Medical Surgical Care Plan for an 80-year-old Male Patient, Exams of Nursing

Download Medical Surgical Care Plan for an 80-year-old Male Patient and more Exams Nursing in PDF only on Docsity! MED SURG Care Plan 4 Test Paper 2024 Patientisa80-year-oldmaleresidingatSentaraWilliamsburgmed- surgeryunit.Patientwasadmittedwithhematuriaonsetstarted8monthsago. PASTMEDICALHISTORY Patienthasahistoryofhypertension,hyperlipidemia,type2diabetes,coronaryheartdisease,gout,GIbleeding,ane mia,kidneydiseasestage3,BPH,diverticulosis. CURRENTORDERS DIET:Diabetic ACTIVITY:Dailyphysicaltherapy,patientneedsnoassistancewithADL’sandisindependent.TREA TMENTS:Patientwillcontinuetoreceiveeverydaymedicationsatappropriatetimes. DEVELOPMENTALASSESSMENT ERIKSON’SSTAGE:Egointegrityvs.Despair(Lillis,Taylor,Lemone&Lynn,2011). EVIDENCE:Patientisveryindependentandneedslittletonoassistance.Patientisawarethatheisindependentan diswantstocontinuetobe. P a g e 1 | 22 MED SURG Care Plan 4 Test Paper 2024 PHYSICALASSESSMENT (Completeheadtotoeassessment.WNLisnotaccepted.Pleasebespecific.) Neurologic:LOC,painassessment,GCSscore Alert&Orientedtoperson,time,place,answersquestio nsappropriately,verbalcommunicationappropriate.P atientreportsnodiscomfort.ROMactiveinpatient’sup perandlowerextremities.GCS14 Respiratory:RateandO2saturation Lungsoundsclearbilaterallytoalllungfields.Symmetri calchestexpansion.Respirations:18,notlabored,reg ularrhythm.Mucousmembranesaremoistandpink.N ocough.O2level100. Cardiovascular:HR,BP,JVD,peripheralpulses,capillaryr efill BP:139/63 Peripheral Pulse:57 Temp:97.5. Radialpulse rate: 59 rhythms normal. Cap refill <3 sec, brisk.Apicalpulse:noaudiblemurmur,noJVD Gastrointestinal:LastBManddescription Abdomenround,soft.Nodiscomfortonabdomendurin gpalpationandnopain.Normalbowelsoundsx4quadr ants.LastBM18MAR13,stoollarge,soft,brown,withh eavyodor. Genitourinary: Continent.Urineisyellow,noodor.Negativeforbladde rdistention. P a g e 2 | 22 MED SURG Care Plan 4 Test Paper 2024 hyperlipidemia Citation: (Vallerand,Sanoski &Deglin,2011) drug- inducedhepatitis,d yspepsia. occurs,therapysho uld bediscontinued. TradeName: Ciprofloxacin GenericName: Cipro Dose:500mgR oute: POTime:every 12 INDICATION:For antibiotic Citation: (Vallerand,Sanoski &Deglin,2011) DrugAction: Inhibitsbacterial DNAsynthesisbyinhi bitingDNAgyraseen zyme.Deathofsusce ptiblebacteria. Is DoseAppropriate? Yes PTsWeight: 83.9kg AdverseReactions: ELEVATEDINTRAC RANIALPRESSURE SEIZURES,agitation, confusion,depressi on,dizziness,drows iness,hallucinatio ns,headache,insom nia,nightmares,par anoia,tremor. NursingImplication s: Observeforsignsand symptoms ofanaphylaxis(rash, pruritus,laryngeale dema,wheezing). Discontinuedrugan dnotify health careprofessionali mmediatelyifthese problemsoccur.Kee pepinephrine, anantihistamine,an dresuscitationequ ipmentclosebyinca se of ananaphylacticreac tion. P a g e 5 | 22 MED SURG Care Plan 4 Test Paper 2024 TradeName:Lasix GenericName: furosemideDo se:20mgRoute:P O Time:twiceaday INDICATION:Loop diuretic Citation: (Vallerand,Sanoski &Deglin,2011) DrugAction: Inhibit thereabsorption ofsodiumandchlorid efromtheloopofHenl eand distal renaltubule.Increas erenalexcretion of water,sodium,chlori de,magnesium,hy drogen, andcalcium.Mayhav erenalandperiphera lvasodilatoryeffects .Effectivenesspersis tsinimpairedrenalfu nction. Is DoseAppropriate? Yes PTsWeight: 83.9kg AdverseReactions: Dizziness,enceph alopathy,headach e,insomnia,hearingl oss,tinnitus,hypote nsionconstipation, diarrhea,drymouth, dyspepsia. NursingImplication s: Notifyhealthcarep roviderifthirst,dry mouth,lethargy,w eakness,hypote nsion, oroliguriaoccurs. MonitorBPandpulse before and duringadministrat ion. Monitorfrequencyof prescriptionrefillsto determinecomplian ceinpatientstreated forhypertension. P a g e 6 | 22 MED SURG Care Plan 4 Test Paper 2024 TradeName: Glucotrol GenericName: glipizideDos e:10mgRoute :poTime:daily INDICATION:For diabetestype2 Citation: (Vallerand,Sanoski &Deglin,2011) Drug Action:Producedby blockingpotassiumc hannels inthebetacellsofthei sletsofLangerhans.B ypartiallyblockingth e potassiumchannel s,thecellremainsdep olarized,increasingt hetimethecellspend sinthecalciumreleas estageofcell,whichr esultsinsignalinglea dingtocalciuminflu x. Is DoseAppropriate? Yes PTsWeight: 83.9kg AdverseReactions:N ausea,vomiting,loss of appetite,diarrhea,c onstipation,upset stomach,headache , andweightgainmay occur.Ifanyof these effectspersistorwor sen,tellyour doctor orpharmacistpromp tly. NursingImplication s: Observeresponsetot heinitialdoseandest ablishmaintenancer egimencautiouslyin older adult ordebilitatedpatient s;early signs ofhypoglycemiaare easilyoverlooked.La btests monitorperiodically duringlong-term therapy:Liverfuncti ontests,serumelectr olytes,andserumos molarity. TradeName: Onglyza GenericName: saxagliptinDo se:2.5mgRoute :POTime:Daily INDICATION:For Citation: (Vallerand,Sanoski &Deglin,2011) DrugAction: D- PP4inhibitorsworkby affectingtheactionof naturalhormonesint he body calledincretins.Incr easedconcentration softheincretinhormo nessuchasglucagon- likepeptide-1(GLP- 1)andglucose- dependentinsulin otropicpolypeptide (GIP)arereleased into thebloodstreamfro mthesmallintestinei nresponsetomeals. Is DoseAppropriate? Yes PTsWeight: 83.9kg AdverseReactions: Upperrespiratorytra ctinfection,Urinarytr actinfection,Headac he,Nasopharyngiti s NursingImplication s: Renalimpairment(e g,serum creatininelevels≥1. 5mg/dLformen,≥1. 4mg/dLforwomen,o rabnormalcreatinin eclearance) Hypersensitivityto metforminhydroc hloride,Acuteorchr onicmetabolicacid osis,includingdiab eticketoacidosis LABDATA&DIAGNOSTICEVALUATION Includedate CITESOURCEFOREACHVALUEANDINDICATION P a g e 7 | 22 MED SURG Care Plan 4 Test Paper 2024 on disorderin whichbloodpressureremain s ertensionmedicationhoweverhisblood P a g e 10 | 22 MED SURG Care Plan 4 Test Paper 2024 abnormallyhigh(areadingof 141/90mmHgorgreater) (Taylor,Lillis,Lomone,&Lyn n,2011) pressureisstillmoderatelyhigh. Diabetestype2 Diabetes is caused by aprobleminthewayyourbody makesor usesinsulin. Insulinisneededtomovebloo dsugar(glucose)intocells,wh ereitisstored and later used forenergy.Whenyouhavetyp e2diabetes,yourfat,liver,and musclecellsdonotrespondco rrectlytoinsulin.Thisiscalledi nsulinresistance.Asaresult, bloodsugardoes notgetintothesecellstobesto redfor energy (Taylor, Lillis,Lomone,&Lynn,2011) Thepatient’sconstanthungerandincreasedthi rstandslowwoundhealing. Hyperlipidemia Cholesterolisafat(alsocalled alipid)thatyourbodyneedsto workproperly.Buttoomuchb adcholesterolcanincreaseyo urchanceofgettingheartdise ase,stroke,andotherproble ms. (Taylor, Lillis,Lomone,&Lynn,2011 ) Thepatientlabsshowedsignsofhyperlipidemia therewerenophysicalsigns. Anemia Anemiaisaconditionthatdev elopswhenyourbloodlacksen oughhealthyredbloodcellsor hemoglobin. Hemoglobinisamainpartofr edbloodcellsandbindsoxyg en.Ifyouhavetoofeworabno rmalredbloodcells,oryourh emoglobinisabnormalorlow ,thecellsinyourbodywillnot getenoughoxygen(Taylor,L illis,Lomone,&Lynn,2011) Thepatientcomplainedoffatigueandwa ssleepyattimes. Diverticulosis A condition of havingdiverticulainthecol on,whichare Thepatientcomplainedofslightabdominalcra mping. P a g e 11 | 22 MED SURG Care Plan 4 Test Paper 2024 outpocketingsof the colonicmucosaand P a g e 12 | 22 1 SaraBernard3/20/1 3 MED SURG Care Plan 4 Test Paper 2024 eport. Patientwillemptybladder Instruct him to drink aminimumof1,500mL(six 8- Increased fluids duringthedaywillincrease urinary 1 SaraBernard3/20/1 3 MED SURG Care Plan 4 Test Paper 2024 completelybydischarge. ounceglasses)fluidsperday. output and discouragebacterialgro wth(Gulanick,Myers,20 11). 3LongTermInterventions: 3Rationales: Catheterize forresidual urine,asappropriate. An enlarged prostatecompressesthe urethrasothaturineisre- tained. Checkingforresidualurinepr ovidesinformationaboutbla dder emptying. (Gulanick,Myers,2011). Limitingestionofbladderir ritants (e.g.,colas, coffee,tea,andchocolate ) Alcohol, coffee,and teahaveanaturaldiureticeff ectandare bladderirritants. (Gulanick,Myers,2011). Provide enoughtime forbladderemptying(10 minutes). Inadditiontotheeffectofane nlargedprostateonthebladd er,stressoranxietycaninhibi t relaxation ofthe urinarysphincter.Sufficientt imeshould be allowed formicturition(Gulanick,My ers,2011). MED SURG Care Plan 4 Test Paper 2024 NURSINGDIAGNOSIS EXPECTEDOUTCOME NURSINGINTERVENTIONS RATIONALE EVALUATION Imbalancednutrition less thanbodyrequirementsrelat edtoanemiaasevidencedby patients’fatigue. ShortTermGoal: Patientwill intake adequatenutrientsbyendofs hift. 3shortterminterventions: Establishetiologicalfacto rsfordiminishednutrition alintake. Observeordiscovermanner stowardeatingandfood. Persuade patient partaking inrecording food intake utilizingadailylog. 3Rationales: Correctevaluationguidesi ntervention.Forexample, patientswithdentitionpro blemsneedreferraltoaden tist,whilepatientswithme morylossesmayneedserv ices suchas Meals-on- Wheels. (Ackley&Ladwig,2011). Various psychological,psychosoci al,andculturalfactorsconcl udethetype,quantity,anda ptnessoffoodconsumed. (Ackley&Ladwig,2011). Establishingoftype,quantit y,andpatternoffoodorfluidi ngestionisaidedbypreciser ecording by patient orcaregiver as the intakehappens; memory isinadequate. (Ackley &Ladwig,2011). Shorttermevaluation: Goalongoing Longtermevaluation: Goalongoing LongTermGoal: WithinoneweekPatientwil ldemonstratebehaviors, 3LongTermInterventions: 3Rationales: Serumalbumin.Thisshow sdegreeofproteinreducti on MED SURG Care Plan 4 Test Paper 2024 15 SaraBernard3/20/201 3 MED SURG Care Plan 4 Test Paper 2024 References(AP Aformat) Ackley,B.J.,&Ladwig,G.B.(2011).Nursingdiagnosishandbookanevidence-basedguidetoplanningcare. (9thed.).St.Louis,Missouri:MosbyElsevier. Corbett,J.V., (2011).Laboratorytestsanddiagnosticprocedureswithnursingdiagnoses7thedition.UpperSaddleRiver,NJ:P earson. Gulanick,M.,&Myers,J.(2011).Nursingcareplans:diagnosesinterventions,andoutcomes.(7thed.).PA:Mosby. Lillis,C.,Taylor,C.,Lemone,P.,&Lynn,P.(2011).Fundamentalsofnursing. (7thed.).Philadelphia,PA:WoltersKluwerHealth,LippincottWilliams&Wilkin. Vallerand,A.H.,Sanoski,C.A.,&Deglin,J.H.(2011).Davis'sdrugguidefornurses. (13thed.).Philadelphia:F.A.DavisCompany. 16 SaraBernard3/20/201 3 MED SURG Care Plan 4 Test Paper 2024