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Student Name: Patricia Robles-Medina Long Term Care RotationCare Plan Template Gender: MaleAge Range (e.g. 60-65 yr): 90-100 Advanced Directives (e.g. Living Will, Medical Durable Power of Attorney, Do Not Resuscitate or Allow Natural Death): Full codeAllergies (Drug/Food/Environment): Iodine (including food products)Reason for Admission: Aftercare, heal trauma for fracture of left hipHt, Wt, and BMI: 67inches, 140 lbs, BMI 22Current Orders (exclude labs/medications/diagnostic tests):Activity: noneDiet: not able to find on chart but he verbalized that the speech pathologist had him drinking thickened liquid and mechanically altered food.Interdisciplinary Services/Consults (e.g. PT, OT, ST, dietary, hospice): noneLanguage spoken: EnglishReligious preference: Non-denominationalFinancial/Insurance concerns: 90% service connectedImmunization status (flu and pneumonia): refused both flu and pneumonia vaccine 1/31/14Domestic/Child/Elder abuse issues: none notedLTC Resident Medical and Surgical HistoryList and briefly describe each medical diagnosis and surgical procedure.Medical history (List top three medical diagnoses in order of priority.) Define medical diagnoses Aftercare, heal trauma fracture left hipDysphagiaCongestive Heart failureFracture of left hip - a break in the continuity of a bone when force is applied that is greater than the strength of the bone CITATION McC14 \l 1033 (McCance & Huether, 2014)Dysphagia – difficulty swallowing that can be caused from mechanical blocking of the esophagus or a functional condition that harms esophageal motility CITATION McC14 \l 1033 (McCance & Huether, 2014)Congestive Heart Failure – the pathophysiologic condition in which the heart cannot generate an adequate cardiac output to perfuse the tissues or increased diastolic filling pressure of the left ventricle or both which can increase the pulmonary capillary pressure CITATION McC14 \l 1033 (McCance & Huether, 2014)Surgical history(List three recent surgical procedures if applicable.)Define surgeriesNone notedLTC Resident Pathophysiology DescriptionState the primary medical diagnosis in your own words, then present data specific to your patient (including corresponding labs, medications, and co-morbidities). Include references in APA format.Medical/surgical diagnosisPathophysiologyResident’s manifestations(signs and symptoms)DysphagiaThere are two types: oropharyngeal and esophageal. A person can have both types as well. Oropharyngeal dysphagia occurs during the swallowing process before food goes into the esophagus. There is a problem in this process that can be due to decreased jaw strength, decreased saliva, or an increase in connective or fatty tissue in the tongue that can interfere with the bolus to be swallowed. This may cause a person to take several swallows to get one bolus into the esophagus. During the esophageal phase, there can be a delay with the bolus because of the change in elasticity of the upper esophageal sphincter. CITATION Kha14 \l 1033 (Khan, Carmona, & Traube, 2014)Impaired swallowing (slow and repeats several times)CoughEsophageal refluxMedication WorksheetDrug NameGeneric and Brand & Time DueClassification andMechanism of actionActions and Indications (Reason MY patient is on this medication)Patient dose,Route, andfrequency Most common or serious side effectsContraindications &Major Interactions (Food and Drug)Nursing Interventions and Patient Teaching(What you need to know before administering)AcetaminophenTylenolprn CITATION Deg11 \l 1033 (Deglin & Vallerand, 2011) antipyretics, nonopioid analgesicMild pain or feverInhibits the synthesis of prostaglandinsPO 325-650mg q 4-6hr Hepatoxicity, Renal failure with high doses, neutropenia, pancytopenia, rashPrevious hypersensitivity; avoid products containing alcohol, aspartame, saccharin, sugar or tartrazine; Severe hepatic impairmentMay increase risk of bleeding with warfarin.Assess overall health status. If malnourished or chronically use alcohol then can be at risk for hepatoxicity. Educate that it may alter blood glucose results. Take exactly as directed and not for more than 10 days. Avoid taking other NSAIDs.SalicylatesAspirinprn CITATION Deg11 \l 1033 (Deglin & Vallerand, 2011)antipyretics, nonopioid analgesicInflammatory disorders, mild to moderate pain, fever, prophylaxis of TIA and MIInhibits the production of prostaglandinsPO 325-100 q 4-6 for pain/feverPO 2.4g/day for inflammationPO 50-325 mg once daily for TIAPO 80-325 mg once daily for MIGI bleeding, dyspepsia, epigastric distress, nausea, anaphylaxis, and laryngeal edemaHypersensitivity to aspirin tartrazine, or other salicylates. Cross sensitivity with other NSAIDs, bleeding disorder or thrombocytopenia, children with viral infections(risk of Reye’s syndrome)May increase the risk of bleeding with warfarin, heparin, ticlopidine, clopidogrel, abciximab, tirofiban, eptifibatideWatch for patients with asthma, allergies for hypersensitivity. Assess for rash, pain, and fever. Instruct patient to take with full glass of water and stay upright for 15-30 minutes, report any tinnitus, bleeding of gums, bruising, black tarry stools, or fever. Caution with use of alcohol and other NSAIDs. OmeprazoleLosec, Prilosec8:45 a.m. CITATION Deg11 \l 1033 (Deglin & Vallerand, 2011)Antiulcer agents, proton pump inhibitorsGERD maintenance of healing in erosive esophagitis. Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH preventing the final transport of hydrogen ions into the gastric lumen.PO 20 mg tablet once a dayDizziness, fatigue, headache, abdominal pain, chest pain. Hypersensitivity St. John’s Wort may decrease levels and may decrease response.Assess for epigastric or abdominal pain, blood in stool, or gastric aspirate. Take as directed. May cause drowsiness or dizziness. Avoid alcohol or NSAIDs or foods that irritate GIFurosemideLasix8:45a.m. CITATION Deg11 \l 1033 (Deglin & Vallerand, 2011)DiureticsEdema due to heart failure, hepatic impairment or renal disease, hypertension.Inhibits the reabsorption of sodium and chloride from the loop of Henle. Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calciumPO 40 mg once a daydehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesaemia, hyponatremia, hypovolemia, metabolic alkalosisHypersensitivity, cross sensitivity with thiazides and sulfonamidesRisk of hypokalemia with other diuretics, amphotericin B, stimulant laxatives or corticosteroids.Assess fluid status, monitor Iand O’s, and edema, lung sounds, turgor, BP, and pulse. Increased risk for falls. Take as directed. Change positions slowly and avoid alcohol and long periods of standing to minimize orthostatic hypotension. Contact dr is rash, muscle weakness, cramps, nausea, dizziness.MetoprololLopresor8:45 a.m. CITATION Deg11 \l 1033 (Deglin & Vallerand, 2011)Antianginals, antihypertensive, beta blockerHypertension, angina pectoris. Prevention of MIBlocks stimulation of Beta1 adrenergic receptorsPO 20 mg once a day Hold if SBP is <100or pulse <50Bradycardia, HF, pulmonary edema, fatigue, weaknessUncompensated HF, pulmonary edema, Cardiogenic shock, bradycardia, heart block, increased sensitivity to beta blockers, Increased risk of bradycardia with digoxin, verapamil, diltiazem, and clonidineMonitor BP, ECG, and pulse frequently. Take as directed, abrupt withdrawal my cause life threatening arrhythmias, hypertension, or myocardial ischemia. Avoid driving because it may cause drowsiness,Lab ValuesLab Data (per Level)Description of Lab TestNormal ValueAdmission Result & DateRecent Result &DateRecent Result &DatePathophysiology explanation of abnormal lab value, including trends and correlation with disease processWBCNO LABS DRAWN IN THE PAST TWO WEEKSNeutrophils (ANC)LymphocyteMonocytesHemoglobin (Hgb)Hematocrit (Hct)PlateletsSerum NaSerum KSerum ClSerum CO2BUNCreatinineGlucoseCaMgProthrombin Time (PT)International Normalized Ratio (INR)Activate Partial Thromboplastin time (APTT)Liver Function TestUrinalysisABGspHpO2pCO2HCO3BEOn room air or what % O2TB testOther:e.g. Vanco troughDiagnostic Tests (e.g. x-ray, ultrasound)(Available for the last three months. Limit to three)TestsPurpose of Test(For THIS patient)Date of TestTest Results NO TESTS AVAILABLEProblem List and DiagnosesProblem(List two. Number problems in order of priority)Nursing Diagnosis with R/T and AEB(List one for each problem.)Impaired swallowingRisk for fallsDeficient knowledge r/t difficulty swallowing, secondary to dysphagia, aeb slowness of swallow, repetitive swallowing, cough, thickened liquids, mechanically altered food CITATION Ack14 \l 1033 (Ackley & Ladwig, 2014)Impaired physical mobility r/t weakness in leg, secondary to hip fracture, aeb slowed movement, use of walker and wheelchair, decreased muscle tone in left leg, gait changes CITATION Ack14 \l 1033 (Ackley & Ladwig, 2014).Nursing Diagnosis Priority # 1 Deficient knowledge r/t difficulty swallowing, secondary to dysphagia, aeb slowness of swallow, repetitive swallowing, cough, thickened liquids, mechanically altered food.General Goal: Resident will understand techniques that reduce the risk of aspiration.Outcome (use SMART format): By the end of my shift, the resident will verbalize an understanding of two techniques that can help reduce the risk of aspirations.Interventions (2 total)Rationale (Provide one rationale for each intervention with citations. Use additional sources besides Ackley & Ladwig book.) Patient Responses – Actual or Anticipated (Objective or subjective) Educate resident on oral care before and after meals.Educate resident on head posture changes during meals.Oral care is important before and after meals so that bacteria that is colonizing in the mouth does not remain in the saliva and have a chance of going into the lungs when being swallowed. When brushing their teeth, bacteria is loosened and can remain in the mouth. It is essential to rinse several times and spit out to make sure the loosened bacteria is gone. If a person is at risk for swallowing the rinse water, then mouth wipes can be just as effective of getting rid of the remaining bacteria CITATION Ike14 \l 1033 (Ikeda, et al., 2014)Raising the chin helps to send the bolus to the back of the mouth and reduce aspirations. Tucking the chin under can help open the airway and reduce aspiration. The resident can do both of these techniques while he is eating depending on if he is swallowing or in-between swallows CITATION Sur12 \l 1033 (Sura, Madhavan, Canaby, & Crary, 2012)Actual response:Patient verbalized that he remembered hearing that from the Speech Language Therapist but that he only brushed his teeth once a day.Anticipated response:Patient will be willing to try some of these techniques. Evaluation of outcome (met, not met, partially met with explanatory rationale): The outcome was not met. I educated the patient about oral care and he listened, but he did not verbalize an understanding back to me. I was not able educate about the head posture due to time constraints.Nursing Diagnosis Priority # Impaired physical mobility r/t weakness in left leg, secondary to hip fracture, aeb slowed movement, use of walker and wheelchair, decreased muscle tone in left leg, gait changes.General Goal: Increase mobility using his walkerOutcome (use SMART format): By the end of two weeks, resident will use walker to walk for at least 10 minutes five times a week.Interventions (2 total)Rationale (Provide one rationale for each intervention with citations. Use additional sources besides Ackley & Ladwig book.) Patient Responses – Actual or Anticipated (Objective or subjective)Recommend to health care team that resident walk with walker five times a week. Demonstrate to resident how to do chair raises from wheelchair.Resident is able to walk with walker 3 times a week. If he can increase the amount of times that he walks then he will increase his mobility CITATION Thi14 \l 1033 (Thingstad, et al., 2014).Resident can do chair raises from sitting position in wheelchair to a standing position and back down again. This will help him strengthen his legs and increase mobility CITATION Thi14 \l 1033 (Thingstad, et al., 2014).Anticipated response:Resident enjoys walking and looks forward to his 3 days already. Resident will walk 5 times a week.Anticipated response:Resident will do chair raises.Evaluation of outcome (met, not met, partially met with explanatory rationale): I was not able to meet my outcome because I didn’t have enough time to put them into action.Evidence Based PracticeBriefly summarize (1-2 pages) an evidence based practice article(s) which supports an area of your plan of care and/or interventions. At least one article must be from a nursing journal and published within the last ten years. Properly cite your source(s) in APA, providing full citation on the reference page. No cover page is required. Attach article(s) in D2L. The article that I am summarizing studied oral care of the elderly who have dysphagia. It discusses how important oral care is for a person who has dysphagia. Mechanical cleaning of the mouth loosens up any bacteria that is colonizing in the mouth. Once you loosen the bacteria, it needs to be eliminated. Rinsing with water, swishing and spitting it out is one way to do this. If an elder has trouble with swallowing, the rinsing water may be swallowed and allow bacteria to get into the lungs which can cause aspirations and lead to aspiration pneumonia. In order for this not to happen, an elder may use a mouth wipes to clean the oral cavity and eliminate the bacteria that has been released CITATION Ike14 \l 1033 (Ikeda, et al., 2014).A crossover trial with 31 participants was initiated. The participant’s teeth were brushed by a unit nurse after breakfast. They were told not to brush their own teeth during the study. After brushing, their tongue was cleaned with a tongue scraper 10 times. Their palate and soft tissues of the mouth were cleaned with a sponge swab. To eliminate the residual contaminants, patients were rinsed with 30 ml of tap water from a syringe and then suctioned one day. At least 24 hours later the same routine was followed but this time to eliminate residual contaminants their teeth, gums, tongue, and palate were wiped with a mouth wipe. A bacteria detection apparatus was used to measure before the oral, after the oral care, after the rinse or wiping, and one hour after the whole procedure. The areas measured were the tongue, the hard and soft palate, and the buccal vestibule of the right lower molars CITATION Ike14 \l 1033 (Ikeda, et al., 2014).The study showed that after oral care the amount of bacteria increases. This is presumed because the bacteria has been loosened. The amount of bacteria decreased significantly after the rinsing. The amount of bacteria decreased significantly after the mouth wipe as well. This demonstrates that either technique can be used. At least one is necessary in order to eliminate the bacteria. Elders who are still able to handle rinsing with water should continue to rinse. If an elder is unable to rinse with water, then this study demonstrated that a mouth wipe is just as effective as rinsing to decrease bacteria. This makes mouth wipes a good alternative. One hour after both procedures, the bacteria had increased again indicating that your mouth will produce bacteria again that is comparable to the amount of bacteria that was there before oral care CITATION Ike14 \l 1033 (Ikeda, et al., 2014). Colonization of bacteria is continuous. This suggests that the more oral care an elder can accomplish, the better chance they have at reducing the risk of swallowing or aspirating bacteria. Aspirating bacteria can lead to aspiration pneumonia and a whole new set of problems for an elderly patient.References BIBLIOGRAPHY Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An Evidence Based Guide to Planning Care (10th ed.). Maryland Heights, MO: Elsevier.Deglin, J. H., & Vallerand, A. H. (2011). Davis's drug guide for nurses (12th ed.). Philadelphia, PA: F.A Davis Company.Gordon, M. (2008). Assess notes. Philadelphia, PA: F.A. Davis Company.Ikeda, M., Miki, T., Atsumi, M., Inagaki, A., Mizuguchi, E., Meguro, M., . . . Matsuo, K. (2014, March 3). Effective elimination of contaminants after oral care in elderly institutionalized individuals. Geriatric Nursing, 1-5.Khan, A., Carmona, R., & Traube, M. (2014, February 1). Dysphagia in the Elderly. Clinics in Geriatric Medicine, 30, 43-53.McCance, K. L., & Huether, S. E. (2014). Pathosphysiology: The Biologic Basis for Disease in Adults and Children. In V. L. Brashers, & N. S. Rote (Eds.). St. Louis, MO: Elesevier.Sura, L., Madhavan, A., Canaby, G., & Crary, M. A. (2012, July 27). Dysphagia in the elderly: management and nutritional considerations. Clinical Interventions in Aging, 287-297.Thingstad, P., Taraldsen, K., Hagen, G., Sand, S., Saltvedt, I., O, S., & J.L, H. (2014). Effectiveness of Task Specific Gait and Balance Exercise 4 months After Hip Fracture: Protocal of a Randomized Controlled Trial - The Eva-Hip Study. Physiotherapy Research International. doi:10.1002/pri. 1599Clinical Assessment DataBP:100/61 Temp:97.3°FPulse:85Resp: 18Pulse ox: 96% Height: 67in Weight: 140lbsBMI: 22Pain scale:none notedLocation: Duration:General Appearance Skin, Hair, NailsHead round, symmetric, and proportionate to body sizeScalp: Clean with no lesions, lumps, or dipsFace (CN, V, VII): Symmetric, sensation on both sides of face, no muscle weaknessEyesVisual Acuity (CN II): Deferred (wears glasses)Visual fields: diminished visual fieldOcular Movements (CN III, IV, VI): slow movementsConjunctiva, Sclera: Sclera a little yellow with red blood vessels showing bilateral, conjunctiva clearPupillary Reflexes (CN III): Pupils are equal, round, reactive to light, slow accommodationEarsExternal Structures: Equal size, slight discharge around hearing aids, no swelling or lesionsNodes (pre and post auricular): No tenderness or swellingNose and SinusesExternal Nose: Symmetric and proportionate to faceSeptum: No presence of deviated septumMucous Membranes: Red and smooth, no selling. Patency: No blockagesOlfactory Sense (CN I): DeferredMouthLips: thin and pink, free of lesions or swellingsMucous Membranes: Pink, no patches or spotsGums: DenturesTeeth: Dentures – cleans once a dayPaletes and Uvula (CN IX, X): Raises slowlyTonsillar areas: Not assessedTongue (CN, XII): Pink, slow side to side movementVoice: clears throat a lot, spits out what he coughs up frequently, not too loudBreath: Slower rate and rhythmNeckGeneral Structure: Temperature is normal, no swelling or lesionsTrachea: midline and symmetricNodes: (list all assessed) No swelling or tenderness in preauricular, posterior auricular, submandibular, submental, tonsillar, superficial cervical, posterior cervical, chain of deep cervical, and supraclavicular nodes.Muscles (CN XI): Symmetric, No swelling or painROM-Cervical Spine: Symmetric, no swelling or pain. Slightly limited range of motionRespiratory – not assessed for nursing care planChest Shape:Type of Respiration:Breath Sounds:Voice Resonance:Adventitious Sounds:Cardiovascular – not assessed for nursing care planExamined client in the following positions:Rate and Rhythm- Apical Pulse:Precordium - Inspection: - Palpation: - Auscultation:Description of Peripheral Pulses:Abdomen – not assessed for nursing care planContour, Tone:Scars, Lesions:Auscultation (bowel sounds, bruits, friction rubs):Palpation of Abdominal Quadrants:Musculoskeletal SystemExtremities: (list all areas assessed) Hips to toesDeformities: Decreased muscle tone in left legGait: Slow but steady, weak in left legJoint Evaluation:Muscle Mass & Strength:ROM:Spine: not assessed for care planContour:Vertebral Joints:ROM/Strength:Neurological System – not assessed for care planCerebral:Mental Status:Orientation:Level of Consciousness:Cerebellar/Motor:Coordination: Involuntary Movements:Sensory:Light touch: ................
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