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Student Name: Krystle Barroga

Due 3/10/15
N256 Mini Care Plan

Week 1 Client
Expected
(complete before assessment)

Found
(complete after assessment)

1. Decreased Cardiac Output


2. Neutropenia
3. Fatigue

1. Decreased Cardiac Output


2. Neutropenia
3. Impaired skin integrity

Focus of physical
assessment

Neurological status: Assess the overall


appearance of the client including level of
consciousness, mental status, mood/affect,
personal hygiene, & oriented to person, place
and/or time
Integumentary System: assess for skin tenting
(dehydration), assess any wounds, surgical
incisions, IV sites, Braden score
Cardiovascular system: Inspect skin color, nail
bed angles, capillary refill, turgor, edema,
temperature and moisture of upper extremities,
assess pulses
Respiratory system: Assess lung sounds (clear,
crackles, wheezing), RR
GI system: Assess oral mucosa, monitor
mucositis, assess abdomen, bowel sounds, last
BM
GU system: color, characteristic of urine,
continent or incontinent?
Hematologic system: Assess for petechiae,
purpura, ecchymosis

Need more
information
from
client/family/
doctor about:

Ask about clients living situation


Ask client about his plans after discharge
Ask if client will have additional help with care
after discharge

Neurological status: Assess the overall appearance of


the client including level of consciousness, mental
status, mood/affect, personal hygiene, & oriented to
person, place and/or time.
Client is alert and oriented to person, place and time.
Appropriate eye contact, appearance, and hygiene.
PERRLA.
Integumentary System:, assess for skin tenting
(dehydration), braden score
Generalized dry skin. Client has abrasions to left lower
extremity; daily wound care with Bacitracin ointment.
Cardiovascular system: Inspect skin color, nail bed
angles, capillary refill, turgor, edema, temperature
and moisture of upper extremities , assess pulses
Regular, normal S1, S2. Heart rate 63bpm. Palpable
peripheral pulses, bilat. No edema noted to LE. Cap
refill <3secs
Respiratory system: Assess lung sounds (clear,
crackles, wheezing), RR
Unlabored breathing, RR: 18/min. No complaints of
SOB. SpO2 97% on RA. Lungs sounds clear,
diminished to lower bases, bilaterally.
GI system: Assess oral mucosa, monitor for mucositis,
assess abdomen, bowel sounds, last BM
Oral mucosa pink and moist. No ulcers, white spots or
thick white coating noted. Abdomen soft and nondeistended. Clients last BM on 3/3, client is on routine
stool softeners.
GU system: color, characteristic of urine, continent or
incontinent?
Continent. Voiding yellow, clear urine. No reports or
hematuria. Denies pain during urination
Hematologic system: Assess for petechiae, purpura,
ecchymosis
Petechiae and puprpura noted to bilateral, lower
extremities, corresponds to platelets abnormally low
platelet counts (33,000) No ecchymosis noted to other
areas of body. No reports of hematuria or blood in
stool.
Client is homeless. He was living in a shelter prior to
admission to hospital. Per clients charts, his brother
is very important to him. Client receiving assistance
from social worker to locate his brother and sister.

Nursing
Diagnoses
(NANDA)

Top three
priorities (goals)
for client care

1. Client will not complain of tiredness or SOB.


Client will report increased energy and ability to
perform desired activities.

2. Client will obtain normal levels of platelets,


Hgb, Hct, WBC, and RBCs

3. Client at reduced risk for local or system


infection AEB normal lab values, normal
temperature and vital signs

Nursing
Interventions

1. Monitor lab values


2. Monitor VS frequently. Assess for SOB,
changes in LOC.
3. Promote adequate nutritional intake and
document.
4. Assess/monitor infection: check temperature,
assess for sore throat, localized redness or
warmth, excessive malaise. Monitor lab values
5. Transfuse blood products as needed
6. Promote adequate rest periods, have client
develop schedule for daily activities and rest.

Teaching
needed/provided

-Explain changes that occur with AML, such as


blood-forming changes
-Signs/Symptoms of worsening heart failure and
when to seek medical attention
-Signs/Symptoms of thrombocytopenia
(excessive bleeding from puncture sites, blood in
stool and urine, ecchymosis, petechiae, purpura)
-Encourage client to attend follow-up
appointments, improve home environment and
follow treatment regimen
Looking for placement in long-term facility or
adult foster care. Client is homeless; prior to
admission, he was living in a shelter. Client is
independent and able to perform ADLs without
assistance.
Encourage client to attend follow-up
appointments with physicians.

Discharge
planning

1. Client had no complaints of tiredness or SOB.


Client was seen ambulating in hallway 10x before
dinner. Client tolerated this activity well.

2. Clients lab values still below normal range.


platelets (33,000)
Hgb (7.6)
Hct (22.6)
RBC (2.51)
WBC (1.0)
3. Client still on neutropenic precautions d/t
decreased WBC. Client is also still on contact
isolation. Lab values still below normal range
platelets (33,000)
Hgb (7.6)
Hct (22.6)
RBC (2.51)
WBC (1.0)
Clients temp WNL: 98.2F
Continue to monitor clients lab values still below
normal range.
platelets (33,000)
Hgb (7.6)
Hct (22.6)
RBC (2.51)
WBC (1.0)
Clients temp WNL: 98.2F
Client continues to take prescribed antibiotics
Vital signs stable, Temp: 98.2 BP: 105/60 HR: 63 RR:
18 O2: 97% RA.
Clients dinner intake adequate. Nourishment
supplement provided for added calories.
Client was able to perform desired activities without
complaints of fatigue or SOB. Client ambulated in
hallway with CNA with no complaints.
Client is aware of blood forming changes associated
with AML.
Client verbalizes understanding that edema and
increased SOB and tiredness are associated with his
health condition, CHF

Client is homeless. Prior to admission, he was living in


a shelter. Client is working closely with social worker
to locate siblings who are living on Oahu. Client is
independent and able to perform ADLs without
assistance.