Nursing Care of Adult and Elderly Clients

Importantly, the data collection indicated that she had a supporting group from her Catholic church. Similarly, the particulars of her support person were immediate spouse and mother. The domestic profile of the support person included a spouse who was living, aged 40years. Subsequently, she had two children (Boy and Girl) of ages 5 and 10 respectively. It is essential to the point that the nature of the relationship between the spouse and her children was good (supportive) while at the bedside. Additionally, she was reported to have a low-grade fever of 99. degrees. In the medical history, it was evident that the patient had also suffered from ulcer and panic disorders. What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? Past Medical History: Peptic ulcer Panic disorder Home Meds: Name, dose, frequency: Famotidine 20 mg by mouth twice a day.

Ativan 1 mg by mouth three times by mouth as needed for anxiety. What VS data is RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: Temperature Pulse Blood pressure Increased temperature indicates infection. Increased heart rate and decreased blood pressure may indicate patient worsening with possibility of sepsis What body system(s) will you most thoroughly assess based on the primary problem or nursing care priority?GI- this was the chief complaint of the patient. What above assessment data is RELEVANT that must be recognized as clinically significant? Please elaborate here… RELEVANT Assessment Data: Clinical Significance: -Ileostomy bag with loose brown stool -Ileostomy stoma intact, pink with no increased redness or bleeding around the sites. Patient denies nausea or vomiting. No bowels sound to left quadrant -Indicates patient with no obstructions, no constipation.

Lashner, march 2013- Cleveland Clinic). This allows the microbes to penetrate the mucosa and submucosa causing inflammation of the colon. What nursing prioritiescaptures the “essence” of your patient’s current status and will guide your plan of care?(List each in the form of a NANDA three-part nursing diagnosis, MUST have a minimum of three)Provide one long term and one short term goal for each diagnosis: A. Nursing Diagnosis #1: Risk for fluids and electrolyte imbalance r/t patient having diarrhea secondary to presence of ileostomy AEB patient had a total of 1100 ml of loose stools within 8 hours period (Ackley. Ladwig. a. Long term goal:Patient will be able to perform activities of daily living easily. b. Short term goal: Patient will be able to report pain management regimen achieves the comfort pain level goal without side effect.

C. Administer IV fluids as ordered and monitor for any side effects. Administer pain medications around the clock and as needed as ordered and reassess for effectiveness. Assess patient ability to self-report pain intensity using the valid pain tool and scale and administer pain medications and reassess pain using appropriate pain tool. Discuss treatment and procedures prior to performing ileostomy care and involve patient in the plan of care. Electrolytes imbalance can cause cardiac arrhythmias, respiratory distress, edema and altered mental status. Makic, p. Involving patient with the plan of their care help ease anxiety involved with the changes of their body function (Ackley. Ladwig. Makic, p. Patient vital signs will have minimum deviation from baseline if any. needs THIS medication Side Effects Nursing Assessment/ Considerations & Follow -up: Famotidine 20 mg IV push Q12 hours (Normal dose) H2-histamine receptor antagonist.

Inhibits histamine at histamine H2- receptor site thus decreasing gastric secretion while pepsin remain at stable level. skidmore, 2018 p. Treatment of GERD and prevention of duodenal ulcers due to use solumedrol Headache, dizziness, somnolence, dysrhythmias, nausea, vomiting, rashes, Stevens-Johnson syndrome -Evaluate effectiveness of the medication by pt verbalizing decreased gastric pain. Avoid giving medications that interact with Pepcid such as anti-acids. Zofran 4 mg IV Q6hrs PRN (average dose) -Antiemetic -Prevents nausea, vomiting by blocking serotonin peripherally, centrally and in the small intestine. Skidmore. p. Prevent nausea and vomiting. Headache, drowsiness, dizziness, dry mouth, rash, bronchospasm. Monitor patient for signs and symptoms of bleeding such as gums, petechiae, hematuria, ecchymosis, blood in the stool, angioedema. Consider alternating injection sites, monitor injection site for inflammation, redness or hematomas. Oxycodone 5 mg PO Q 4hrs PRN moderate pain.

Opiate analgesic, semisynthetic derivative. inhibits ascending pain pathways in the CNS, increases pain threshold, alters pain perception (Skidmore. Skidmore. p. Mild - moderate pain management, or fever -Nausea, vomiting, hepatotoxicity, hepatic seizure, renal failure, rashes, urticaria, cyanosis, jaundice. Skidmore. p. Teach patient to increase fluids intake, eat fluids and vegetable to prevent constipation associated with use of pain medications. Teach patient on the importance of walking after surgery and use of incentive spirometer. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? -Patient participation on ileostomy care and take lead during care, change ileostomy bag with minimum assistance. Patient verbalize understanding of signs and symptoms of infection and when to report to the nurse and MD. Reports to the nurse the number of times she uses incentive spirometer in one hour.

You have done an excellent job for this point, now finish strong and provide an SBAR report to the nurse who will be caring for this patient after you  References.