Week 2 Care Map

Week 2 Care Map

1. Medications: Keppra, Insulin, Lipitor, Lovenox, Flomax

2. DNR/DNI

3. Safety: Fall precaution, seizure precautions, aspiration precautions

4. G-Tube Placement

   • 1. Nurs Dxn: Risk for Aspiration
     • R/t: impaired ability to swallow
       • AEB: G-tube insertion
         • Interventions
           • 2. Keep HOB >30 during G-tube feedings, and keep raised for 1 hour after feeding
             • Pt. was kept at 30-60 degrees while feeding and for 1 hr after
           • 3. Have suction equipment readily available and if aspiration occurs, suction immediately
             • Available and checked to make sure it was working during 60 sec scan
           • 9. Educate family on the proper way to feed and administer medications and water through the G- tube as well as proper cleaning
             • Caregiver, daughter, and wife were educated and used teach back method to show accuracy and understand
           • 8. Refer a nutritionist to provide appropriate diet for pt. with newly inserted G-tube
             • Nutritionist provided detailed instructions for RN and family about diet: Diet included enteral Isosource 1.5 q4h
           • 1. Follow unit policy for checking the placement of the tubing before initial feedings begin
             • Tube feeding was confirmed by X-Ray and orders were to begin feedings through G-tube on 9/6 at 0700
           • 5. Check gastric residuals before all feedings and hold feedings if residual is present
             • Checked before feeding and med administration
           • 4. Auscultate lung sounds before and after every feeding through G-tube, as well as q2h and as needed
           • 7. Monitor LOC, RR, depth, and effort of pt qhr; note any signs of dyspnea, cough, cyanosis, wheezing, hoarseness, sputum, fever
           • 6. Check glucose levels before feedings - pt diabetic

5. Advanced Parkinson's Disease

   • 3. Nurs Dxn: Impaired Verbal Communication
     • R/t cognitive impairement
       • AEB: inability to communication wants and needs through words
         • Interventions
           • 1. Use of comprehensive nursing assessment to determine cognitive level, language spoken, literacy level, and asking family about baseline
             • Assessment concluded that pt could understand most verbal cutes but could not respond, only used a head nod
           • 2. Determine clients own perception of communication difficulties and the potential solutions available
           • 4. Include family and caregiver in plan of care and help with communication process between pt and RN
             • When caregiver and daughter arrived, they understood more of the nonverbal cues and it became easier to understand the needs of the pt
           • 3. Speak in a clear and concise tone and verbalize all actions to the patient regardless if pt responds
             • Every action was spoken aloud and verbalized; asked pt if okay and head nod was given in response
           • 5. Consult communication therapist for alternative communication methods
           • 6. Reduce background noise if possible so that pt can hear all instructions given to them
           • 7. Use alternative forms of communication if possible through writing, signing, etc.
             • Pt unable to achieve this intervention r/t cognitive impairment

6. Bed Ridden

   • 2. Nurs Dxn: Risk for Pressure Ulcer
     • R/t: Being bed ridden
       • AEB: inability to stand or walk
         • Interventions
           • 1. Assess skin q2h; obtain VS
             • Assessed q2h
           • 2. Turn and reposition pt q2h on a schedule
             • Repositioned with CNA on schedule
           • 3. Keep skin dry, clean, and intact; assess need for cleaning bowel/urine incontinence
             • Helped clean pt twice with CNA
           • 4. Assess using a standardized scale (Braden) as needed
           • 5. Use of wedge or other pressure relieving device during shift as needed
             • wedge used during shift
           • 6. Consult with Nutritionist/OT/PT as needed
           • 7. Education family and caregiver of the importance of repositioning and procedures regarding pressure ulcers
             • Family and caregiver aware of importance
     • Medication given: Lovenox for DTV

7. Morning VS: RR 16, HR 59, BP 112/54, 02 97, Pain 0, Wt 136, T 97.5, Glucose 84