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Nursing Assessment FormClient Name: S.T. Medical Diagnosis: SEE PATHOLOGY RECORDClient Perception of Health Needs: Unable to state due to aphasia Client Goals for Health: Unable to state due to aphasia Allergies (food, medication, environmental)No known allergies. MedicationsSEE MEDICATION RECORDDietary considerationsEncourage fluidsDoesn’t like condiments or saucesCan eat independently if the meal doesn’t require utensilsNeeds to be set up and encouraged to promote good intakeIs currently on a regular/cut up diabetic diet with nectar level 1 fluids In December of 2014 doctors orders for client to be NPO status due to pneumonia x 4 throughout the year but wife would like client to continue eating cut up diet to maintain quality of lifeVital SignsT 36.80CtympanicP 64 weak and irregularR 14 shallow and unlabouredBP 120/82 lying flat O2 sats: 92 on room air Pain rating 0 HEALTH ASSESSMENT DATA Physiological VariableGeneral Appearance/Mental State:Male, 76 years old. Grey hair cut very short and balding. Blue eyes. Pleasant demeanour and smiles often. Rarely makes eye contact. Usually dressed in button down shirts and jeans. Slouches in wheelchair and keeps head down. Constantly fidgeting. Keeps right arm flexed at the elbow and held close to the abdomen. Limited facial expressions but looks relaxed. Cooperative with care. Understands speech but is unable to respond verbally. Nods or shakes his head to answer yes or no questions. Unable to determine orientation. GCS of 11 and suffers from dementia. Cardiovascular System:Diagnosed with hypertension and hyperlipidemia BP: 120/82 lying flat taken on left armRadial pulse 64 weak and irregularApical pulse 64 strong and irregularS1 & S2 heart sounds heard at all cardiac sites with no additional soundsHeart sounds are muffledNo edema noted in peripheral extremities, all extremities are pink and warm to touchRadial, ulnar, carotid, brachial pulses palpableCapillary refill <2 seconds No cyanosis noted in nail beds or extremities Respiratory System:Diagnosed with Chronic Obstructive Pulmonary Disease 14 respirations per minute shallow and unlaboured SPO2 of 92% on room air Decreased air entryLung sounds clear in upper lobes bilaterally. Unable to assess lung sounds in right middle and left and right lower lobes bilaterally due to client not breathing through his mouth Symmetrical chest expansion Occasional productive cough with clear viscous mucous, usually approximately dime sized Gastrointestinal System:Bowel sounds in all 4 quadrantsUmbilical hernia with protrusion mid abdomenHas bowel incontinence and wears a large briefOften constipated but usually relieved with the use of suppository Poor fluid intake approximately 500ml per shift Client eats well, usually >75% of mealsAppears hydrated, no tenting noted, mucous membranes and lips pink and moistAbdominal distension but soft on palpation BMI is 21.56 (healthy weight) Urinary System:Incontinent of urineWears a large briefNo bladder distension notedIs often incontinent throughout the night No history of UTI’sSensory Systems:Wears reading glasses but does not require prescription lensesMust speak loud to be heard but client does not wear a hearing aidHas hemiparesis on right side due to CVA Unable to verbally communicate more than “yes” or “no” but often opts to nod or shake his head when asked yes or no questions Nervous System:Diagnosed with Parkinson’s DiseaseExpressive aphasia following CVADysphagia – should be NPO statusGCS of 11Unable to determine orientationPupils are approximately 2mm, equal and reactive to lightTremors in both hands bilaterallyDenies painSleeps well through the nightLimited facial expressions but smiles oftenTympanic temperature 36.8 degrees Celsius Integumentary System:History of pressure ulcers on buttocks and left heel Perineum is often moist due to bladder incontinence causing redness in the area Skin is pale and moist, no dry skin notedSkin is warm to touchSunspots and moles on head and faceOuter third of eyebrows are very thin as a result of hypothyroidism Scant amount of body hair on limbs Hair on head is grey and thinNails are cut short Has no current pressure ulcers or skin tears/abrasions No bruising noted Musculoskeletal System:Height: 188.0 cm (6’2) Right sided hemiparesis as a result of CVASuffers from Parkinson’s DiseaseTremors in both hands Muscle weakness, weak resistance Participates in leg bike exercises to try to maintain leg strength2 person assist with mechanical lift to transferIs unable to reposition himself independently and often slides down in his chair Rigid right arm flexed at the elbow and held close to the abdomenLikes to fidget with things in his fingers with his left hand Needs extensive assistance with dressingIs able to bring left hand to mouth to drink fluids/eat finger food Able to flex, extend and circumduct with left arm, only able to extend (limited to 45 degrees) with right arm. Reproductive System:Male 2 children (son and daughter)3 grandchildren (1 boy and 2 girls)Endocrine System:Diagnosed with Type 2 Diabetes Diagnosed with hypothyroidismTSH levels are appropriate while on synthroid medication Currently on diabetic diet to manage blood glucose levels and not on any anti-diabetic medicationClient Resuscitation Status:C2 – Terminal care. Diagnosis will cause eventual death, efforts are aimed at symptom control, no resuscitation, surgery is not appropriate, life sustaining measures should be discontinued unless necessary for comfort, life support interventions should not be initiatedSpiritual Variable (Environment)Unable to determine spiritual practices due to aphasiaHas no indication in his room of spirituality Does not attend church services Developmental Variable (Environment)Client is in the ego-integrity vs. despair stage in Erikson’s stages of developmentI believe the client is on the despair end of the spectrum because he is unable to verbally converse with family, other residents or health care staffClient has deteriorated immensely physically since admissionClient was more social with other residents upon admission and now prefers to spend time in his room and attends less activities Sociological Variable (Environment)Visited by family 2-3 x a monthWife (Barbara) often visits in the evenings a few times a week Participates in approximately 4 programs a month over the past 12 monthsEats meals in the dining room with a meal mateWatches TV in the pod with other residents between breakfast and lunch Psychological Variable (Environment)Suffers from dementiaSocial isolation from family Loss of function/increase in dependence on health care staff over the past year may cause feelings of helplessness Unable to verbally communicate except for occasional “yes” or “no”Enjoys to watch the noon hour news in his room Determinants of health impacting client’s health (Environment)Client is immobile and unable to transfer or reposition independently Client is at risk for skin breakdown, pressure ulcers, shearing, constipation, loss of functionClient is at risk for decreased healing time if pressure ulcers occur due to Type 2 DiabetesClient suffers from right sided hemiparesis and needs extensive assistance with hygiene and activities of daily livingClient has a history of CVA and at risk for a reoccurrence due to hypertension/hyperlipidemia Client is at risk for helplessness, loneliness, depression, anxiety, fear and other emotional distress due to diagnoses and dependence on health care staffClient is at risk for aspiration pneumonia, should be NPO but has been refused by his wife to maintain quality of life. Currently on Nectar Level 1 fluids. Interdisciplinary Team MembersRN, LPN, SPNPhysicianHCARecreational/Occupational TherapyDietaryFoot CareFamily members Health PrioritiesTo maintain skin integrity To avoid infection To ensure adequate nutrition To encourage fluid intake To assist with all ADL’sTo maintain comfort To avoid/reduce painTo encourage social interaction Client StrengthsFriendly and cooperativeSmiles oftenEnjoys reading and watching TV Client’s wife is actively involved in care and makes suggestions to health care staff about how to better care for the client Has been more verbal over the past week than when I first received him into careLaboratory/Radiology ReportsFebruary 3rd, 2015 (most recent) - Hgb A1C - 5.9 [4.3-6.1] within acceptable range - TSH – 1.13 [0.20-4.00] within acceptable range - Creatnine – 76 [50-115] within acceptable range - GFR – 83 [>59] within acceptable range Pathophysiology RecordMust be written in your own words (i.e., as if teaching a patient)Medical DiagnosisPathophysiologySigns and SymptomsComplicationsParkinson’s DiseaseParkinsonism is a progressive disorder of the nervous system that affects motor skills (or intentional movements), causing slowness or stiffness of movements and often tremors in the extremities. There is a chemical in our brains called dopamine that affects our movements. When the cells that generate dopamine malfunction or die, symptoms of Parkinson’s disease begin. Tremor (often the first sign), stiff and aching muscles, slow movement, limited range of motion in the limbs, weakness of the face and throat muscles, poor balance and difficulty walking. Depression and emotional changes as a result of decreased dopamine levels and diagnosis, dysphasia, sleep disorders, inability to control the bladder, constipation. Chronic Obstructive Pulmonary Disorder (COPD) COPD is a progressive lung disease that includes asthma, chronic bronchitis and emphysema separately or in combination. COPD is characterized by chronic inflammation of the lung tissue. There are tiny air sacs in the lungs that expand when they are oxygenated by the air we breathe in. This disease may cause a buildup of mucous in the lungs and the air sacs may become filled with mucous, unable to expand and oxygenate effectively. Chronic cough (longer than 3 months), cough with mucous production, shortness of breath, wheezing, fatigue, frequent respiratory infections. Respiratory infections such as pneumonia, pulmonary hypertension, pulmonary edema, increased risk of heart failure, peripheral edema and pneumothorax (collapsed lung). HypertensionHypertension is a consistent high blood pressure reading of 140/90. Hypertension is an increase of the pressure on the heart and the arteries to pump the blood through the body. The increase in pressure causes a decrease in elasticity of vessels and a thickening effect of the heart walls. The heart walls thicken to try to compensate for the increase in pressure but it causes the heart to become weaker. Headache, blurred vision, weakness, confusion, nausea, fatigue, change in mental status. Cardiovascular disease, stroke, damage to the kidney, heart and eyes. Type 2 Diabetes Mellitus Type 2 diabetes is a disorder of the pancreas. The pancreas creates and releases a hormone called insulin, which helps the body breakdown and use sugar from our diet for energy. The insulin binds with the sugar in our blood (glucose) and transports it into our body cells to be used. With Type 2 Diabetes, the pancreas still creates and releases insulin, but it may not be enough to meet the requirements of the body cells or the body may be unable to use the insulin produced. This means that the body’s many cells are not receiving the food source they need to function.Increased thirst and urination, increased hunger, weight gain or loss, fatigue, blurred vision, slow healing time.Most complications of diabetes are a result of heart and blood vessel damage, nephropathy, neuropathy, eye damage, foot damage, hearing impairment.Impaired gas exchange related to decreased oxygenation of alveoli secondary to COPD as evidenced by SPO2 of 92% on room air. Client goal: Client will have adequate oxygenation. Client outcome: Client will have an adequate oxygen/carbon dioxide exchange as evidenced by SPO2 of >92%, no evidence of cyanosis and unlabored respirations between 12-20. Administer bronchodilator medications to maintain a patent airway and improve alveolar ventilation. (Day, Paul, Williams, Smeltzer & Bare, 2014, p. 652) Monitor sputum for any signs of infection including a change in colour, character, consistency or amount and take temperature daily. (Day et. al., 2014, p. 660) Monitor and report any signs or symptoms of hypoxia or dyspnea including cyanosis, a SPO2 of < 92% or restlessness. (Day et. al., 2014, p. 658) 1) Goal partially met. I was able to administer ventolin and atrovent to client for AM meds but the client refused to inhale the atrovent after administering the ventolin during noon meds. The client’s respirations were 16 breaths a minute, shallow and unlabored upon 0730 vital signs and after lunch respirations were 12 breaths a minute, deep and unlabored. Will continue with this intervention throughout care and trial new ways to encourage the client to accept the inhalers. 2) Goal met. Upon mucous productive coughs during lunchtime I noted sputum was clear, viscous and approximately dime sized which was normal for this client. His temperature has remained between 36.0 and 37.0 degrees Celsius. I will continue with this intervention. 3) Goal met. Client’s lips and skin has been consistently pink and warm to touch with oxygen saturation ranging from 92-94%. Client has not been restless since receiving into care, he remains seemingly relaxed as evidenced by facial expressions. I will continue with this intervention. Risk for aspiration related to impaired swallowing secondary to CVA. Client goal: Client will not aspirate.Client outcome: Client will demonstrate effective swallowing free of aspiration as evidenced by absence of coughing while eating and drinking. Encourage the client to eat slowly and chew all food well before attempting to swallow to aid in the passage of the bolus from the esophagus to the stomach. (Day et. al., 2014, p. 1098) Ensure that the client remains in semi or high fowlers position with the chin tucked down while eating and at least 30 minutes afterwards to avoid food remaining in the esophagus. (Day et. al., 2014, p. 1098) Provide nectar-thickened fluids to client during and between meals to aid in the passage of food from the esophagus to the stomach. (Potter & Perry, 2014, p. 1073) Goal partially met. I have not been able to be present with the client during all meal times but when I am present I ensure that the client spends approximately 10-15 seconds chewing each bite to make swallowing more effective. I will continue with this intervention and attempt to be present for more meals to encourage this practice.Goal met. I have positioned the client’s wheelchair at an approximate 60 degree angle during meal times and have positioned his chin accordingly throughout feeding. I have also rescheduled his afternoon nap to 1300 to accommodate the time needed for food to pass through the esophagus. I will continue with this intervention. Risk for falls related to Levodopa Carbidopa medication for Parkinson’s disease. Client goal: Client will not fall.Client outcome: Client will not fall within the next two weeks in my care. Ensure that the clients wheelchair remain in a semi-fowlers position at all times (Potter & Perry, 2014, p. 801) Always keep the side rails of the bed in the upright position when the client is in bed (Potter & Perry, 2014, p. 798)Provide the client with non-slip shoes to wear when out of bed (Potter & Perry, 2014, p. 798) Goal met. I have positioned the client’s wheelchair at an approximate 60-degree angle prior to transferring in the AM and it remains at that angle throughout the day. A fall has not occurred. I will continue this intervention.Goal met. When the client is transferred into bed the side rails are always upright to maintain the clients safety and a fall has not occurred. I will continue with this intervention.Goal met. The client wears non-slip footwear at all times while in his wheelchair and a fall has not occurred. I will continue with this intervention. 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 ImplicationsGeneric: Levodopa/Carbidopa 200/50mg Trade: Levocarb CR Class: Dopamine agonist (antiparkinson agent) Dose ordered: 200/50mg PO QID Safe dose: Yes. 25 mg carbidopa/100 mg levodopa 3 times daily. May be increased every 1–2 days until desired effect is achieved (max = 8 tablets of 25 mg carbidopa/100 mg levodopa/day).Levodopa is converted into active dopamine in the central nervous system and acts as the neurotransmitter, resulting in a relief in tremors. Carbidopa prolongs the time that Levodopa is active in the central nervous system. Involuntary movements, anxiety, dizziness, hallucinations, memory loss, blurred vision, nausea, vomiting, diarrhea, dark urine or sweat, orthostatic hypotension. Administer on a regular schedule, eating after administration may decrease GI upset but foods high in protein may alter the effect of the drug, reposition slowly to avoid orthostatic hypotension, rinse mouth and provide oral hygiene regularly to decrease dry mouth. Assess for signs of toxicity (involuntary muscle twitching, protrusion of tongue, spasmodic eye winking, facial grimacing).Generic: Levothyroxine SodiumTrade: SynthroidClass: thyroid preparation (hormones) Dose ordered: 75mcg PO daily Safe dose: Yes. 50 mcg as a single dose initially, then can be increased q 2-3 weeks by 25mcg a day, maintenance dose is usually 75mcg/day. Replaces or supplements the thyroid hormones. Increases the metabolic rate of body tissues (the function of thyroid hormone in the body). Headache, insomnia, irritability, angina, arrhythmias, tachycardia, abdominal cramps, diarrhea, vomiting, sweating, hyperthyroidism. Administer before breakfast with a full glass of water, patients with dysphasia may take tablet crushed, watch for signs and symptoms of hyperthyroidism (toxicity, including: tachycardia, chest pain, diaphoresis, tremors) Generic: Ipratropium Bromide Trade: Atrovent Class: Bronchodilator (anticholinergic) Dose ordered: 20mcg/dose, 2 puffs via chamber 4 times a day Safe dose: Yes. 2 inhalations 4 times daily (not to exceed 12 inhalations/24 hours or more frequently than q 4 hour). For acute exacerbations, 4–8 puffs using a spacer device as needed. Dilates the airways in the bronchi and lungs to promote effective breathing and decreases mucous secretions. Atrovent blocks the action of a natural chemical we have in our bodies that causes the muscles in our airways to narrow. The blocking of this chemical is what causes the airway dilation. Onset: 1-3 minutesDizziness, headache, blurred vision, sore throat, paradoxical bronchospasm, hypotension, palpitations, GI irritation, nausea, rashAssess respiratory status prior to administration and at peak. When used concurrently with other inhalation medications, administer adrenergic bronchodilators first, then ipratropium, then corticosteroids with 5 minutes in between. Rinse mouth following administration.Generic: Salbutamol Trade: VentolinClass: BronchodilatorDose ordered: 2 puffs via chamber 4 times a day Safe dose: Yes. 2 inhalations q 4-6 hours Ventolin acts in the lungs on receptors called beta-receptors. When these receptors are stimulated, it causes the muscles of the airway to relax. This promotes effective breathing. Onset: 5-15 minutesNervousness, tremors, restlessness, insomnia, chest pain, palpitations, arrhythmias, hypertension, hyperglycemia, nausea, vomiting, hypokalemiaAssess lung sounds, BP and pulse before administration and during peak of medication, note amount and color of sputum produced. Prime the inhaler prior to administration, allow one minute between inhalations, rinse mouth after administration. Use first when used concurrently with other inhalation meds, allow 5 minutes in between medications.Generic: 0.3% ciprofloxacin + 0.1% dexamethasone Trade: CiprodexClass: anti-infectives and anti-inflammatory (steroidal)Dose ordered: 3 drops to affected ear PRN Safe dose: Yes. 3mg/ml of ciprofloxacin and 1mg/ml of dexamethasone Ciprofloxacin: Prevents bacteria from multiplying by altering the DNA. Once the DNA is mutated, it cannot reproduce effectively and eventually will die off. Dexamethasone: suppresses inflammation and the natural immune response by acting on the cells that release inflammatory response chemicals. Dexamethasone inhibits the cells from releasing these immune response chemicals and thereby reduces inflammation. Ciprofloxacin: elevated intracranial pressure, seizures, hallucinations, headache, dizziness, tremor, hyper/hypoglycemia, peripheral neuropathy Dexamethasone: hallucinations, headache, increased intraocular pressure, hypertension, edema, nausea, vomiting. Warm solution in hands before administering to avoid vertigo, encourage fluids, position client in lateral recumbent position to administer ear drops and ensure they remain in that position for 5 minutes following administration. Generic: Hydrocortisone cream Trade: Uremol HC Class: corticosteroid (anti-inflammatory) Dose ordered: 1% apply sparingly BID Safe dose: Yes. Apply sparingly to affected area 2-4 times daily Hydrocortisone works by inhibiting the body cells from releasing immune response chemicals. The inhibition of these chemicals being released slows down the inflammatory response causing a decrease in redness, swelling and pain. Burning, dryness, edema, folliculitis, hypersensitivity reactions, adrenal suppression. Wear gloves while applying, avoid eyes, and apply sparingly. Nursing Care Plan - SummaryDescribe the benefits of using the nursing process and the nursing concepts in your assessment and nursing care.Nursing Assessment and CareI used the nursing process to guide my nursing assessments and nursing care. I was able to integrate the knowledge I obtained in theory class to aid me in my critical thinking and clinical judgment. During the assessment phase of the nursing process, I gathered information to determine the priorities for my client and develop the nursing diagnoses. The assessment phase of the nursing process was a great learning experience for me because it was the first time I’ve had to assess a client that suffers from aphasia. I struggled in my assessment because I was not able to ask open-ended questions to gather subjective information. For example, when doing vitals I asked my how he slept. After realizing that my client couldn’t answer my question, I had to adjust my questions to accommodate my resident’s limited “yes” or “no” communication style. Once I made the adjustment in my communication it was much easier to gather the data I needed. After the assessment phase, I was able to determine my clients priority health concerns and develop nursing diagnoses; impaired gas exchange, risk for aspiration, and risk for falls. I was able to establish these nursing diagnoses and determine my resident’s health needs based on the information I had gathered during the assessment phase. Once the initial assessment phase was complete, I was able to begin the planning phase of the nursing process. In the planning phase, I created reasonable and achievable goals and outcomes for my client to improve his quality of life. At this point in the nursing process I was able to determine nursing interventions that would aid me in creating a safe, supportive and caring environment for my client that would benefit his current health status and improve his quality of life. The implementation phase, following the planning phase, allowed me to apply the interventions that I had developed. This phase in the nursing process allowed me to enact the interventions I had developed and achieve the goals and outcomes previously outlined for my resident. At this point, I spent extra time with my resident during meal times to assist with feeding and drinking which led me to gather even more information that could be applied to my nursing care. This stage is so beneficial to the nurse and the client because it allows the nurse to engage in all stages of the nursing process to better care for the client. The extra time spent with the client during this phase permits the nurse to further assess and plan for care. After the implementation phase, it is essential that the nurse engage in the evaluation phase to determine the effectiveness. Without this stage, the nurse would not be able to determine if interventions need to be augmented, if the interventions are successful or if the client is responding well to the plan of care. In this stage I was able to ensure that my client was making progress in his health status, such as an increase in fluid intake, a decrease in reddened skin and even an increase in ability to communicate after building a strong rapport and therapeutic relationship. The nursing process is so important to the nurse and the client to ensure that care is client centered and goal oriented. This resident assignment was a great learning experience for me and I am so thankful for the opportunity to spend time with this client. I have learned so much from this client and he has really developed my communication skills and ability to adjust my care. ReferencesDay, R. A., Paul, P., Williams, B., Smeltzer, S., & Bare, B. (2010). Brunner & Suddarth's textbook of Canadian medical-surgical nursing (2nd Canadian ed.). Philadelphia: Lippincott Williams & Wilkins.Potter, P., & Perry, A. (2013). In J. Ross-Kerr, M. Wood, B. Astle, & W. Duggleby (Eds.), Canadian fundamentals of nursing (5th ed.). Toronto, ON: Elsevier Canada. ................
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