Plan of care:Please read and help if possible:)

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Hi everyone i have an assignment due on monday. Im an a div2 nursing student 3 months into my course. I have my first placement early july:):s:/

On finding abnormal substances in urine such as(ketones,proteins) what should be ordered within a div2 nursing students scope??

I am doing a plan of care for a shift of work in a ward for a specific patient. He was hit and dragged by a car.He is also homeless, has no contactable people.

How would i prioritise his care?

He has an idwelling catheter insitu(not sure what insitu is) he didnt void prior to surgery.He is in pain(states pain in his chest a 7 out of 10) has had surgery for a compound fracture of his left tibia(in plaster cast). He has not eaten for two days, last drink was alcohol prior to accident. He has lacerations and abrasions on his body and some lacerations hv been sutured.

Has a temp of 38, heartrate 80 but ireegular

bp 150/90(High, hypertensive, resps 28, blood glucose level 11. Doctor has noted he has an enlarged liver and he has chronic bronchitits. english is 2nd language. Is a smoker

Non weight bearing!

On observation:He is brusied, poorly groomed, old scabbed lesions.yellowish complexion with pale lips and uses accessory muscles to breathe.

He vomits 230 mls blood is presesnt.

On observation of his charts, history and info i hv been given.

I would

Monitor Fluids, suggest a fluid balance chart, pain relief, walkers,bedbath( because he is immobile and would have an impaired skin integrity)? further testing, montior respirations and pattern of breathing. Further blood testing( proteins and keytones were found)?interpreter, encourage him not to smoke within his stay? What would as i a nursing student do. If what i hv written above is correct who would i talk to, superior nurses who then contact doctors? Im a bit lost here

To all of you that rae further into their course,newly graduated nurses and those with years of experience. please help me out:) :p

Thankyou!

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Sorry for the spelling mistakes.

Hope to see something soon:)

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Sorry, I don't have any answers for you about this plan of care, but I can help with this:

He has an idwelling catheter insitu(not sure what insitu is)

"in situ" (two words) is Latin for "in place". So, his indwelling catheter is currently in place.

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When you're looking to prioritize care for any patient, think first of your ABCs (Airway, Breathing, Circulation). Once all those are accounted for and acted up, then look to Maslow's Hierarchy of Needs...basic physical needs must be met first, then move up the pyramid from there.

What type of surgery did he have?

In the case of this gentleman, I'm concerned about the chest pain in relation to his tibial fracture...I'm wondering about the possibility of a fat embolism from the fracture. So, I want to look at the vitals but I also want to look at the patient to see if he seems anxious/restless, does he seem to be breathing with difficulty, etc.?

Once the ABCs are settled, you'll need to get him cleaned up so you can assess his skin fully, attend to his nutritional needs, get a social work consult to help with placing him where he can have help after hospital discharge, psych consult if needed to help with issues leading to homelessness, on & on & on...

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Specializes in Nursing Education.

With enlarged liver and last drink of alcohol 2 days ago, you might want to make sure he is being observed for s/sx of alcohol withdrawal, too.

As for the lab tests, the only things that you can order would have to be within the scope the nursing practice. For example, if pt had elevated WBCs, then you could implement protective isolation precautions. But sometimes abnormal lab values mean that a medical intervention is needed. If the MD is not already aware, then you as the RN would be responsible for calling the MD and informing him if it is urgent so that he can order interventions in his scope of practice.

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Specializes in Dialysis.

Remember also to look up proper positioning for post-surgical patients. Depending on the surgery and type of anesthesia used, he should be instructed and encouraged in the use of an incentive spirometer. This will help to reduce the likelihood of pneumonia, especially in light of his existing respiratory issues. Glucose level...11! Was this on admission after not eating for 2 days? Holy cow. Reassess his glucose level after proper nutrition and hydration and watch his level of consciousness. Do your best to keep care predictable and explain everything. Check frequently for TRUE understanding and not just head-nodding.

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Specializes in Case Management.

a PT/OT eval would be in order after all injuries assessed and xrayed. You would not ask for an order for a walker, you would wait for the evals and PT/OT would recommend, then it would be ordered.

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Hi, you should use a systematic approach, using the A-E

A - Airways

B- Breathing

C- Circulation

D- Disability

E - Exposure

Would also need to do relevant referals to other professionals such as dieticians, ots, physios, mental health, respiratory team, etc

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It's all about ABC's and Maslow's.

Not only do you use this in writing careplans, but it is KEY when answering priority questions on exams.

Cheers!

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