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Nursing Assessment FormClient Name: 15-2 E.M.Medical Diagnosis: SEE PATHOLOGY RECORDClient Perception of Health Needs: UnknownClient Goals for Health: UnknownAllergies (food, medication, environmental)Penicillin, TriazolonMedicationsSEE MEDICATION RECORDDietary considerationsHeart healthyVital SignsT 36.7P 64R 20BP 122/70O2 84-91Pain rating 0HEALTH ASSESSMENT DATA Physiological VariableGeneral Appearance/Mental State:Pleasant grey haired 92-year-old overweight female. Wears glasses and hearing aides in both ears. Pleasant demeanor and no complaints of pain.Cardiovascular System:Hypertension, Myocardial infarction, History of TIA, Peripheral Artery disease. Heart auscultated in all five landmarks no abnormal sounds heard. No noticeable distention of jugular veins. Cap refill less than two seconds.Respiratory System:COPD/Asthma. Decreased sounds auscultated upon expiration. Audible wheezing heard upon expiration orally. No adventitious sounds heard upon auscultation. Gastrointestinal System:Heart healthy diet. Dentures. Help with cleaning dentures and assistance with putting them in. Urinary System:Renal insufficiency. Incontinent and continent. Clear yellow urine voided per toilet x2. Sensory Systems:Use of glasses for vision, hearing aides bilaterally, difficulty with vision, cataracts. Use of walker for ambulation.Nervous System:N/AIntegumentary System:Assistance with personal hygiene, history of pressure ulcer right buttocks, umbilical hernia, cellulitis. Small reddened blanching areas noted on the 2nd and 3rd toe of feet bilaterally, Reddened skin in the breast and abdominal folds, barrier cream applied. Musculoskeletal System:AAT, compression stockings. Reproductive System:N/AEndocrine System:N/AClient Resuscitation Status:R1Spiritual Variable (Environment)UnknownDevelopmental Variable (Environment)92 years old, according to Erickson’s Theory she is in the developmental stage of Integrity vs. Despair this stage faces losses in physical abilities as well as social losses like retirement, illness and loss of loved ones (Potter & Perry, 2014).Sociological Variable (Environment)Currently admitted in the hospital waiting placement in a ltc facilityPsychological Variable (Environment)Pleasant demeanor has some family dynamics that are causing her stress in regards to the handling of her money.Determinants of health impacting client’s health (Environment)In need of assistance with ADL’s currently waiting placement in a LTC facility.Interdisciplinary Team MembersDoctor, resident, nurse practitioner, nurse, unit clerk, health care aide, cleaning staff, porters, and student nurse.Health Priorities:To find placement in a LTC facilityClient Strengths Pleasant demeanour and complaint with health care Pathophysiology RecordMedical DiagnosisPathophysiologySigns and SymptomsComplicationsHypertensionHypertension is an increase in cardiac resistance in the cardiac system and can be related to peripheral resistance as well as diabetes and many other contributing factors (Braun & Anderson, 2011). Signs and symptoms are often asymptomatic can be an increase in blood pressure, headaches, nausea, vomiting and fatigue (Braun & Anderson, 2011).This can lead to renal insufficiency, stroke and pulmonary edema (Braun & Anderson, 2011).Congestive Heart FailureA secondary condition caused be an overload of work required of the heart and a decreased ability of the heart to function properly (Braun & Anderson, 2014). The diseases that can contribute to CHF in this patient are hypertension, COPD and calcification of the mitral valve annulus. CHF is usually classified by left or right heart failure but either or will contribute to the impairment of the other side of the heart eventually (Braun & Anderson, 2014).A decrease in cardiac output and lung congestion are signs of left heart failure which tend to be less noticeable until the latter stages (Braun & Anderson, 2014). These symptoms lead to a decrease in blood circulation to the organs, crackles that can be heard in the lungs, poor urinary output, coughing and cyanosis (Braun & Anderson, 2014). Right heart failure signs are similar to that of lung disease such as fatigue, exercise intolerance, dyspnea and syncope (Braun & Anderson, 2014). These are often thought to be symptoms of lung disease that is often associated with right sided heart failure (Braun & Anderson, 2014). Left heart failure is deadly causing acidosis, hypoxia, cardiac arrhythmias and decreased blood supply to the kidneys. Right heart failure is associated with peripheral edema pleural effusions and distention of the neck veins (McConnell, 2014).AsthmaAsthma is inflammation of the lungs, it makes breathing and exercise difficult (Lippincott, Williams & Wilkins, 2011).Signs and symptoms are breathlessness, wheezing and tightness in the chest (Lippincott, Williams & Wilkins, 2011).Hypoxia and acidosis can result from asthma (Lippincott, Williams & Wilkins, 2011).COPDOne of the most common causes of death in the world COPD is a generalized term used to describe lung disease like asthma, chronic bronchitis, and emphysema (Braun & Anderson, 2011).Chronic cough, dyspnea wheezing, pursed lip breathing, tachypnea, crackles and wheezing in the lungs, hypoxemia, hyperventilation and alkalosis (Braun & Anderson, 2011)Total airway obstruction or status asthmaticus needs to be treated as a medical emergency (Braun & Anderson, 2014).Transient Ischemic AttackIs a loss of blood flow to an area of the brain that causes loss in brain function (Braun & Anderson, 2014).Usually seen as difficulty speaking, blurred vision or vision loos and one sided weakness (Braun & Anderson, 2014).Death of the affected brain tissue and loss of function (Braun & Anderson, 2014).Nursing Process Care Plan Nursing DiagnosisActivity Intolerance (r/t) imbalance between oxygen supply and demand (aeb) exertional dyspneaPlanningClient Goals: Teach the patient about use of medication to ease dyspnea prior to exertionExpected Outcomes: To decrease the risk of dyspnea upon exertion nurse will educate the patient about the use of medication in puffers will decrease the incidence of this.InterventionsList Interventions:Teach patient of use of therapeutic medication to decrease incidences of dyspnea.Rationale for Interventions:By teaching the patient of use of medication to decrease dyspnea and this will increase her use before exertion.EvaluationHeard audible wheezing before use of puffers and absence of wheezing post use of medication(Gulanick & Myers, 2014)Nursing Process Care Plan Nursing DiagnosisSelf-care deficit (r/t) impaired mobility and transfer ability (aeb) use of mobility aidesPlanningClient Goals: patient will ask for help in when needing to preform ADL’s 2.Expected Outcomes: Patient will have increased ability to perform ADL’s with help from nurse and care aides by ringing call bell and asking for help when needing to preform ADL’sInterventions1.List Interventions:Anticipate needs of patient and explain use of call bell keeping it in reach of the patient at all times. 2.Rationale for Interventions:By anticipating the needs of the patient it will help decrease the need for the client to use the call bell if not compliant and allow nurse to keep a close eye on patient and provide care when needed. By keeping call bell in reach and explaining its’ use nurse will increase the chances of patient using the call bell and decrease self-care deficit.EvaluationPatient was quick to ask for help when needed. Offered to help for A.M. care and toileting and the patient gladly accepted the help. (Gulanick & Myers, 2014)Nursing Process Care Plan Nursing DiagnosisImpaired gas exchange (r/t) loss of lung tissue elasticity (aeb) SP02 of 84% post exertion PlanningClient Goals: To maintain oxygen levels above 90% by taking deep breaths post exertion to increase oxygen levels.Expected Outcomes: Patient will take slow deep breathes when oxygen levels are low to increase oxygen levels.InterventionsList Interventions:Monitor the patient’s oxygen levels and encourage deep breathing when oxygen levels are low.Rationale for Interventions:By showing the patient her oxygen level it will inform her of how low it can go. Then encouraging deep breathing can teach her that by taking a few breaths she can increase her oxygen back to healthy levels.EvaluationWhen we took the patients oxygen levels they were low and I encouraged deep breathing and her oxygen increased very quickly to healthy levels. (Gulanick & Myers, 2014)Medication Research RecordEnsure you relate the medication information to the appropriate medical diagnosis. Please use lay terms as if you were teaching a patient.Medication/Reason for Medication OrderDosage/Safe DoseAction as Related to Medical DiagnosisCommon Side EffectsNursing ImplicationsASA, Entrophen, ASAPHEN EC81mgProphylactic treatment of Tia’sGI bleeding, nausea, anaphylaxis, abdominal pain, anorexia, anemiaMonitor for sensitivity it increases in patients with asthmaAtorvastatin20mgLipid lowering agentRhabdomyolysis, rash, amnesia, confusion, dizziness, bronchitis, abdominal crampsDiet history in regards to fat intakeLisinopril10mgAntihypertensiveAngioedema, dizziness, fatigue, hypotension, rash, hyperkalemiaMonitor for edema, rales, and crackles, monitor bp, and pulseSalbutamol100mcg 2 puffs via spacer 4x dailyThis is a safe doseA Bronchodilator use to prevent and control airway obstructions in COPDParadoxical bronchospasm, nervousness, restlessness, tremor, insomnia, nausea, vomiting, hyperglycemia and hypokalemiaWatch for wheezing which would indicate paradox bronchospasm, assess lung sounds pulse and BP before admin and during peak of admin which is 60-90minsAcetaminophen650mg do not exceed 4 grams or 4000mg per dayAntipyretic and non-opioid analgesicConstipation, headache, fatigue, insomnia, fever, rashAssess for rash, fever, fatigue, joint pain, pain location. Carbamazepine may increase damage to liver and decrease effects of acetaminophenCholecalciferol2000 unitsPrevention of deficiencyArrhythmia, pancreatitis, headache, irritability, constipation, anorexiaObserve for hypocalcemiaCyanocobalamin1000mcgAntianemicHeadache, diarrhea, itching, pulmonary edemaAssess for signs of B12 deficiencyCalcium500mgMineral and electrolyte supplementHeadache, cardiac arrest, tingling, bradycardiaObserve for hypocalcemia, BP and pulseFolic Acid5mgAntianemicRash, irritability and difficulty sleepingAssess for signs of anemia(Vallerand, Sanoski & Hopfer Deglin, 2015)Nursing Care Plan - SummaryDescribe the benefits of using the nursing process and the nursing concepts in your assessment and nursing care.Assessment:This care plan taught me a lot about what I really need to be watching with this patient. I had a good idea before but after doing this care plan it really made me aware of all the factors affecting this patient. Also some of the symptoms that she may be experiencing as a side effect from the medications she is taking rather than effects of the diseases she has. Nursing Care: This care plan taught me what I need to focus on for this patient when it comes to nursing measures. ................
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