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Pages: (19) « First ... 4 5 [6] 7 8 ... Last » ( Go to first unread post )

 Grano's hangout, Where I talk about whatever I want to.
treacherous
Posted: Mar 28 2009, 04:59 PM


Let Hammy have his Bison. I've got Zod.


Group: Admin
Posts: 3,499
Member No.: 37
Joined: 10-June 08



QUOTE (Darkender @ Mar 28 2009, 04:41 PM)
What a shame. Some people are just so angry inside...

Solomon is an angry little man trapped in an unknown aged man's body.


--------------------
Points:

Ursa: You are master of all you survey.
General Zod: [bored] So I was yesterday. And the day before.




QUOTE (SilverSurfer092 @ Apr 9 2009, 03:27 AM)
WTFYES  Treacherous is full of pwnage.
Top
Pseudonym
Posted: Mar 28 2009, 05:12 PM


FPL Failure


Group: Members
Posts: 1,219
Member No.: 203
Joined: 26-January 09



QUOTE (granobulax @ Mar 28 2009, 12:56 AM)
QUOTE (Solomon @ Mar 27 2009, 11:10 PM)
Just imagine a grown adult like that.

Maybe I should come visit you, and repay you for all those hugs. teu42.gif

Bring it! ninja.gif

Ninjas+Hugs= pokesmily.gif


--------------------
Points: More than Bison


Give me half.
Top
Solomon
Posted: Mar 28 2009, 08:59 PM


Head Admin


Group: Admin
Posts: 7,680
Member No.: 3
Joined: 9-January 08



QUOTE (treacherous @ Mar 28 2009, 04:59 PM)
Solomon is an angry little man trapped in an unknown aged man's body.

That pretty much sums it up. happy.gif


--------------------

Points:

"The first shot rang out from somewhere and I heard a bullet wiz by my face. With my pump action shotgun ready, I shoot the first fool I see."

Grano's so gangster.
Top
granobulax
Posted: Mar 31 2009, 03:14 AM


He's even got his hand over where I live...


Group: Admin
Posts: 7,880
Member No.: 35
Joined: 31-May 08



Well, here's this semester's care plan I had to do for my Nursing II class. It kinda gives an Idea of the stuff I have to do. The patients name has been omitted for privacy and legal issues. If anyone bothers to read some of it, you'll learn what's entailed in being a nurse.

MOHAVE COMMUNITY COLLEGE
NURSING DEPARTMENT
NURSING CARE PLAN
NUR 122
Clinical date for care plan: 3/10/2009
Student: Granobulax S.N. MCC
ASSESSMENT
A. ADMISSION DATA
Date of admission: 2/19/2009
Medical diagnosis: Acute Respiratory Distress
Age: 63 (Client appears older than stated age) Sex: Male Marital Status: Divorced in 1990
Ethnicity: Caucasian Religion: Nondenominational
Physician Specialty: Internal Medicine
Vital signs upon admission:
B/P: 80/54 P: 65 R: 16 T: 98.0 Ht: 5’10” Wt: 86.5 Kg (192 lbs)
Allergies: No known allergies
(Chart data)
B. HEALTH-ILLNESS TRANSITION
History of present illness: History of COPD. No previous experiences with ARDS. Pneumonia suspected but not confirmed. Client states, “I’ve been pretty healthy all my life. Only in this last year have I had any major problems.” Client also stated, “There was no ‘attack’, just a gradual decline in my breathing. It started just over a year ago when my breathing just got worse and worse. I finally had to come in to the hospital because I couldn’t take it any more.” (Client data)
Significant client health history (include family history): The client has a history of hyperkalemia, pneumonia, chronic obstructive pulmonary disease, hypertension, deep vein thrombosis, and post traumatic stress disorder (Chart data). Client states, “My father committed suicide, my sister committed suicide, and my mother died of Alzheimer’s disease.” There is noted occurrence of admitting diagnosis within family history, however possible psychological damage associated with traumatic family deaths noted (Client data).
Pathophysiology of primary diagnosis (definition, etiology, signs and
symptoms. Underline behavior exhibited by this client. Cite reference.)
Acute Respiratory Distress Syndrome: The basic changes in the lungs result from injury to the alveolar wall and capillary membrane, leading to release of chemical mediators, increased permeability of alveolar capillary membranes, increased fluid and protein in the interstitial area and alveoli, and damage to the surfactant-producing cells. These events result in decreased diffusion of oxygen, reduced blood flow to the lungs, difficulty in expanding the lungs, and diffuse atelectasis. Reductions in tidal volume and vital capacity occur. Damage to lung tissue progresses as increased numbers of neutrophils migrate to the lungs, releasing proteases and other mediators. Hyaline membranes form from protein-rich fluid in the alveoli, and platelet aggregation and micro thrombi develop in the pulmonary circulation, causing stiffness and decreased compliance. If the patient survives, diffuse necrosis and fibrosis are apparent throughout the lungs.
Excess fluid in the lungs predisposes to pneumonia as a complication. Congestive heart failure may develop.
Etiology: Severe or prolonged shock may cause ARDS because of ischemic damage to the lung tissue. Inflammation in the lungs arises directly from such events as inhalation of toxic chemicals or smoke; excessive oxygen concentration in inspired air; severe viral infections in the lungs; toxins from systemic infection, particularly by gram-negative organisms; fat emboli; explosions; aspiration of highly acidic gastric contents; or long trauma. Other causes include disseminated intravascular coagulation, cancer, acute pancreatitis, and uremia.
Signs and symptoms: Early signs may be masked by the effects of the primary problem. Onset is usually marked by dyspnea, restlessness, rapid, shallow respirations, and increased heart rate. Arterial blood has measurements indicate a significant decrease in PO2. As lung congestion increases, the accessory muscles are used, rales can be heard, productive cough with frothy sputum may be evident, and cyanosis and lethargy with confusion develop. A combination of respiratory and metabolic acidosis evolves as diffusion is impaired and anaerobic metabolism is required. (Gould, 2002, p. 414-415)
4. Holistic assessment
a. Physiological integrity
System Subjective Data Objective Data
Cardiovascular
Client states he has never experienced any problems with his heart or blood vessels. History of hyperkalemia with abnormal heart rhythms. Heart rate low normal upon admission and has maintained normal range cardiovascular function throughout hospital stay.
Respiratory
Client states he has episodes of panic and anxiety. He worries about what he eats and drinks for fear of increasing his cough. When he has difficulty breathing, he compares it to the feeling of drowning, where he cannot get air. Admitted with acute respiratory distress syndrome with possible pneumonia. Arterial blood gas levels indicate respiratory acidosis. Wheezing and crackles present with diminished lung sounds. Pulse oxemetry at 95% with O2 nasal canula at 3 L. O2 stats dropped to 89% upon exertion with O2 at three litters with nasal canula. Audible wheezes noted at time of exertion.
Gastro-intestinal
Client stated frustration with needing assistance to use the restroom. Client prefers the bedpan to needed assistance with ambulation to restroom. Clients bowel sounds present in all four quadrants. Previous bowel movement 3/9/2009
Genito-urinary
Client states no problems. Urine straw colored and clear. Odorless with lab results confirming no urinary tract infection. Specific gravity of 1.0150, within normal limits.
Neuro/Sensory
Client states no problems. Client sight assisted with the aid of glasses. Hears voices without asking to repeat. Has tactile use of hands as evidenced by client stating his lunch was hot upon touching food. No neuro/sensory dysfunction observed.
Musculoskeletal
Client complains of weakness and fatigue. Client after transfer from bed to chair and again upon transfer from chair to bed, respirations were exaggerated as evidenced by respirations increased to 28 and shallow.
Skin
Client states reoccurring dull to sharp pain on a scale of 2/10 to 5/10 from Agent Orange he received during Vietnam War. Client states “I know that it itches, but I know not to scratch it because it gets worse.” Visible erythema on anterior portion of forearms. Dry skin covering whole body with wrinkling skin attributed to aging. No open or bleeding areas noted.
(Client data)
b. Psychosocial integrity
Client’s perception of effect of illness/surgery on self-concept: The client stated, “My military training has lead me to lead a very independent life. I have always been able to depend on myself while still being able to help my friends and family.” Now, since he’s been sick with COPD and this recent outbreak of respiratory distress, the client states that he feels the loss of his independence. “The simple things seem to be the worst. Like going to the bathroom without help. It’s embarrassing.” Client has a potential for ineffective coping related to statements of independence and embarrassment. The client has stated a real difficulty with having to rely on any help at all. Client’s affect: The client exhibited subtle affect. He spoke in a monotone voice and his demeanor appeared calm. His tone was more ‘matter of fact’ than sad or depressed.
Coping mechanisms
c. Cultural considerations
Role: marital status, children, parents, etc.: Divorced in 1990 from his wife of over thirty years. He has one son, age 30 and one daughter, age 29. Client states that, “My son and I hadn’t been on speaking terms in 16 years but over this last year that I’ve been having these breathing problems, he’s been talking to me.” Client then goes on to say, “After I get better, I’m moving to Missouri with my son. He’s going to help me whenever I need help.” Client recognizes this as a positive aspect of his health illness. The Client mother died of Alzheimer’s disease and both his father and only sister committed suicide. Client declined to speak further on the suicides other than to say, “It happens.” He then states that his military training has helped to numb him from things like suicide. Client has potential for self-harm related to statements of family suicides and statement of “My military training has numbed me to things like that.”

2. Client’s preferences unique to culture: hygiene, diet support: Client states bathing no more than once a week for fear of asking for help with bathing. He states embarrassment when asking friends or family for help with ADL’s. Client states he has a bad diet. He eats once a day or every other day. He states he eats a lot of fast food because he does not want to have to cook.
3. Compliance with health care plan: Since hospitalization, Client has been compliant with his health care plan as evidenced by participation in all treatments, respiratory therapy, physical therapy, and dietary. Client states understanding of care plan and states necessity of changes in medical and physical needs to able him to lead a productive life with minimal health risk. Client states “Now that I know more about my disease, I can do what it takes to feel more comfortable with my problems. That’s why I’m moving to Missouri with my son to have the help I need.” The client is due to be transferred to the Gardens rehab facility as has been suggested by his physician for strengthening needed to reach ultimate level of functioning with ADL’s and maintain as much independence as possible.
d. Spiritual state
Client’s statements that reflect joy/purpose of living vs. hopelessness
2. Client’s inner strength/weaknesses: Client identified his strengths to be independence, self reliance, and a good decision maker. Client expressed a reliance on others and a lack of trust in others as his weaknesses. By showing trust in his son, the client has reached one of his goals of showing trust in others.
5.
Diagnostic Tests
(including blood work,
x-rays, scans, etc.) Results
(abnormals in red) Indicate possible reasons for abnormal results
Complete Blood Count
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
PLT
MPV
SEGS
LYMPHS
MONOS
EOSINS
BASOS
SEG#
LYMPHS#
MONOS#
EOSINS#
BASOS#
Coagulation
PROTIME
INR
PTT
Urinary Analysis
Color (Urine)
Character
Glucose Qual.
Bilirubin
Keytones
SPEC GRAV.
Blood
pH-UA
Protein Qual
Urobilinogen
Nitrate
Leukocytes
Collect type
Epith Cells
RBC/Urine
WBC/Urine
Bacteria
Chemistry Profile
Na
K+
Cl-
CO2
GAP
GLU
BUN
CREAT
B/C
Ca++
PO4
T.P
ALB
GLOB
A/G
OSMO
AST
ALT
ALK
T.BIL
BIL-D
BIL-I
CHOL
TRIG
Mg ++
10.2 (4.8-10.8 k/cmm)
3.97 L (4.70-6.10 Mil/cmm)
11.9 L (13.1-17.1 gm/dl)
34.2 L (42.0-52.0%)
86.2 (80.0-94.0 fl)
29.9 (27.0-34.0 pg)
34.7 (33.0-37.0 gm/dl)
13.0 (11.5-13.5%)
232 (150-450 k/cmm)
7.1 L (7.4-10.4 fl)
89 H (50-70%)
7 L (20-45%)
4 (0-10%)
0 (0-2%)
0 (0-2%)
9.1 H (2.0-7.3 k/cmm)
0.7 L (1.0-4.8 k/cmm)
0.4
0.00 L (0.04- 0.44 k/cmm)
0.03
13.1 (11.1-14.5 Sec.)
1.0 L
21.9 L
Straw
Clear
Negative
Negative
Negative
1.0150 (1.0030-1.0350)
Negative
6.5 (4.6-8.0)
Negative
0.2 (0.1-0.2)
Negative
Negative
Cath
None
None
1-5/HP
None
136 (135-145 mEq/l)
3.9 (3.5-5.0 mEq/l)
97 L (100-108 mEq/l)
29 (21-32 mEq/l)
10 (1-12)
107 (70-110 mg/dl)
27 H (6-20 mg/dl)
1.2 (0.5-1.2)
20 (6-20 ratio)
8.5 (8.5-10.5)
3.4 (2.5-4.9)
6.6 (6.0-8.2 gm/dl)
3.0 L (3.4-5.0 gm/dl)
3.6 (2.0-4.0 mg/dl)
0.8 L (1.0-3.0 ratio)
278 (275-286 mOs/kg)
31 (15-37 u/l)
166 H (30-65 u/l)
79 (50-138 mg/dl)
0.71 (0.20-1.00 mg/dl)
0.26 (0-0.30 mg/dl)
0.5 (0.2-0.8 mg/dl)
244 H (140-199 mg/dl)
128 (35-150 mg/dl)
1.8 (1.8-2.4 mg/dl)

Anemia, bone marrow failure, erythropoietin deficiency, hemorrhage, malnutrition, over hydration, nutritional deficiencies of; iron, copper, folate, vitamin B-12, vitamin B-6. (RBC Count, 2009)
Anemia, erythropoietin deficiency, malnutrition, nutritional deficiencies of; iron, folate, vitamin B-12, vitamin B-6. Over hydration. (Hemoglobin, 2009)
Blood loss, anemia, bone marrow failure, destruction of red blood cells, malnutrition or specific diet deficiencies, (Hematocrit (HCT), 2009)

Disseminated intravascular coagulation, hemolytic anemia, hypersplenism, idiopathic thrombocytopenic purpura. (Platelet Count, 2009)
Bacterial infection, many inflammatory processes, during physical stress (Differential, 2006)
Sepsis (Blood Differential, 2009)

Bacterial infection, many inflammatory processes, during physical stress (Differential, 2006)
Sepsis (Blood Differential, 2009)

Alcohol intoxification, over production of certain steroids in the body (such as cortisol) (Eosinophil Count – Absolute, 2009)

Client is on Lovenox prophylacticly. There’s not enough information to support reasons for a low PTT/INR.

Certain kidney disorders, chronic compensated respiratory acidosis, congestive heart failure, excessive sweating, gastric suctioning, metabolic alkalosis, overhydration, syndrome of inappropriate ADH secretion, vomiting. (Serum Chloride, 2009)

Congestive heart failure, excessive protein levels, gastrointestinal bleeding, hypovolemia, kidney disease, kidney failure, shock. (BUN, 2009)

Ascites, glomerulonephritis, liver disease, malabsorbtion, malnutrition. (Albumin – Serum, 2009)
Overproduction of globulins, underproduction of albumins, selective loss of albumin in the circulation. (Total Protein and A/G Ration, 2009)

Celiac disease, Cirrhosis, hepatitis, hereditary hemochromatosis, liver ischemia, liver tumor, use of drugs that are poisonous to the liver. (ALT, 2009)

Biliary cirrhosis, high fat diet, nephrotic syndrome. (Cholesterol – Test, 2009)
6.
Medications
(up to 5) Purpose for this client Nursing implications/
teaching
Amlodipine 5mg tab PO

ASA/Aspirin 81mg tab PO

Enoxaparin 40mg Sub Q Injection

Fentanyl 50mcg /hr Transdermal

Potassium Chloride 20 mEq PO Systemic vasodilatation resulting in decreased blood pressure.

Decreased platelet aggregation.

Prevention of deep vein thrombosis.

Moderate to severe chronic pain requiring continuous opioid analgesic therapy for an extended time.

Replacement. Prevention of deficiency. Assessment:
Monitor blood pressure and pulse before therapy, during dose titration, and periodically during therapy. Monitor intake and output ratios and daily weight. Assess for signs of CHF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention.
Patient/Family Teaching:
Advise client to take medications as directed, even if feeling well. Take missed doses as soon as possible unless almost time for next dose; do not double doses. May need to be discontinued gradually. Instruct client on correct technique for monitoring pulse. Instruct client to contact health care professional if heart rate is <50 bpm. Caution client to change positions slowly to minimize orthostatic hypotension. May cause drowsiness or dizziness. Instruct the client on the importance of maintaining good dental hygiene and seeing dentists frequently for teeth cleaning to prevent tenderness, bleeding, and gingival hyperplasia. Instruct client to avoid concurrent use of alcohol or OTC medications, especially cold preparations, without consulting a health care professional. Advise client to notify health care professional if irregular heartbeats, dyspnea, swelling of hands and feet, pronounced dizziness, nausea, constipation, or hypotension occurs or if headache is severe or persistent. Caution client to wear protective clothing and use sunscreen to prevent photosensitivity reactions. Advise client to inform health care professional of medication regiment before treatment or surgery. Encourage client to comply with other interventions for hypertension (weight reduction, low sodium diet, smoking cessation, moderation of alcohol consumption, regular exercise, and stress management.) Medication controls, but not cures hypertension. Instruct client and family in proper technique for monitoring blood pressure. Advise client to take blood pressure weekly and to report significant changes to health care professional.*
Assessment:
May cause elevated serum ALT, AST, and alkaline phosphatase. May return to normal despite continued use. If severe abnormalities or active liver disease occurs, discontinue and use with caution in the future. May alter results of serum uric acid, urine vanillylmandelic acid, protirilin induced thyroid stimulating hormone, urine hydroxyindoleacetic acid determinations, and radionuclide thyroid imaging. May lower serum potassium and cholesterol concentrations. Prolongs bleeding time for 4-7 days. Monitor patient for tinnitus, headache, hyperventilation, agitation, mental confusion, lethargy, diarrhea, and sweating. If these symptoms appear, withhold medication and notify physician or other health care professional immediately.
Patient/Family Teaching:
Instruct patient to take salicylates with a full glass of water and to remain in an upright position for 15-30 min after administration. Advise patient to report tinnitus, unusual bleeding of gums, bruising, black tarry stools, or fever lasting longer than 3 days. Caution patient to avoid concurrent use of alcohol with this medication to minimize possible gastric irritation; 3 or more glasses of alcohol per day may increase the risk of GI bleeding. Caution patient to avoid taking concurrently with acetaminophen or NSAIDs for more than a few days, unless directed by health care professional to prevent analgesic nephropathy. Tablets with an acetic (vinegar-like) odor should be discarded. Advise patients receiving aspirin prophylactically to take nly prescribed dose. Increasing the dose has not been found to provide additional benefits.*
Assessment:
Assess for signs of bleeding and hemorrhage (Bleeding gums; nosebleeds; unusual bruising; black, tarry stools; hematuria; fall in hematocrit or blood pressure; guaiac-positive stools). Notify physician if these occur. Assess for evidence of additional or increased thrombosis. Symptoms depend on area of involvement. Monitor neurological status frequently for signs of neurological impairment. May require urgent treatment. Monitor for hypersensitivity reactions (chills, fever, urticaria). Report signs to physician. Observe injection sites for hematomas, ecchymosis, or inflammation. Monitor CBC platelet count, and stools for occult blood periodically during theapy. If thrombocytopenia occurs, monitor closely. If hematocrit decreases unexpectedly, assess the patient for potential bleeding sites. May caus increase in AST and ALT levels. For overdose, protamine sulfate 1mg for each mg of enoxaparin should be administered by slow IV injection.
Patient/Family Teaching:
Advise patient to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to health care professional immediately.*
Assessment:
Assess type, location, and intensity of pain before and 24 hours after application and periodically during therapy. Monitor pain frequently during initiation of therapy and dose changes to assess need for supplementary analgesics for breakthrough pain. Assess blood pressure, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Physical stimulation may be sufficient to prevent significant hypoventilation. Dose may need to be decreased by 25-50%. Initial drowsiness will diminish with continued use. Prolonged use may lead to physical and psychological dependence and tolerance. This should not prevent patient from receiving adequate analgesia. Most patients who receive opioid analgesics for pain do not develop psychological dependence. Progressively higher doses may be required to relieve pain with long-term therapy. It may take up to 6 days after increasing doses to reach equilibrium, so patients should wear higher dose through 2 applications before increasing dose again. Assess bowel function routinely. Prevent constipaiion with increased intake of fluids and bulk, and laxatives to minimize constipating effects. May increase plasma amylase and lipase levels. If an opioid antagonist s required to reverse respiratory depression or coma, naloxone (narcan) is the antidote.
Patient/Family Teaching:
Instruct patient in how and when to ask for pain medication. Instruct patient in correct method for application and disposal of dransdermal system. Tatalities have occurred from children having access to improperly discarded patches. May be worn while bathing, showering, or swimming. May cause drowsiness or dizziness. Caution patient to call for assistance when ambulating or smoking and to avoid driving or other activities requiring alertness until response to medication is known. Advise patient to change positions slowly to minimize dizziness. Caution patient to avoid concurrent use of alcohol or other CNS depressants with this medication. Advise patient that fever electric blankets, heating pads, saunas, hot tubs and heated water beds increase the release of fentanyl from the patch. Advise patient that good oral hygiene, frequent mouth rinses and sugarless gum or candy may decrease dry mouth.*
Assessment:
Assess for signs and symptoms of hypokalemia (weakness, fatigue U wave on ECG, arrhythmias, polyuria, polydipsia) and toxicity (hyperkalemia; slow, irregular heartbeat; fatigue; muscle weakness; paresthesia; confusion; dyspnea; peaked T waves; depressed ST segments; prolonged QT segments; widened QRS complexes; loss of P waves; and cardiac arrhythmias) Treatment of toxicity includes discontinuation of potassium, and administration of sodium bicarbonate to correct acidosis, dextrose and insulin to facilitate passage of potassium into cells. Monitor serum potassium before and periodically during therapy. Monitor renal function, serum bicarbonate, and pH. Hypomagnesemia should be corrected to facilitate effectiveness of potassium replacement. Monitor serum chloride because of hypochloremia may occur if replacing potassium without concurrent chloride.
Patient/Family Teaching:
Explain to patient purpose of the medication and the need to take as directed, especially when concurrent digoxin or diuretics are taken. A missed dose sould be taken as soon as remembered within 2 hr; if not, return to regular dose schedule. Do not double dose. Emphasize correct method of administration. Instruct patient to avoid salt substitutes or low-salt milk or food unless approved by health care professional. Patient should be advised to read all labels to prevent excess potassium intake. Advise patient regarding sources of dietary potassium. Encourage compliance with recommended diet. Instruct patient to report dark, tarry, or bloody stools; weakness; unusual fatigue; or tingling of extremities. Notify health care professional if nausea, vomiting, diarrhea, or stomach discomfort persists. Dosage may require adjustment. Emphasize the importance of regular follow-up exams to monitor serum levels and progress.*
*(Davis’s Drug Guide for Nurses 10th Edition, 2005)
C. Developmental Transitions: The client is having difficulty with dealing with his deteriorating lungs. He states a sense of panic when he has difficulty breathing. Client teaching should assist with this transition to latter stages of his COPD. The client states acceptance to all other issues attributed to aging.
Erikson’s Developmental Stage/Task: The client is struggling between integrity and despair. Client states his integrity is from years of military training. Despite all that has happened to him over the last year, he prides himself on his independence to this point. He states he is fighting off despair as the realization of his waning independence is leading to a role of dependence.
Role changes: The client is having difficulty transitioning from a provider to being cared for. With the reconciliation with his son, the client has decided to move to allow for assistance from his son. The client has stated difficulty with this because of his independence and lack of trust in others.
D. Situational Transitions (divorce, work changes, relocation, hospitalization): The clients hospitalization for acute respiratory distress syndrome has made the client aware that he will be in need of constant assistance for the first time in his life. The client also had difficulty with transitioning from his divorce 19 years ago. His wife left him and his son refused to speak to him for 18 years after the divorce.
E. Organizational Transitions (access to/movement within the healthcare system) : Client states no difficulty with access to or movement within the healthcare system.
7.Significance of Assessment Findings: Shortness of breath and diminished lung sounds throughout all lobes suggests that the client will be in need of long term assistance, whether with family as the primary care provider or through a long term care facility. Psychological therapy would be beneficial for the patient to deal with his post traumatic stress disorder as well as possible psychological problems associated with tragic family deaths.
II. NURSING DIAGNOSES
A. List all relevant nursing diagnoses for this client
B. Top 2 Priority Nursing Diagnoses according to Maslow as applied to this client.
III. Plan of Safe Effective Care
Using the two diagnoses that are the highest priorities, make a short and a long-term
goal, interventions, outcomes and rationales for each.
NURSING DIAGNOSIS
Impaired gas exchange r/t altered oxygen supply m/b reduced tolerance for activity*
GOALS (expected outcome):
Short term: Client will keep an O2 level of > 94% by 1600 today.
Long term: Client will remain free of symptoms of respiratory distress.*


INTERVENTIONS RATIONALE
Assess respiratory rate, depth. Note use of accessory muscles, pursed lip breathing, and inability to speak / converse.

Elevate head of bed, assist client to assume position to ease work of breathing. Include periods of time in prone position as tolerated. Encourage deep-slow or pursed-lip breathing as individually needed / tolerated.

Assess / routinely monitor skin and mucous membrane color.


Auscultate breath sounds, noting areas of decreased air-flow and / or adventitious sounds.




Palpate for fremitus.


Monitor level of consciousness / mental status. Investigate changes.




Evaluate level of activity tolerance. Provide calm quiet environment. Limit client’s activity or encourage bed / chair rest during acute phase. Have client resume activity gradually and increase as individually tolerated.






Nonitor vital signs and cardiac rhythm.



Monitor / graph serial ABG’s and pulse oximetry.


Administer supplemental oxygen judiciously, using appropriate delivery method and titrate as indicated by ABG results and client tolerance.


Administer antianxiety, sedative, or narcotic agents with caution.





Prepare for additional referrals / interventions; e.g., pulmonary specialist, pulmonary rehabilitation program.* Useful in evaluating the degree of respiratory distress and / or chronicity of the disease process.

Oxygen delibery may be improvd by upright position and breathing exercises to decrease airway collape, dyspnea, and work of breathing. Recent research supports use of prone position to increase PaO2.

Cyanosis may be peripheral or central. Duskiness and central cyanosis indicate advanced hypoxemia.

Breath sounds may be faint because of decreased airflow or areas of consolidation. Presence of wheezes may indicate bronchospasm / retained secretions. Scattered moist crackles may indicate interstitial fluid / cardiac decompensation.

Decrease of vibratory tremors suggests flid collection or air trapping.

Restlessness and anxiety are common manifestations of hypoxia. Worsening ABG’s accompanied by confusion / somnolence are indicative of cerebral dysfunction due to hypoxemia.

During severe / acute / refractory respiratory distress, client may be totally unable to perform basic self-care activities because of hypoxemia and dyspnea. Rest interspersed with care activities remains an important part of treatment regimen. An exercise program is aimed at improving aerobic capacity and functional performance, increasing endurance and strength without causing severe dyspnea and can enhance sense of well-being.

Tachycardia, dysrhythmias, and changes in blood pressure can reflect effect of systemic hypoxemia on cardiac function.

PaCO2 usually elevated, and PaO2 is generally decreased, so that hypoxia is present in a greater or lesser degree.

Used to correct / prevent worsening of hypoxemia improve survival, and quality of life. Supplemental oxygen can be provided during exacerbations only, or as a long-term therapy.

May be used to reduce dyspnea by controlling anxiety and restlessness, which increases oxygen consumption / demand exacerbating dyspnea. Must be monitored closely because depressive effect may lead to respiratory failure.

May be indicated to confirm diagnosis and optimize appropriate treatment. A multidisciplinary approach including education and exercise treaining may be helpful in improving client function and quality of life.*
*(Nursing Care Plans, 2006)
IV. EVALUATION
A. Short term goal (met, partially met, not met)
Client maintained an O2 level of 95% throughout shift.
B. Long term goal (met, partially met, not met)
Unable to assess at this time.
NURSING DIAGNOSIS
Imbalanced Nutrition: less than body requirements r/t fatigue m/b Reported altered taste sensation, aversion to eating, lack of interest in food*
GOALS (expected outcome):
Short term: Client will eat 90% of breakfast and lunch by 1600 today.
Long term: Demonstrates lifestyle changes to maintain appropriate weight.*
INTERVENTIONS RATIONALE
Assess dietary habits, recent food intake. Note degree of difficulty with eating. Evaluate weight and body size.









Auscultate bowel sounds.





Give frequent oral care, remove expectorated secretions promptly, provide specific container for disposal of secretions and tissues.

Encourage a rest period of 1 hr before and after meals. Provide frequent small feedings.

Avoid gas-producing foods and carbonated beverages.


Avoid very hot or very cold foods.


Weigh as indicated.



Consult dietitian / nutritional support team to provide easily digested, nutritionally balanced meals by appropriate means.

Review laboratory studies; e.g., serum albumin / prealbumin, transferring, amino acid profile, iron, nitrogen blance studies, glucose, liver function studies, electrolytes.

Administer supplemental oxygen during meals as indicated.* Client in acute respiratory distress is often anorectic because of dyspnea, sputum production, and medication effects. In addition many COPD clients habitually ead poorly even though respiratory insufficiency creates a hypermetabolic state with increased caloric needs. As a result, client often is admitted with some degree of malnutrition. People who have emphysema are often thin with wasted musculature.

Diminished / hypoactive bowel sounds may reflect decreased gastric motility and constipation related to limited fluid intake, poor food choices, decreased activity, and hypoxemia.

Noxious tastes, smells, and sights are prime deterrents to appetite and can produce nausea and vomiting with increased respiratory difficulty.

Helps reduce fatigue during mealtime, and provides opportunity to increase total calorie intake.

Can produce abdominal distention, which hampers abdominal breathing and diaphragmatic movement and can increase dyspnea.
Extremes in temperature can precipitate / aggravate coughing spasms.

Useful in determining caloric needs, setting weight goal, and evaluating adequacy of nutritional plan.

Needs to provide maximal nutrients with minimal client effort.


Evaluates / treats deficits and monitors effectiveness of nutritional therapy.



Decreases dyspnea and increases energy for eating, enhancing intake.*
*(Nursing Care Plans, 2006)

IV. EVALUATION
A. Short term goal (met, partially met, not met)
Client ate 100% of his breakfast but only 80% of lunch.
B. Long term goal (met, partially met, not met)
Unable to assess at this time.









Chart data acquired via client chart, Kingman Regional Medical Center, March 10, 2009.

Client data acquired in interview with client, Kingman Regional Medical Center, March 10, 2009.

Barbara E. Gould, Med. (2006). Pathophysiology for the Health Professions; Third Edition. Toronto, Ontario, Canada: Elseveir Inc.

RBC Count. (2009) Retrieved March 17, 2009, from MedlinePlus Web site; http://www.nlm.nih.gov/medlineplus/ency/article/003644.htm

Hemoglobin. (2009) Retrieved March 17, 2009, from MedlinePlus Web site; http://www.nlm.nih.gov/medlineplus/ency/article/003645.htm

Hematocrit (HCT). (2009) Received March 17, 2009, from MedlinePlus Web site; http://www.nlm.nih.gov/medlineplus/ency/article/003646.htm

Platelet Count. (2009) Received March 17, 2009, from MedlinePlus Web site; http://www.nlm.nih.gov/medlineplus/ency/article/003647.htm

Differential. (2006) Received March 17, 2009, from RnCeus Web site; http://www.rnceus.com/cbc/cbcdiff.html

Blood Differential. (2009) Received March 17, 2009, from MedlinePlus Website; http://www.nlm.nih.gov/medlineplus/ency/article/003657.htm

Eosinophil Count – Absolute. (2009) Received March 17, 2009, from MedlinePlus Web site; http://www.nlm.nih.gov/medlineplus/ency/article/003440.htm

Serum Chloride. (2009) Received March 17, 2009, from MedlinePlus Web site; http://www.nlm.nih.gov/medlineplus/ency/article/003485.htm

BUN. (2009) Received March 17, 2009, from MedlinePlus Web site; http://www.nlm.nih.gov/medlineplus/ency/article/003474.htm

Albumin – Serum. (2009) Retrieved March 17, 2009, from MedlinePlus Web site; http://www.nlm.nih.gov/medlineplus/ency/article/003480.htm

Total Protein and A/G Ratio. (2009) Retrieved March 17, 2009, from Lab Tests Online Web site; http://www.labtestsonline.org/understandin...es/tp/test.html

ALT. (2009) Retrieved March 17, 2009, from MedlinePlus Web site; http://www.nlm.nih.gov/medlineplus/ency/article/003473.htm

Cholesterol – Test. (2009) Retrieved March 17, 2009, from MedlinePlus Web site; http://www.nlm.nih.gov/medlineplus/ency/article/003492.htm

Judith Hopfer Deglin and April Hazard Vallerand. (2005) Davis’s Drug Guide for Nurses: Tenth Edition. Philadelphia, PA: F.A. Davis Company.

Marilynn E. Doenges, Mary Frances Moorhouse, and Alice C. Murr. (2006) Nursing Care Plans. Philadelphia, PA: F.A. Davis Company.


--------------------
Points:


I scare little kids.
user posted image

QUOTE (treacherous @ Aug 16 2008, 12:12 PM)
RRRAOAAOAOAORRARRAA!!...  Blue lights and sirens rang through the night!! Yeah, they all wanna kill each other... HERE ME CITY!! THE STREETS BELONG TO THE GANGS NOW!! THIS IS THE NEW ORDER!! PREPARE FOR CHAOS!!

Solomon and I may be gangsta, but treach is the gangsta of the year!
Top
treacherous
Posted: Mar 31 2009, 03:38 AM


Let Hammy have his Bison. I've got Zod.


Group: Admin
Posts: 3,499
Member No.: 37
Joined: 10-June 08



Ack! Cut that out. It hurts me head.


--------------------
Points:

Ursa: You are master of all you survey.
General Zod: [bored] So I was yesterday. And the day before.




QUOTE (SilverSurfer092 @ Apr 9 2009, 03:27 AM)
WTFYES  Treacherous is full of pwnage.
Top
granobulax
Posted: Mar 31 2009, 03:42 AM


He's even got his hand over where I live...


Group: Admin
Posts: 7,880
Member No.: 35
Joined: 31-May 08



QUOTE (treacherous @ Mar 31 2009, 03:38 AM)
Ack! Cut that out. It hurts me head.

Your head hurts? I can't imagine why. You should try WRITING one. There's TRUE writing laugh.gif


--------------------
Points:


I scare little kids.
user posted image

QUOTE (treacherous @ Aug 16 2008, 12:12 PM)
RRRAOAAOAOAORRARRAA!!...  Blue lights and sirens rang through the night!! Yeah, they all wanna kill each other... HERE ME CITY!! THE STREETS BELONG TO THE GANGS NOW!! THIS IS THE NEW ORDER!! PREPARE FOR CHAOS!!

Solomon and I may be gangsta, but treach is the gangsta of the year!
Top
treacherous
Posted: Mar 31 2009, 03:43 AM


Let Hammy have his Bison. I've got Zod.


Group: Admin
Posts: 3,499
Member No.: 37
Joined: 10-June 08



QUOTE (granobulax @ Mar 31 2009, 03:42 AM)
Your head hurts? I can't imagine why. You should try WRITING one. There's TRUE writing laugh.gif

Hall of Fame worthy.


--------------------
Points:

Ursa: You are master of all you survey.
General Zod: [bored] So I was yesterday. And the day before.




QUOTE (SilverSurfer092 @ Apr 9 2009, 03:27 AM)
WTFYES  Treacherous is full of pwnage.
Top
granobulax
Posted: Mar 31 2009, 03:50 AM


He's even got his hand over where I live...


Group: Admin
Posts: 7,880
Member No.: 35
Joined: 31-May 08



QUOTE (treacherous @ Mar 31 2009, 03:43 AM)
Hall of Fame worthy.

Should I post it on the FPL? laugh.gif


--------------------
Points:


I scare little kids.
user posted image

QUOTE (treacherous @ Aug 16 2008, 12:12 PM)
RRRAOAAOAOAORRARRAA!!...  Blue lights and sirens rang through the night!! Yeah, they all wanna kill each other... HERE ME CITY!! THE STREETS BELONG TO THE GANGS NOW!! THIS IS THE NEW ORDER!! PREPARE FOR CHAOS!!

Solomon and I may be gangsta, but treach is the gangsta of the year!
Top
treacherous
Posted: Mar 31 2009, 02:25 PM


Let Hammy have his Bison. I've got Zod.


Group: Admin
Posts: 3,499
Member No.: 37
Joined: 10-June 08



QUOTE (granobulax @ Mar 31 2009, 03:50 AM)
Should I post it on the FPL? laugh.gif

Everyone would vote for it, because they'd feel guilty that they don't get it.


--------------------
Points:

Ursa: You are master of all you survey.
General Zod: [bored] So I was yesterday. And the day before.




QUOTE (SilverSurfer092 @ Apr 9 2009, 03:27 AM)
WTFYES  Treacherous is full of pwnage.
Top
Pseudonym
Posted: Mar 31 2009, 08:34 PM


FPL Failure


Group: Members
Posts: 1,219
Member No.: 203
Joined: 26-January 09



QUOTE (granobulax @ Mar 31 2009, 03:14 AM)
Student: Granobulax S.N. MCC

Your name is really granobulax ohmy.gif


--------------------
Points: More than Bison


Give me half.
Top
granobulax
Posted: Mar 31 2009, 10:31 PM


He's even got his hand over where I live...


Group: Admin
Posts: 7,880
Member No.: 35
Joined: 31-May 08



laugh.gif No, that's not my real name. My first name is Josh and there's only one other person on this site who knows my last name.


--------------------
Points:


I scare little kids.
user posted image

QUOTE (treacherous @ Aug 16 2008, 12:12 PM)
RRRAOAAOAOAORRARRAA!!...  Blue lights and sirens rang through the night!! Yeah, they all wanna kill each other... HERE ME CITY!! THE STREETS BELONG TO THE GANGS NOW!! THIS IS THE NEW ORDER!! PREPARE FOR CHAOS!!

Solomon and I may be gangsta, but treach is the gangsta of the year!
Top
Jailer411
Posted: Apr 1 2009, 12:01 AM


The one and only.


Group: Members
Posts: 2,320
Member No.: 175
Joined: 17-January 09



QUOTE (granobulax @ Mar 31 2009, 04:31 PM)
laugh.gif No, that's not my real name. My first name is Josh and there's only one other person on this site who knows my last name.

Bloody Freak.


--------------------
4/24/11 8:48CMT

Signature has been changed, forum remains locked.
Top
granobulax
Posted: Apr 1 2009, 04:59 AM


He's even got his hand over where I live...


Group: Admin
Posts: 7,880
Member No.: 35
Joined: 31-May 08



QUOTE (Jailer411 @ Apr 1 2009, 12:01 AM)
Bloody Freak.

He know's it too? huh.gif


--------------------
Points:


I scare little kids.
user posted image

QUOTE (treacherous @ Aug 16 2008, 12:12 PM)
RRRAOAAOAOAORRARRAA!!...  Blue lights and sirens rang through the night!! Yeah, they all wanna kill each other... HERE ME CITY!! THE STREETS BELONG TO THE GANGS NOW!! THIS IS THE NEW ORDER!! PREPARE FOR CHAOS!!

Solomon and I may be gangsta, but treach is the gangsta of the year!
Top
treacherous
Posted: Apr 1 2009, 11:51 AM


Let Hammy have his Bison. I've got Zod.


Group: Admin
Posts: 3,499
Member No.: 37
Joined: 10-June 08



QUOTE (granobulax @ Mar 31 2009, 10:31 PM)
laugh.gif No, that's not my real name. My first name is Josh and there's only one other person on this site who knows my last name.

ninja.gif


--------------------
Points:

Ursa: You are master of all you survey.
General Zod: [bored] So I was yesterday. And the day before.




QUOTE (SilverSurfer092 @ Apr 9 2009, 03:27 AM)
WTFYES  Treacherous is full of pwnage.
Top
granobulax
Posted: Apr 2 2009, 09:20 PM


He's even got his hand over where I live...


Group: Admin
Posts: 7,880
Member No.: 35
Joined: 31-May 08



Well, today I got the worst test grade I've recieved since being in the nursing program. I failed the test by 1% at a 74% sad.gif

Now, my test grade average for the semester is an 80%, only 5% above failing.

Damn. sad.gif


--------------------
Points:


I scare little kids.
user posted image

QUOTE (treacherous @ Aug 16 2008, 12:12 PM)
RRRAOAAOAOAORRARRAA!!...  Blue lights and sirens rang through the night!! Yeah, they all wanna kill each other... HERE ME CITY!! THE STREETS BELONG TO THE GANGS NOW!! THIS IS THE NEW ORDER!! PREPARE FOR CHAOS!!

Solomon and I may be gangsta, but treach is the gangsta of the year!
Top
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