Nursing Care of Adult and Elderly Clients

Document Type:Case Study

Subject Area:Nursing

Document 1

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. 8 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.

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Ativan 1 mg by mouth three times by mouth as needed for anxiety. 5 low Patient blood loss during surgery Hct (F: 35-44%) (M:39-50%) 31. 1 low Status post-surgery. Platelets (150-450x 100/µl) 249 wnl normal range Neutrophil % (42-72) 52 wnl Normal range Other: RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: WBC, RBC, Hgb, Na, K Elevated WBC indicates infection, decreased RBC and Hgb indicates increased blood loss. K decreased indicates loss of potassium from the vomiting or diarrhea Na increased indicates dehydration, Na decreased indicates Na loss from diarrhea, vomiting, nasal gastric suctioning. This labs within normal range for this patient. 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.

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Increased heart rate and decreased blood pressure may indicate patient worsening with possibility of sepsis Current Assessment: These are examples, write in your actual & complete assessment findings! Be sure to use appropriate terminology by using your Health Assessment textbook and other provided resources GENERAL APPEARANCE: Hispanic female sitting up in the bed comfortably. Alert with appropriate eye contact, dressed in hospital gown, appears clean,hair is well groomed,and facial make upappropriately for her age. No signs of acute distress noted. NEURO: Alert and oriented to person, place, time, and situation. Denies any pain. No bladder tenderness or distention noted. SKIN: Skin pink, warm to touch. Good skin turgor. No tenting. 1 If your patient is on TELEMETRY, include the rhythm strip here with correct interpretation: N/A III.

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Clinical Reasoning Begins 1. What is the primary problem that your patient is most likely presenting with? Ulceration colitis 2. What is the underlying cause/pathophysiology of this concern? (APA format and MUST be referenced!) “Ulceration colitis is characterized by Inflammation and ulceration of the colon and the rectum” (Dirksen, lewis (mosby) p. The inflammation is diffused and involves the mucosa and submucosa of the colon. b. Short term goal: Patient will maintain an abscess of muscle cramping. B. Nursing Diagnosis #2: Acute pain r/t surgical incision status post laparoscopic assisted proctocolectomy with ileoanal pouch secondary to diagnosis of ulceration colitis. (Ackley. Makic, p. a. Long term goal:Patient will demonstrate adaptation to physical change related to the presence of ileostomy as evidence by adjustment to lifestyle changes.

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b. Short term goal: Patient will demonstrate acceptance of the body change as evidence by patient observes, touch and assist with ileostomy care with a goal of self-care when discharged home. Ladwig. Makic, p. 349) -Administering pain medications routinely and as needed with breakthrough pain medications after surgical procedures prevents poor pain management which will promote tolerance of patient ADLS. -Self reporting is considered the single most reliable indicator of pain presence. Pain is subjective. -Patient will be able to self-perform ileostomy care by discharge date. What is the worst possible/most likely complication to anticipate based on the primary problem? Infection to the surgical incision or stoma site. What nursing assessments will identify this complication EARLY if it develops? Fever, increased pain to the surgical site, increased redness or inflammation to the stoma site.

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What nursing interventions will you initiate if this complication develops?Notify MD immediately of the sign and symptoms for new orders of blood cultures, lactic acids other labs such as WBC. Administer antipyretic as ordered for fever, cooling measures as needed. (Skidmore. 2018 p. 811) For severe pain secondary to diagnosis ulceration colitis and surgery for creation of ileoanal pouch. Drowsiness, dizziness, sedation, respiration depression, respiration arrest, apnea. -Pain type, character, and severity of pain prior to giving morphine. Lovenox 40 mg Sub QQ24hrs (Average) -Anticoagulant, antithrombotic. -Binds to antithrombin III inactivating factors Xa/IIa, thereby resulting in higher ratio of anti-factor Xa to IIa. (Skidmore. 2018 p. 435) -Prevention of DVT, PE status post abdominal surgery for ileoanal pouch creation. (Skidmore. 2018 p. 893) Monitor patient respiration rate, depth and character.

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-Monitor patient bowels sounds, last bowel movement and feeling of constipation. -Assess patient pain, severity, quality and scoreprior to giving medications and reassess effectiveness. ) – document progress and reason for this modality. Wound care to the surgical site and ileostomy site and monitoring for sign and symptoms for infection. VI. Education Priorities/Discharge Planning (total 5 points): What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem? -Educate patient on ileostomy care, empty of the ileostomy bag and how to change the ileostomy bag as needed. -Teach patient how to monitor signs and symptoms of infections to the surgical/ stoma sites such as increased pain to the site, increased redness to site, purulent drainage to site or fever and report to nurse or MD immediately.

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Patient was exited to have her kids come and visit her. What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person? (Note: This is your opportunity to address spiritual care, therapeutic interventions & communication strategies) -Active listening of the patient and her needs, and answer patient questions promptly. - provide a personalized care to the patient. -Engage patient with her plan of care. - Provide spiritual and community resources that may be available to the patient prior to discharge. JP drainage output = 10 ml sanguineous Skin: Color Pink, with good skin turgor, no rashes, no pressure ulcers, surgical incision intact with no redness to incision site JP drainage on right upper quadrant of abdomen intact.

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