Medication Preparation Log: Student Name ✓ Solved

Medication Preparation Log MPLstudent Name

Medication Preparation Log (MPL) Student Name_________________________________________________ Clinical Rotation Date__________________________________________ Patient Initials Room # Code Status Allergies Diagnosis Relevant Medical/Surgical History Drug Dose/Range Route Time Reason for RX Top 4 Side Effects Nursing Care Plan Form Student Name Date Patient (initials only) Patient Medical Diagnosis Nursing Diagnosis (use PES format) Assessment Data (Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis) Goals & Outcome (Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.) Nursing Interventions (List at least three nursing or collaborative interventions with rationale for each goal & outcome.) Rationale (Provide reason why intervention is indicated / therapeutic; provide references.) Outcome Evaluation & Re-planning (Was goal met? How would you revise the plan of care according the patient’s response to current plan?)

Sample Nursing Care Plan:

Student Name: Sally Jones

Date: 1/17/12

Patient (initials only): R. N.

Patient Medical Diagnosis: Stroke

Nursing Diagnosis (use PES format): Impaired physical immobility related to motor track dysfunction as evidenced by weakness and lack of coordination.

Assessment Data (Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)

Goals & Outcome (Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.) Nursing Interventions (List at least two nursing or collaborative interventions with rationale for each goal & outcome.) Rationale (Provide reason why intervention is indicated/therapeutic; provide references.) Outcome Evaluation & Replanning (Was goal(s) met? How would you revise the plan of care according the patient’s response to current plan of care?)

1. +2 weakness on left upper and lower extremity

2. Inability to walk without assistance (patient shuffles when walks and gets confused as to which leg needs to move to propel forward)

Statement #1: Patient will perform ROM exercises each hour during the shift.

Statement #2: Patient will ambulate from bed to door twice by the end of shift.

1. Educate pt about importance of ROM exercises.

Rationale: If pt understands the importance of ROM exercises (to maintain and hopefully increase strength), the pt is more likely to participate in exercises (Potter & Perry, p. 4).

2. Assist pt w/ ROM exercises while teaching him how to perform ROM exercises.

3. Consult with physical therapist for strength training and development of a mobility plan

1. Determine amount of assistance needed to get patient out of bed and ambulate.

2. Clear walkway of hazards. Pt is at risk for falls so clearing hazards will provide a safe path to ambulate (Potter & Perry, p. 3).

1. If patient understands the important of ROM exercises (to maintain and hopefully increase strength), the patient is more likely to participate in exercises (Potter & Perry, p. 4).

2. Pt needs to be instructed on how to perform ROM exercises and performing the exercises while instructing the patient will solidify his understanding so he can perform exercises on his own (Potter & Perry, p. 5).

3. Techniques such as gait training, strength training, and exercise to improve balance and coordination can be very helpful for rehabilitation patients (Tempin, Tempkin, & Goodman).

Weakness and lack of coordination can cause the pt to be off balance which would put him at risk for a fall. Determining level if assistance needed before trying to assist out of bed and ambulate will prevent a fall for the patient (Potter & Perry, p. 2).

2. Pt is at risk for falls so clearing hazards will provide a safe path to ambulate (Potter & Perry, p. 3).

Outcome #1: Pt partially met goals. He was open to and understanding of the need to perform ROM exercises, but he still needs guidance in how to perform. Will continue to with current plan.

Outcome #2: Patient exceeded goal: he walked 4 times. Wil modify plan to increase distance (to nurses’ station).

Paper For Above Instructions

In the field of nursing, medication preparation and nursing care planning are critical skills that help ensure that patients receive safe and effective care. This paper presents a comprehensive medication preparation log and a nursing care plan for a patient named R.N. who has been diagnosed with a stroke, highlighting the necessity of utilizing assessment data, establishing clear goals, implementing effective interventions, and evaluating outcomes. The nursing diagnostic process, along with effective medication management, plays a pivotal role in enhancing patient care and achieving optimal health outcomes.

Patient Overview

Patient Initials: R.N.

Clinical Rotation Date: [To Be Filled]

Room #: [To Be Filled]

Allergies: [To Be Filled]

Diagnosis: Stroke

Relevant Medical/Surgical History: [To Be Filled]

Nursing Diagnosis

The nursing diagnosis is formulated using the PES format, which emphasizes the Problem, Etiology, and Symptoms. In this case, the nursing diagnosis is: “Impaired physical mobility related to motor track dysfunction as evidenced by weakness and lack of coordination.” This diagnosis accurately captures the patient's needs after a stroke and frames the nursing interventions needed to address these issues.

Assessment Data

To support the nursing diagnosis, the following assessment data were collected:

• +2 weakness on left upper and lower extremities
• Inability to walk without assistance, exhibiting shuffling gait
• Patient confusion regarding mobilization and leg movement
• Reported discomfort during attempts to mobilize

Goals and Outcomes

Establishing measurable and time-specific goals is crucial for patient recovery. The following goals were identified for R.N.:

• Statement #1: The patient will perform range of motion (ROM) exercises each hour during the shift.
• Statement #2: The patient will ambulate from bed to door twice by the end of the shift.

Nursing Interventions

To achieve the outlined goals, several nursing interventions have been strategically planned:

1. Educate the patient about the importance of ROM exercises to enhance mobility. If the patient understands their significance, compliance with exercises is likely to improve (Potter & Perry, p. 4).
2. Assist the patient with performing ROM exercises, providing guidance and encouragement to bolster independence.
3. Consult with a physical therapist to develop a tailored strength training and mobility plan to further support rehabilitation.
4. Assess the amount of assistance needed for getting the patient out of bed and ambulating safely to prevent falls.
5. Clear the walkway of potential hazards to ensure a safe environment for ambulation.

Rationale for Interventions

The rationale for each intervention is crucial to ensure that interventions are evidence-based and appropriate:

• The education provided helps the patient understand the implications of impaired mobility, promoting engagement in their recovery process (Potter & Perry, p. 4).
• Assisting the patient enhances their confidence and ability to perform exercises correctly, laying the groundwork for future independence (Potter & Perry, p. 5).
• Referring to a physical therapist allows for individualized interventions that can significantly enhance rehabilitation outcomes (Tempin, Tempkin, & Goodman).
• Assessing assistance needs helps ensure safety during mobility attempts, thereby reducing the risk of falls (Potter & Perry, p. 2).
• Removing hazards from the pathway is a proactive measure to support safe ambulation (Potter & Perry, p. 3).

Outcome Evaluation and Re-planning

Outcome evaluation is a critical aspect of the nursing process. For R.N., the outcomes were as follows:

• Outcome #1: The patient partially met the goal of performing ROM exercises; however, ongoing support and guidance are needed.
• Outcome #2: The patient exceeded expectations by ambulating four times; thus, the plan will be modified to increase the distance of ambulation.

Future revisions to the care plan will focus on enhancing patient independence in executing mobility tasks, expanding the ambulation distance further, and continuing education on the significance of exercises and mobility.

Conclusion

This medication preparation log and nursing care plan for patient R.N. illustrate the importance of comprehensive nursing assessments, the development of targeted interventions, and consistent evaluation and re-planning to achieve desired patient outcomes. As healthcare practitioners, it is our responsibility to adapt and customize care plans as per individual patient needs, acknowledging their unique circumstances and promoting their journey toward recovery.

References

• Potter, P. A., & Perry, A. G. (Year). Fundamentals of Nursing. [Publisher].
• Tempin, T., Tempkin, H. M., & Goodman, J. (Year). Rehabilitation Nursing: A Contemporary Approach. [Publisher].
• [Additional References]