Clinical Make-up Assignment – Cheap Research Essays

THE INFORMATION IN PURPLE IS THE PATIENT INFORMATION NEEDED TO COMPLETE THE PAPER. 
Select a patient from clinical and bases this paper on the assessment and plan of care
REQUIREMENTS: THE FOLLOWING ELEMENTS MUST BE INCLUDED IN THE PAPER
Background Information on the adult health client:
• Demographics
72 year old female
Asian
• History of present illness
Left Breast Cancer
• Relevant past medical and surgical history
Mastectomy Mod Rad with Dermabond (02/05/2016)
Left Breast Cancer (diagnosed 08/2015)
Chemo (09/2015)
Port- a -Cath (Right Upper Subclavian – 09/2015)
Anemia
Bilateral JP drains
• Admitting diagnosis (es)
Left Breast Cancer
• Course of current hospitalization to date
Admitted 02/04/2016
• Review of systems (ROS) with rationale for abnormal findings
Ambulates alone
• Assessment findings during day(s) of care. Includes vital signs, focusedassessment, and data from monitoring devices.
Vital Signs : 02/06/16 @ 0700
BP – 132/73
Pulse – 78
Temp – 98.3F
O2 – 97: nasal cannula on 2Liters
Pain – 0/10
Respiratory Rate – 18
Focused assessment:
Alert and oriented times 3
No distress
Pleasant
Wound – intact, clean, dry
JP drains with serosanguinos output & in place
Breast flap well perfused
Good symmetry
IV site 20 G Right hand
intact / clean / no signs of infiltration or infection
Monitoring Devices:
Intake and Output:
Intake IV – 750mL
Intake ORAL – 240mL
Output (drainage) – 620mL
Laboratory and Diagnostic Tests
Identify and list all lab values and diagnostic tests/procedures performed. Include the rationales for performing the tests and for

any abnormal results. Provide an analysis of the relationships between/among the diagnostic tests and lab results with the critically-

ill individual’s current condition(s).
Test Name Result Date Completed
Hemoglobin 6.3 (LOW) 02/06/2016 @ 0645
Hematocrit 20.6 (LOW) 02/06/2016 @ 0645
POCT glucose 113 02/06/2016 @ 0700
Medications
Indicate the trade name and generic name, the medication classification, the therapeutic use, major adverse effects, the nursing

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implications, and patient teaching. Also include the rationale(s) as to why the medication is prescribed for treatment. For example,

document the rationale for how the treatment corrects the critically-ill individual’s condition or a side effect of another drug that

is prescribed for treatment.
Sodium Chloride 500mL daily IV
Insulin Human Lispro sliding scale subq (high blood sugars)
Dextrose/Water 12.5gm PRN IV
Glucagon 1mg PRN subq (high blood sugars)
Promethazine HCL 12.5mg every 6 hours PRN IV (nausea)
Morphine Sulfate (PCA Pump) 1 syringe (PAIN – Patient controlled pump)
Naloxone Hcl 0.4 mg every 3 minutes PRN
Ondansetron Hcl 4 mg every 8 hours PRN IV (nausea)
Heparin Sodium IV
Nursing Diagnoses(Two parts of this section has been completed – the rest has not)
In order of priority, identify three (3) nursing diagnoses for the plan of care. The nursing diagnoses may include “Risk for” and

“Potential Complications” (PCs). Include three (3) nursing outcomes, a minimum of three (3) nursing interventions (completed), and a

minimum of three (3) collaborative interventions for each nursing diagnosis or potential complication.
1. Impaired Skin Integrity
a. Intervention: Encourage early ambulation and mobilization.
b. Intervention: Assess incision site taking note of size, color, location, temperature, texture, consistency of wound/lesion if

possible
c. Intervention: Encourage increase in protein and calorie intake.
2. Risk for Ineffective Breathing Pattern
a. Intervention: Use pulse oximetry to monitor oxygen saturation and pulse rate.
b. Intervention: Monitor vital capacity in patients with neuromuscular weakness and observe trends
c. Intervention: Instruct client to deep breathe during waking hours or use an incentive spirometer.
3. Ineffective Peripheral Tissue Perfusion

a. Intervention: Identify changes related to systemic or peripheral alterations in circulation.
b. Intervention: Evaluate signs of infection when immune system is compromised.
c. Intervention: Position patient in semi-fowler’s position
Routine Nursing Management
Describe independent nursing care you provided in the care of the patient. Examples include, but are not limited to: activity level,

position, ongoing monitoring, nutrition, patient education, wound care etc. The rationale must be included for each intervention.
Independent care I provided – helped patient get out of bed – walk around room,
patient wanted hot tea – provided her the items needed to make her own tea,
monitored patient during blood transfusion, educated the patient on the
importance of washing hands and keeping wound sites clean and dry.
Interdisciplinary (ID) Care Collaborative Management
Identify the members of the interdisciplinary team caring for the adult health client. Provide a brief description of their roles and

responsibilities. Interdisciplinary team members include, but are not limited to: physician, pharmacist, lab/diagnostic tests

personnel, respiratory therapy, physical therapy, occupational therapy, speech therapy, social work/case management, pastoral care,

ethicist, etc.
Physician – the physicians
Pharmacist –
Lab Personnel –
Therapeutic Modalities
Describe the various therapeutic modalities used in the management of care for the adult health patient. Discuss the extent of the

nurse’s responsibilities and skills required to manage the therapeutic modality in comparison to the responsibilities of the members of

the interdisciplinary team. Therapeutic modalities include but are not limited to: oxygen therapy dialysis. The rationale must be

included for each modality.
Nursing Role Reflection
Provide a brief summary of how your role interacted with the members of the interdisciplinary team. Include in your summary:
• Analysis of communication style preferences among interdisciplinary team members and with the critically-ill individual and