care plan
Post on 19-Jul-2016
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Client Diagnosis: Shortness of breath, hypoxia
Assessment
Nursing Diagnosis (NANDA approved):
Nursing Diagnosis: Deficient Knowledger/t: emotional state affecting learningA.E.B.: questioning members of the health care teamComplete Nursing Diagnosis Statement:
Client Centered Outcome: Pt. will describe rationale for treatment/therapy
Planning / Implementation
Interventions:
1. Consider the pts. ability to learn (eg; mental acuity, ability to see and year, existing pain, emotional readiness, motivation, and previous knowledge.)
A. Rationale: Learning readiness changes over time based on situational, physical and emotional challenges. The nurse assumes the role of authority, guide, motivator, mentor, and consultant depending on the learning readiness of the pt. (Ackley, pg. 504)
2. Assess personal context and meaning of illness (eg., perceived changes in lifestyle, financial concerns, cultural patterns.)
A. Rationale: Improved symptom management and pt. satisfaction were noted as a result of interventions that focused on the needs of the pt and the meaning and perspective of their illness. (Ackley, pg. 505)
3. Repeat and reinforce information during several brief sessions.
A. Rationale: At times, the energy level of pts. may be diminished. Brief sessions focus attention on essential information. Older pts. benefit from repeated follow up sessons. (Ackley, pg. 506)
4. Use verbal and non-verbal therapeautic communication approaches including active listening to encourage pt. to ask questions to gain the knowledge they are seeking
A. Rationale: A nurses communication skills contributes to the well being of pts. and minimizes psychosocial problems. (Ackley, pg. 262)
Evaluation
Evaluation of Client Centered Outcome:
Assessment
Nursing Diagnosis (NANDA approved):
Nursing Diagnosis: Ineffective Breathing Patternr/t: hypoxiaA.E.B.: shortness of breath
Complete Nursing Diagnosis Statement:
Client Centered Outcome: Pt. O2 saturation will remain > 95 during shift.
Planning / Implementation
Interventions:
1. Auscultate breath sounds every 1 – 2 hours. Listen for diminished breath sounds, crackles and wheezes.
A. Rationale: The presence of crackles and wheezes may alert the nurse to airway obstruction, which may lead to or exacerbate existing hypoxia. (Ackley, pg. 375)
2. Monitor the client’s behavior and mental status for the onset of restlessness, agitation confusion, and (in the later stages) lethargy.
A. Rationale: Changes in behavior and mental status can be an early sign of impaired gas exchange. (Ackley, pg. 175)
3. Monitor O2 sat continuosly using pulse oximetry.
A. Rationale: An oxygen saturation of < 90% indicates significant oxygenation problems. . Pulse oximetry is a useful tool for tracking and/or readjusting or supplementing oxygen. (Ackley, pg. 375)
4. Note use of accessory muscles, nasal flaring, retractions, irritability, confusion or lethargy.
A. Rationale These symptos signal increasing respiratory signal increasing respiratory difficulty and increasing hypoxia (Ackley, pg. 176)
Evaluation
Evaluation of Client Centered Outcome:Goal partially met. Pts. O2 was 95 for most of the shift, but did go down to 94 at times.
Diagnostic Test/Lab Test
Normal Value Pt. Value/ Implications of
value
Nursing Considerations/ Why this test was needed for patient
Glucose 70 - 110PV: 236 - 419
Imp: blood sugar high and not well controlled
NC: Monitor bg frequently and as per providers orders. Assess for signs of hypoglycemia such as increased thirst, vision changes, polyuria, or changes in cognition.
Why: To administer proper dose of insulin to pt.
Neutrophils 40 - 60 PV: 85
Imp: Value is high – pt. could be developing or trying to stave off an infection.
NC: Assess frequently for fever, normal breath sounds, weakness and fatigue and other signs of infection.
Why: To determine if her SOB may be caused by an infection.
Lymphocyte 20 - 40PV: 0.8
Imp: Steroid use is affecting the low level – indicates
NC: Trend values by looking at lab values every time they are drawn to determine if value is improving.
Why: To assess the pts. immune
immune system compromised. This puts pt. at risk for infection
function and ability to fight off infection.
Echocardiogram Structures all functioning appropriately with no abnormalies present
PV: All views within normal limits – nothing of significance to note
Imp: Ruled out heart structures causing the pts. symptoms
NC: assure pt. study is painless. Position pt. appropriately for study to be performed accurately.
Why: To determine if structure and function of the heart is within normal limits – to rule out structural deficiencies causing SOB and hypoxia pt. is experiencing
EKG Normal Sinus Rhythm
PV: Premature Ventricular Contractons
Imp: abnormal finding that must be investigated and treated.
NC: Ensure leads are placed appropriately to ensure accurate reading., and that skin is clean and dry so electrodes stay in place.
Why: To assess electrical current function and any abnormalies.
Patient Teaching Plan
Knowledge Deficit r/t Pt. educational
Need
Patient/Resident Specific Teaching
Content: Include Specific
Instructions Given and Method of
Instructions
Patient/Resident Strengths to
Learning
Patient/Resident Barriers to Learning
Evaluation of Patient/Resident
Learning
Medication Dose & Route
Therapeutic Use and Side Effects
Nursing Considerations & Why was this medication
given to the patient/resident?
Insulin Detemir
20 units q hs
TU: lowers bg by moving glucose into the cells
SE: hypoglycemia
NC: Insulin needs can increase in a hospitalized pt
Why: To keep bg levels within normal limits
Aspirin 81 mg q dayTU: propholactic use to as a blood thinner
SE: seizures, coma, GI bleeding,thrombocytopenia, neutropenia, leukopenia
NC: Monitor AST, ALT bilirubin, Bun, creatnine, biliburbin. Also I & O
Why: Propholactically to decrease chance of MI
Simvastatin 20 mg q hsTU: reduces cholesterol synthesis
SE: Liver dysfucntion, pancreatitis, myositis, rhabdomyolysis
NC: Liver dysfucntion, pancreatitis, myositis, rhabdomyolysis
Why: treatment for hypercholesterolemia
Gabapentin 200 mg tid po
TU: Neuropathic pain
SE: diplopia, leukopenia
NC: Assess for signs of infection such as fever, redness or swelling d/t risk of leukopenia, assess for mental status changes
Why: Diabetic nerve pain
Lovenox40 mg q 24 hours sq
TU: Anti-coagulant, prevention of DVT’s
SE: bleeding, fever, edema
NC: Assess for signs of bleeding, teach pt. to report any unusual bleeding or bruising immediately – skin assessment important
Why: Venous stasis d/t immobility
Magnesium Oxide
400 mg tid po
TU: Increases osmotic pressure, drawing fluid into colon
SE: flaccid paralysis, circulatory collapse
NC: Assess I & O, monitor for signs of mag toxicity such as thirst, confusion, decrease in reflexes
Why: Arrhythmias
Allopurinol 100 mg q poTU: reduces uric acid
SE: thrombocytopenia, anemia, leukopenia, bone marrow suppression
NC:
Why: Prophalactic tx of gout
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