Priority # 2

Nursing Process- N3005

Student Name: Giorgia Adams Date: 2/16/2017

Client Initials: B.J., 69 years, Hispanic Medical Diagnosis: hypotension and dehydration on admission, history of CVAs,
type II diabetes, hypertension

Surgical Procedure(s): numerous abdominal surgeries in the past, unspecified type

Diagnostic Procedure(s): CT on admission to ED, lab work

Allergy: Penicillin

Summary of Patient Status/Reason for Admission

BJ is a 69 y/o Hispanic male who was taken to emergency department due to changes in behavior including problems with
communication, episodic slurred speech, increased sleepiness, and decreased food intake. After emergent evaluation he received
diagnoses of hypotension (58/42) and dehydration.

Hospital stay was notable for malignant hypertension treated pharmacologically with variable results (based on available records 170-
190 systolic, 205/92 in chart, 130-140/85-90 in nurses report); renal insufficiency treated with hydration; and right side hemiplegia
subsequent to CVA for which he is receiving physical therapy. Patient also has type II diabetes controlled with corrected dose insulin
and oral glucose.

Charted system assessment included the following: RR 18-22, BP 205/92, faint respiratory wheezing on left lung, trace edema on right
extremities. Blood work revealed out of normal range Na (146 mEq/L), fasting glucose (240), creatinine (2.2mg/dL), and BUN (22
mg/dL).

DOB: 07/14/1945
Social Status: lives alone.
Past Medical History: hypotension, dehydration, multiple CVAs, type II diabetes, hypertension, anemia, altered mental status
Past Surgical History: multiple abdominal surgeries of unspecified type

Family History: brother had CVA VITALS from chart:

Nutrition: 1800 ADA Diet, edentulous T- afebrile
Mobility level: right-side hemiplegia, cane, one person assist Pulse: 78 +2
RR: 18-22 (normal 10-20)
B/P: 205/92
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Nursing Process: Plan of Care for your Patient

DATA NURSING GOAL & NURSING RATIONALES EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS

Subjective 1. Fluid volume Patient will remain - Monitor location and extent - Causes of peripheral Goal met: patients was 1+
Data: excess r/t free of edema until of edema using the 1+ to 4+ edema in clients with at morning and end of shift
compromised end of current shift scale to quantify edema. heart failure are related to assessment.
(Data obtained regulatory medications,
from history as mechanism compensatory changes
no direct patient subsequent to that influence hydrostatic
report was history of pressure, and fluid
available for chronic renal retention, among other
review) insufficiency things (Ackley, B.J.,
and evidenced Ladwig, G.B., Flynn
Renal by trace right Makik, M.B. (2017).
insufficiency side edema, Nursing Diagnosis
and dehydration abnormal blood Handbook: an evidence-
on admission BUN, sodium, based guide to planning
and creatinine care, 11th Edition (pp.
Diabetes levels, increased 394). St. louis, MO:
mellitus respiration, Elsevier.)
mental agitation Patient will maintain - Monitor vital signs to
Objective normal cardiac obtain baseline data and - Heart failure results in Goal met: HR: 86 (60-100)
Data: output, and vital note decreasing blood dyspnea, edema, and BP: 136/90, T: 98.4
signs as measured pressure, tachycardia, and orthopnea. The secondary
- Trace right daily during shift tachypnea characteristics are weight
side edema with gain, hepatomegaly,
extremities cool jugular vein distention,
to touch. palpitations, crackles,
oliguria, coughing,
- Elevated BUN clammy skin, and skin
(22) color changes (pp.394).
- Elevated Patient will remain - With head of bed elevated
creatinine free of jugular vein 30 to 45 degrees, monitor - Increased intravascular Goal met: jugular vein
(2.2) distention , positive jugular veins for distention volume results in jugular pulsation inspected with
- Elevated and S3 heart sound vein distention, edema, patient in semi-Fowler
sodium (146) throughout shift crackles, and S3 heart position and recorded as
- Fasting sound (pp.394). bulging and 2+ intensity
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glucose (240) Patient will have a
- Hypertension urine output of
- Respiratory 0.5mL/Kg/hr or more - Monitor serum and urine - BUN and creatinine are Goal partially met: patient
pattern (18-22) with normal urine osmolality, serum sodium, monitored currently, but voided 33.3mL/hr and
- Mental osmolarity and blood urea nitrogen they lack sensitivity, and sample was sent to
agitation specific gravity and (BUN)/creatinine ratio, and an overall assessment of laboratory for analysis.
patient will maintain hematocrit for client fluid status is Results were not available
BUN, sodium, and abnormalities. critical before fluid is for review at end of shift.
creatinine levels administered (pp.394). I/O measured as follows:
within normal ranges - Monitor intake and output; total intake = 600mL;
by the end of shift note trends reflecting - Accurately measuring output 100mL urine
decreasing urine output in intake and output is
relation to fluid intake important for the client
with fluid volume
overload (pp.394).

Maintain clear lung - Auscultate lung sounds for - Acute pulmonary edema Goal met: lungs auscultated
sounds; no evidence crackles, monitor may be due either to and free of crackles,
of dyspnea or respiration effort, and increased permeability of breathing was unlabored
orthopnea until end determine the presence and the alveolar capillary
of shift severity of orthopnea. barrier, in the case of
acute lung injury, or to
increased pulmonary
microvascular hydrostatic
pressure, in the case of
cardiogenic pulmonary
edema (pp.394).

Subjective 2.Risk for Skin and Mucous - Inspect and monitor skin - Systematic inspection can Goal met: skin inspected at
data: impaired skin Membranes will condition at least once a identify impending beginning of shift, redness
none integrity. Risk remain intact until the day for color or texture problems early. (pp.809) was localized, no edema or
factors: diabetes, end of the shift as changes, redness, localized localized heat present. No
Objective Data: right side evidenced by the heat, edema or induration, lesions observed.
- Red skin on hemiplegia, Skin intactness/Skin pressure damage,
right heel alteration in lesions not dermatological conditions,
- Diabetes metabolism present/Tissue or lesions.
- Right side secondary to perfusion/Skin
hemiplegia DM, alteration temperature - Evaluate for use of - Maintain the head of the Goal met: pillow placed
in sensation specialty mattresses, beds, bed at the lowest possible under patient calf to prevent
secondary to or devices as appropriate degree of elevation to heel from touching bed and
DM reduce shear and use lift keep elevated.
 Priority # 2
devices, pillows, foam
wedges, and pressure-
reducing devices in the
bed. (pp.809)

Patient will - Teach the client and or - If the pressure applied Goal met: patient was
demonstrate caregivers to use pillows, over a capillary exceeds explained the need to keep
understanding of foam wedges, and pressure- the normal capillary affected area away from
importance to reducing devices to prevent pressure and the vessel is objects exerting pressure.
maintain skin pressure injury occluded for a prolonged Patient demonstrated
integrity period of time, tissue understanding by
ischemia can occur. If the verbalizing ok.
patient has reduced
sensation and cannot
respond to the discomfort
of the ischemia, tissue
ischemia and tissue death
result. (Potter, P. A.,
Perry, A., & Stockert, P.
(2016). Fundamentals of
Nursing, 9th Edition (pp.
1185). St. Louis, MO:
Elsevier.)
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Nursing Process: Plan of Care for your Patient
Medication Worksheet

MEDICATION DRUG CLASS/ WHY THIS NURSING

GENERIC NAME/ ACTION/ SIDE EFFECTS MEDICATION IS CONSIDERATIONS/
TRADE NAME THERAPEUTIC OUTCOME PRESCRIBED FOR INTERVENTIONS FOR
THIS CLIENT YOUR CLIENT
Generic Name: insulin Functional Class: Antidiabetic Anaphylaxis Diabetes Follow with meal within 10-
Aspart Human 100 U/mL Blurred vision 15 minutes
Trade Name: NovoLOG Dry mouth
Dose: sliding scale Action: Decreases blood glucose Flushing Monitor blood sugar
Route: SubQ Inj Redness
Frequency: tid Swelling Watch for serious allergic
Times Due: 0800-1200 Hypoglycemia reaction (anaphylaxis)
1700-2200 Therapeutic Outcome: Peripheral edema
Decreased blood glucose levels
Glucose=200 as checked by in diabetes mellitus
PCA,
Administered 10 units
Generic Name: Functional Class: calcium Headache, fatigue, dizziness, to treat hypertension Assess fluid volume status
Amlodipine channel blocker, asthenia, anxiety, depression,
Trade Name: Norvasc antihypertensive insomnia, paresthesia, Assess for angina
Dose: 5mg somnolence
Route: PO Peripheral edema, bradycardia, Monitor drop in B/P and
Frequency: qam Action: dilates blood vessels and hypotension, palpitations, pulse
Times Due: 0900 improves blood flow syncope, chest pain
Nausea, vomiting, diarrhea, Monitor liver enzymes for
Hold for BP <90 gastric upset, constipation, signs of hepatotoxicity
Therapeutic Outcome: Lower flatulence, anorexia, gingival
Administered (BP 136/90) blood pressure hyperplasia, dyspepsia Monitor cardiac status: B/P,
Nocturia, polyuria, sexual pulse, respiration, ECG
difficulties
Rash, pruritus, urticaria,
alopecia
Flushing, muscle cramps,
cough, weight gain, tinnitus,
epistaxis, pulmonary edema,
dyspnea
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Generic Name: docusate Functional Class: laxative constipation identify cause of constipation
sodium cap emollient Bitter taste,
Trade Name: Colace throat irritation Advice patient that product
Dose: 100mg may take up to 3 days to
Route: PO Action: Increases water, fat Nausea, soften stools
Frequency: qam penetration in intestine; allows anorexia,
Times Due: 0900 for easier passage of stool cramps, Discontinue if patient
diarrhea experiences cramping, rectal
Held due to loose stools in Therapeutic Outcome: bleeding, nausea, vomiting
last bowel movement Passage of softened stool, Rash
absence of constipation
Generic Name: omeprazole Functional Class: proton pump Pneumonia antiulcer Assess for electrolyte
cap inhibitor, antiulcer Hepatic failure imbalance especially with
Trade Name: Losec, Headache prolonged use (3 mo.-1 year)
PriLOSEC Dizziness
Dose: 20mg Action: suppresses gastric Asthenia Monitor hepatic enzymes for
Route: PO secretion by blocking final step Diarrhea signs of toxicity
Frequency: qam of stomach acid production Abdominal pain
Times Due: n/a Vomiting Assess GI for pain swelling,
Nausea and anorexia
administered Therapeutic Outcome: decreases Constipation
gastroesophageal reflux and Flatulence Can take up to 4 days to
duodenal ulcers back pain become effective
upper respiratory tract infection
cough
Generic Name: Functional Class: nonopioid Hepatotoxicity pain Monitor liver function, renal
acetaminophen tab analgesic Steven-Johnson Syndrome function, blood studies
Trade Name: Tylenol GI bleeding
Dose: 650 mg Renal failure Check I&O for decreased
Route: PO Action: blocks pain impulses, Cyanosis renal output
Frequency: q6h antipyretic by inhibition of Jaundice
Times Due: prn prostaglandins in the CNS Coma Assess for signs of chronic
Death poisoning: rapid, weak pulse;
Administered for leg pain N/V dyspnea; cold, clammy
6/10 Therapeutic Outcome: Abdominal pain extremities; report
Decreased pain and fever immediately to prescriber
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Generic Name: Metformin Functional Class: antidiabetic Heart failure Type II Diabetes Discontinue temporarily for
Trade Name: Glucophage Lactic acidosis surgical procedures when
tab 500mg Thrombocytopenia patient is NPO, or if contrast
Dose: 1 TAB Action: Inhibits hepatic glucose N/V media is used; resume when
Route: PO production and increases Diarrhea patient is eating
Frequency: qam sensitivity of peripheral tissue Rash
Times Due: 0900 to insulin Headache Assess for hypoglycemic
Tinnitus reaction
administered Therapeutic Outcome: Blood Fatigue
glucose at normal levels Weakness Monitor liver and renal
Dizziness function
Generic Name: aspirin Functional Class: nonopioid Tinnitus Prevent blood clots Assess for hepatotoxicity,
Trade Name: Bayer analgesic Hearing loss allergic reaction, ototoxicity,
Aspirin Intracranial hemorrhage renal function, blood studies,
Dose: 81mg Action: Blocks pain impulses by GI bleeding edema
Route: PO blocking COX-1 in CNS Thrombocytopenia
Frequency: qam Hepatitis
Times Due: n/a reduces inflammation by Anemia
inhibition of prostaglandin Dysrhythmia
administered synthesis; Broncospasm
Rash
antipyretic action results from
vasodilatation of peripheral
vessels;

decreases platelet aggregation

Therapeutic Outcome:
Decreased pain, inflammation,
fever; absence of MI, transient
ischemic attacks, thrombosis
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Nursing report:

Patient assessed on 2/16/17, environment was cleared of safety hazards such as syringe on the bed, candy on the bed, bed rails down, dirty tissues on
bed. Throughout shift, patient was observed resting comfortably in bed and did not show signs of agitation. His right heel showed redness and a
pillow was placed under his leg to keep area off of bed and prevent skin breakdown. He was afebrile, with bp 136/90 and hr 86. He reported being
hungry and was given his breakfast as soon as his glucose was checked (glucose 200) and received his insulin injection. Mr. B.J. demonstrated
compensatory behaviors for his right side hemiplegia and chose to eat independently with minimal assistance. He received his daily bath with partial
assistance as he chose to wash his right side with his left hand, he received assistance during the rest of his bath including oral care with mouthwash.
Patient tolerated bath and did not report any pain. Medication were administered per MAR except for the stool softener as he reported loose stool
during his most recent bowel movement. Mr. B.J. requested to sit in the chair and tolerated transfer to chair without any report of pain. He played
cards with a patient from the next room down and was observed to have a good time. He also requested to ambulate with his cane and received
assistance. Ambulation was tolerated but once returned to bed, Mr. B.J. reported pain in his right leg rated 6/10 and received Acetaminophen 650mg
prn. He was able to take a nap through the shift and at last check he was sitting in bed reading a magazine and resting comfortably. His limbs were
free of edema, lungs clear, skin intact and warm, I/O measured, waiting for urinalysis results.