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Mini Care Plan: FB Kate Hart Client Situation: F.B is a 91 year old man who was admitted to St. Martha's hospital after his daughter's encouraged him to visit his doctor for a geriatric assessment due to a rapid deterioration in his state of health. Up until this time F.B had been living alone in his home, and completing ADLs independently, but due to his present condition is now awaiting placement in a long term care facility. His diagnosis upon admission included CVA, Ca Prostate, Dementia, Anemia, and metastatic bowel, but is in remarkably good shape for his age. F.B has had Ca Prostate for many years, and also has a history of Pneumonia, and is hearing impaired. F.B experiences moderate dysphagia and unsteady gait, and therefore have fluids thickened, a mechanical diet, and uses a walker to mobilize. Appetite has decreased since recent deterioration in health and client has lost 7 lbs, according to family. Since admission has had several procedures including Barium swallow, mini mental assessments (scoring 16/30 and 7/30), CT's of the Abdomen/Pelvis and Head, a bone scan, as well as a gastrograftin enema. The client and family have consulted with Dr. Steeves and decided that F.B's cancer will not be operated on. During his hospitalization F.B has tried to climb over his rails several times, and therefore bed alarms and a lap belt are currently being used. His last BM was September 25/08. F.B has no known allergies and medications currently include ECASA 81mg PO OD, Flutamide 250mg PO BID, Vit B12 1000mcg PO OD Scientific Rationale Prostate cancer is the most frequently diagnosed cancer in men. Symptoms of prostate cancer may include problems passing urine, such as pain, difficulty starting or stopping the stream, or dribbling, low back pain, pain with ejaculation. Prostate cancer treatment often depends on the stage of the cancer. Treatment may include surgery, radiation therapy, chemotherapy or control of hormones that affect the cancer (Day & Paul, 2007). Cognitive function deterioration as with dementia, leads to a decline in ability to perform basic activities of daily living. With such impairments, safety becomes a concern and often constant supervision is required, as the client can become disorientated to place and time, and may be unable to follow simple directions (Potter & Perry, 2001). The patient is often unable to recognize the consequences of his or her actions and therefore will exhibit irrational and impulsive behaviors (Day & Paul, 2007). List of Prioritized Diagnostic Statements 1 Acute Confusion r/t degenerative brain disease secondary to dementia AMB mini mental assessment scores. 2 Risk for falls r/t lack of awareness of environmental hazards, impaired sensory function, and unsteady gait. 3 Self care deficit syndrome r/t cognitive deficits and confusion secondary to Dementia AMB inability to complete ADLs. 4 Risk for injury r/t lack of awareness of environmental hazards, impaired sensory function, and unsteady gait. 5 Imbalanced Nutrition: Less than bodily requirements r/t decreased desire to eat r/t dysphagia AMB weight loss. 6 Memory Impaired r/t degenerative brain disease secondary to dementia AMB mini mental assessment scores. 7 Constipation r/t decreased peristalsis secondary to immobility AMB client not having a bowel movement in four days. 8 PC: Anemia 9 PC: Hypoxia 10 Noncompliance r/t poor memory, degenerative brain disease secondary dementia AMB mini mental assessment scores, and failure of client to follow instructions. 11 Risk for impaired skin integrity r/t impaired mobility 12 PC: Pneumonia Client Outcomes: 1 Vital Signs will remain WNL on September 29/08. 2 Client will have a bowel movement on September 29/08. 3 Client will be orientated to person place on September 29/08. 4 Client will remain free from injury on September 29/08. Client and Nurse Interventions Nurse will: 1 monitor vitals, q4h 9 12 2 encourage client and family to share concerns 1 2 3 4 5 6 7 10 3 Reduce/Eliminate risk factors 24 4 Explain activities and procedures thoroughly 1 3 6 10 5 Position changes q2h 11 6 Monitor O2 Stats 8 9 12 7 Monitor skin color 8 9 12 8 Assist/complete ADLs in collaboration with client 1 3 4 6 9 Monitor BM 7 10 Ensure call bell is within client's reach 1 2 4 6 10 Client will: 11 Ring for assistance as needed 1 2 4 6 10 12 Consume adequate amounts at meal times 5 13 Client will participate in ADLs in collaboration with nurse 1 2 4 6 10 Evaluation 1 Met-Vital Signs remained WNL on September 29/08. 2 Unmet-Client did not have a bowel movement on September 29/08. 3 Met- Client will be orientated to person place on September 29/08. 4 Met-Client remained free from injury on September 29/08. Mini Care Plan: EB Kate Hart Client Situation E.B. is an 86 year old woman who was admitted to St.Martha's hospital via EHS on September 11/08 after experiencing respiratory distress, becoming extremely weak and short of breath, and stating that she "had trouble getting air on". Her admitting diagnoses include CHF,COPD, as well as secondary diagnoses of pulmonary edema and pneumonia. Upon admission wheezes and crackles heard bilaterally, and she had a productive cough with pink tinged sputum. This cough with sputum had apparently been present for quite some time, prior to admission. E.B. has a past history of CAD,IHD, stomach reflux, heart attack in 1999, arthritis in hands and her left knee, and colorectal cancer with a resection performed in 1999. Upon admission vitals were 86,40,36.2,117/58, and 81%. She was alert and orientated x3, but in severe respiratory distress being, only being able to speak 1-2 words per breath. She has no known allergies, and is on a cardiac diet. She also is a DNR client. Throughout her hospitalization E.B has become short of breath upon minimal exertion, and is currently on 3L of oxygen via nasal cannula, which she also uses at home. She is currently working with physiotherapy She states that she is feeling much better than she did when she first came to hospital, and is not as short of breath, however she still tires easily. Her last bowel movement was on September 26th, 2008. E.B. uses a walker to mobilize, and is orientated x3. She has two daughters that visit her often in the hospital, and speaks very highly of them. She is a very friendly and co-operative lady, and is quite knowledgeable regarding her current health status, and medications. Current meds are Crestor 10mg PO OD, Spinronolactone 25mg PO OD, Combivent Neb QID, Spiriva 18mg inhaler OD, Colace 100mg PO BID, Nitropatch 0.6mg OD, Ramipril 15mg PO OD, Myostatin swish 7 swallow 5ml PO OD, Ventolin Neb 2.5mg q30mins PRN, Ativan 0.5mg-1mg s/l q4h PRN. Her most recent lab values that were out of range were: Sodium 127 (L), Potassium 5.3 (H), Chloride 92 (L), Urea 14.5 (H), and Calcium 1.87 (L). Scientific Rationale When the heart is unable to pump a sufficient amount of blood to meet the metabolic needs of the body heart failure can occurs. This can happen when there is a disorder that interferes with the ability of the ventricles to fill or eject blood. Heart failure usually causes volume overload as well as pulmonary edema. COPD along with other pulmonary diseases can also play a role in heart failure. Some of the signs and symptoms of heart failure are dyspnea, weakness, activity intolerance, wheezing, and coughing. It may present as an increase or decrease in blood pressure, increased JVP, crackles and wheezes heard in the lungs, as well as decreased breath sounds, and edema (Day & Paul, 2007). Chronic obstructive pulmonary disease includes diseases that impair airflow and cause obstruction (ie emphysema, chronic bronchitis).COPD is characterized by three main symptoms which are known to usually get progressively worse over time, and include cough, SOB, and sputum production. It may present itself upon assessment as dullness over areas of consolidation, distended neck veins, edema, cough, sputum production, and uses of accessory muscles during respiration (Day & Paul, 2007). List of Prioritized Diagnostic Statements 1) Impaired exchange r/t excessive or thick secretions secondary to COPD, and imbalance between O2 supply and demand, AMB decreased 02 sats 2) Self care deficit syndrome r/t fatigue secondary to COPD AMB client becoming SOB with minimal exertion. 3) Activity intolerance r/t compromised OZ transport system secondary to CHF and CPOD AMB client becoming SOB with minimal exertion. 4) Impaired physical mobility r/t fatigue secondary to COPD and CHF AMB client spending most of time in bed and stating she is tired. 5) Constipation r/t decreased peristalsis secondary to immobility AMD client not having a bowel movement for 3 days. 6) Excess fluid volume r/t increased preload, decreased contractility and decreased cardiac output secondary to CHF AMB edema. 7) Imbalanced nutrition:less than body requirements r/t decreased desire to eat secondary to fatigue and SOB. 8) PC: Anemia 9) PC: Electrolyte imbalance 10) Risk for falls r/t fatigue secondary to COPD, CHF, and OA 11) Risk for impaired skin integrity r/t impaired mobility 12) PC: Pneumonia Client Goals: Client will report feeling less SOB, and participate in ADLs Client Outcomes 1 Vital Signs will remain WNL on September 29/08. 2 Client will have a bowel movement on September 29/08. 3 Client will participate in activity as tolerated on September 29/08. 4 Client will remain free from injury on September 29/08. Client and Nurse Interventions Nurse will: 1 monitor vitals, q4h 1 2 3 8 12 2 auscultate lung fields and abdomen 1 5 6 12 3 Reduce/Eliminate risk factors 10 11 4 Perform ROM 34 5 Position changes q2h 11 6 Monitor O2 Stats 1 8 12 7 Monitor skin color 1 8 12 8 Assist/complete ADLs in collaboration with client 4 10 9 Monitor intake and output 67 10 Monitor BM 57 11 Monitor lab values 6 Client will: 12 Ring for assistance as needed 10 11 13 Consume adequate amounts at meal times 67 14 Client will participate in ADLs in collaboration with nurse 4 10 Evaluation 1 Met- Client's vitals remained "within her range of normal". 2 Unmet- Client did not have a BM, as per end of shift. 3 Met- Client participated in physiotherapy, and reported "feeling good" after. 4 Met- Client remained free from harm and injury.
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