irregular HR  ● decreased blood pressure (BP) ● Palpitations ● SOB (Honan, 2019)
Hypothyroidism   
Gastroesophageal reflux disease (GERD)                 
Aspiration Pneumonia                 
Chronic Dysarthria           
Tonsil Cancer           

Diagnostics and expectations (labs and diagnostic tests with details including purpose, normal ranges for labs, and patient education for diagnostics; include a correlation of the findings to your patient [what do the findings mean])

Diagnostic Test & PurposeReference Range/Expected NormalResultsPatient EducationCorrelation to Patient
CT scan is used to detect and to monitor diseases and certain conditions such as cancer, heart disease (Honan,2019).Normal organs and tissue morphology. (Honan ,2019) Educate the patient on the procedure and explain the findings. 
Chest X-ray        
Viral Panel        40-320 IU/L   
WBC Purpose: the test is used to detect the number of WBCs in blood. This can help in detecting bloodstream infections (Honan,2019).4.5-11.0 K/mcl (Honan,2019)3.9Educate the patient on the reasons for elevated WBC levels. . (Hona,2019)A high WBC count indicates the presence of infection/germs and should be administered appropriate antibiotics. Patient is taking Amoxicillin.
Hemoglobin (Hb)-is part of a CBC and identifies an iron-rich protein (Hb) in red blood cells that carries oxygen to tissues. (Honan,2019)13.5-16g/100ml   (Honan,2019)7.3/dlPatient education: need for increased intake of fluids/food high in Iron, folic acid, and Vitamin B12 (Honan, 2019)The patient has a Low Hb, which indicates anemia and should be treated. Patient is taking vitamin B12
Blood Glucose test is used to identify blood sugar levels to diagnose and monitor diabetes. (Honan,2019)  65-100mg/dl (Honan ,2019)102 mg/dlPatient education includes importance of monitoring and controlling blood sugar to avoid diabetic complications (Honan, 2019) 
  EGFR 57    
Ca2+ levels test.              Purpose: it is a routine test used to examine the levels of calcium in the blood.(Honan,2019)  8.5-10.2 mg/dl   (Honan,2019)8.1mg/dl    Educate patient. to take calcium supplement by consuming foods rich in calcium, such as milk ( Honan, 2019)Patient has slight hypocalcemia and may be responsible for the weakness and muscle spasm.
Red Blood Cells. Part of a CBC is used to identify the numbers, size, and types of RBC in the blood (Honan, 2019)              4.32-5.72 million cells/mm3   (Honan,2019)3.85million cells/mm3Patient education on the importance of nutritional foods rich in Iron, folic acid, and Vitamin B12 (Honan, 2019)The patient has anemia and is being treated with vitamin B12 which is one of the three components for RBC formation.
Chloride test Purpose: The test examines the chloride ion levels in the blood (Honan,2019).              96-106mg/dl     (Honan,2019)117mg/dlEducate the patient on the dangers of elevated Cl as it affects fluid balance. (Honan,2019)Elevated Cl indicates acidosis or kidney failure. patient is encouraged to increase fluid intake (Honan,2019).  
CO2 Test Purpose: Part of the larger electrolyte panel tests and is used to measure the amount of carbon dioxide in the blood (Honan,2019).  23-29mmol/L (Honan,2019)26mmol/LEducate the patient on the findings of the test.Normal C02 levels may indicate kidney and lung function.
Magnesium test Purpose: Used to test the levels of Mg2+ ions in the blood (Honan,2019).1.3-2.3mEq/dl (Honan,2019)1.8mg/dlExplain the procedure to the patient and the findings. (Honan,2019)This shows that the patient value is within normal levels.
An-ion gap test. Purpose: To investigate the acid-base balance in the blood. It examines the electrolyte balance (Honan,2019).4-12mEq/L (Honan,2019)4mEq/LExplain the procedure and the findings of the test. (Honan, 2019)An-ion gap within normal range reveals a balance of electrolytes in the body. This patient values are within normal range.
Phosphorus test Purpose: used to examine phosphorous levels in the blood (Honan,2019).2.8-4.5mg/dl (Honan,2019)4.2mg/dlExplain the procedure and the findings of the test to the patient. (Honan,2019) 
Hematocrit. 36.9 % is a part of a CBC and identifies how much space red blood cells take up in the blood (Honan, 2019)  40-50% (Honan,2019)21.9%Educate on signs and symptoms of low hematocrit and encourage intake of food rich in Iron, vitamin B12, and folic acid (Honan,2019)This patient has low hematocrit readings and therefore low red blood cell counts. Patient is on anemia treatment regimen,
Platelets -is a part of the complete blood count (CBC) panel, and it is used to identify platelets in the blood (Honan, 2019)150-450,000/mm3 (Honan,2019)235,000/mcLEducate the patient on the procedure and the findings. Explain the effects of high or low blood platelet count. (Honan ,2019) 
Serum Sodium test It is used to examine the level of sodium in a patient’s blood (Honan,2019).          135-145mEq/L (Honan,2019)133mEq/LEducate the patient on the procedure and the findings. (Honan,2019) 
BUN test It is used to assess kidney function.10-20mg/dl (Honan,2019)32mg/dlExplain the procedure and the findings. (Honan,2019)  Elevated BUN levels show kidney dysfunction consistent with this patient.
Potassium serum levels are identified to determine organ failure, hypokalemia, and hyperkalemia (Honan,2019)3.5-5mEq/L (Honan,2019)4 mEq/LEducate patient on the importance of maintaining normal potassium levels as high or low potassium levels can affect the cardiovascular system and the presence of abnormal heart rhythm. Rich Potassium food such as Banana, Avocado such be encouraged. (Honan,2019) 
Serum Bicarbonate test. It is part of the larger electrolyte panel test that is used to measure electrolyte balance.                              22-28mEq/L (Honan,2019)17.0mEq/LEducate on causes of low HCO3 and the importance of maintaining the right acid -base balance by adhering to proper fluid intake and compliance to prescribed treatments. (Honan, 2019)This indicates metabolic acidosis as evidenced by low Serum Bicarbonate which indicates Kidney problem.
Troponin I- blood serum levels of cardiac forms of troponin is used in diagnosis of heart damage or heart attack (Honan, 2019).0-0.04 ng/mL0.19Provide the patient with information on how to identify and report any myocardial injury-related signs and symptoms as well as how to stop modifiable risk factors that will exacerbate the condition.  The patient has a past medical hx of atrial fibrillation and an increased troponin
EKG -monitors the electrical signals in the heart to identify heart problems and monitor heart health (Honan,Normal Sinus Rhythm Ventricular & Atrial Rate: 60-100 P-R interval 120ms-200ms QRS duration <100ms  QTC- 340-450mVentricular Rate93 BPM Atrial Rate93 BPM P-R Interval 140ms QRS Duration114ms QTC Calculation474msEducate the patient on identifying key signs and symptoms of a cardiac emergency such as chest pain, arm paresthesia, dizziness etc (Honan,2019)A prolonged QRS complex indicates hyperkalemia and presence of dysrhythmias
BNP-is used to diagnose or rule out heart failure (Honan, 2019)<100pg/ml (Honan ,2019)NeededEducation includes for the patient to report any signs and symptoms of heart failure that includes SOB, weight gain, edema, cough ( Honan,2019)BNP is used in diagnoses or to indicate the presence of heart failure in the patient

Note: Information derived from Honan, L. (2019) focus on Adult Health Medical -Surgical Nursing (2nd ed) Wolters Kluwer Health

         Lippincott Williams& Wilkins. Norris. T. (2020)

Medical/Surgical InterventionDefinitionRationalePatient EducationCorrelation to Patient
Chest Tube            
ThoracentesisA procedure in which a needle is inserted through the chest wall to aspirate fluid or air from the pleural space (Honan,2019A thoracentesis is used for removal of fluid and air from the pleural cavity, and aspiration of pleural fluid for analysis. Removal of fluid promotes lung expansion (Honan, 2019).Educate the patient to avoid activity that’ll put pressure on the lungs and cause further shortness of breath until the fluids are removed to improve lung compliance (Honan,2019On assessment, the patient was identified to have fluid in the pleural cavity, and it needed to be aspirated to avoid complications such as lung damage, pneumothorax, pleural thickening and infection
CT chest imagingA computerized scan of the chest cavity using visual acuity to assess the organs / tissues in the abdomen. (Honan,2019)To investigate the cause of the patient’s symptoms and confirm the presence of pneumoperitoneum. (Honan, 2019)Educated on the procedure and its importance, and the need for patient’s cooperation during the procedure. (Honan ,2019)CT helps understand the patient’s condition better. Patient’s result helped confirm primary diagnosis.  
  Percutaneous endoscopic gastrostomy (PEG)  A procedure in which a feeding tube insertion is placed through the skin into the stomach (Honan, 2019).The PEG tube allows the patient to receive their nutrition intake (Honan, 2019).Educate the patient to report an intolerance to medications and food administered through the tube and any abdominal discomfort (Honan,2019)The patient has a tracheal tube and is unable to receive nutrition and medication parenterally and requires a PEG tube that delivers nutrients directly to the GI tract
           

Note. Information derived from Honan, L. (2019). Focus on Adult Health Medical -Surgical Nursing (2nd ed). Wolters Kluwer Health

  • Lippincott Williams &Wilkins, Norris, T. (2020)
Nursing Management of Care InterventionsRationale for Determining Safety and Appropriateness of the InterventionOutcome Expected (Effectiveness)
  Aspiration PrecautionPatient is on NPO; the patient also produces tenacious secretions and is unable to clear it properly, putting the patient at risk for aspiration. Precautions include elevating the head of the bed, assessing feedingTo examine effectiveness of aspiration precautions the nurse must identify maintenance of oxygenation status, respiratory rate, no signs of regurgitation, shortness of breath as well as good quality of breathing (Honan, 2019).
Incentive spirometer Teaching      The patient underwent abdominal surgery and is at risk of developing postoperative atelectasis due to reduced lung expansion. Incentive spirometry encourages deep breathing and prevents respiratory complications (Doenges et al., 2022).This patient demonstrated proper incentive spirometer use, such as slow and deep inhalation using the device, and is performing regular spirometry exercises as instructed.
Monitoring of vital signs `  Regular monitoring of vital signs helps identify changes in the patient’s condition (Doenges et al., 2022).The patient will exhibit stable vital signs and improved neurological status. Persistent or severe alterations in vital signs or neurological status may indicate a need for additional medical interventions or diagnostic tests.
Patient and family educationIt helps them understand the patient’s condition, treatment plan, and self-care post-e   discharge, enhancing cooperation and support (Doenges et al., 2022).The patient and family will clearly understand the patient’s medical condition, treatment plan, and the importance of seeking appropriate follow-up care and support.
Nursing Management of Care InterventionsRationale for Determining Safety and Appropriateness of the InterventionOutcome Expected (Effectiveness)
Post-op surgical site monitoring and wound care.    Regular wound care and monitoring are essential to prevent infection and detect any early complications (Doenges et al., 2022).This patient shows no signs of wound infection, appropriate wound healing is going on, and absence of surgical site complications.
NPO Feeding: Jevity 1.5 Cal  To meet the patient’s dietary needs PEG tube feeding is used. NPO feeding is also necessary, to prevent malnutrition and restore nutrition, fluid and electrolyte levels that contribute to the primary diagnosis of anemia (Honan, 2019).Improvements in laboratory values such as hemoglobin, red blood count, fluid, and electrolyte levels are expected outcomes. Monitor the patients’ weight increase in and evaluate their ability to tolerate feeding as well as gastric residual after meals (Honan, 2019).

Note: Information derived from Honan, L.(2019).Focus on Adult Health Medical -Surgical Nursing (2nd ) . Wolters Kluwer Health

-Lippincott Williams & Wilkins, Norris.T. (2020)

Related IPEC Defined and explainedTeam Members IdentifiedRelationship to Patient Plan of CareNurse Responsibilities/Engagement Strategies
Interprofessional communicationThis is effective and respectful communication among team members and with the patient. It also involves having the capacity to communicate while being considerate of the needs of other team members (IPEC, 2016).Nurse, surgeon, medical officer, nutritionist, counselor, and social worker.Sharing patient information, discussing treatment alternatives, and collaborating requires good communication.   Physicians and Pharmacist are key players that nurses collaborate with on daily basis during rounds. This makes effective interprofessional communication imperative. The client’s has extensive comorbidities with numerous medications. Patient diabetes and obesity needs the expert intervention of and RD or diabetic educator to support with dietary assessment and modification. Patient comorbidities includes obesity and arthritis that could impair mobility and ADLs hence effective communication among the interdisciplinary health care team as well as with patient and family members to ensure adherence. Patient’s limitation includes immobility, incontinence, and basic care (bathing, toileting, and grooming) which will require effective communication and collaboration between nurse and unlicensed assistive personnel (UAP) to support with patients’ needs because ineffective communication may not highlight precautionary measures (patient BMI, wound area, IV lines, allergies) and compromise patient safety. Coordination with Social worker/care coordinator is imperative because the socio-economic needs and support system of the patient will be evaluated and with collaborative actions. (IPEC, 2019)  Nurses should attend team meetings, communicate patient information, and update patients’ conditions.   Nursing code of ethics Provision 2.3 emphasize on collaboration among interdisciplinary team to foster high quality care and patient-centered health care. This provision makes it imperative for transparency and open communication among those responsible for patient and health outcomes.   The nurse as the “key player” for coordinating, facilitating, and advocating for patient in their care, has the responsibility of applying the nursing process “ADPIE” in an effective, efficient, and quality patient-centered manner. Nurses have the responsibility of ensuring pertinent patient concerns, challenges, progress, and goals are discussed during rounds/hurdles with inter-disciplinary team. Likewise effective communication with incoming shift is imperative to assure safe. (IPEC,2019)  
Teams and TeamworkCollaboration with other healthcare providers to offer patient-centered care is this competency’s aim. It requires appreciating each team member’s skills and roles and actively contributing to yield better patient outcomes (IPEC, 2016).Nurse, surgeon, medical officer, nutritionist, counselor, and social workerSuccessful cooperation means that each member provides their knowledge to treat the patient’s acute medical conditions and overall care.    Medication reconciliation cannot be completed without support/input from pharmacy department. The patient’s significant cardiac history and comorbidities provides a lengthy and complex medication list. The pharmacist reviews adverse effect, interaction, duplication of all medications, and reconcile medication list. Patient will need PT/OT support to facilitate mobility and provide modalities that will enhance performance of activities of daily living (ADLs). The registered dietician is a key team member to facilitate the dietary goal of the patient. A PMH of obesity and diabetes will need dietary modification (DASH) and nutritional plan that will enhance recovery. (IPEC,2019)        The nurse’s role can be considered as the “hub” to safe, quality patient-centered care because he/she is regarded as the coordinator, educator, facilitator, advocate, focused on resolving pertinent patient care needs. Nurses will provide care that is safe, timely, effective, and equitable in a team-based care method. Consequently, nurses actively collaborate with interdisciplinary professionals to ensure efficient, effective, and quality standard care that meets the satisfaction of the patients, their families, and community.   (IPEC,2019)  

Medications: List the medications used to treat the patient with the identified disorder. Use the Lippincott Advisor on Drugs to complete the table. Cite your source(s).

Medications Include medication, dosage, route, frequency, time, and why YOUR patient is getting this medication.Pharmacological Class & Mechanism of ActionAssessment Needed Prior to Giving Medication Look up this information in the Drug Guide. Think about what would make you feel safe giving the medication & what findings would make you question giving the medication.Important Side/Adverse Effects-Could you identify it if it were happening?Evaluation of Effectiveness What data would the nurse collect and analyze to assess medication effectiveness? Is there an antidote for this medication?
1. Acetaminophen (Tylenol)  Dose:mg tablet Frequency: 3 times daily Route: Oral Purpose: to manage mild pain and fevers (Lippincott Advisor for Education Drugs,2022)Class: Analgesic and antipyretic MOA: It inhibits prostaglandin synthesis in the central nervous system, hence reducing pain and fever (Lippincott Advisor for Education: Drugs, 2022).-identify patient’s level of pain – Identify any Renal impairment – Identify any Hepatic impairmentHepatotoxicity Jaundice Renal Failure Hypersensitivity reaction Impairment to the liver and kidney will worsen with intake of acetaminophen. Allergy to Acetaminophen (Lippincott Advisor for Education: Drugs,2022)  To analyze medication effectiveness the nurse will assess for reduced pain levels.  Antidote: If overdose, a gastric lavage is performed or activated charcoal is administered to stop absorption (Lippincott Advisor for Education: Drugs, 2022).  
2. Ampicillin – sulbactam (UNASYN) Dose: 3g Frequency: Q6H Route: Intravenous    Class: Penicillin MOA: It inhibits bacterial cell wall synthesis (Lippincott Advisor for Education: Drugs, 2022).Check for allergies to penicillin, assess for renal function, and assess for any signs of infection or need for prophylaxis.GIT disturbances. Check for allergic reactions (rash, itching, swelling) and severe diarrhea, which may be a sign of C. difficileassociated colitis. Creatine ClearnceMonitor for resolution of infection symptoms. No specific antidote for Ampicillin but gastric lavage or activated charcoal can be used
3 Chlorhexidine gluconate Dose:  15 ml Frequency: 2 times daily Route- Oral (Swish and Spit) Purpose:        Class: MOA:  Drugs, 2022). (Lippincott Advisor for Education: Drugs, 2022).   (Lippincott Advisor for Education: Drugs, 2022).  Antidote- (Lippincott Advisor for Education: Drugs, 2022).
4 Famotidine (PEPCID) Dose: 20mg Frequency: 1x daily QAM  Route: Per PEG Tube Purpose:  Class MOA: (Lippincott Advisor for Education: Drugs, 2022).. (Lippincott Advisor for Education: Drugs, 2022). (Lippincott Advisor for Education: Drugs, 2022).(Lippincott Advisor for Education: Drugs, 2022). (Narcan)
5 Bupropion (WELLBUTRIN XL) Dose: 150mg XL tablet, Frequency: 1 tablet by mouth once every morning Route: Oral Purpose: To treat depression.  Class: Antidepressant MOA: It works by inhibiting the reuptake of norepinephrine, serotonin, and dopamine (Lippincott Advisor for Education: Drugs, 2022).Assess the patient’s mental health status, including signs of depression, suicidal ideation, or behavior.  (Lippincott Advisor for Education: Drugs, 2022).Photosensitivity, aggression, tremors, Mood changes, restlessness, and suicidal thoughts. (Lippincott Advisor for Education: Drugs, 2022).Assess for improvements in mood and depressive symptoms. No specific antidote but gastric lavage or activated charcoal can be used.  (Lippincott Advisor for Education: Drugs, 2022).
6 Levothyroxine (SYNTHROID) Dose:  88mcg Frequency: Nightly Route: Per G Tube Purpose:  Class: (Lippincott Advisor for Education: Drugs, 2022). (Lippincott Advisor for Education: Drugs, 2022).    (Lippincott Advisor for Education: Drugs, 2022).  (Lippincott Advisor for Education: Drugs, 2022).
7 Sodium Fluoride Dose: 5000PPM1.1 % Gel Frequency:1 daily Route: Purpose: (Lippincott Advisor for Education: Drugs, 2022).   
8, Triamcinolone Dose:0.1 % ointment   Purpose: .  (Lippincott Advisor for Education: Drugs, 2022).       (Lippincott Advisor for Education: Drugs, 2022).   (Lippincott Advisor for Education: Drugs, 2022).   (Lippincott Advisor for Education: Drugs, 2022).  . (Lippincott Advisor for Education: Drugs, 2022).
9 Pantoprazole (Protonix)  Dose:40 mg. injection Frequency:1 time daily   Route: Intravenous Purpose: used to lower stomach acidity levels in patients with gastric/peptic ulcers. This patient has duodenal ulcer.  (Lippincott Advisor for Education: Drugs, 2022).    Class: Proton pump inhibitor MOA: It reduces stomach acid production by inhibiting the proton pump in gastric parietal cells (Lippincott Advisor for Education: Drugs, 2022).Assess for GERD, gastric or peptic ulcers, and duodenal ulcers. Assess for patient allergies to the drug. (Lippincott Advisor for Education: Drugs, 2022).   headaches, nausea, and increased risk of bone fractures.  (Lippincott Advisor for Education: Drugs, 2022).  Resolution of GI symptoms. No antidote. Rx is symptomatic management. (Lippincott Advisor for Education: Drugs, 2022).  
10. Sodium Bicarbonate Dose: 650mg Route: Per NG Tube Frequency: 2 times daily Purpose:  (Lippincott Advisor for Education: Drugs, 2022).  Class: Vitamin supplement MOA: It helps in the metabolism of carbohydrates (Lippincott Advisor for Education: Drugs, 2022).Assess for malnutrition and deficiency of vitamin B-1. (Lippincott Advisor for Education: Drugs, 2022).Thiamine is generally safe; however, it may have the following side effects; nausea, itching, sweating, weakness, and flushing. (Lippincott Advisor for Education: Drugs, 2022).Check for improvement in thiamine deficiency symptoms. No antidote since its water soluble and excess is removed from the body with urine
11 Senna (SENOKOT) tablet Dose: 17.2 mg Route: Per PEG Tube Frequency: 2 times daily Purpose: (Lippincott Advisor for Education: Drugs, 2022).    Class: Beta-blocker MOA:  (Lippincott Advisor for Education: Drugs, 2022).(Lippincott Advisor for Education: Drugs, 2022).     (Lippincott Advisor for Education: Drugs, 2022).    (Lippincott Advisor for Education: Drugs, 2022).
12. Plasmacyte -A bolus Dose:1000ml Route: Intravenous Frequency: STAT 13. Metoprolol tartrate (LORESSOR) tab Dose: 25mg Frequency: every 8 hours Route: Per PEG Tube Purpose:      Class: MOA: (Lippincott Advisor for Educat   (Lippincott Advisor for Education: Drugs, 2022).  (Lippincott Advisor for Education: Drugs, 2022).  (Lippincott Advisor for Education: Drugs, 2022).
13. Ondansetron (ZOFRAN) injection Dose: 4 mg Route: Intravenous Frequency: every 6 hours   Purpose:  Class:(Lippincott Advisor for Education: Drugs, 2022).(Lippincott Advisor for Education: Drugs, 2022).   (Lippincott Advisor for Education: Drugs, 2022).. (Lippincott Advisor for Education: Drugs, 2022).  
14. Pancrelipase (Lip-Prot-Amyl) (CREON) 12000-38000units 12000 Dose: 1 Capsule Route: PerNG Tube: 2 times daily PRN Purpose: (Lippincott Advisor for Education: Drugs, 2022).Cl (Lippincott Advisor for Education: Drugs, 2022). (Lippincott Advisor for Education: Drugs, 2022).   (Lippincott Advisor for Education: Drugs, 2022).  (Lippincott Advisor for Education: Drugs, 2022).  
  15. Cyclobenzaprine tab Dose: 10 mg  Route: Per G Tube Frequency 3 times daily Purpose:  (Lippincott Advisor for Education: Drugs, 2022).Class: (Lippincott Advisor for Education: Drugs, 2022). (Lippincott Advisor for Education: Drugs, 2022).   (Lippincott Advisor for Education: Drugs, 2022).  . (Lippincott Advisor for Education: Drugs, 2022).  
16. Enoxaparin Sodium (LOVENOX) Dose: injection 80 mg Frequency: 2 times daily Route: Subcutaneous Purpose:  (Lippincott Advisor for Education: Drugs, 2022).  Class: (Lippincott Advisor for Education: Drugs, 2022).   (Lippincott Advisor for Education: Drugs, 2022). (Lippincott Advisor for Education: Drugs, 2022). (Lippincott Advisor for Education: Drugs, 2022).
17. Albuterol 2.5 mg/3ml Dose: nebulizer solution 2.5 mg Frequency:   Purpose: used to treat asthma and COPD by relaxing the airway muscles  (Lippincott Advisor for Education: Drugs, 2022).  Class: Beta2-adrenergic agonist MOA: It relaxes the airway’s smooth muscles, thus causing bronchodilation (Lippincott Advisor for Education: Drugs, 2022).Assess the patient’s respiratory status, history of respiratory conditions, and any contraindications.  (Lippincott Advisor for Education: Drugs, 2022).Common side effects include tremors, rapid heart rate, and nervousness. Monitor for cardiovascular effects and signs of worsening respiratory distress. (Lippincott Advisor for Education: Drugs, 2022).Assess for improved lung function and relief of respiratory symptoms. No specific antidote. (Lippincott Advisor for Education: Drugs, 2022).
18 Alteplase (CATHFLO) Dose: 4mg in sodium chloride 0.9 % 30 ml spring Route: Intrapleural Frequency: use within 8 hours Purpose:      
19 Dornase alfa (PULMOZYME) Dose: 5mg Frequency: Route: Intrapleural Purpose:    
20 Guaifenesin (ORGANIDIN) tab Dose: 200mg Route: Per NG Tube Frequency: 4 times daily Purpose:    
21. Ergocalciferol (VITAMIN D2) Dose: 200mcg/ml (8000units/ml) drops Route: Purpose:    
     
22Nutritional Supplements DOSE:(JEVITY 1.5 CAL/FIBER) LIQD ROUTE: Per NG Tube FREQUENCY: PURPOSE:      
     
23.Vitamin E Dose: 400 unit/15 ml LIQD ROUTE: Per NG Tube Frequency: Purpose:    
24.Polyethylene glycol (MIRALAX) DOSE:    
25.RESTASIS 0.05% ophthalmic emulsion    
Priority Nursing Diagnosis Using your problem list from your nursing assessment, formulate the priority nursing diagnosis/problem appropriate to your patient’s condition or needs. List the problem, what it is related to, and the evidence from your assessment that the problem exists.   Provide a rationale for the selection of this nursing diagnosis as the priority nursing diagnosis.Outcome   Write a patient centered, measurable, realistic outcome that includes a target date.Interventions    Select six nursing actions that are appropriate to meet the needs of your patient, making sure that they relate (must align) to the nursing diagnosis/problem you selected. Be sure that the interventions will help to achieve the outcome that you created.Scientific Rationale  Explain the scientific rationale for each nursing intervention that you have selected and cite your source.Evaluation of outcome Describe how the patient is/would be expected to be progressing toward meeting the outcome. Use both subjective and objective data to help you evaluate your patient’s progress.   
Diagnosis: Impaired gas exchange related to ineffective airway clearance secondary to asthma, evidenced by shortness of breath (Doenges et al., 2022).     Rationale:  Impaired gas exchange may result from conditions that limit the patient’s ability to breathe effectively, for instance, asthma, which leads to narrowing of the airway and excessive mucus secretion.                                      Outcome: The patient will be able to breathe effectively and achieve at least 95% oxygen saturation levels.           Target Date: within the next 24 hours (Doenges et al ,2019)1. Monitor respiratory rate and oxygen saturation   2. Administer oxygen therapy   3. Assist with positioning   4. Encourage deep breathing and coughing exercises   5. Monitor for signs of respiratory distress   6. Elevate the head of the bed. (Doenges et al ,2019)1. Regular assessment of respiratory rate and oxygen saturation provides data on the patient’s oxygenation status.   2. Supplemental oxygen can enhance oxygenation and relieve shortness of breath if oxygen saturation levels are below the target range (Doenges et al., 2022).   3. Proper positioning can improve lung expansion and oxygenation. Elevating the head of the bed or encouraging the patient to sit upright can help alleviate shortness of breath.   4  Evaluation Progress: increase in O2 stats. At least 90% Subjective Data Evidence: The patient reports feeling more comfortable with easier breathing.   Objective Data Evidence: Oxygen saturation levels are within the target range
Additional Nursing Diagnoses Using your problem list from the nursing assessment, list three additional priority nursing diagnostic labels/list the problem appropriate to your patient’s condition or needs.  Provide a rationale for the selection of this nursing diagnosis as the non-priority nursing diagnosis.Outcome   Write a patient-centered, measurable, realistic outcome that includes a target date.Interventions    Select six nursing actions that are appropriate to meet the needs of your patient, making sure that they relate to the nursing diagnosis you selected. Be sure that the interventions will help to achieve the outcome that you created.Scientific Rationale  Explain the scientific rationale for each nursing action that you have selected and cite your source.Evaluation of outcome Describe how the patient is/would be expected to be progressing toward meeting the outcome. Use both subjective and objective data to help you evaluate your patient’s progress.   
           (Doenges et al., 2022).       
2. Risk for Infection related to invasive procedure elevated body temperature.   This nursing diagnosis is a non – priority because it identifies a potential risk and not an occurring problem. (Doenges et,al)    Outcome: The patient will be free of infection. Vital signs will remain normal.         Target Date: Throughout the hospital stay. (Doenges et al., 2022).      1. dressing and monitoring of the incision site.   2. Administer prophylactic antibiotics as prescribed   3. Educate the patient on signs of infection   4. Promote hydration and adequate nutrition   5. Monitor vital signs regularly   6. adhere to aseptic techniques while attending to the incision site.  (Doenges et al., 2022).    1. for early detection of infection.   2. To prevent post-op infections   3. This empowers the patient to report any changes promptly.   4. This supports the immune system’s function and wound healing   5. Signs of fever help one detect infection on the wound.   6. This prevents the introduction of infectious microbes into the wound.Evaluation Progress: The patient shows no signs of infection.   Subjective Data Evidence: The patient reports no increased pain, redness, swelling, or drainage at the incision site.   Objective Data Evidence: The site appears clean. Vital signs are normal (Doenges et al., 2022).  
Risk for falls related to altered mobility secondary to unsteady gait as evidenced by patient use of assistive device.  Outcome: the patient will achieve and improved gait and be able to walk for short distances without assistance.     Target date: within the next 72 hours.1. Assess gait and mobility 2. Ensure adequate lighting 3. Educate the patient on assistive device use 4. Place call bell within reach 5. Remove unnecessary materials on the floor 6. Encourage the use of non-slip footwear and keep the floor dry.1. To identify any changes or deteriorations in their condition. 2. good lighting can help prevent falls by enhancing visibility and reducing tripping hazards. 3. This enables the patient to use the device appropriately for maximum benefit and to avoid injury. 4. To call for help in order to reduce the risk of falls during unassisted attempts at mobility. 5. Clean and tidy floors free from rugs and other things prevent patient from accidents. 6. To provide better stability and reduce the risk of slippingEvaluation Progress: The patient has not experienced any falls while using the assistive device.   Subjective data evidence: The patient reports feeling confident in using the assistive device   Objective data evidence: There are no reports of falls or near-falls in the patient’s medical records.
3. Anxiety-related to substance use as evidenced by restlessness and nervousnessOutcome: The patient will experience and verbalize comfort and demonstrate the ability to employ anxiety-reducing strategies effectively.           Target Date: within 24 hours1. Talk and listen to the patient actively.   2. Provide a safe and calming environment.   3. Educate the patient on stress-reduction techniques, relaxation exercises, and coping mechanisms   4. Involve other members of the team, for instance psychiatrist.   5. Administer medications as prescribed   6. Introduce staff at handoff1. active listening allows the patient to express feelings and fears, thus reducing emotional distress.   2. This can help reduce anxiety and promote a sense of security for the patient.   3. This helps the patient to cope with the anxiety.   4. Involving mental health professionals can provide specialized interventions and support.   5. anxiolytics and sedatives help manage anxiety in cases where psychotherapy proves futile (Doenges et al., 2022).   6. This will prevent the patient from having doubts and ensure cooperation.Evaluation Progress: The patient’s anxiety has decreased. He demonstrates the ability to employ anxiety-reducing strategies. Subjective Data Evidence: The patient reports comfort and more control of their emotions.   Objective Data Evidence:  The patient appears calmer and able to cope than before.

Integration of CNL Competencies: Select one topic from each of the CNL competency areas that you can utilize in the care of the patient. In the table below, indicate the chosen topic from each competency area, and write a summary (minimum of one paragraph for each) of how the CNL competencies will be included in the plan of care in the Integration of CNL Role in Plan of Care Table. Cite your sources.

Integration of CNL Role in Planning Care Table

CNL Competency: Nursing leadershipCNL Competency: Clinical Outcomes and ManagementCNL Competency:
1. Horizontal Leadership 2. Interdisciplinary Communication and Collaborative Skills 3. Advocacy and the CNL 4. Integration of the CNL Role 5. Lateral Integration1. Illness and Disease Management 2. Knowledge Management 3. Health Promotion, Disease Prevention, and Injury Reduction 4. EBP 5. Advanced Clinical Assessment1. Team Coordination 2. Economics and Finance for the CNL 3. Health Care Systems/Organizations 4. Health Care Policy 5. Quality Improvement, Risk Reduction, and Patient Safety 6. Health Care Informatics 7. Ethical Considerations for CNL
  Chosen Topic: Interdisciplinary Communication and Collaborative Skills   Integration into the plan of care:   Collaboration and communication among interdisciplinary teams are critical in addressing patients’ multifaceted medical and psychosocial requirements. In this regard, the CNL will facilitate frequent meetings with healthcare specialists such as physicians, nurses, addiction counselors, and social workers to ensure comprehensive consideration of both physical health factors alongside mental health aspects when outlining care protocols for their patients (King & Sally O’toole Gerard, 2016). This proactive approach fosters better teamwork, enabling more informed decision-making, resulting in higher quality outcomes that ultimately improve the overall well-being of clients undergoing treatment within the facility.  Chosen Topic: Health Promotion, Disease Prevention, and Injury Reduction   Integration into the plan of care:   Health promotion and disease prevention are crucial elements in a patient’s care. The CNL will collaborate with healthcare professionals to incorporate various interventions (King & Sally O’toole Gerard, 2016). These include educational programs on substance abuse counseling services that promote healthy behaviors while preventing potential health concerns. Additionally, proactive measures such as mitigating infection risks shall be incorporated into this comprehensive program.  Chosen Topic: Quality Improvement, Risk Reduction, and Patient Safety   Integration into the plan of care:   To enhance the patient’s plan of care, the CNL will prioritize quality improvement and safety measures by employing tactics to avoid complications related to complex medical problems (King & Sally O’toole Gerard, 2016). The care plan will include regular risk assessments regarding infections and falls, as well as a focus on infection control methods. In addition, the CNL shall join in analyzing root causes for issues that may arise from substance abuse or surgical complications with an aim towards improving overall standards of care while mitigating risks involved.( King,et,al ,2021)          

Self-Reflection in Critical Thinking and Clinical Reasoning:

1, What was the most important thing you learned from completing this assignment?

Upon completing the assignment, I understand the importance of adopting a comprehensive and compassionate approach to ensuring patient welfare. We must consider multiple medical and psychosocial factors by not limiting our assessment solely to their physical state but also paying attention to their emotional health, personal history, and societal circumstances. Embracing such holistic methods can greatly enhance healthcare services while simultaneously improving patients’ outcomes.

2. What risk management strategies could you anticipate implementing when caring for a patient with this disorder?

To minimize risks, I would employ a multifaceted approach that includes monitoring overdose and withdrawal indicators, implementing fall prevention methods based on the probability of instability, adhering to rigorous infection control protocols for surgical site infections, and adopting pain management strategies targeted at mitigating potential complications associated with opioids. To effectively manage these identified hazards requires effective communication among all healthcare professionals.

3.Thinking about lateral integration of care, who would you anticipate needing to coordinate care for your patient? How would you initiate this?

I would anticipate the CNL to coordinate care for my patient. To initiate this coordination, I would facilitate regular team meetings to discuss the patient’s progress and hand over patient care to the CNL. Then, I would explain this to the client to ensure a smooth transition.

4. Thinking of what you learned from this activity, what will you do to improve your future practice while caring for patients with alterations of this disorder to improve your patient’s outcomes?

I will emphasize the assessment and provision of assistance for mental health, acknowledging the significance of attending to underlying mental health illnesses that may potentially contribute to the patient’s challenges. Furthermore, I will persist in giving precedence to interdisciplinary teamwork and communication, guaranteeing that all members of the team are well-informed and in agreement regarding their approach to patient care. Enhancing patient outcomes and the overall quality of service will be of utmost importance.

References

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales (16th ed.). F.A. Davis Company.

Honan, L. (2019). Focus on adult health: Medical-Surgical nursing (2nd ed.). Wolters Kluwer.

IPEC. (2016). IPEC core competencies. Www.ipecollaborative.org; IPEC. https://www.ipecollaborative.org/ipec-core-competencies#:~:text=The%20IPEC%20panel%20identified%20four

King, C. R., & Sally O’toole Gerard. (2016). Clinical nurse leader certification review. Springer Publishing Company, Llc.

Lippincott Advisor for Education: Drugs. (2022). Wolters Kluwer Health Norris, T. (2020). Lippincott CoursePoint Enhanced for Porth’s Essentials of Pathophysiology. Course point. https://phoenix-app.thepoint.lww.com/content

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