* * Fundamentals of Nursing (NSG 1355) Care Plan * * * ------------------------------------------------- Admission History * ------------------------------------------------- * ------------------------------------------------- Patient Information: Age: 60 Gender: Male Weight and Height: 390 lbs, 76” BMI: 47.47 (Morbidly Obese) * ------------------------------------------------- * ------------------------------------------------- Primary Language: English Religion: Latter-Day Saint Culture: Caucasian * ------------------------------------------------- * ------------------------------------------------- Resusiciation Status: Full Code * ------------------------------------------------- * ------------------------------------------------- Admitting Diagnosis: Altered Mental Status * ------------------------------------------------- * ------------------------------------------------- Reason for Admit: Client was initially admitted to hospital due to severe depression and suicide ideation. Other serious health factors limit him for being able to fully care for himself and so he was transferred to Woodland Park Care Center. * ------------------------------------------------- * ------------------------------------------------- Psychosocial issues: Client is single, never been married. His primary insurance is Regence Blue Cross, with his sister as secondary contact for insurance. Client did not disclose if he has other family members still living. Client is morbidly obese and disabled with a lower left leg amputation below the knee. Prior to admission, client cared for himself * ------------------------------------------------- * ------------------------------------------------- Comorbidities: Fluid Overload, Morbid Obesity, Lower Left Leg Amputation Below Knee, Acute Respiratory Failure, Chronic Respiratory Failure, Atrial Fribrillation, Left Heart Failure, Acute Kidney Failure, Debility, General Muscle Weakness, Ileostomy. * ------------------------------------------------- * ------------------------------------------------- Allergies: NKDA * ------------------------------------------------- * ------------------------------------------------- Tobacco/alcohol: History of alcohol and smoking. Client reports no drinking or smoking since 1989. * ------------------------------------------------- * ------------------------------------------------- Physical Activity/Physical Limitations: Client is wheelchair-bound. He requires assistance with most ADL’s, inlcuding showering, dressing, and transfers between bed and wheelchair, Client has is continent for urine and utilizes a bedside urinal. He has an ileostomy and requires assistance to empty the bag and clean the stoma. Client has occasional stool leakage and has a rectal pouch. Client has a Braden Score of 14 and is at Moderate Risk for developing pressure ulcers. He is a Low Fall Risk per the Morse Fall Scale (score 35) and the Avalon Fall Scale (10). * * Source: Client’s chart and the client Pathophysiology:Major Problem:Altered Mental Status is a general term used to describe various disorders of mental functioning, ranging from mild confusion to complete unresponsiveness and coma. Altered Mental Status most often refers to an abnormal change in responsiveness and awareness. It can be a sign of a serious underlying medical condition. Usual Signs and Symptoms:Changes in brain function – such as confusion, memory loss, loss of alertness, attention span, loss of orientation, defects in judgment or thought, poor regulation of emotions, and disruptions in perception, speech, mobility, and behavior. This change can happen suddenly or over days.Increased Risk Factors include: heart attacks, hip fractures, infections (such as urinary tract infections or pneumonia), medical history of high blood pressure, heart problems, diabetes, or psychiatric illness.Signs that the client had:This client demonstrated confusion, defects in judgment and thought, as well as poor regulation of emotions.He also had some of the factors that increase risk of altered mental status that include: urinary tract infection, heart problem, and psychiatric illness (depression). |

Source: http://www.medicinenet.com/altered_mental_status/symptoms.htm

Drug/trade/generic | Dosage/route/schedule | Reason for UseFor the Client | Top Three Nursing Considerations | ascorbic acid (Vitamin C) | 500mg PO Q Day | wound healing, collagen formation | 1. Assess that wound is healing.2. Administer with food to reduce GI distress.3. | vitamin B complex | 1 capsule PO Q Day | Supplement PO nutrition. | 1. Administer with food to prevent likelihood of stomach upset.2. Monitor for constipation.3. | multivitamin | 1 capsule PO Q Day | Supplement PO nutrition | 1. Administer with food to prevent likelihood of stomach upset.2. Monitor for constipation.3. Assess PO intake… | Flomaxtamsulosin HCL | 0.4mg PO Q Day | Prostatic hyperplasia (urinary urgency, hesitancy, nocturia). | 1. Administer 30 minutes after the same meal every day2. Monitor intake and output ratios and daily weight, and assess for edema daily.3. Monitor for dizziness. Caution patient to change positions slowly to minimize orthostatic hypotension. | vitamin D | 2000U PO Q Day | Bone health. | 1. Administer with food to maximize absorption.2. Monitor for constipation.3. | zinc sulfate | 220mg PO Q Day | Tissue repair, wound healing. | 1. Administer with food to decrease gastric irritation.2. Monitor for nausea or vomiting.3. Assess that wound is healing. | CardizemDiltiazem | 360mg PO Q Day | Atrial fibrillation. | 1. Monitor intake and output ratios and daily weight, and assess for edema daily to assess drug effectiveness.2. Advise client to avoid large amounts of grapefruit juice due to possible interaction with medication.3. Monitor for dizziness. Caution patient to change positions slowly to minimize orthostatic hypotension. |
7
7
6
6
5
5
4
4
3
3
2
2
1
1

Drug/trade/generic | Dosage/route/schedule | Reason for UseFor the Client | Top Three Nursing Considerations | Antara, Fenoglide, Lipofen, Lofibra, Tricor, Triglidefenofibrate | 160mg PO Q Day | Hyperlipidemia. | 1. Administer with food to maximize absorption.2. Monitor for signs and symptoms of gallstones (nausea and vomiting, feeling bloated, pale-colored bowel movements, dark-colored urine) 3. Monitor for abdominal, diarrhea or constipation. | vitamin A | 10,000U PO Q Day | Supplement PO nutrition and help with wound healing | 1. Administer with or after meals.2. Periodically monitor visual acuity by assessing pupil dilation with penlight. [Vitamin A may cause miosis (excessive constriction of pupil), papilledema (optic neuritis), and nystagmus (involuntary rapid eye movement).]3. Monitor for symptoms of hypervitaminosis A syndrome (headaches, irritability, yellow-orange discoloration of skin, drying and desquamation of skin and lips, hair loss, anorexia, vomiting, joint and bone pain). | Fungoid, Lotrimin AF, Micatin, Zeasorb-AFmiconazole nitrate | 2% cream, apply topically 2 times Q Day to pannus and folds of thigh | Fungal infection | 1. Clean and thoroughly dry the area to be treated. 2. Inspect involved areas of skin and mucous membranes for improvement of infection.3. Wear gloves when applying medication. | Mycostatin, Nilstatnystatin powder | Apply topically to pannus and folds of thigh BID | Fungal infection | 1. Clean and thoroughly dry the area to be treated. 2. Inspect involved areas of skin and mucous membranes for improvement of infection.3. Wear gloves when applying medication. | Duonebipratropium bromide/albuterol sulfate | 0.5mg – 3mg/3ml Solution, inhale BID | Respiratory Failure | 1. Monitor respiratory status (rate, breath sounds, dyspnea).2. Monitor pulse for increased rate and rhythm.3. Monitor for dizziness. | chlorophyll | 1 tablet PO BID | Reducing ileostomy odor | 1. Monitor for diarrhea.2. Monitor for nausea or vomiting.3. Monitor respiratory status (rate, breath sounds, dyspnea)… WHY?? |
10
10
13
13
12
12
11
11
9
9
8
8

Drug/trade/generic | Dosage/route/schedule | Reason for UseFor the Client | Top Three Nursing Considerations | acidophilus | 2 tablets PO BID | Support growth of “good” bacteria in intestinal tract | 1. Administer on empty stomach or best effectiveness.2. Monitor for excessive diarrhea for possible C-Diff.3. Use hand hygiene with soap and water for precautionary C-Diff | Coumadinwarfarin | 7mg PO Q Day | Clot prevention | 1. Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; tarry, black stools; hematuria).2. Monitor blood pressure – a drop in blood pressure could indicate a bleed.3. Advise patient to not drink cranberry juice or products while on Coumadin due to possible interaction with medication. | Prinivil, Zestrillisinopril | 20mg PO Q Day | Hypertension | 1. Monitor for dizziness. Caution patient to change positions slowly to minimize orthostatic hypotension 2. Monitor blood pressure for effectiveness and possible hypotension.3. Monitor weight and assess patient routinely for resolution of fluid overload (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention). | Lasixfurosemide | 80mg PO BID | Fluid retention/edema | 1. Administer with food or milk to minimize gastric irritation.2. Monitor for dizziness. Caution patient to change positions slowly to minimize orthostatic hypotension.3. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. | Percocet, Roxicet, Oxycetoxycodone/acetaminophen | 10/325mg PO BID @ 1000 and 2200, PRN Q 6 hrs | Pain | 1. Monitor pulse for possible bradycardia, respirations for hypoventilation, and blood pressure for hypotension. 2. Caution patient to change positions slowly to minimize orthostatic hypotension.3. Monitor for constipation. | MS Continmorphine sulfate | 15mg PO BID | Pain | 1. Monitor pulse, and respirations for hypoventilation. 2. Monitor blood pressure for hypotension. Caution patient to change positions slowly to minimize orthostatic hypotension.3. Monitor for constipation. |
19
19
18
18
17
17
16
16
15
15
14
14

Drug/trade/generic | Dosage/route/schedule | Reason for UseFor the Client | Top Three Nursing Considerations | Lidoderm Patchlidocaine patch | 5% transdermal patch, PRN 1x Q day | Pain on shoulders and right knee | 1. Assess skin for irritation.2. Monitor for dizziness.3. Monitor blood pressure, pulse, and respirations for hypotension and/or hypoventilation. | Tylenolacetaminophen | 500mg PO TID PRN | Pain | 1. Do not exceed 4,000mg in 24 hrs (combined total from med#18 and #21).2. Administer with food to minimize stomach upset.3. Monitor for signs and symptoms of drug-induced hepatitis (i.e. jaundice, abdominal pain, diarrhea, dark urine, nausea, vomiting). | CPAP(Continuous Positive Airway Pressure) | Q HS | Obstructive sleep apnea | 1. Monitor SPO2, titrate to keep >90%.2. Monitor patient periodically throughout night to ensure mask is on securely over nose and mouth and that tubing is free of kinks3. Assess skin under and around mask for signs of irritation. | O2(oxygen) | HFNC @ 6L/M | Respiratory Failure | 1. Monitor SPO2, titrate to keep >90%.2. Monitor blood pressure and heart rate for signs of respiratory distress.3. Assess skin for irritation from cannula (base of nose and behind ears). | * 21
21
20
20
23
23
22
22