Nursing Care Plan 7 Knowledge Deficit

Case Scenario #8 Ambulatory Patient Care Scenario Instructions: For this case scenario you will develop a nursing care plan using the Standardized Nursing Languages (SNL) of NANDA, NOC & NIC. You will be completing the blank telephone encounter form that accompanies scenario. •

Mrs. Carter is a 56 y.o. female, who was seen five days ago in your surgical clinic by Dr. Such&so. Mrs. Carter was discharged from the hospital eleven days ago following surgical removal of a benign abdominal cyst.

•

The patient has telephoned the clinic complaining of post-operative problems, specifically with her abdominal incision. In the last twenty-four to thirty-six hours, Mrs. Carter has noticed her incision is mildly though continuously tender to touch, & appears slightly reddened & swollen. She denies any drainage. Mrs. Carter does note that she’s feeling ”run down” & “washed out,” more so than any time since her operation; she had anticipated being recovered from her surgery by now, & fully returned to her prior activity level. She periodically feels “warm” & flushed, but hasn’t checked her temperature because she’s unsure how.

•

Mrs. Carter denies any nausea or vomiting, diarrhea or constipation since her post-operative visit. Her past medical history is non-contributory; she has no known (medicinal) allergies. Currently, Mrs. Carter’s medications consist of Tylenol on an as-needed basis. She has taken Tylenol four times in the last twenty-four hours, for incisional tenderness.

•

Mrs. Carter notes that she was instructed, at her post-operative visit, that dressing the incision was no longer necessary. She also states she was instructed that she could now resume her usual hygiene practices, & has taken a tub bath twice since her last clinic visit.

Functional Health Patterns Nursing assessment data is organized in Functional Health Patterns. Functional Health Patterns can help direct the choice of Nursing Diagnoses. The eleven functional health patterns are: Health Perception–Health Management Nutritional-metabolic Activity-Exercise Self-Perception/Self-Concept Coping/Stress/Tolerance Value/Belief

Cognitive–Perceptual Elimination Sleep/Rest Role/Relationship Sexuality/Reproductive

The Functional Health Patterns that are relevant for Mrs. Carter, listed in order of importance, are: Health Perception–Health Management Cognitive–Perceptual Activity-Exercise

Relevant information should be recorded in Assessment, Past Medical History & Current Medications on the Patient Telephone Encounter form.

Step 1. Choosing the Nursing Diagnosis (es) (NANDA) The following nursing diagnoses are appropriate for this patient. In practice, you may select additional nursing diagnoses.

Nursing Diagnosis: Infection, Risk for

Defining Characteristics: Patient complains of incision is tender to touch, & appears reddened & swollen. She denies any drainage. Risk Factors: Invasive procedure

Nursing Diagnosis: Knowledge Deficit

Defining Characteristics: Patient says she hasn’t checked her temperature because she’s unsure how.

Nursing Diagnosis: Fatigue

Defining Characteristics: Mrs. Carter does note that she’s feeling a ”run down” & “washed out;” she had anticipated being fully returned to her prior activity level. While each of these nursing diagnoses are appropriate, for the purposes of this exercise let’s use the second diagnosis, Knowledge

Deficit

On the Patient Telephone Encounter form, check the nursing diagnosis, correlating them with the assessment data you have gathered. In the event that diagnosis selections are not listed as choices among Chief Nursing Diagnosis, you will need to write them in as “other.”

Dr. Such&so is consulted as a result of Mrs. Carter’s contact with the clinic. He orders blood cultures to be drawn & oral antibiotics, Cephalexin 750mg PO Q6 hrs x 10 days, after obtaining these cultures.

Step 2. Choosing the Nursing Outcomes (NOCs). The next step is to select nursing outcomes, either among the nine listed or adding others, that can best affect the nursing diagnosis. Listed below are two appropriate nursing outcomes, for the NANDA, Knowledge

Deficit

Nursing Outcomes: Knowledge: Medication

Indicators: recognition of need to inform health provider of all medications being taken statement of correct medication name description of side effects of medication description of medication precautions description of correct administration of medication Each pertinent indicator should be closely monitored, both upon initial contact & thereafter until diagnosis resolution.

Nursing Outcomes: Knowledge: Infection Control

Indicators: description of practices that reduce transmission description of monitoring procedures description of follow-up for diagnosed infection Select one of the above listed nursing outcomes for this care plan exercise. Rate Mrs. Clark’s current status by using a circle (â) to indicate the score that best represents her status. Use a triangle (ã) to select the score that will best represent the desirable score for Mrs. Clark.

Step 3. Choosing the Nursing Interventions. (NICs) Having selected an outcome for Mrs. Clark, you will need to select the interventions that will best move her toward this outcome. The following Nursing Interventions are appropriate for this patient. Review the activities listed below each NIC & select five.

NIC: Other - Infection Control

Activities – ensure appropriate wound care technique encourage fluid intake (as appropriate) encourage rest instruct patient to take antibiotics, as prescribed. These are the discrete activities selected to comprise our individualized Infection Control intervention; these represent only a portion of the available activities (see NIC, 3rd edition, page 398).

NIC: Medication Management

Activities - For the purposes of this scenario, assume you’ll instruct Mrs. Clark on how to: monitor patient for therapeutic effect of medication facilitate changes in medication with physician, as appropriate teach pt and/or family the expected action and side effects of the medication obtain physician order for patient self-medication, as appropriate instruct patient when to seek medical attention Again, these are discrete activities selected to comprise our individualized Medication Management intervention; these represent only a portion of the available activities (see NIC, 3rd edition, page 451).

The remainder of the Patient Telephone Encounter form (Comments/Provider orders & Disposition of Care) documents the implementation of these Nursing Interventions, & plans for necessary monitoring. Included among these plans is a scheduled follow-up, by the nurse, with the patient; we are to call Mrs. Clark back, & check on her status, in twenty-four hours.

Instructions: For this case study, you will evaluate your patient’s progress against the nursing care plan, you have just developed. You will document this progress utilizing the Follow-Up Patient Telephone Encounter form. Twenty four hours after Mrs. Clark’s call to the clinic, you have made arrangements to contact her in order to follow-up with medical & nursing interventions, & to determine progress toward identified outcomes. Mrs. Clark reports that her initial temperature yesterday was 100.2 F; now twenty hours later, Mrs. Clark’s temperature is 99.2. Additionally, she reports a good nights sleep last night, & feels quite rested this afternoon, more her usual old self. She notes her incision seems top feel less sore, & thinks the Tylenol might be working better than it did before. Her incision continues to evidence no drainage, & is less red than it was yesterday. She took the initial dose of her antibiotic prescription at 2 PM yesterday, & three doses since. Record the pertinent information as assessment information. Reevaluate nursing outcomes; whether or not differences exist between values identified yesterday & those of today. Ascertain if interventions selected yesterday remain appropriate; are additional interventions needed? Based upon your nursing (re) assessment, & perhaps follow-up consultation with the physician (as necessary), determine what events will complete Disposition of Care.

UNIVERSITY OF MICHIGAN HEALTH SYSTEM PATIENT TELEPHONE ENCOUNTER Date

Time

Birthdate

Provider

Insurance

Patient Name Registration #

REASON FOR CALL: Sick Treatment/Medication Question

CALLER:

Referral _________________ Test Results _____________ __________________________

Prescription Refill Pharmacy Name ______________

Can Results Be Left On Answering Machine

Pharmacy Phone______________ MEDICATION

Y/N

Medication Refill Request

# Left

Message taken by _______________________________

Patient

Spouse

MD

Pharmacy

Home Care

Group Home

Parent

Other:_________________

Home Phone:_________________________

Strength

Alternate Phone:_______________________ Frequency Quantity Given Refills Given

Date/Time ______/_______

Voice Mail:

Y N Date/Time Retrieved: ______/______

ASSESSMENT (CHIEF COMPLAINT/ SYMPTOMS/DURATION/SIGNIFICANT FINDINGS):

ALLERGIES: PAST MEDICAL HISTORY: CURRENT MEDICATIONS/TREATMENTS/THERAPIES: CHIEF NURSING DIAGNOSIS: (CHECK APPROPRIATE DIAGNOSIS) Activity intolerance Activity intolerance, risk for Adjustments, impaired Airway clearance, ineffective

Diarrhea Disuse, risk for Diversional activity deficit Family coping, ineffective

Altered body temperature, risk for Anxiety

Family coping – potential for growth Family process, altered

Aspiration, risk for Body image disturbance Bowel incontinence

Fatigue Fear Fluid volume deficit

Breathing pattern, ineffective

Fluid volume deficit, risk for

Cardiac output, decreased Caregiver role strain Caregiver role strain, risk for Constipation

Fluid volume excess Fluid volume imbalance, risk for Gas exchange, impaired Health seeking behavior

Constipation, Risk of

Hyperthermia Individual coping, ineffective

Okay to file

Infection, risk for Injury, risk for Knowledge deficit Management of therapeutic regimen, effective Management of therapeutic regimen, ineffective Management of therapeutic regimen, ineffective - family Nausea Noncompliance Nutrition, altered – less than body requirements Nutrition, altered – more than body requirements Oral mucus membrane, altered Pain Pain, chronic Peripheral neurovascular dysfunction, risk for Physical mobility, impaired Potential for enhanced spiritual well-being

Self esteem disturbance Situational low self esteem Skin integrity, impaired Skin integrity, risk for impaired Sleep deprivation Sleep pattern disturbance Spiritual distress Spiritual distress, risk for Tissue integrity, impaired Tissue perfusion, altered Urinary elimination, altered Verbal communication, impaired Walking, impaired Other (specify)____________ Other (specify)____________ Other (specify)____________

UNIVERSITY OF MICHIGAN HEALTH SYSTEM PATIENT TELEPHONE ENCOUNTER

Pain Level Coping Knowledge Quality of Life Self Care Mobility Compliance Risk Control Anxiety Other________

Nursing Interventions

1 1 1 1 1 1 1 1 1 1

Best State

Worst State

Nursing Outcomes Current Status Desired Status

2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5

Active Listening Emotional Support Counseling Crisis Intervention Self Care Assistance Medication Management Nutrition Management Teaching/Education Health System Guidance Pain Management Family Support Other_________________________________________________ Other_________________________________________________ __________________________________Protocol Utilized

Comments/Provider orders:

DISPOSITION OF CARE: Prescription Authorized

Prescription called in/ mailed by:_______________________________________ Signature/Title Date/Time Referral Authorized for ________________________________________________________________________ Emergency Room or L&D Advised Declined Appointment Advised Appt. Made________________

Authorization for: _____________________________ Appt. Not Necessary at this time Declined

Consultation and /or follow-up with:____________________________________________________________________ Instruction/Information

Verbalized Understanding

provided___________________________________________ Advice per________________________________________________ Protocol

Home Care

Report called to: ________________________________________

Results provided

Call back on _________________ (date) to assess outcomes. Signature

Title

Date

Time

Signature

Title

Date

Time

Signature

Title

Date

Time

Telephone Consultation (Initial) Telephone Consultation (Total)

<5 minutes <5 minutes

<10 min <10 min

11-20 min 11-20 min

21-30 min 21-30 min

6

31-40 min 31-40 min

41-50 min 41-50 min

51-60 min >60 min. 51-60 min >60 min.

UNIVERSITY OF MICHIGAN HEALTH SYSTEM PATIENT TELEPHONE ENCOUNTER Follow Up Patient Name

Date

Time

Registration #

ASSESSMENT:

Consistently

4 4 4

5 5 5

• • •

Elimination pattern in expected range Urine/stool passage without pain Other:

• Reports following prescribed regimen • Other: Coping • Uses available social support

1 1

2 2

3 3

4 4

5 5

• •

Food and fluid Weight

•

Other:

1

2

3

4

5

•

Uses effective coping strategies

1

2

3

4

5

•

Other:

1

2

3

4

5

• • •

Modifies lifestyle to reduce risk Uses health care services to control risk Other:

1 1 1

2 2 2

3 3 3

4 4 4

5 5 5

3 3

4 4

5 5

Quality of Life

Substantially

Moderately

Mildly

Not

•

Satisfaction with health status

1

2

3

4

5

•

Satisfaction with achievement of life goal

1

2

3

4

5

1 1 1

2 2 2

3 3 3

4 4 4

5 5 5

• Satisfaction with close relationships • Other • NURSING INTERVENTIONS:

Active Listening Emotional Support Counseling Crisis Intervention

5 5 5

•

• •

Wound healing Resolution of edema

Resolution of wound odor Other:

1

2

3

4

5

1 1

2 2

3 3

4 4

5 5

Pain • Reported pain • Frequency of pain

None

2 2

4 4 4

1 1

2 2

3 3

4 4

5 5

•

1

2

3

4

5

1

2

3

4

5

Length of pain

•

Other:

Self Care •

Eating

•

Hygiene

• Other: Mobility • Muscle movement • Ambulation (walking) • Other

Self Care Assistance Medication Management Nutrition Management Teaching/Education

Okay to file

7

Completely independent

1 1

3 3 3

Slight

• •

2 2 2

Independent with assis. Device

5

1 1 1

Nutritional Status

Moderate

Extensive

4

5 5 5

Requires assistive device

Substantial

3

4 4 4

Substantial

Moderate

2

3 3 3

Requires Asst. per. & device

Limited

1

Knowledge (Specify Indicators)

2 2 2

Severe

None

•

Extremely

Risk Control

1 1 1

Elimination

Dependent does not participate

Compliance

Not Compromised

Often

3 3 3

Mildly Compromised

Sometimes

2 2 2

Controls anxiety response Reports adequate sleep Other:

Moderately Compromised

Rarely

1 1 1

Anxiety • • •

Substantially Compromised

Never

Circle number to indicate present status

Extremely Compromised

Nursing Outcomes

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1 1 1

2 2 2

3 3 3

4 4 4

5 5 5

Health System Guidance Pain Management Family Support Other ___________________________

UNIVERSITY OF MICHIGAN HEALTH SYSTEM PATIENT TELEPHONE ENCOUNTER Follow-Up Comments/Provider Orders:

DISPOSITION OF CARE: Prescription Authorized

Prescription called in/ mailed by:_______________________________________ Signature/Title Date/Time Referral Authorized for ________________________________________________________________________ Emergency Room or L&D Advised Declined Appointment Advised Appt. Made________________

Authorization for: _____________________________ Appt. Not Necessary at this time Declined

Consultation and /or follow-up with:____________________________________________________________________ Instruction/Information

Verbalized Understanding

provided___________________________________________ Advice per________________________________________________ Protocol

Home Care

Report called to: ________________________________________

Results provided

Call back on _________________ (date) to assess outcomes. signature

Title

Date

Time

signature

Title

Date

Time

signature

Title

Date

Time

Telephone Consultation (Initial) Telephone Consultation (Total)

<5 minutes <5 minutes

<10 min <10 min

11-20 min 11-20 min

21-30 min 21-30 min

8

31-40 min 31-40 min

41-50 min 41-50 min

51-60 min >60 min. 51-60 min >60 min.