solved

solved. Question
Answered step-by-step
Asked by oyinfowokan2004

You are a nurse working in a skilled nursing facility. You have a new patient that was admitted from a hospital with the diagnosis of dehydration, hyponatremia, and suspected geriatric neglect. 

Please see the chart below.

Name

DOB

Age

 Mary Johnson

2/2/1938

83 yrs

Admitting Vitals

Blood Pressure 90/71

Pulse 108

SpO2 95% RA

Temp 97 F

Weight 130 lbs

Height 5 foot 1 inch

Pain 4/10

Previous Medical History

Hypertension

Obesity

Breast cancer

Diabetes Type II

 

Family Medical History

 Mother- CVA, Coronary Artery disease

Father- Heart attack

Assessment

Neuro- Alert and Oriented to person and place, speech is clear but confused at times but she is able to be reoriented.

Cardiac- Heart rate is regular rate and rhythm. Radial pulses are intact but diminished bilaterally. 

Respiratory- Breathing is easy and unlabored, Breath sounds are clear throughout. 

Skin- Skin is pale, cool to touch on hands and feet, but warm centrally. Skin turgor is at 5 seconds on back of hand.  Small area on sacrum is reddened and non blanchable. 

  

Abdomen- Abdomen is soft to touch, non tender. Bowel sounds are normoactive. 

Gento Urinary- Urinary output for last 8 hours as reported from hospital was 235 ML.  Patient denies any pain on urination or in genitals area. 

Musculoskeletal- Muscle strength throughout is weakened bilaterally. 

 

 

Report from discharging  hospital

Patient was taken to hospital by EMS called by Meals on Wheels driver due to the patient found on the floor of her living room unable to get up. No injuries from fall, x-rays and CT clear.  The patient reports that she lives at home alone. She has been widowed for 5 years and has 3 children who live in other states. Contacting the children was attempted an unsuccessful. The patient reports that her only meals are from the meal service. The patient was admitted due to severe dehydration, hyponatremia. The patient has little appetite, eating only 1/4-1/3 of each meal and small sips of fluids despite encouragement. Primary care provider reports that the patient was last seen a year ago and was in fair health, receiving oral meds for DMII, her last documented weight was 167 lbs. 

 

 use the following table to create a care plan:

Assessment- provide top 3 concerning assessments and 3 other assessments that should be made based on the above assessment. 

Diagnosis-  list 3 applicable nursing diagnoses for this patient. 

Planning-  plan 5 NURSING interventions for this patient corresponding to your diagnoses for these patients. 

Implementation-  list 3 interventions that can be delegated to CNAs or LPNs and 3 interventions that cannot be delegated. 

Evaluation-  list 3 assessment findings that would indicate that the patient is improving and 3 assessment findings that would indicate that the patient is worsening. 

SCIENCE
HEALTH SCIENCE
NURSING

solved