Medical Care Plan for 82-year-old Male Patient, Exams of Nursing

Download Medical Care Plan for 82-year-old Male Patient and more Exams Nursing in PDF only on Docsity! MED SURG CarePlan Update 2024 Patientisa82-year-oldmaleresidingatSentaraCareplexmed- surgeryunit.Patientwasadmittedwithacuterenalfailure. PASTMEDICALHISTORY Patienthasahistoryofhypertension,hyperlipidemia,peritonealdialysis,kidneytran splant2012,type2diabetes,nolongerneedsdialysis,extensivecardiachistory,beni gnprostatichypertrophy,historyofsupraventriculartachycardia,coronaryheartd isease. CURRENTORD ERSDIET:Reg ACTIVITY:Dailyphysicaltherapy,patientneedsnoassistancewithADL’sandisi ndependent.TREATMENTS:Patientwillcontinuetoreceiveeverydaymedicati onsatappropriatetimes. DEVELOPMENTALASSESSMENT ERIKSON’SSTAGE:Egointegrityvs.Despair(Lillis,Taylor,Lemone&Lynn,2011). EVIDENCE:Patientstates“Idon’tneedhelpIhavecomethisfaralready”.Patientishap pytobealiveandtalksaboutbeingluckytogetakidneydonorthatsavedhislife. Page 1 of 27 MED SURG Care Plan 3 CLINICALPHYSICALASSESSMENT Latest Update PHYSICALASSESSMENT (Completeheadtotoeassessment.WNLisnotaccepted. Pleasebespecific.) Neurologic:LOC,painassessment,GCSsco re Alert&Orientedtoperson,time,place,an swersquestionsappropriately,verbalco mmunicationappropriate.Patientreport snodiscomfort.ROMactiveinpatient’sup perandlowerextremities.GCS14 Respiratory:RateandO2saturation Lungsoundsclearbilaterallytoalllungfie lds.Symmetricalchestexpansion.Respi rations:18,notlabored,regularrhythm. Mucousmembranesaremoistandpink. Nocough.O2level98. Cardiovascular:HR,BP,JVD,peripheralpul ses,capillaryrefill BP:141/64 Peripheral Pulse:60 Temp:98.5. Radialpulse rate: 65 rhythms normal. Cap refill <3 sec, brisk.Apicalpulse:noaudiblemurmur, noJVD Gastrointestinal:LastBManddescription Abdomenround,soft.Nodiscomfortona bdomenduringpalpationandnopain.No rmalbowelsoundsx4quadrants.LastBM 18MAR13,stoollarge,soft,brown,withh eavyodor. Page 2 of 27 MED SURG Care Plan 3 CLINICALPHYSICALASSESSMENT Latest Update GenericName: Atorvastatin Dose: 20mgRoute: POTime:bed timeINDICA TION:For goftotalandLD Lcholesterolan dtriglycerides. Slightlyincreas es HDLcholestero l.Reductionofli pids/cholester olreducestheri skofmyocardia linfarction. ate? Yes PTsWeight 77.6kg Dizziness, headache,inso mnia, weakness,rhi nitis, bronchitis,che stpain,periphe ral edema,abdo minal cramps,constipation, diarrhea,flatus ,heartburn,alte redtaste, Ifpatientdevel opsmuscleten dernessdurin gtherapy,CPKl evelsshouldb emonitored.If CPKlevelsare >10timesthe upperlimitofn ormalormyop athy Page 5 of 27 MED SURG Care Plan 3 CLINICALPHYSICALASSESSMENT Latest Update hyperlipidemi a Citation: (Vallerand,Sa noski&Deglin, 2011) drug- inducedhepat itis,dyspepsia. occurs,therap yshould bediscontinu ed. TradeName:So diumBicarbon ate GenericName: SodiumBicar bonateDose:1 300mgRoute: PO Time:3timesada y INDICATION:For metabolicacido sis Citation: (Vallerand,Sa noski&Deglin, 2011) DrugAction: Sodiumbicarbo nateisasystemi calkalizer,whic h increasesplas mabicarbonate ,buffers excesshydrog en ionconcentrati on,andraises blood pH,therebyrev ersingtheclinic almanifestatio nsofacidosis.Iti salsoaurinarya lkalizer,increa sing theexcretion of freebicarbonat eionsintheuri ne. Is DoseAppropri ate? Yes PTsWeight: 77.6kg AdverseReactio ns: Edema,flatule nce,gastricdis tention,hyper natremia,hy pocalcemia, hypokalemia, sodiumandwa terretention. NursingImplic ations: Assesstheclie nt’sfluid balancethrou ghout thetherapy. Thisassessm entincludesint akeandoutput ,dailyweight,e demaandlung sounds. Page 6 of 27 MED SURG Care Plan 3 CLINICALPHYSICALASSESSMENT Latest Update TradeName: Cytovene GenericNam e:Gancicl ovir Dose:190mgi n100ml Route:IV Time:Every12hr s INDICATION:For treatmentofCM V Citation: (Vallerand,Sa noski&Deglin, 2011) DrugAction: Inhibitsbinding ofdeoxyguan osinetriphosp hatetoDNApol ymerase byterminating DNAsynthesis, therebyinhibiti ng viralreplicatio n Is DoseAppropri ate? Yes PTsWeight: 77.6kg AdverseReactio ns: SEIZURES,abn ormaldreams, coma,confusio n,dizziness,dr owsiness,hea dache,malaise ,nervousness,r etinaldetach ment,hemorr hage,intraocu larpressurespi kes, NursingImplic ations: Monitorliverfu nctiontestres ults. Monitorneutro philandplatele tcounts. Assessfluidinta keandoutputto ensureadequa tehydration.M akesurepatient hasregularoph thalmicexamin ationsduringbo thinductionand maintenancet herapy. TradeName: GenericNam e: DrugAction: Loperamideact sbyslowinginte stinal Is DoseAppropri ate? AdverseReactio ns: Drowsiness,di zziness, NursingImplic ations: Page 7 of 27 MED SURG Care Plan 3 CLINICALPHYSICALASSESSMENT Latest Update LABOrdered: WB CH GB . ClientValue s: 14.1 9.2 NormalValues 4.0-11.0 3.8-5.8 (Corbett&B anks,2012) . IndicationforDiseases/Illness Hematocrit(he-MAT-uh- krit)istheproportionofyourtotalblo odvolumethatiscomposedofredblo odcells.Ahematocrit(Hct)testindica teswhetheryouhavetoofewortoom anyredbloodcells(Corbett &Banks,2012). LABOrdered: ClientValue s: NormalValues: IndicationforDiseases/Illness RenalPanelS odium Calcium 135 8.0 135mm ol/l8.4- 10.4mg/ dl Thispanelprovidesanassessmentof yourKidneyfunctiontodetermineyou rriskofkidneydiseaseandyourgener alstateofnutrition(Corbett&Banks,2 012). Albumin 2.9 3.5-5.0g/dl (Corbett&B anks,2012) . MEDICALDIAGN Page 10 of 27 MED SURG Care Plan 3 CLINICALPHYSICALASSESSMENT Latest Update OSIS CITESOUR CE MEDICALDIAGNOS IS TEXTBOOKCLIN ICALPICTURE Definition, Signs, andSymptomsthatsh ouldbeseen CLIENT’SACTUALCLINICALPICTU RE WhatSignsandSymptomsyourpa tientactuallyexhibited Hypertension Highbloodpressur e:acommondisor derinwhich Thepatient’sbloodpressureiscontr olledbyhypertensionmedicationh oweverhisblood Page 11 of 27 MED SURG Care Plan 3 CLINICALPHYSICALASSESSMENT Latest Update blood pressure remainsabnormally high(areadingof141/ 90mmHgorgreater) (Taylor,Lillis,Lomone ,&Lynn,2011) pressureisstillmoderatelyhigh. Diabetestype2 Diabetesiscausedbya probleminthewayyou rbodymakesorusesin sulin.Insulinisneeded tomovebloodsugar(g lucose)intocells,wher eitisstoredandlaterus edforenergy.Whenyo uhavetype2diabetes, yourfat,liver,andmus clecellsdonotrespond correctlytoinsulin. This is called insulinresistance.A saresult,bloodsugar doesnotgetintothes ecellstobestoredfor energy(Taylor,Lillis, Lomone,&Lynn,20 11) Thepatient’sconstanthungerandi ncreasedthirstandslowwoundhe aling. Hyperlipidemia Cholesterolisafat(als ocalledalipid)thatyo urbodyneedstowork properly.Buttoomuc hbadcholesterolcani ncreaseyourchanceo Thepatientlabsshowedsignsofhyp erlipidemiatherewerenophysical sgins. Page 12 of 27 MED SURG Care Plan 3 CLINICALPHYSICALASSESSMENT Latest Update 4. Fatiguerelatedtopatientslowenergylevelasevidencedbyexcessivesleep. 5. Imbalancednutritionlessthanbodyrequirementsrelatedtoanorexiastate. Page 15 of 27 MED SURG Care Plan 3 CLINICALPHYSICALASSESSMENT Latest Update 1 SaraBernard3/15/1 3 NURSINGCAREPLAN StudentName:SaraBernard Date:3/11/13 Class:Med-surg PatientInitials:J.S Acareplanshouldstartwiththemajorissuesforthatclient.Writethetopthreeprioritynursingdiagnosisforthisclient,wit hthehighestpriorityfirst.Besuretoinclude“relatedto”,“asevidencedby”,or“riskfactors”(ifatriskdiagnosis)foreach medical/ psychdiagnosis.Writeoneshorttermandonelongterm“expectedoutcome”(measurablegoal)pernursingdiagnosiss tatedintermsofclientachievement-“theclientwill…”).List3specificnursingactions(interventions)foryourshortterm andyourlongtermnursingdiagnosisandgivethescientificrationaleforselectingtheactionyouwillusetoworktowardth atgoal. NURSINGDIAGNOS IS EXPECTEDOUTCO ME NURSINGINTERVEN TIONS RATIONALE EVALUATION (NANDAAPPROVE D) (MeasurableGoal) (Whatdoyouplantodo ?) (Whyareyoudoingth is?) CiteSourceforEach Rationale (Includeyourmeas ureinyourevalu ation) 1 SaraBernard3/15/1 3 Impairedtissueperfu sionrelated to increasedperiphera lvascular resistanceasevidenc edbypatientbloodpr essurereading. ShortTermGoal: Patientwillmaintai nabloodpressurele ssthan140/90duri ngmyshift. LongTermGoal: Patientwillmaintai nabloodpressurele ssthan140/90until discharge. 3shortterminterventio ns: Monitorvitalsignsatl eastevery2hoursan dasneeded. Administerantihyper tensivemedicationas ordered. Teachpatientabo utthepossiblesid eeffectsofmedic ations andsigns/sympto mstoreport. 3LongTermInterventi ons: Takemedicationsasd irected. MonitorBPweek lyandrecord. 3Rationales: To monitorbaseline vitals(Gulanick,Myer s,2011). Topromotewelln ess(Gulanick,My ers,2011). Promoteknowledgea ndcompliance(Gulan ick,Myers,2011). 3Rationales: Promotescomplian cetomedicalregim en(Gulanick,Myer s,2011). Physician assesses recordformedication adjustments(Gulanic k,Myers,2011). Shorttermevaluation: Goalmet Longtermevaluation: Goalongoing roved function asevidencedbyind ependentmobility . 3LongTermInterventi ons: 3Rationales: Clientwillstatethesy mptomsofinfectiono fwhichtobeaware by the time ofdischarge. Useappropriatehand hygienesuchasbywa shinghandsthoroug hlywithsoapandwat erorusinganalcohol- basedhandrub(Ackl ey&Ladwig,2011). Performorassistwith ROMtounaffectedj oints. Carefullywashandp atdryskinincludinga llskinfoldstoclean area thoroughly. (Ackley&Ladwig,20 11). Demonstrateandas sistwithtransfertec hniques anduseofmobilityai dssuchaswalkeran dwheelchair. Teach client to demonstratestress reduction techniques. (Ackley&Ladwig,2 011). NURSINGDIAGNOS IS EXPECTEDOUTCO ME NURSINGINTERVENT IONS RATIONALE EVALUATION Excessivefluidrelat edtodecreaseglom erularfiltrationasevi ShortTermGoal: Demonstratestabiliz edfluidvolumewithb alancedintakeando 3ShortTermInterventi ons: Monitorurineoutput ,notingamountand 3Rationales: Urineoutputmaybes cantyand concentrated(especi Shorttermevaluation: Shorttermgoalisinpro gress. dencedbyretention, andpittingedema. utput,breathsounds clear/ clearing,vitalsignswi thinacceptablerang e,stableweight,anda bsenceofedema.by endofshift. color,aswellastime ofdaywhendiuresis occurs. Monitor/ calculate24- hourintakeandoutp ut(I&O)balance. Establishfluidintake scheduleiffluidsare medically allyduringtheday)be causeofreducedren alperfusion. Recumbencyfavors diuresis;therefore,ur ineoutputmaybeincr easedatnight/during bedrest. (Gulanick,Myers,20 11). 14 SaraBernard3/15/201 3 Referen ces(APA format) Ackley,B.J.,&Ladwig,G.B.(2011).Nursingdiagnosishandbookanevidence- basedguidetoplanningcare.(9thed.).St.Louis,Missouri:MosbyElsevier. Corbett,J.V., (2011).Laboratorytestsanddiagnosticprocedureswithnursingdiagnoses7th edition.UpperSaddleRiver,NJ:Pearson. 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&Wil kin. Vallerand,A.H.,Sanoski,C.A.,&Deglin,J.H.(2011).Davis'sdrugguidefornurses. (13thed.).Philadelphia:F.A.DavisCompany. 15 SaraBernard3/15/201 3