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Recognize & Analyze Cues Prioritize Hypotheses Generate Solutions Interventions What Long Term Outcome Resolution of the N Dx/Problem Quote Who When Timing Direct Client Care- hands-on interventions fom RN/UAP Individualized 1. The client will by O RN O UAP 2. The cliant will by O RN O UAP Short Term Outcome Objective Data Progress Toward Long Term Outcome 3. The client will O RN O UAP by ORN O UAP The client will Assessments for Outcome Progress To assess progress toward outcomes O RN O UAP 1. The RN wll ORN O UAP 2. The RN will O RN OUAP Most Objective Datum Number preferred ORN OUAP The RN will Human Response N Dx/Problem O RN OUAP The RN will

Recognize & Analyze Cues Prioritize Hypotheses Generate Solutions Interventions What Long Term Outcome Resolution of the N Dx/Problem Quote Who When Timing Direct Client Care- hands-on interventions fom RN/UAP Individualized 1. The client will by O RN O UAP 2. The cliant will by O RN O UAP Short Term Outcome Objective Data Progress Toward Long Term Outcome 3. The client will O RN O UAP by ORN O UAP The client will Assessments for Outcome Progress To assess progress toward outcomes O RN O UAP 1. The RN wll ORN O UAP 2. The RN will O RN OUAP Most Objective Datum Number preferred ORN OUAP The RN will Human Response N Dx/Problem O RN OUAP The RN will

Phlebotomy Essentials
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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this is a care plan that i need. the first picture is a article read it and fill out the care plan please and thank you.
Header Boyd Dubois Shift Report The patient is Boyd Dubois who is 58 ya. DOB is July 4, 1963, male and Baptist who underwent a right hip arthroplasty yesterday by Dr. James McCray. He is 74 in/188 cm and 240 lbs/108.9 Kg. He is allergic to lodine and shellfish, both cause hives. He has a history of GERD, hypothyroidism, and COPD with a 30 pack-year smoking history, he usually does not use oxygen. He has osteoarthritis of the hips for 10 years with increasing difficulty in ambulating and recently started using a cane. He is maried to his third wife who is 28 xg and estranged from his 4 children whose ages range from 22-38 e He is a Full Code and does not have and Advanced Directive. He has an order for 02 PRN to maintain Sp02 between 88% and 92%. He reports pain at the R hip incision site as 6 out of 10 and received morphine 2 mg IV 2 hours ago. He also has hydrocodone ordered, but it has not been given. Labs are H & H was 17.9 & 48% and now 9.9 and 27, WBCS were 7 and are now 10, Na is 135, and K+ is 3.8. He has an IV in the L forearm with lactated ringers running at 125 ml/hour. 0400 VS 99.4 F/37.4 Cc-78 - 19 128/82 89% RA He has a right hip incision with an intact dressing, the dressing has a 2 cm diameter spot of serosanguinous drainage. Šurgery will change the first dressing He also has a Jackson Pratt drain in the right hip with 10 ml of serosanguinous drainage for the night shift. He is taking ice chips well and has sipped some water, His diet may be advanced as tolerated. He said something about eating breakfast. He is on Standard Precautions and is on bedrest. Physical Therapy will sce and start ambulation today. He of course is a High Fall Risk. Neuro is alert and oriented times 4 and is sleepy with morphine. Cardiac is S1 S2, sinus rhythm, no murmurs, no rubs, Respiratory expiratory wheezing and crackles throughout, respirations are labored with movement. Mucous is yellow, copious, and thick & tenacious. GUGU is active bowel sounds, no reports of heartburn, Voiding OK without difficulty. continued Footer Header Integumentary is pale with circumoral cyanosis with any exertion, skin dry, there is a R hip incision Coccyx is not reddened. Ortho/Mobility is moves all extremities and needs help moving in bed. Psychosocial is pleasant and cooperative. It is noteworthy that he is worried about mobility postop, he is a golfer and is afraid he will not gct to play now. The plan of care is for him to be in the hospital for 2 or 3 nights and then he will go home where his wife will take care of him. There are no pending tests and the only pending order is PT to see today. continued
Transcribed Image Text:Header Boyd Dubois Shift Report The patient is Boyd Dubois who is 58 ya. DOB is July 4, 1963, male and Baptist who underwent a right hip arthroplasty yesterday by Dr. James McCray. He is 74 in/188 cm and 240 lbs/108.9 Kg. He is allergic to lodine and shellfish, both cause hives. He has a history of GERD, hypothyroidism, and COPD with a 30 pack-year smoking history, he usually does not use oxygen. He has osteoarthritis of the hips for 10 years with increasing difficulty in ambulating and recently started using a cane. He is maried to his third wife who is 28 xg and estranged from his 4 children whose ages range from 22-38 e He is a Full Code and does not have and Advanced Directive. He has an order for 02 PRN to maintain Sp02 between 88% and 92%. He reports pain at the R hip incision site as 6 out of 10 and received morphine 2 mg IV 2 hours ago. He also has hydrocodone ordered, but it has not been given. Labs are H & H was 17.9 & 48% and now 9.9 and 27, WBCS were 7 and are now 10, Na is 135, and K+ is 3.8. He has an IV in the L forearm with lactated ringers running at 125 ml/hour. 0400 VS 99.4 F/37.4 Cc-78 - 19 128/82 89% RA He has a right hip incision with an intact dressing, the dressing has a 2 cm diameter spot of serosanguinous drainage. Šurgery will change the first dressing He also has a Jackson Pratt drain in the right hip with 10 ml of serosanguinous drainage for the night shift. He is taking ice chips well and has sipped some water, His diet may be advanced as tolerated. He said something about eating breakfast. He is on Standard Precautions and is on bedrest. Physical Therapy will sce and start ambulation today. He of course is a High Fall Risk. Neuro is alert and oriented times 4 and is sleepy with morphine. Cardiac is S1 S2, sinus rhythm, no murmurs, no rubs, Respiratory expiratory wheezing and crackles throughout, respirations are labored with movement. Mucous is yellow, copious, and thick & tenacious. GUGU is active bowel sounds, no reports of heartburn, Voiding OK without difficulty. continued Footer Header Integumentary is pale with circumoral cyanosis with any exertion, skin dry, there is a R hip incision Coccyx is not reddened. Ortho/Mobility is moves all extremities and needs help moving in bed. Psychosocial is pleasant and cooperative. It is noteworthy that he is worried about mobility postop, he is a golfer and is afraid he will not gct to play now. The plan of care is for him to be in the hospital for 2 or 3 nights and then he will go home where his wife will take care of him. There are no pending tests and the only pending order is PT to see today. continued
Assessment & Analysis Recognize & Analyze Cues Planning Prioritize Hypotheses Generate Solutions Interventions Quote Long Term Outcome Who RN/UAP Direct Client Care - hands-on interventions for What When W Timing Resolution of the N Dx/Problem Individualized 1. The client will by O RN O UAP 2. The cliant by O RN O UAP will Short Term Outcome Objective Data Progress Toward Long Term Outcome 3. The client will O RN O UAP by O RN OUAP 4. The ciant by will Assessments for Outcome Progress To assess progress toward outcomes O RN O UAP 1. The RN will O RN D UAP Most Objective Datum Number preferred O RN O UAP The RN will 3. O RN The RN will 19 O UAP Human Response N Dx/Problem O RN IUAP The RN will Related Factor(s)/Pathophyslology R/T Interdisciplinary Consults ReferralMobilire SSN Student Name 20 4897 words English (United States) 2 Accessibilitv Investigate
Transcribed Image Text:Assessment & Analysis Recognize & Analyze Cues Planning Prioritize Hypotheses Generate Solutions Interventions Quote Long Term Outcome Who RN/UAP Direct Client Care - hands-on interventions for What When W Timing Resolution of the N Dx/Problem Individualized 1. The client will by O RN O UAP 2. The cliant by O RN O UAP will Short Term Outcome Objective Data Progress Toward Long Term Outcome 3. The client will O RN O UAP by O RN OUAP 4. The ciant by will Assessments for Outcome Progress To assess progress toward outcomes O RN O UAP 1. The RN will O RN D UAP Most Objective Datum Number preferred O RN O UAP The RN will 3. O RN The RN will 19 O UAP Human Response N Dx/Problem O RN IUAP The RN will Related Factor(s)/Pathophyslology R/T Interdisciplinary Consults ReferralMobilire SSN Student Name 20 4897 words English (United States) 2 Accessibilitv Investigate
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