Nursing Care Plan

 


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Medical Diagnoses:  Chronic kidney failure, arteriosclerotic cardiovascular disease, hypothyroidism, seizure disorder, osteoarthritis, mixed incontinence, congestive heart failure, hypertension, depression, hx bladder cancer, depression, hyperlipidemia, thrombocytopenia, peripheral vascular disease

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:  Client reported, “The food doesn’t taste very good and I’m not very hungry.”

         

         

Objective:  Client ate 50% of the meal provided.



Problem:  at risk for imbalanced nutrition, less than body requirements.

      

 

    

      

      

      

      

      

Long Term:  Client will be free of signs of malnutrition within 30 days.

         

Monitor for signs of malnutrition, including brittle hair, bruising, dry skin, pale skin and conjunctiva, muscle wasting, smooth red tongue, chelosis and disorientation.    Untreated malnutrition can result in death. ((Nursing Diagnosis Handbook, Ackley and Ladwig, pg. 576).

Interventions were implemented

Client is currently evidencing signs of malnutrition.  Goal not achieved. 

Noted that client has several s/s of malnutrition, including bruising, dry skin and mucosal membranes and muscle wasting.  Continued monitoring is warranted.   

R/T: 

      

biological factors and pharmacological agents

      

      

      

      

Short Term:  Client will indicate preferred foods.

 Prepare the client for meals.  Clear unsightly supplies and excretions.  A pleasant environment helps promote intake.  (Nursing Diagnosis Handbook, Ackley and Ladwig, pg. 579.)

 

Client indicated preferred foods.

Prepared client for meal, washed hands and face and removed tissues from bed.

AEB:  as evidenced by reduced hunger sensations and a dietary intake of less than the recommended daily allowance (RDA)

      

 

     

      

      

      

      

      

*I = Implementation.  Check those interventions/actions/orders that were implemented

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Describe pathophysiology of primary illnesses:  Consuming less calories than the body requires to maintain a basal metabolic rate can lead to a negative nitrogen balance.  This leads to catabolism of the muscle tissue to meet the body’s energy requirements which leads to muscular atrophy and weakness.  This further increases the negative nitrogen balance.  By consuming less calories than the body needs, the client is at risk for increased infections, decreased wound healing rates, and electrolyte imbalances.  If it continues, malnutrition can eventually lead to organ failure and death.

         

Medications

Name/Dose

Why does resident receive?

Major Side Effects

Nursing Implications

         

         

Acetaminophen/500 mg

         

Pain

Negligible with recommended dosage, rash, dark urine, or pale stools

Monitor for S&S of hepatotoxicity.

         

         

Bisacodyl/ 10 mg supp rect

         

Constipation

Cramping, nausea, diarrhea, fluid and electrolyte disturbances.

Monitor for bowel function, observe for s/s of electrolyte imbalances

         

MI Acid

         

         

Indigestion

Alkalosis

Monitor for relief, observe for s/s of metabolic imbalance

         

Milk of Magnesia

         

         

Constipation

Cramping, nausea, diarrhea, fluid and electrolyte disturbances.

Monitor for bowel function, observe for s/s of electrolyte imbalances

         

Nitroglycerin

         

         

Chest Pain

Headache, apprehension, blurred vision, weakness, vertigo, dizziness, faintness, muscle twitching, pallor, perspiration, and cold sweat.

Monitor for changes in consciousness, assess for headache, supervise ambulation, assess for blurred vision and dry mouth, monitor for overdose symptoms.

         

Saliva Sub Solution

Dry mouth

No major Side effects

Monitor client’s Mucosal membranes to determine level of effectiveness

Metoprolol 25 mg

Hypertension

Erythematous rash, fever, headache, muscle aches, sore throat, laryngospasm, respiratory distress, dizziness, bradycardia, fatigue, Raynaud’s phenomena, nausea, heartburn, dry mouth and mucus membranes, hypoglycemia, SOA

Monitor BP prior to administration, report significant changes, monitor I&O , daily weight, auscultate daily for pulmonary rales, withdraw drug if patient manifests mental depression; can progress into catatonia.

Aspirin EC 81mg

Platelet aggregation inhibition

Nausea, vomiting, heartburn, stomach pain, ulceration, prolonged bleeding time.

Monitor for bleeding, and stomach pain.

Citalopram/40mg

Depression


Fatigue, fever, hypotension, nausea, vomiting, abdominal pain, insomnia.

Watch for worsening depression.

Diltiazem CD 240mg

Atria fibrillation

Headache, fatigue, dizziness, drowsiness, tremor, constipation.

Check BP and ECG. Monitor for headache, supervise ambulation.

Enulose10mg/15ml

Chronic Constipation

Flatulence, belching, abdominal cramps, pain, diarrhea

Promote fluids

Oxycotin/ 10mg

Pain

Dizziness, sedation, anorexia, constipation, hepatotoxicity, pruritis, dysuria, bleeding.

Monitor for light headedness and sedation.  Monitor for s/s of overdose.

Senna Plus/

8.6mg-50mg

Constipation

Strong cramping and gripping pains in the abdomen, electrolyte imbalance, and loss of body fluids.  Nausea, rash, swelling of the fingertips, weight loss, and dark pigmentation in the colon.

Monitor for effectiveness of bowel relief, monitor for electrolyte imbalances, n/v, and rash.

Trazodone/ 50 mg

Depression

Drowsiness, insomnia, headache, impaired memory, hypotension, chest pain.

Monitor pulse, observe patients activity level, check for hypotension.

Valproic Acid/ 250 mg

Seizures

Sedation, drowsiness, dizziness, hallucinations, emotional upset, indigestion, anorexia, abdominal cramps.

Monitor patient alertness.

Peleverus Ont

Skin break down

No major side effects

Monitor skin condition to assess for improvement.

Remeron/7.5mg

Depression

Back pain, malaise, abnormal dreams, tremor, hypertension.

Monitor for worsening depression, weight gain, and orthstatic hypotension.

Prilosec/ 40mg

GERD

Headache, dizziness, fatigue, abdominal pain.

Monitor for s/s of hypotenstion and pain.

         



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