Develop a comprehensive plan of care/treatment

August 23, 2022 0 Comments

Physiology homework help
nursing writing
In this third and final submission of your Course Project, you will be completing a comprehensive care plan. This written assignment should include the following:

Comprehensive Plan of Care

Develop a comprehensive plan of care/treatment with short and long term goals and include safety needs, special considerations regarding personal needs, cultural/spiritual implications, and needed health restoration, maintenance, and promotion.

Client name Mr. Brown
Client age: 72yrs
Gender: Male
Religion: Jewish
Ethnic: African American
Illness: T3 burst fracture
Family History: Mr. Brown is from a family of six. He’s the only male child in the family with five siblings. He lost both his parent to high blood pressure when he was at the age of 35. Currently, Mr. Brown has been battling this condition for the past six years. During my assessment, his blood pressure was 165/90 which indicates that he is also experiencing high blood pressure, which is family heredity. Our focus for this project is the disease Mr. Brown is experiencing the T3 disease
Question One

Drug Name Trade & generic name, dose, route & frequency Pharmacological & therapeutic drug class & Expected action in the body What medical diagnosis is your patient taking this drug for? How will it help them? Side Effects & Adverse Reactions/ Complications/Top drug interactions Nursing Administration Special Instructions and Assessments Client Education Evaluation of Medication Effectiveness (e.g. Pain Scale)
– Dosage:
– route:
3 days daily
– generic:
(Gunnström et al., 2022). – Therapeutic:

Fluid is altered
that results in colon.
fluid buildup

– T3 burst
-the patient has
agonized injury in the spinal
cord, this
will assist in colon

– also the patient has a problem in his
bladder and bowel . This medication
aids in making the bowel soft when he is constipating.
-Anxiety, memory loss, blurred vision, insomnia, depression, fatigue, dizziness,

– interactions:
applicable drug

(Vallerand, 2021). – Assess for abdominal distention and bowel function

– evaluate
intake and
output ratios in the body.

– Do not take the dose twice or skip the dose as prescribed.

– if a dose is
skipped it
ought to be taken immediately and given a duration of 6 hours before the next dosage
(Gunnström et al., 2022).

– route:

– dose:
Daily4 times

– generic:
baclofen – Therapeutic:

– contains
impulses at the

bladder and bowel purpose may
also be enhanced
(Gunnström et al., 2022). The patient has a problem in his bowel and
Bladder hence the medication may
help mend his
bowel and bladder
(Vallerand , 2020). Side effects

nasal congestion, insomnia, headache, hypotension,
pruritus, and fatigue,

– interactions:
Analgesics, and alcohol
(Vallerand, 2020). – Assess

– Monitor
patient closely
during test

ought to be
present for
effects in the body
(Gunnström et al., 2022). – Advice the patient to take medication as prescribed.
– instruct the patient to avoid continuous usage of alcohol while undergoing medication.
(Vallerand, 2020).
Dose: 100mg
Frequency: Daily
Generic: Zoloft – Therapeutic:

serotonin in the
CNS hence
Helping Serotonin activities.

incidence of
Panic attacks and Antidepressant
(Vallerand, 2020). -Patient lives alone and does not have close family members.

-He has
painful damage which has made him
became paralyzed
from the abdomen
downwards. Sertraline
can assist him in lessening
his depression
and anxiety
(Vallerand, 2020). Side effects:
thoughts, diabetes and agitation

Simultaneous use
of alcohol is
– Monitor
appetite and

– evaluate for
particularly in
taking other

– Evaluate for
during therapy
(Gunnström et al., 2022). – Instruct client
to take
missing a dose.
– Advise
patient to
consult the doctor if side effects persist.
– emphasize on alcohol avoidance during therapy sections
(Vallerand ,

Route: orally
Frequency: after every six hours
-generic: hydrocodone

Anexsia Norco – Therapeutic:
allergy, cold,
and cough

-Decrease in
rigorousness of
pain and dominance of
the cough
(Gunnström et al., 2022). – Patient has a
stage 3 pressure
ulcer to his
coccyx. The hydrocodone will
assist in relieving pain in the body.

-Hydrocodone is
also an
and could aid
with his urine
(Vallerand, 2020). side effects
-Sedation, euphoria, hallucinations, diplopia, dyspepsia,

– interactions:
Use with
as alcohol may
cause profound
sedation leading to death
2020). – Assess blood pressure before and periodically
in the course of intake.
– Check the functioning of the bowel frequently (Vallerand,
2020). – Instruct
patient on how
and when to
ask for and take pain medication.

-Recommend to the patient that hydrocodone is a drug to make him heal.

– instruct patient to inform the doctor if pain persists. (Vallerand, 2020).
Frequency: after every three days
Route: Taken Orally
Dosage: 10mg – Therapeutic:

-Stimulation of
receptors in veins and

pressure and
vascular tone
2020). Paraplegia:
prescription is
used in the
indicative monitoring of
hypotension in impaired patients.

medicine can
assist in preventing
(Vallerand, 2020). Side effects
– hypertension, dizziness, urinary urge, nervousness, and confusion

-Drug interaction:
Simultaneous use of alcohol
– check the patients’ blood pressure often.
– analyze if the drug
therapy is
successful in the incidence of reducing
– monitor and
report signs of
CNS toxicity
– if the medication is used to
Protect the
Incontinence in the urine,
evaluate the
inconsistency to
assist in
determining if
drug therapy
is effective
– evaluate for
(Gunnström et al., 2022). – Ask the patient to report cases of side effects in the body
(Gunnström et al., 2022).

Question Two

Labs and Diagnostic Tests
CMP lab test might be considered in order to monitor glucose levels. Normal range would be 65-110 mg/dL if an abnormal finding is seen it could indicate pre-diabetes or diabetes for our client (Rasmussen University, 2021). A CBC could also be considered in this case in order to check his WBC due to his pressure ulcer. White blood cell normally ranges the count between 5,000 to 10,000 mm³, while an eminent white blood cell count ranges more than 11,000, which would indicate inflammation or invasive infection (Rasmussen University, 2021). A diagnostic test could be used to determine the level of depression experienced by the patient.
Most depressed people will score between 50 and 69; if he scores between these ranges, he is at greater risk for depression (Gunnström et al., 2022). A CRP test could be ordered to determine the amount of CRP in the blood. If our patient’s CRP is persistently high following his surgery, it could indicate the presence of postoperative infection.

A set of core competencies can help advance adherence to rules of a newly designed health care system as shown by the report, which aims to provide patient-centered treatment, work in multidisciplinary teams, use evidence-based procedure, implement improvement activities, and utilize informatics. Finally, as the committee stresses, narrowing the quality gap can be realized at least in part by transforming health professions’ education.

Gunnström, M., Zdolsek, J. H., & Hahn, R. G. (2022). Plasma volume expansion and fluid kinetics of 20% albumin during general anesthesia and surgery lasting for more than 5 hours. Anesthesia & Analgesia, 134(6), 1270-1279.
Rasmussen University. (2021). Laboratory Values Resources.
Vallerand, A. H. (2020). Davis’s Drug Guide for Nurses (17th Edition). F. A. Davis Company.

Part 2

Medical history
Mr. Brown comes from a family of six and is the only male child out of the six children. He states that he lost his parent to high blood pressure when he was 35. He reports that he has been battling this condition for the last six years. During my assessment, the patient’s blood pressure was found to be 165/90, indicating high blood pressure due to family heredity. The evaluation and analysis show that Mr. Brown is experiencing the T3 disease.
Summary of the admitting diagnosis
The admitting diagnosis is T3 disease since the patient was diagnosed with T3 burst. The patient has a fracture characterized by agonized injury in the spinal cord. T3 disease is associated with high total T3 levels or high free T3 levels, implying that the patient may have hyperthyroidism. Low T3 levels suggest that the patient’s body is producing excess thyroid hormone patient may have hypothyroidism, a condition whereby the body does not make sufficient thyroid hormone. The thyroid produces a hormone known as triiodothyronine, recognized as T3. It also creates a hormone known as thyroxine, identified as T4. These hormones regulate body temperature, heart rate, and metabolism (Shahid et al., 2022). A T3 test is often ordered if the patient is suspected of having a problem with their thyroid. In this case, the patient was diagnosed and admitted for T3 disease, whereby his thyroid was not producing enough thyroid hormone. The symptoms associated with T3 disease include but are not limited to fatigue, dry skin, constipation, muscle weakness, depression, elevated blood cholesterol level, puffy face, hoarseness, and others.

Secondary Medical diagnosis
Prediabetes or Diabetes
The other possible diagnosis for the patient is Prediabetes or diabetes. The Pathophysiology of Prediabetes is the same as type 2 diabetes, which causes insulin resistance and early beta cell failure. In Prediabetes, rapid oscillations of insulin secretion and a decrease in amplitude of large pulses are lost. The causes of Type 2 diabetes are multifactorial and entail environmental and genetic elements that affect the functioning of beta-cell function and muscle, adipose tissue, liver, or pancreas tissue (Skyler et al., 2017). It is often associated with insulin resistance, whereby cells do not use insulin properly. As a result, the pancreas cannot produce sufficient insulin to meet the increased demand.
Pressure Ulcer
Pressure ulcers occur due to injuries caused to the skin and the underlying tissue, mainly due to prolonged pressure on the skin. Pressure ulcers nearly affect anyone but often affect individuals confined to a bed or those sitting in a wheelchair or chair for extended periods (Zaidi & Sharma, 2022). The symptoms associated with pressure ulcers include discolored skin, warm or spongy patches on the skin, itchiness or pain in the affected area, and discolored patches when the skin is pressed.
Inflammation or Invasive Infection
Invasive bacteria are pathogens invading the body where bacteria are generally absent, such as soft tissues such as muscle, meninges, and the bloodstream. Examples of bacteria that cause invasive infection include Streptococcus pneumonia, Haemophilus influenza, and Neisseria meningitides (von Lilienfeld-Toal et al., 2019). When invasive infections occur, they often present very severe diseases that need proper care and can lead to death.
The Pathophysiology of depression is associated with a deficiency of dopamine, serotonin, or norepinephrine in the central nervous system. The brain uses several chemicals as messengers to communicate with the nervous system and other parts of itself. Neurons constantly exchange neurotransmitters as a way of communicating with each other. All brain functions require this kind of communication system. Depression is associated with imbalances in brain neurotransmitters, including dopamine, serotonin, or norepinephrine (Kaltenboeck & Harmer, 2018). Serotonin regulates several essential psychological functions, including aggression, sexual behavior, sleep, eating, and mood. A decrease in serotonin production results in depression in some individuals particularly associated with suicidal thoughts.

Head to toe Assessment

I conducted an assessment on Mr. Brown I obtained his permission by explaining what was expected of him and what I will be doing during the process, The assessment started by staying in an enclosed room to provide privacy and ensure the environment was conducive. I washed my hands and began asking focused interview questions while inspecting skin color for the presence of cyanosis or pallor, nail discoloration, jugular vein distention, and edema. I also inspect his neck; I ask Mr. Brown to dorsiflex (extend) the neck and swallow a sip of water. Palpation of the thyroid gland by standing behind the patient. Both lobes and the isthmus of the thyroid gland are palpated for any nodules or diffuse enlargement. Mobility of the thyroid gland with swallowing was assessed with palpation. Nodules arising from the thyroid gland typically move with swallowing. Examination of the thyroid gland is completed by palpating the regional cervical lymph nodes for any enlargement. inspecting his rate, and rhythm and I checked for chest symmetry with inspiratory and expiratory movement. After the inspection, I listen to the heart sound using the diaphragm and bell of the stethoscope depending on what I am listening for. I listened at the aortic, pulmonic, tricuspid, mitral areas, and Erb’s points respectively. I also listened for carotid pulses checking for bruits; I listened to lung sounds. I palpated and compared the rate, rhythm, and quality of arterial pulses bilaterally, including the carotid, radial, brachial, posterior tibialis, and dorsalis pedis pulses. I check for skin tenting or swelling, using the palm of my hand I check at the mitral area for the presence of heaves or thrill. I palpated the anterior and posterior chest for tactile fremitus while asking her to say 99. I percussed the chest, and clear, low-pitched sounds were heard in all areas. I asked about past medical history, any past hospitalizations, or surgeries.

Questions asked include:
• Do you have a past medical history of blood pressure, stroke, heart attack, and COPD? Yes, he has a family history of blood pressure
• Do you have a family history of Thyroid disease or lung infection such as pneumonia or tuberculosis?
• Do you have any difficulty swallowing?
• Any pain around your neck?
• Do you have any chest pain?
• Any shortness of breath?
• Do you have difficulty breathing?
• Do you Smoke?
• Do you take alcohol?
• Any swelling on your feet?
• Have you ever thought of killing your self

Techniques used are:

Subjective Data:
• Patient has a past family history of heart disease
• Patient denies any allergic reaction to medication or food.
• Patient denies swelling of the feet
• The patient taking any medications blood pressure
• Reports taking the yearly flu vaccine, up to date on the COVID vaccine

Objective Data
• Inspect his neck, asks Mr. Brown to dorsiflex (extend) the neck, and swallow a sip of water.
• Palpation of the thyroid gland by standing behind the patient. Both lobes and the isthmus of the thyroid gland are palpated for any nodules or diffuse enlargement. Mobility of the thyroid gland with swallowing was assessed with palpation. Nodules arising from the thyroid gland typically move with swallowing.
• Listen to the patient’s heart and lung sounds. No murmurs or rubs were heard in the heart sound; lung sounds were clear.
• Inspected chest expansion. Chest expansion is rhythmic and symmetrical during inspiratory and expiratory breathing.
• Pulses were 2+ bilaterally in all extremities, capillary refill <3 seconds, no swelling, tenting, or pitting was noted.
• No heaves or lifts were noted in the sternum and anterior chest wall

Kaltenboeck, A., & Harmer, C. (2018). The neuroscience of depressive disorders: A brief review of the past and some considerations about the future. Brain and Neuroscience Advances, 2, 2 39821281879926.
Zaidi, S. R., & Sharma, S. (2022). Pressure Ulcer. StatPearls Publishing.
Shahid, M. A., Ashraf, M. A., & Sharma, S. (2022). Physiology, Thyroid Hormone. StatPearls Publishing.
Skyler, J. S., Bakris, G. L., Bonifacio, E., Darsow, T., Eckel, R. H., Groop, L., Groop, P., Handelsman, Y., …& Ratner, R. E. (2017). Differentiation of Diabetes by Pathophysiology, Natural, History, and Prognosis. American Diabetes Association, 66(2), 241-255.
von Lilienfeld-Toal, M., Wagener, J., Einsele, H., Cornely, O. A., & Kurzai, O. (2019). Invasive Fungal Infection. Deutsches Arzteblatt International, 116(16), 271-278.