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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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