Nursing Care Plan- Basic Conditioning Factors|Legit essays
Posted: February 20th, 2023
Fully on Campus – 2023 Winter Quarter
Module 08 Written Assignment – Otitis Media
Module 08 Written Assignment – Otitis Media
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Module 08 Content
1.
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An 8-year-old girl comes to your ambulatory care clinic with complaints of left ear pain for the past 3 days. She had respiratory infection a week ago. On physical examination, the tympanic membrane is bulging.
Answer the following questions:
1. What else should you ask the client?
2. What teaching would you reinforce to prevent the recurrence of otitis media?
3. What expected outcomes would be specific to this situation?
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Rasmussen University School of Nursing Name: Date:
Care Plan #
Rasmussen University School of Nursing
| ALLERGIES: | ||||
| Medications: List all medications by generic name (trade name), dosages, classifications, and the rationale for the medications prescribed for this client. Include major considerations for administration and the possible negative outcomes associated with this medication. Identify both of the following:
1: What the medication does to the body to the cellular level; 2: Why is the client taking the medication? Medication Classification Dosage & Route Rationale Assessment |
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CONCEPT MAP
Pathophysiology – (to the cellular level)
Medical Diagnosis
Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies). What symptoms does your client present with?
Complications
Treatment (Medical, medications, intervention and supportive)
Risk Factors (chemical, environmental, psychological, physiological, and genetic)
Nursing Diagnosis
Problem statement (NANDA diagnosis):
Related to (What is happening in the body to cause the issue?):
As evidenced by (Specific symptoms):
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| LAB VALUES AND INTERPRETETION
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| LAB | Range | Value | Value | MEANING (If WDL then explain the possible reason for the lab) | LAB | Range | Value | Value | MEANING |
| HEMATOLOGY | CHEMISTRY | ||||||||
| CBC | Glucose | ||||||||
| WBC | BUN | ||||||||
| RBC | Cr | ||||||||
| HGB | GFR | ||||||||
| HCT | Na | ||||||||
| PLATLETS | K | ||||||||
| Diff: | CO2 | ||||||||
| Polys | Ca | ||||||||
| Bands | Phos | ||||||||
| Lymph | Amylase | ||||||||
| Mono | Lipase | ||||||||
| Eosin | Uric Acid | ||||||||
| GBC indices | Protein | ||||||||
| MCV | Albumin | ||||||||
| MCH | Cl | ||||||||
| MCHC | Enzymes | ||||||||
| COAGs | LDH | ||||||||
| PT | CPK | ||||||||
| INR | SGOT | ||||||||
| PTT | SGPT | ||||||||
| ABGs (V or A) | Troponin I | ||||||||
| PH | Myoglobin | ||||||||
| PCO2 | |||||||||
| PO2 | Cholesterol | ||||||||
| BASE EX: | |||||||||
| SAT: | |||||||||
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URINALYSIS |
Range |
Value |
Value |
Meaning |
Others not listed:
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Findings |
Meaning |
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| Color | Gastroccult | ||||||||
| Clarity | Hemoccult | ||||||||
| Sp. Gravity | |||||||||
| pH | EKG | ||||||||
| Protein | |||||||||
| Glucose | CT Scan | ||||||||
| Ketones | |||||||||
| Bilirubin | |||||||||
| Occ. Blood | MRI or MRA | ||||||||
| Urobilinogen | |||||||||
| WBC | |||||||||
| RBC | |||||||||
| Epithelia | Ultrasound | ||||||||
| WBC | |||||||||
| RBC | |||||||||
| Epith Cell | |||||||||
| Bacteria | |||||||||
| Hyaline Cast | |||||||||
| Gran Cast | Bedside Procedures: | ||||||||
| Leukocytes | |||||||||
| Nitrite | |||||||||
| ACCUCHECKS | |||||||||
| Additional information:
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| Universal Self-Care Deficits: ASSESSMENT: (Highlight all abnormal assessment findings) | |||||||||
| Vital Signs | Time: | Time: | |||||||
| Oxygenation/ Circulation | Intake: | ||||||||
| SpO2
1. 2. 3. |
Accu-check
1. 2. 3. 4. |
Output:
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| Cardiovascular Assessment
Specialty devices:
Teaching needs: |
Heart Sounds:
Skin Temp/Moisture/Color:
Edema: JVD:
Peripheral Pulses:
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Pain assessment (OPQRST)
Rating: Location: |
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| Respiratory Assessment
Special devices:
Oxygen:
Teaching Needs:
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Lung sounds:
Anterior: Posterior:
Respiratory effort: Respiratory pattern: Reg/Irreg |
Cough:
Respiratory treatment: Medication(s): Frequency: Rationale for use: |
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| Neurological Assessment:
Assistive devices :
Teaching Needs: |
Level of Consciousness: Alert / Verbal / Pain / Unresponsive
Orientation: Person / Place / Time / Events
Fine motor function:
Gross motor functioning:
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Sleep patterns (During admission):
Sleep patterns (at home):
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| GI Assessment:
LBM (include description):
Teaching needs: |
Abdominal Assessment: (observe – auscultate – palpate)
Alteration in eating or elimination patterns:
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Nutrition Metabolic Assessment:
% diet taken:
Alternative nutritional methods:
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| GU assessment:
Teaching needs: |
Last void:
Due to void: Alternative urinary elimination method: (if urinary catheter in place, when inserted)
Bladder scan |
Assessment of urinary patterns:
Urine assessment (color odor concentration etc.)
LMP |
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| Integumentary Assessment:
Teaching needs: |
Color/ Mucous membranes
Hydration:
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Wound Care:
Condition of skin: |
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| Nutritional Assessment:
Teaching needs: |
Diet:
Eating patterns:
Insulin administration:
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Treatment of hypoglycemia:
Alternative feeding patterns: |
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| IV Therapy
IV fluids infusing:
Rate: Tubing dated?
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IV Site Assessment: Location
Date of insertion: Change (site or dressing)
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IV removal: | Reason for removal: | ||||||
Additional information:
REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS THE SPECIFIC RESPONSE.
PLAN OF CARE: Use your top “2” priorities
| NANDA NURSING DIAGNOSIS use NANDA definition | Expected outcomes of care (Goals) | Interventions | Patient response | Goal evaluation |
| NRS DX:
Problem Statement:
R/T: (What is the cause of the symptom)
Manifested by: (Specific symptoms)
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Short term goal : Create a SMART goal that relates to hospital stay.
Long term goal : Create a SMART goal that is appropriate for discharge.
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This is specific to the client that you are caring for. A list of planned actions that will assist the client to achieve the desired goal. (i.e., obtain foods that the client can eat/ likes)
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Identify what the client’s response or “outcome is to the goal or care that you have provided. i.e., client ate 45% of lunch) | Was it met? Not met? Partially met? If only partially met, what adjustments need to be made? |
| NANDA NURSING DIAGNOSIS use NANDA definition | Expected outcomes of care (Goals) | Interventions | Patient response | Goal evaluation |
| NRS DX:
Problem Statement:
R/T: (What is the cause of the symptom?)
Manifested by: (specific symptoms)
|
Short term goal: Create a SMART goal that relates to hospital stay.
Long term goal: Create a SMART goal that is appropriate for discharge.
|
This is specific to the client that you are caring for. A list of planned actions that will assist the client to achieve the desired goal. (i.e., obtain foods that the client can eat/ likes)
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Identify what the client’s response or “outcome is to the goal or care that you have provided. i.e., client ate 45% of lunch)
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Was it met? Not met? Partially met? If only partially met, what adjustments need to be made?
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SOLUTION
- What else should you ask the client?
- You should ask the client about the severity and quality of the pain, any associated symptoms like fever or hearing loss, any previous history of ear infections, and any recent changes in the client’s environment or behavior that may have led to the infection.
- What teaching would you reinforce to prevent the recurrence of otitis media?
- To prevent the recurrence of otitis media, you can reinforce the following teaching:
- Avoid exposing the client to secondhand smoke or other environmental irritants.
- Encourage the client to practice good hygiene, including washing hands regularly and avoiding close contact with individuals who have respiratory infections.
- Ensure that the client completes the full course of any prescribed antibiotics.
- Discuss with the client the importance of seeking medical attention if the symptoms of ear infection reoccur.
- What expected outcomes would be specific to this situation?
- Specific expected outcomes for this situation may include:
- Relief of pain and discomfort
- Resolution of the infection and absence of fever
- Improvement in hearing
- Prevention of further episodes of otitis media
Nursing Care Plan 9
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