Nursing Care Plan for an 82-year-old Male Patient with Renal Failure and Hypertension, Exams of Nursing

Download Nursing Care Plan for an 82-year-old Male Patient with Renal Failure and Hypertension and more Exams Nursing in PDF only on Docsity! MED SURG CAREPLAN EXAM. LATEST VERSION 2024. GUARANTEED SUCCESS FOR GRADE A+. TOP RATED EXAM STUDY GUIDE 2024!! Patient is a 82-year-old male residing at Sentara Careplex med-surgery unit. Patient was admitted with acute renal failure. PAST MEDICAL HISTORY Patient has a history of hypertension, hyperlipidemia, peritoneal dialysis, kidney transplant 2012, type 2 diabetes, no longer needs dialysis, extensive cardiac history, benign prostatic hypertrophy, history of supraventricular tachycardia, coronary heart disease. CURRENT ORDERS DIET: Reg 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 states “I don’t need help I have come this far already”. Patient is happy to be alive and talks about being lucky to get a kidney donor that saved his life. pg. 2 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 98. Cardiovascular: HR, BP, JVD, peripheral pulses, capillary refill BP: 141/64 Peripheral Pulse: 60 Temp: 98.5. Radial pulse rate: 65 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. pg. 5 Trade Name: Lipitor Generic Name: Atorvastatin Dose: 20 mg Route: PO Time: bedtime INDICATION : For Drug Action: Lowering of total and LDL cholesterol and triglycerides. Slightly increases HDL cholesterol. Reduction of lipids/cholesterol reduces the risk of myocardial infarction. Is Dose Appropriate? Yes PTs Weight 77.6 kg Adverse Reactions: Dizziness, headache, insomnia, weakness, rhinitis, bronchitis, chest pain, peripheral edema, abdominal cramps, constipation, diarrhea, flatus, heart burn, altered taste, Nursing Implications: If patient develops muscle tenderness during therapy, CPK levels should be monitored. If CPK levels are >10 times the upper limit of normal or myopathy pg. 6 hyperlipidemia Citation: (Vallerand, Sanoski & Deglin, 2011) drug-induced hepatitis, dyspepsia. occurs, therapy should be discontinued. Trade Name: Sodium Bicarbonate Generic Name: Sodium Bicarbonate Dose: 1300mg Route: PO Time: 3 times a day INDICATION: For metabolic acidosis Citation: (Vallerand, Sanoski & Deglin, 2011) Drug Action: Sodium bicarbonate is a systemic alkalizer, which increases plasma bicarbonate, buffers excess hydrogen ion concentration, and raises blood pH, thereby reversing the clinical manifestations of acidosis. It is also a urinary alkalizer, increasing the excretion of free bicarbonate ions in the urine. Is Dose Appropriate? Yes PTs Weight: 77.6 kg Adverse Reactions: Edema, flatulence, gastric distention, hypernatremia , hypocalcemia, hypokalemia, sodium and water retention. Nursing Implications: Assess the client’s fluid balance throughout the therapy. This assessment includes intake and output, daily weight, edema and lung sounds. pg. 7 Trade Name: Cytovene Generic Name: Ganciclovi r Dose: 190mg in 100 ml Route: IV Time: Every 12 hrs INDICATION: For treatment of CMV Citation: (Vallerand, Sanoski & Deglin, 2011) Drug Action: Inhibits binding of deoxyguanosin e triphosphate to DNA polymerase by terminating DNA synthesis, thereby inhibiting viral replication Is Dose Appropriate? Yes PTs Weight: 77.6 kg Adverse Reactions: SEIZURES, abnormal dreams, coma, confusion, dizziness, drowsiness, headache, malaise, nervousness, retinal detachment, hemorrhage, intraocular pressure spikes, Nursing Implications: Monitor liver function test results. Monitor neutrophil and platelet counts. Assess fluid intake and output to ensure adequate hydration. Make sure patient has regular ophthalmic examinations during both induction and maintenance therapy. Trade Name: Generic Name: Drug Action: Loperamide acts by slowing intestinal Is Dose Appropriate? Adverse Reactions: Drowsiness, dizziness, Nursing Implications: pg. 10 LAB Ordered: WB C HG B . Client Values: 14.1 9.2 Normal Values 4.0-11.0 3.8-5.8 (Corbett & Banks, 2012). Indication for Diseases / Illness Hematocrit (he-MAT-uh-krit) is the proportion of your total blood volume that is composed of red blood cells. A hematocrit (Hct) test indicates whether you have too few or too many red blood cells (Corbett & Banks, 2012). LAB Ordered: Client Values: Normal Values: Indication for Diseases / Illness Renal Panel Sodium Calcium 135 8.0 135mmol /l 8.4- 10.4mg/dl This panel provides an assessment of your Kidney function to determine your risk of kidney disease and your general state of nutrition (Corbett & Banks, 2012). Albumin 2.9 3.5-5.0g/dl (Corbett & Banks, 2012). MEDICAL DIAGNOSIS CITE pg. 11 SOURCE MEDICAL DIAGNOSIS TEXTBOOK CLINICAL PICTURE Definition, Signs, and Symptoms that should be seen CLIENT’S ACTUAL CLINICAL PICTURE What Signs and Symptoms your patient actually exhibited Hypertension High blood pressure: a common disorder in which The patient’s blood pressure is controlled by hypertension medication however his blood pg. 12 blood pressure remains 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 The patient labs showed signs of hyperlipidemia there were no physical sgins. pg. 15 5. Imbalanced nutrition less than body requirements related to anorexia state. 16 Sara Bernard 3/15/13 Student Name: Sara Bernard Date: 3/11/13 Class: Med-surg Patient Initials: J.S A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest priority first. Be sure to include “related to”, “as evidenced by”, or “risk factors” (if at risk diagnosis) for each medical/psych diagnosis. Write one short term and one long term “expected outcome” (measurable goal) per nursing diagnosis stated in terms of client achievement - “the client will…”). List 3 specific nursing actions (interventions) for your short term and your long term nursing diagnosis and give the scientific rationale for selecting the action you will use to work toward that goal. NURSING DIAGNOSIS EXPECTED OUTCOME NURSING INTERVENTIONS RATIONALE EVALUATION (NANDA APPROVED) (Measurable Goal) (What do you plan to do?) (Why are you doing this?) Cite Source for Each Rationale (Include your measure in your evaluation) NURSING CARE PLAN 17 Sara Bernard 3/15/13 Impaired tissue perfusion related to increased peripheral vascular resistance as evidenced by patient blood pressure reading. Short Term Goal: Patient will maintain a blood pressure less than 140/90 during my shift. Long Term Goal: Patient will maintain a blood pressure less than 140/90 until discharge. 3 short term interventions: Monitor vital signs at least every 2 hours and as needed. Administer antihypertensive medication as ordered. Teach patient about the possible side effects of medications and signs/symptoms to report. 3 Long Term Interventions: Take medications as directed. Monitor BP weekly and record. 3 Rationales: To monitor baseline vitals (Gulanick, Myers, 2011). To promote wellness (Gulanick, Myers, 2011). Promote knowledge and compliance (Gulanick, Myers, 2011). 3 Rationales: Promotes compliance to medical regimen (Gulanick, Myers, 2011). Physician assesses record for medication adjustments (Gulanick, Myers, 2011). Short term evaluation: Goal met Long term evaluation: Goal ongoing Long Term Goal: Within one week patient will display strength, ROM, and improved function as evidenced by independent mobility. Note and report laboratory values such as WBC count and cultures. WBC count and neutrophils are better diagnostic tests for adults for signs of infection (Ackley & Ladwig, 2011). Long term evaluation: Goal ongoing 3 Long Term Interventions: 3 Rationales: Client will state the symptoms of infection of which to be aware by the time of discharge. Use appropriate hand hygiene such as by washing hands thoroughly with soap and water or using an alcohol- based hand rub (Ackley & Ladwig, 2011). Perform or assist with ROM to unaffected joints. Carefully wash and pat dry skin including all skin folds to clean area thoroughly. (Ackley & Ladwig, 2011). Demonstrate and assist with transfer techniques and use of mobility aids such as walker and wheelchair. Teach client to demonstrate stress reduction techniques. (Ackley & Ladwig, 2011). NURSING DIAGNOSIS EXPECTED OUTCOME NURSING INTERVENTIONS RATIONALE EVALUATION Excessive fluid related to decrease glomerular filtration as evidenced by retention, and pitting edema. Short Term Goal: Demonstrate stabilized fluid volume with balanced intake and output, breath sounds clear/clearing, vital signs within acceptable range, stable weight, and absence of edema.by end of shift. 3 Short Term Interventions: Monitor urine output, noting amount and color, as well as time of day when diuresis occurs. Monitor/calculate 24- hour intake and output (I&O) balance. Establish fluid intake schedule if fluids are medically 3 Rationales: Urine output may be scanty and concentrated (especially during the day) because of reduced renal perfusion. Recumbency favors diuresis; therefore, urine output may be increased at night/during bedrest. (Gulanick, Myers, 2011). Short term evaluation: Short term goal is in progress. 14 Sara Bernard 3/15/2013 Referenc es (APA format) Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook an evidence-based guide to planning care. (9thed.). St. Louis,Missouri: Mosby Elsevier. Corbett, J.V., (2011). Laboratory tests and diagnostic procedures with nursing diagnoses 7th edition. Upper Saddle River, NJ: Pearson. Gulanick, M., & Myers, J. (2011). Nursing care plans: diagnoses interventions, and outcomes. (7th ed.). PA: Mosby. Lillis, C., Taylor, C., Lemone, P., & Lynn, P. (2011). Fundamentals of nursing. (7th ed.). Philadelphia,PA: Wolters Kluwer Health, Lippincott Williams &Wilkin. Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2011). Davis's drug guide for nurses. (13th ed.). Philadelphia : F.A. Davis Company. 15 Sara Bernard 3/15/2013