Nursing care plan

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Nursing care plan on two diagnoses.

Patient male 52 DOB 9/25/1971

Chief complaint- coming home post op from colostomy 13 days ago 10/10 abd pain with blood noted in a colostomy bag. reported a fever of 101.5. Tachycardia hr in the 140s, initial bp 90s/40

History of present illness- 53 yr old male, diagnosed with rectal cancer awaiting chemotherapy, discharged from hospital on 10/26/23 to rehab after admission for an abscess of the gluteal region with malignant fistula and incontinence. The patient underwent bilateral dorsal transversus abdominis plane block with laparoscopic sigmoid loop colostomy creation. Presented to the emergency department from the rehab facility complaining of worsening foul smelling drainage through the gluteal region associated with pain         

 The first diagnosis is an abscess of the gluteal region with a malignant fistula. 

The second diagnosis is rectal cancer. And the medication he is on is Cefepime, vancomycin for antibiotics and Dilaudid for pain. 

This patient has no allergies. 

Need to find

* Nursing assessment plan

*Nursing diagnosis for both medical diagnoses 

Social history- Denies alcohol use, Substance abuse- Marijuana

Lab results and care plan instructions are attached. 

Fundamentals of Nursing Care Plan

First MI Last Name

Department of Nursing, Keiser University

NUR 1022C Fundamentals of Nursing

Instructor Name

Due Date of Paper

Student Name: Date:

Client Data:









Language Spoken:


Marital Status:

Code Status:

Past Surgeries:


Social Habits:

Vital Signs:





SAO2 sat:

Present History: Admitting Medical Diagnosis:

A. Why client is in hospital:

Medical diagnosis (does not include signs and symptoms)

Admitting Diagnosis Information:

This paragraph should describe what the signs and symptoms that caused patient to come to the hospital. It should not be what the doctor writes word for word. Paraphrase-put into your words. You may quote the patient.


This paragraph is to define and explain the admitting diagnosis/disease.

This paragraph should explain the etiology. The etiology is what causes the disease.

This paragraph should explain the pathophysiology of the patient’s disease. Pathophysiology describes what the disease does to the body.

Clinical Manifestations/Signs and Symptoms:

This/these paragraphs should explain what the textbook manifestations are and whether signs and symptoms of the patient are similar or different.

Medical Management:

This/these paragraphs should explain the textbook medical management for the admitting diagnosis disease. What medical management is currently being done for the patient?

Past History/Secondary Diagnosis:

Name an additional diagnosis that the patient has.


Complete definition/etiology and pathophysiology for the secondary diagnosis as above.

Clinical Manifestations/Signs and Symptoms:

Complete clinical manifestations and signs and symptoms for secondary diagnosis as above.

Medical Management

Complete the medical management of the secondary diagnosis as completed above.




List of Medications

Medication Name/





Side Effects

Nursing Implication

You will need to address three medications that pertain to this patient’s disease. Choose two from the admitting diagnosis or one from the secondary diagnosis.

The words in red are examples of what info needs to be written.

· To decrease BP.

· If patient is experiencing any anginal attacks, to decrease their frequency and severity.

· To decrease the need for nitrate therapy.

· To increase activity tolerance (Vallerand, Sanoski, & Deglin, 2017, p. 147).

· Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. 

Therapeutic Effects: Systemic vasodilation resulting in decreased BP.

· Coronary vasodilation resulting in decreased frequency and severity of attacks of angina (Vallerand et al., 2017, p. 147).

· Hypersensitivity

· Systolic BP <90 mmHg

· Use cautiously in:

· Severe hepatic impairment, aortic stenosis, history of HF (Vallerand et al., 2017, p. 147).

CNS: dizziness, fatigue. 

CV: peripheral edema, angina, bradycardia, hypotension, palpitations. 

GI: gingival hyperplasia, nausea. 

Derm: flushing (Vallerand et al., 2017, p. 147).


· Monitor BP and pulse before therapy, during dose titration, and periodically during therapy.

· Monitor ECG periodically during prolonged therapy.

· Monitor intake and output ratios and daily weight.

· Assess for signs of HF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention).

· Monitor frequency of prescription refills to determine adherence.

Angina: Assess location, duration, intensity, and precipitating factors of patient’s anginal pain.

Patient/Family Teaching:

· Advise patient to take medication as directed, even if feeling well. Take missed doses as soon as possible within 12 hrs of missed dose. If >12 hrs since missed dose, skip dose and take next dose at scheduled time; do not double doses. May need to be discontinued gradually.

· Instruct patient on correct technique for monitoring pulse. Instruct patient to contact health care professional if heart rate is <50 bpm.

· Caution patient to change positions slowly to minimize orthostatic hypotension.

· May cause drowsiness or dizziness. Advise patient to avoid driving or other activities requiring alertness until response to the medication is known.

· Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken, to avoid alcohol, and to consult health care professional before taking any new medications, especially cold preparations.

· Advise patient to notify health care professional if irregular heartbeats, dyspnea, swelling of hands and feet, pronounced dizziness, nausea, constipation, or hypotension occurs or if headache is severe or persistent.

· Caution patient to wear protective clothing and use sunscreen to prevent photosensitivity reactions.

Angina: Instruct patient on concurrent nitrate or beta-blocker therapy to continue taking both medications as directed and to use SL nitroglycerin as needed for anginal attacks.

· Advise patient to contact health care professional if chest pain does not improve or worsens after therapy, if it occurs with diaphoresis, if shortness of breath occurs, or if severe, persistent headache occurs.

Hypertension: Encourage patient to comply with other interventions for hypertension (weight reduction, low-sodium diet, smoking cessation, moderation of alcohol consumption, regular exercise, and stress management). Medication controls but does not cure hypertension.

· Instruct patient and family in proper technique for monitoring BP. Advise patient to take BP weekly and to report significant changes to health care professional (Vallerand et al., 2017, pp. 147-148).


Eliquis 2.5 mg, 1 tab PO 2x daily

· DVT prophylaxis

· Reduction in risk of stroke/systemic embolism in nonvalvular atrial fibrillation (Vallerand et al., 2017, p. 178).

· Acts as a selective, reversible site inhibitor of factor Xa, inhibiting both free and bound factor. Does not affect platelet aggregation directly but does inhibit thrombin-induced platelet aggregation.

· Decreases thrombin generation and thrombus development. 

Therapeutic Effects: Treatment and prevention of thromboembolic events (Vallerand et al., 2017, p. 178).

· Previous severe hypersensitivity reactions

· Active pathological bleeding

· Severe hepatic impairment

· Not recommended for use in patients with prosthetic heart valves

· Concurrent use of strong dual inducers of CYP3A4 and P-gp

· PE with hemodynamic instability or requiring thrombolysis or pulmonary embolectomy

Use cautiously in:

· Neuroaxial spinal anesthesia or spinal puncture, especially if concurrent with an indwelling epidural catheter

· Drugs affecting hemostasis

· History of traumatic/repeated spinal puncture or spinal deformity (↑ risk of spinal hematoma)

· Discontinuation ↑ risk of thromboses;

· Surgery;

· Renal impairment (dose ↓ may be required;

· Moderate hepatic impairment (↑ risk of bleeding) (Vallerand et al., 2017, p. 178).

Heme: bleeding. 

Misc: hypersensitivity reactions including anaphylaxis (Vallerand et al., 2017, p. 178).


· Assess patient for symptoms of stroke, DVT, PE, or peripheral vascular disease periodically during therapy.


Toxicity and Overdose:

 An antidote or reversal agent is not available. Effects persist for at least 24 hrs after last dose. Oral activated charcoal decreases apixaban absorption, lowering plasma concentrations. Other agents and hemodialysis do not have a significant effect.


· When 
converting from warfarin, discontinue warfarin and start apixaban when INR is <2.0.

· When 
converting from apixaban to warfarin, apixaban affects INR, so INR measurements may not be useful for determining appropriate dose of warfarin. If continuous anticoagulation is necessary, discontinue apixaban and begin both a parenteral anticoagulant and warfarin at time of next dose of apixaban, discontinue parenteral anticoagulant when INR reaches acceptable range.

· When 
switching between apixaban and anticoagulants other than warfarin, discontinue one being taken and begin the other at the next scheduled dose.

For surgery, discontinue apixaban at least 48 hrs before invasive or surgical procedures with a moderate or high risk of unacceptable or clinically significant bleeding or at least 24 hrs prior to procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled.

PO: Administer twice daily without regard to food.

· For patients who cannot swallow tablet, 5 mg and 2.5 mg tablets can be crushed, suspended in water, D5W, or apple juice, or mixed with applesauce and administered immediately orally. May also be suspended in 60 mL of water or D5W and promptly administered through a nasogastric tube.

Patient/Family Teaching:

· Instruct patient to take apixaban as directed. Take missed doses as soon as remembered on the same day and resume twice daily administration; do not double doses. Do not discontinue without consulting health care professional; may increase risk of having a stroke, DVT, or PE. If temporarily discontinued, restart as soon as possible. Store apixaban at room temperature.

· Inform patient that they may bruise and bleed more easily or longer than usual. Advise patient to notify health care professional immediately if signs of bleeding (unusual bruising, pink or brown urine, red or black, tarry stools, coughing up blood, vomiting blood, pain or swelling in a joint, headache, dizziness, weakness, recurring nose bleeds, unusual bleeding from gums, heavier than normal menstrual bleeding, dyspepsia, abdominal pain, epigastric pain) occurs or if injury occurs, especially head injury.

· Caution patient to notify health care professional if skin rash or signs of severe allergic reaction (chest pain or tightness, swelling of face or tongue, trouble breathing or wheezing, feeling dizzy or faint) occur.

· Advise patient to notify health care professional of medication regimen prior to treatment or surgery.

· Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications, especially St. John’s Wort. Risk of bleeding is increased with aspirin, NSAIDs, warfarin, heparin, SSRIs or SNRIs (Vallerand et al., 2017, p. 179).


Labs and Diagnostic Test:

Labs And Diagnostic Test/Labs

Purpose/ Indications

Normal Values

Client Result

Interpretation of Abnormal Results


· To measure the blood glucose level after a fasting period

· To help assess whether hematologic blood sugar levels are being controlled by treatment measures (Daniels, 2014, p. 392).

Fasting: 60 – 110 mg/dL

111 mg/dL ()

Elevated levels may indicate:

· Diabetes (must correlate with other factors and labs)

· Hyperthyroidism

· Cushing syndrome

· Pancreatitis

· Severe liver disease

· Shock

· Trauma

· Drugs such as glucagon, adrenal corticosteroids, oral contraceptives, and some diuretics

Factors that may interfere with results:

· Uremia (Daniels, 2014, pp. 393-394)


· To help determine whether a patient has liver or kidney disease

· To determine whether enough protein is being absorbed by the body (Ellis, 2018, p. 33).

3.5 – 5.5 g/dL

3.3 g/dL ()

Decreased levels may indicate:

· Cirrhosis, liver disease, alcoholism

· Severe burns, severe skin disease (Stevens-Johnson)

· Severe malnutrition, malabsorption, anorexia

· Inflammatory bowel disease (Crohn’s disease and ulcerative colitis)

· Thyroid disease, Cushing disease

Factors that may interfere with the results:

· Penicillin, sulfonamides, aspirin, and ascorbic acid (decrease)

· Prolonged bed rest

· IV fluids, rapid hydration, overhydration (Ellis, 2018, p. 33).


· To determine infection or inflammation.

· To determine the need for further tests, such as bone marrow biopsy.

· To monitor response to chemotherapy (Ellis, 2018, p. 519).

4.0 – 11.0 th/mcL

11.6 th/mcL ()

For an accurate diagnosis, differential test results must be interpreted in relation to the total WBC.

Elevated levels may indicate:

· Infection

· Abscess

· Leukemia

· Tissue necrosis due to burns, myocardial infarction, or gangrene

Factors that may interfere with results:

· Digestion, exercise, or stress

· Anticonvulsants, anti-infectives, most antineoplastics, NSAIDs, and thyroid hormone antagonists

· Elderly patients with overwhelming sepsis (Ellis, 2018, p. 519).

Nursing Diagnosis Two

This is where you will write your second nursing diagnosis.

Nursing Interventions

Discuss three nursing interventions that go with the second diagnosis.

Nursing Rationales

Discuss three rationales that go with each intervention.

Nursing Diagnosis Three

This is where you will write your third nursing diagnosis.

Nursing Interventions

Discuss three nursing interventions that go with the third diagnosis.

Nursing Rationales

Discuss three rationales that go with each intervention.

Nursing Assessment: head to toe physical assessment including IVs, tubes/drains/wounds if appropriate


Diagnostic tests:

– Patient will ______________ as evidenced by_______, _______, ________, ________.

Goals: Written as SMART goals (specific, measurable (action verbs), attainable, realistic, timed)

Minimim 2 short term goals, 1 long term goal






Goal met or not met, continue, discontinue, or reevaluate. Explain each evaluation. Match each evaluation to the goals written above.





Nursing Diagnosis:
Written in NANDA format: ___________ related to ____________ as evidenced by ____________.


Rationale for nursing intervention. Must match each intervention written.






What are your nursing interventions so patient can meet goals written above? Must match goals above.






What is wrong with your patient?


Written in 7th edition APA format. All referenced citations should be found on this page. is a good resource to use to appropriately document references and citations.





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