A.P - 92 years old

A.P - 92 years old

1. hypothyroidism

   • levothyroxine 112 mcg daily

2. GERD

   • pantoprazole 40 mg BID

3. MI

   • clopidogrel 75 mg daily
   • aspirin 81 mg daily
   • nitroglycerin 0.4 mg prn for chest pain

4. peri-rectal abscess complicated by vertebral osteomyelitis with a chronically draining parasacral wound and fistula formation to the rectal stump status post coccyx removal

   • NURSING DIAGNOSIS - risk for infection secondary to peri-rectal abscess and impaired skin integrity r/t complications of vertebral osteomyelitis GOALS - protect, clean and heal the wound, prevent injury, maintain skin integrity, prevent infection and additional skin breakdown INTERVENTIONS - monitor vital signs especially patients temp, patients wound dressing will be changed daily per wound care orders, proper hand hygiene will be performed before and after dressing changes, assess and document wound characteristics, assess patients nutritional status for healing,  OUTCOME - patient will not have any further skin breakdown, patient wound will be kept clean and free from any further infection
   • wound care daily

5. CAD

   • NURSING DIAGNOSIS - risk for decreased cardiac output GOALS - free of complications and achieved desired activity INTERVENTIONS - administer heart medications, monitor vital signs, encourage to report any chest pain or SOB, auscultate breath sounds and heart sounds, provide adequate rest periods, evaluate mental status and watch for confusion or disorientation, assess skin color and quality of pulses, monitor pulse oximetry, monitor labs, administer O2 if needed.   OUTCOME - increased activity tolerance, decreased episodes of dyspnea, angina, and dysrhythmias and stable vital signs

6. iron deficiency anemia

   • NURSING DIAGNOSIS - activity intolerance r/t imbalance between oxygen supply and demand.   GOALS - ADL's met by self or with assistance, no complications INTERVENTIONS - monitor labs, monitor vital signs, assess patients ability to perform ADL's assessing weakness and fatigue, promote rest periods, administer iron supplement and additional iron in diet OUTCOME - lab values in acceptable range, increase in activity tolerance and pulse, BP and respirations within patients normal range.
   • ferrous sulfate 325 mg daily
   • WBC-8.09 RBC-3.64 HGB-9.0 HCT-28.0 MCV-77.0 MCH-24.8 platelets-365
     • generalized weakness, fatigue, palpitations, tachycardia, increased BP, and decreased activity tolerance

7. recurrent UTI's - urinary catheterization

   • cranberry tabs
   • cipro 500 mg daily
   • burning, abdominal pain, odorous urine, confusion
     • frequent UA's

8. Hyperlipidemia

   • rosuvastatin 5 mg Mon, Wed and Fri

9. ambulatory dysfunction/generalized weakness and activity intolerance

   • NURSING DIAGNOSIS - activity intolerance r/t generalized weakness GOALS - restore the patients ability to perform regular activities in a healthy manner without experiencing any signs or symptoms of activity intolerance and free from falls and injuries.   INTERVENTIONS - monitor vital signs, encourage activity, assess the patients ability to perform ADL's and basic activities, watch for early signs of fatigue, dizziness, and/or weakness, assess for abnormal discomfort or dyspnea during activities,  OUTCOME- patient is able to display and use effective energy management techniques, patient is able to provide positive feedback in response to activity level, patient is able to display physiological improvements over time, patient is able to maintain regular cardiovascular  and respiratory functions during activities, patient is free from falls or injuries
   • walker with ambulating
   • assist with 1
   • PT/OT each 2 times weekly

10. HX of malignant tumor of rectum and colon cancer

    • colostomy
      • NURSING DIAGNOSIS - risk for impaired skin integrity r/t absence of sphincter at stoma GOALS - no complications, proper self care and colostomy care INTERVENTIONS - inspect stoma and peristomal skin area OUTCOME - maintain skin integrity around stoma, healing and no skin breakdown

11. stage IV chronic kidney disease

    • NURSING DIAGNOSIS - excess fluid volume r/t compromised regulatory mechanism (renal failure) GOALS - fluid and electrolyte balance, no complications and no pain or discomfort  INTERVENTIONS - monitor heart rate and BP, auscultate lungs and heart sounds, monitor labs, administer/restrict fluids OUTCOME - appropriate urinary output with specific gravity and near normal labs, stable weight, vital signs in range and absence of edema.  
    • Bun-22 Creatinine-1.46

12. undiagnosed internal abdominal pain

    • NURSING DIAGNOSIS -chronic pain related to cause unknown GOALS - investigate and have further testing - possible MRI being scheduled INTERVENTIONS - pain assessment, administer pain meds, promote rest, relaxation exercises and breathing techniques, vital signs.  OUTCOME-pain relief to a satisfactory level, pt able to relax and sleep, pt able to get out of bed
    • tramadol 50 mg TID prn for pain
    • acetaminophen 650 mg 1 tab prn for pain
    • severe pain

13. neurogenic bladder

    • NURSING DIAGNOSIS - impaired urinary elimination r/t neurogenic bladder secondary to radiation for colon cancer GOALS - no complications or infections, patient self caths, patient comfort INTERVENTIONS - patient education and self catheterization,  OUTCOME - improved quality of life
    • intermittent self catheterization
    • unable to urinate, frequent UTI's, loss of feeling that bladder is full

14. bilateral hearing impairment

    • patient to wear hearing aids and talk louder and face the patient while speaking
    • bilateral hearing aids