Care Plan for 80-Year-Old Male: Nursing Diagnosis, Interventions, Outcomes, Exams of Nursing

Download Care Plan for 80-Year-Old Male: Nursing Diagnosis, Interventions, Outcomes and more Exams Nursing in PDF only on Docsity! MED SURG Care Plan 4 Study Guide Test Paper Patient is a 80-year-old male residing at Sentara Williamsburg med-surgery unit. Patient was admitted with hematuria onset started 8 months ago. PAST MEDICAL HISTORY Patient has a history of hypertension, hyperlipidemia, type 2 diabetes, coronary heart disease, gout, GI bleeding, anemia, kidney disease stage 3, BPH, diverticulosis. CURRENT ORDERS DIET: Diabetic ACTIVITY: Daily physical therapy, patient needs no assistance with ADL’s and is independent. TREATMENTS: Patient will continue to receive everyday medications at appropriate times. DEVELOPMENTAL ASSESSMENT ERIKSON’S STAGE: Ego integrity vs. Despair (Lillis, Taylor, Lemone & Lynn, 2011). EVIDENCE: Patient is very independent and needs little to no assistance. Patient is aware that he is independent and is wants to continue to be. P a g e 1 | 24 MED SURG Care Plan 4 Study Guide Test Paper PHYSICAL ASSESSMENT (Complete head to toe assessment. WNL is not accepted. Please be specific.) Neurologic: LOC, pain assessment, GCS score Alert & Oriented to person, time, place, answers questions appropriately, verbal communication appropriate. Patient reports no discomfort. ROM active in patient’s upper and lower extremities. GCS 14 Respiratory: Rate and O2 saturation Lung sounds clear bilaterally to all lung fields. Symmetrical chest expansion. Respirations: 18, not labored, regular rhythm. Mucous membranes are moist and pink. No cough. O2 level 100. Cardiovascular: HR, BP, JVD, peripheral pulses, capillary refill BP: 139/63 Peripheral Pulse: 57 Temp: 97.5. Radial pulse rate: 59 rhythms normal. Cap refill <3 sec, brisk. Apical pulse: no audible murmur, no JVD Gastrointestinal: Last BM and description Abdomen round, soft. No discomfort on abdomen during palpation and no pain. Normal bowel sounds x 4 quadrants. Last BM 18MAR13, stool large, soft, brown, with heavy odor. Genitourinary: Continent. Urine is yellow, no odor. Negative for bladder distention. P a g e 2 | 24 MED SURG Care Plan 4 Study Guide Test Paper hyperlipidemia Citation: (Vallerand, Sanoski & Deglin, 2011) drug-induced hepatitis, dyspepsia. occurs, therapy should be discontinued. Trade Name: Ciprofloxacin Generic Name: Cipro Dose: 500 mg Route: PO Time: every 12 INDICATION: For antibiotic Citation: (Vallerand, Sanoski & Deglin, 2011) Drug Action: Inhibits bacterial DNA synthesis by inhibiting DNA gyrase enzyme. Death of susceptible bacteria. Is Dose Appropriate? Yes PTs Weight: 83.9 kg Adverse Reactions: ELEVATED INTRACRANIAL PRESSURE SEIZURES, agitation, confusion, depression, dizziness, drowsiness, hallucinations, headache, insomnia, nightmares, paranoia, tremor. Nursing Implications: Observe for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify health care professional immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction. P a g e 5 | 24 MED SURG Care Plan 4 Study Guide Test Paper Trade Name: Lasix Generic Name: furosemide Dose: 20 mg Route: PO Time: twice a day INDICATION: Loop diuretic Citation: (Vallerand, Sanoski & Deglin, 2011) Drug Action: Inhibit the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Increase renal excretion of water, sodium, chloride, magnesium, hydrogen, and calcium. May have renal and peripheral vasodilatory effects. Effectiveness persists in impaired renal function. Is Dose Appropriate? Yes PTs Weight: 83.9 kg Adverse Reactions: Dizziness, encephalopathy, headache, insomnia, hearing loss, tinnitus, hypotension constipation, diarrhea, dry mouth, dyspepsia. Nursing Implications: Notify health care provider if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs. Monitor BP and pulse before and during administration. Monitor frequency of prescription refills to determine compliance in patients treated for hypertension. P a g e 6 | 24 MED SURG Care Plan 4 Study Guide Test Paper Trade Name: Glucotrol Generic Name: glipizide Dose: 10mg Route: po Time: daily INDICATION: For diabetes type 2 Citation: (Vallerand, Sanoski & Deglin, 2011) Drug Action: Produced by blocking potassium channels in the beta cells of the islets of Langerhans. By partially blocking the potassium channels, the cell remains depolarized, increasing the time the cell spends in the calcium release stage of cell, which results in signaling leading to calcium influx. Is Dose Appropriate? Yes PTs Weight: 83.9 kg Adverse Reactions: Nausea, vomiting, loss of appetite, diarrhea, constipation, upset stomach, headache, and weight gain may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly. Nursing Implications: Observe response to the initial dose and establish maintenance regimen cautiously in older adult or debilitated patients; early signs of hypoglycemia are easily overlooked. Lab tests monitor periodically during long-term therapy: Liver function tests, serum electrolytes, and serum osmolarity. Trade Name: Onglyza Generic Name: saxagliptin Dose: 2.5mg Route: PO Time: Daily INDICATION: For Citation: (Vallerand, Sanoski & Deglin, 2011) Drug Action: D-PP4 inhibitors work by affecting the action of natural hormones in the body called incretins .Increased concentrations of the incretin hormones such as glucagon-like peptide-1(GLP-1) and glucose- dependent insulinotropic polypeptide (GIP) are released into the bloodstream from the small intestine in response to meals. Is Dose Appropriate? Yes PTs Weight: 83.9 kg Adverse Reactions: Upper respiratory tract infection, Urinary tract infection, Headache, Nasopharyngitis Nursing Implications: Renal impairment (eg, serum creatinine levels ≥1.5 mg/dL for men, ≥1.4 mg/dL for women, or abnormal creatinine clearance) Hypersensitivity to metformin hydrochloride, Acute or chronic metabolic acidosis, including diabetic ketoacidosis LAB DATA & DIAGNOSTIC EVALUATION Include date P a g e 7 | 24 MED SURG Care Plan 4 Study Guide Test Paper common disorder in which blood pressure remains by hypertension medication however his blood P a g e 10 | 24 MED SURG Care Plan 4 Study Guide Test Paper abnormally high (a reading of 141/90 mm Hg or greater) (Taylor, Lillis, Lomone,& Lynn, 2011) pressure is still moderately high. Diabetes type 2 Diabetes is caused by a problem in the way your body makes or uses insulin. Insulin is needed to move blood sugar (glucose) into cells, where it is stored and later used for energy. When you have type 2 diabetes, your fat, liver, and muscle cells do not respond correctly to insulin. This is called insulin resistance. As a result, blood sugar does not get into these cells to be stored for energy (Taylor, Lillis, Lomone,& Lynn,2011) The patient’s constant hunger and increased thirst and slow wound healing. Hyperlipidemia Cholesterol is a fat (also called a lipid) that your body needs to work properly. But too much bad cholesterol can increase your chance of getting heart disease, stroke, and other problems. (Taylor, Lillis, Lomone,& Lynn,2011) The patient labs showed signs of hyperlipidemia there were no physical signs. Anemia Anemia is a condition that develops when your blood lacks enough healthy red blood cells or hemoglobin. Hemoglobin is a main part of red blood cells and binds oxygen. If you have too few or abnormal red blood cells, or your hemoglobin is abnormal or low, the cells in your body will not get enough oxygen (Taylor, Lillis, The patient complained of fatigue and was sleepy at times. P a g e 11 | 24 MED SURG Care Plan 4 Study Guide Test Paper Lomone,& Lynn,2011) Diverticulosis A condition of having diverticula in the colon, which are outpocketings of the colonic mucosa and The patient complained of slight abdominal cramping. P a g e 12 | 24 1 Sara Bernard 3/20/13 MED SURG Care Plan 4 Study Guide Test Paper to report. Patient will empty bladder Instruct him to drink a minimum of 1,500 mL (six 8- Increased fluids during the day will increase urinary 1 Sara Bernard 3/20/13 MED SURG Care Plan 4 Study Guide Test Paper completely by discharge. ounce glasses) fluids per day. output and discourage bacterial growth (Gulanick, Myers, 2011). 3 Long Term Interventions: 3 Rationales: Catheterize for residual urine, as appropriate. An enlarged prostate compresses the urethra so that urine is re- tained. Checking for residual urine provides information about bladder emptying. (Gulanick, Myers, 2011). Limit ingestion of bladder irritants (e.g., colas, coffee, tea, and chocolate) Alcohol, coffee, and tea have a natural diuretic effect and are bladder irritants.(Gulanick, Myers, 2011). Provide enough time for bladder emptying (10 minutes). In addition to the effect of an enlarged prostate on the bladder, stress or anxiety can inhibit relaxation of the urinary sphincter. Sufficient time should be allowed for micturition (Gulanick, Myers, 2011). MED SURG Care Plan 4 Study Guide Test Paper NURSING DIAGNOSIS EXPECTED OUTCOME NURSING INTERVENTIONS RATIONALE EVALUATION Imbalanced nutrition less than body requirements related to anemia as evidenced by patients’ fatigue. Short Term Goal: Patient will intake adequate nutrients by end of shift. 3 short term interventions: Establish etiological factors for diminished nutritional intake. Observe or discover manners toward eating and food. Persuade patient partaking in recording food intake utilizing a daily log. 3 Rationales: Correct evaluation guides intervention. For example, patients with dentition problems need referral to a dentist, while patients with memory losses may need services such as Meals-on- Wheels. (Ackley & Ladwig, 2011). Various psychological, psychosocial, and cultural factors conclude the type, quantity, and aptness of food consumed. (Ackley & Ladwig, 2011). Establishing of type, quantity, and pattern of food or fluid ingestion is aided by precise recording by patient or caregiver as the intake happens; memory is inadequate. (Ackley & Ladwig, 2011). Short term evaluation: Goal ongoing Long term evaluation: Goal ongoing Long Term Goal: Within one week Patient will demonstrate 3 Long Term Interventions: 3 Rationales: Serum albumin. This shows degree of protein MED SURG Care Plan 4 Study Guide Test Paper Long Term Goal: kidney, and brain. Assist the patient in identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol. Reinforce the importance of adhering to treatment regimen and keeping follow up appointments. 3 long Term Interventions: Suggest frequent position changes, leg exercises when lying down. Help patient identify sources of sodium intake. Stress importance of accomplishing daily rest periods. can exist without symptom or even when feeling well (Gulanick, Myers, 2011). These risk factors have been shown to contribute to hypertension (Gulanick, Myers, 2011). Lack of cooperation is common reason for failure of antihypertensive therapy. (Ackley & Ladwig, 2011). 3 Rationales: Decreases peripheral venous pooling that may be potentiated by vasodilators and prolonged sitting or standing. (Ackley & Ladwig, 2011). Two years on moderate low salt diet may be sufficient to control mild hypertension. (Ackley & Ladwig, 2011). Alternating rest and activity increases tolerance to activity progression. (Gulanick, Myers, 2011). Long term evaluation: Long term goal is ongoing. MED SURG Care Plan 4 Study Guide Test Paper MED SURG Care Plan 4 Study Guide Test Paper