TRINA JOY G.

DOMANTAY
BSN III – 2
CASE STUDY
1. What do you suspect is the reason for Mrs. Greene’s confusion?
ANS: THE PATIENT’S CONFUSION COULD BE THE CAUSE OF HER UNDERLYING ILLNESS OR
DRUG TOXICITY WHICH LEADS FOR HER TO HAVE A CONFUSION.
2. Would you describe Mrs. Greene’s confusion as delirium or dementia? Provide a rationale for
your decision and explain the difference between delirium and dementia.
ANS: THE PATIENT’S CONFUSION IS DUE TO DELIRIUM BECAUSE AS WHAT HER SON TOLD
THE NURSE, HE STATE THAT MRS. GREEN MENTAL HEALTH STATUS IS FINE THAT HE AND
HER MOTHER HAD A PERFECT CONVERSATION. DELIRIUM IS TYPICALLY CAUSED BY AN
ACUTE ILLNESS OR DRUG TOXICITY, IT ALSO AFFECTS ATTENTION AND IS OFTEN
REVERSIBLE. WHILE DEMENTIA IS CAUSED BY THE OCCURRENCE OF AN ANATOMICAL
CHANGES IN THE BRAIN WHICH HAS SLOWER ONSET AND IT IS GENERALLY
IRREVERSIBLE.
3.What are three appropriate nursing diagnoses that address Mrs. Greene’s change in mental
status?
ANS: Risk for injury related to suicidal ideations, illusions, hallucinations.

Disturbed thought processes related to delusional thinking.

Impaired verbal communication related to cognitive impairment.

4. State at least three outcome goals that should be included in the plan of care for Mrs.
Greene’s

diagnosis of acute confusion.

ANS: PATIENT will remain free from any self harm during hospitalization.

Patient maintains reality orientation and communicate clearly with others

Patient regains normal reality orientation and level of consciousness.

5. Provide five nursing interventions to include in the plan of care for Mrs. Greene’s
diagnosis of acute confusion.

ANS: Promote patient’s safety. Remove all potentially dangerous objects from

client’s environment; in a disoriented, confused state, clients may use objects to harm self
or others.

Provide an appropriate environment. Maintain a low level of stimuli in client’s

environment (low lighting, few people, simple decor, low noise level) because anxiety increases in a
highly stimulating environment.
 Stay calm and reassure patient. Maintain a calm manner with the client;
attempt to prevent frightening client unnecessarily; Provide continual reassurance and
support.

Observe suicide precautions. Sit with client and provide one-to-one observation if

assessed to be actively suicidal; client safety is a nursing priority, and one-to-one
observation may be necessary to prevent a suicidal attempt.

Ask assistance from others when needed. Have sufficient staff available to execute a
physical confrontation, if necessary; assistance may be required from others to provide for
physical safety of client or primary nurse or both.

6. Briefly discuss strategies that help prevent the need for restraints. List five nursing
interventions to include in Mrs. Greene’s plan of care now that she needs bilateral soft wrist
restraints for her safe.
ANS: USING RESTRAINT IS NOT ONLY ABOUT HOLDING A PERSON FIRMLY
THERE ARE STRATEGIES TO DO IN PREVENTING RESTRAINT WE MUST FIRST
REDUCED THE FACTORS THAT MAY ALTER PATIENT’S BEHAVIOR.
 NURSING CARE PLAN FOR MRS. GREENE

Nursing Expected
Assessment Planning Nursing Interventions Rationale
Diagnosis Outcome
S: Ø Risk for Short Observe patient’s Close observation is Short
behaviour during routine necessary to protect from
injury: self Term: Term:
patient care. self harm.
O: patient directed r/t
After 4 Assess the congruency of To determine the need for After the
manifested: command
hours of behaviors prompt intervention NI the
hallucinati NI the patient
patient Listen carefully suicidal Such behaviours are haven’t
Patient may ons
will not statements and observe critical clues regarding harmed
manifest: harm for non-verbal indications risk for self harm. herself
himself of suicidal intent. therefore
Restlessness the goal is
To improved self esteem
Panic    Self esteem and avoid risk for suicidal met
enhancement-self esteem ideations
Delirium Long
Long journal, give positive
Self feedback, Term:
Term:
mutilation
Hallucination To determine the need for
After 2 management-assess, help prompt intervention After the
days of NI client describe needs that NI the
the patient might be reflected in the Suicide risk increases patient
will content of the when  plans and means have been
refrain hallucination, identify exists refrained
from triggers of hallucinations from
suicidal suicidal
threats or Ask direct questions to threats or
behaviour determine suicidal intent , behaviour
gestures. plans for suicide, and gestures
means to commit suicide . therefore
the goal is
met.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUA

Objective: Disturbed thought Long-term: Assess attention Determines ability Long-term:
-Disorientation to processes r/t After 2 days of span/distractibility to participate in After 2 days
person, place and degenerative nursing and ability to planning and nursing
time process as intervention, the make decisions or executing care. interventio
manifested by patient will problem solve. patient was
-Memory deficit, memory deficit maintain usual to maintain
altered attention reality orientation. Test ability to To assess degree reality orien
span, and receive, send, and of impairment. therefore th
decreased ability Short-term: appropriately is met
to grasp ideas After 8 hours of interpret
nursing communications. Early recognition Short-term
-Impaired ability intervention, the of changes After 8 hou
to make decisions patient will: Perform periodic promotes nursing
and problem solve -Identify ways to neurologic proactive interventio
compensate for assessment, as modifications to patient was
-Disordered cognitive indicated. plan of care. to:
thought impairment and -Identify wa
sequencing memory deficits Inability to compensat
-Demonstrate maintain cognitive
behaviors to Reorient to time, orientation is a impairment
minimize changes place, and person sign of memory de
in mentation as needed. deterioration. -Demonstra
behaviors t
To prevent further minimize ch
Provide safety deterioration. in mentatio
measures such as therefore th
is met
side rails, padding
as necessary and
close supervision Provides
as indicated. stimulation while
reducing fatigue.
Schedule
structured activity Client may
and rest periods. respond with
anxious or
Maintain a aggressive
pleasant, quiet behaviors if
environment and startled or
approach client in overstimulated.
a slow, calm
manner. May aid in
reducing
confusion, and
Give simple increases
directions, using possibility that
short words and communications
simple sentences. will be understood
and remembered.
 To convey interest
and worth to
Listen with regard. individual.

To assist client in
Allow ample time developing coping
for client to strategies.
respond to
questions and
comments and Provides clues to
make simple aid in recognition
decisions. of reality.

Maintain reality
oriented
relationship and Confrontation
environment potentiates
(clocks, calendar, defensive
personal items). reactions and may
lead to patient
Present reality mistrust and
concisely and heightened denial
briefly and do not of reality.
challenge illogical
thinking. To avoid triggering
fight and flight
responses.

Reduce Client may feel

provocative threatened and
stimuli, negative may withdraw or
criticism, rebel.
arguments and
confrontations. To create
therapeutic milieu.
Refrain from
forcing activities Enhances intake
and and general well
communications. being.

Respect Sleep deprivation

individuality and may further impair
personal space. cognitive abilities.

Provide for Aids in

nutritionally well maintaining reality
balanced diet, orientation and
 incorporating may reduce fear
client’s and confusion.
preferences as
able.

Promote adequate
rest and
undisturbed
periods of sleep.

Establish a regular
schedule for
expected
activities.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Activity Short Term 1. Assess patient’s 1. Influence of After 4 hours
 Ø intolerance Goal: After 4 ability to perform choice of of giving
  related to hours of giving tasks/ noting interventions effective
general effective reports of assistance nursing
malaise nursing weakness, fatigue 2. Enhance rest interventions,
Objective:
interventions, and difficulty to lower body’s the patient
-Patient the patient will accomplishing oxygen was able to
appears weak be able to cope task. requirements, cope with
-Unable to with 2. Recommended and reduces fatigue as
perform some generalized quiet atmosphere; strain on the evidenced by
activities of weakness bed rest if heart and lungs verbalization
daily indicated stress- 3. Enhances lung of feelings of
living(ADL’s) Long Term need to monitor expansion to comfort and
-Spends most Goal: and limit visitors, maximize participating in
of the time on phone calls and oxygenation for passive ROM
bed Within 2 days of repeated cellular uptake. therefore the
giving nursing unplanned 4. Although help goal is met
interventions, interruptions may be
the patient will 3. Elevated head of necessary, self After 2 days of
be able to bed as tolerated. esteem is giving nursing
demonstrate an 4. Provided/recomme enhanced intervention,
increase in nded assistance when pt does the patient
activity with activities/ things for self. was able to do
tolerance as ambulation as simple ADLs
evidenced by necessary, therefore the
doing simple allowing pt to do as goal is met
ADL’s much as possible
 DRUG STUDY

Prescribed
and
Generic Recommend
Name ed
Mechanis Adverse
Brand Dosage, Contraindi Nursing
m of Indication Reactio
Name Frequency, cation Responsiblities
Action n
Classific and
ations route of
Administrati
on
Levofloxacin Availability: Inhibits the >Acute Hypersensitivi CNS: 1. Avoid rapid or bolus
>Ophthalmic enzyme DNA bacterial ty to drug, its seizures I.V. administration,
Iquix, solution: Quizin- gyrase in exacerbation components, GI: because this may
Levaquin, 0.5% (5 mg/ml) susceptible of chronic or other pseudome cause severe
Novo- >Premixed gram-negative bronchitis quinolones mbranous hypotension.
Lefloxacin, solution for and gram- >Community- colitis 2. Check v/s, specially
Oftaquiz, injection: 250 positive acquired Hematolog BP. Too-rapid
Quixin, mg/50 ml, 500 aerobic and pneumonia ic: infusion can cause
Tavanic mg/100 ml, 750 anaerobic >Nosocomial lymphocyt hypotension.
mg/150 ml bacteria, pneumonia openia 3. Closely monitor
Pharmacolo >Solution for interfering caused by Metabolic: patients with renal
gic Class: injection with bacterial methicillin- hypoglyce insufficiency.
Fluoroquinol (concentrated): DNA susceptible mia 4. Assess for severe
one 500 mg/20 ml synthesis. strains of Other: diarrhea, which may
>Tablets: 250 Stapylococcu Steven- indicate
Therapeutic mg, 500 mg, 750 s aureus, Johnson pseudomembranous
Class: Anti- mg Pseudomona syndrome colitis.
Infective s aeruginosa, 5. Watch for
Indications and Serratia hypersensitivity
Pregnancy Dosages marcescens, reaction. D/C drug
risk >Acute bacterial Escherichia immediately of rash
category: C exacerbation of coli, or other s/sx occur.
chronic Klebsiella 6. Watch for s/sx of
bronchitis pneumonia, tendinitis or tendon
Adults: 500mg Haemophilus rupture.
I.V. or P.O. q 24 influenza, or 7. Tell patient to stop
hours for 7 days Streptococcu taking drug and
>Community- s pneumonia; contact prescriber if
acquired complicated he experiences s/sx
pneumonia skin and skin- of hypersensitivity
Adults: 500 mg structure reaction or severe
I.V. or P.O. q 24 infections diarrhea..
hours for 7 to 14 >Acute 8. Instruct patient to
days, or 750 mg bacterial stop taking drug and
I.V. or P.O. q 24 sinusitis notify prescriber
hours for 5 days caused by S. immediately if
>Nosocomial pneumonia, tendon pain,
pneumonia H. influenza, swelling, or
caused by or Moraxella inflammation occurs.
methicillin- catarrhalis
susceptible >Uncomplicat
strains of ed skin and
Stapylococcus skin-structure
aureus, infections
Pseudomonas >Complicated
aeruginosa, UTI
Serratia >Chronic
marcescens, bacterial
Escherichia coli, prostatitis
Klebsiella >Conjunctiviti
pneumonia, s
Haemophilus >Corneal
influenza, or ulcers
Streptococcus
pneumonia;
complicated skin
and skin-
structure
infections
Adults: 750 mg
I.V. or P.O. q 24
hours for 7 to 14
days
>Acute bacterial
sinusitis caused
by S.
pneumonia, H.
influenza, or
Moraxella
catarrhalis
Adults: 500 mg
I.V. or P.O. q 24
hours for 10 to
14 days or 750
mg P.O. or I.V. q
24 hours for 5
days
>Uncomplicated
skin and skin-
structure
infections
Adults: 500 mg
I.V. or P.O. q 24
hours for 7 for 10
days
>Complicated
UTI
Adults: 250 mg
I.V. or P.O. q 24
hours for 10
days or 750 mg
P.O. q 24 hours
for 5 days
>Chronic
bacterial
prostatitis
Adults: 500 mg
I.V. or P.O. q 24
hours
>Conjunctivitis
Adults and
children ages 1
and older: one or
two drops of
0.5% ophthalmic
solution into
affected eye q 2
hours while
awake and one
or two drops 2 4
hours while
awake on days 3
to 7.
>Corneal ulcers
Adults and
children ages 6
and older: On
days 1 to 3, one
or two frops of
1.5% ophthalmic
solution instilled
into affected eye
q 30 minutes to 1
hour while
awake and q 4 to
6 hours after
retiring.

Dosage
adjustment:
● Renal
impairment