85yr/Male

85yr/Male

1. Dx: Advanced Dementia

   • Nursing Dx: Chronic Confusion
     • AEB: Diminished mental capacity
       • R/t: Impaired short and long term memory
         • Interventions
           • 8. Engage client in individualized communication to maximize client interaction and response by beginning every conversation with their name and introducing self
           • 5. Assess client for signs of depression and anxiety, irritability, agitation, loss of concentration, insomnia, and poor appetite q2h
           • 1. Assess LOC and AOx3 q2h
             • Pt. NOT oriented to person, place or time during shift
           • 7.. Break down/assist with self-care activities one at a time and give one direction at a time; use gestures and allow for adequate time for patient to complete ADL; model desire action if necessary
           • 2. Ensure that client is in a safe environment by removing potential hazards such as sharp objects and harmful liquids.
             • 60 second scan performed
           • 6. Apply bed alarm for patient and assess the need for a 1:1 sitter
             • Pt. had sitter in room as well as bed alarm on
           • 3. Have pt engage in as much activity as possible, such as turn, ambulating, or transferring from bed to chair
             • Pt. unable to ambulate; turned q2h during shift
           • 4. Give medications as prescribed and initiate all other ordered therapies as scheduled
             • Given Memantine as scheduled
           • 9. Consult OT/PT for consult/therapy
   • NOT orientated to person, place, or time upon assessment

2. Dx: Failure to Thrive

   • Nursing Dx: Risk for Pressure Ulcer
     • AEB: Blanchable redness on sacrum
       • R/t: Inability to ambulate
         • Interventions
           • 2. Turn and reposition q2h following schedule
           • 4. Apply preventative Mepilex onto sacrum and assess need for change q2h
           • 7. Consult with Nutrition/OT/PT specialist if needed
           • 3. Keep area clean, dry, and intact; assess need for bowel/urine clean up
             • Pt. had two loose stools during shift, stool sample recommended
           • 6. Use of wedge or other pressure relieving device to relieve pressure
             • Wedge used during shift
           • 1. Assess area q2h; Obtain vital signs
             • Morning VS: BP 151/71, T 97.6, RR 17, HR 64, 02 96
           • 5. Perform skin assessment using Braden Scale q2h
         • Medication: Heparin given to prevent DVT

3. Dx: Dysphagia

   • Nursing Dx: Risk for Aspiration
     • AEB: Difficulty Swallowing
       • R/t: Coughing when food is eaten
         • Interventions
           • 3. HOB > 30-45 degrees while eating and for 1 hour after eating; preferably have pt. sit at 90 degrees in a chair while eating
             • Pt. was positioned at 90 degrees for all feedings and left at 30 degrees for 1 hour after
           • 1. Monitor RR, depth, effort (and other vital signs such as temperature) and note any signs of aspiration such as dyspnea, SOB, cough, cyanosis, wheezing, sputum, as well as fever Q2h and as needed
           • 2. Monitor gag reflux, cough reflex, and swallowing ability to assess risk for aspiration beforeall feedings/med pass
             • Pt given spoonful of apple sauce before all feedings or PO meds to assess ability to swallow
           • 5. Have suction available; if aspiration occurs suction immediately (not in my scope of practice but is for a RN)
           • 6. When feeding, feed slowly and allow adequate time for pt. to chew and swallow; check for placement of feeding tube if necessary before feeding
           • 8. Consult speech therapist for a swallow assessment as needed
           • 4. Follow all prescribed doctors orders for eating/PO medications
             • PO Meds were crushed and given in apple sauce: Hydrochlorothiazide, Valsartan, Atrovastatin, Docusate Sodium, SennaPOD, Memantine, Lactobacillus Acidophius, Sertaline tab
           • 7. Assess need for PO meds to be given through other routes
   • Pt on a dysphagia/puree diet; crush medications when PO
   • Focused RR and LOC assessment done Q2h

4. MEDICATIONS: 1. Hydrochlorothiazide 2. Valsartan 3. Atrovastatin 4. DocusateSodium 5. Heparin 6. SennaPOD 7. Memantine 8. Lactobacillus Acidophius 9. Sertaline tab

5. Safety Precautions: Fall Risk, Aspiration Precaution, 1:1 Sitter; High risk for VTE (venous thromboembolism)

6. Morning Lab Values: WBC 6.7, RBC, 3.53, HGB 10.3, HCT 32.3, BUN 15, CREAT 0.72, Na 141, Chloride 112