Care Plan example

Published: 2021-07-02 00:55:05
essay essay

Category: Chemistry

Type of paper: Essay

This essay has been submitted by a student. This is not an example of the work written by our professional essay writers.

Hey! We can write a custom essay for you.

All possible types of assignments. Written by academics

GET MY ESSAY
Patient admitted to coral bay 06/29/2013 with a primary diagnosis of CVA. Patient’s HX includes uti, bipolar, hypertension, chest pain and difficulty walking. Patient is married and resides at home. She is ambulatory and does not smoke. She is a does not drink, and does not do illegal drugs. Mrs. T. L has a sedentary lifestyle, she has a desk job and enjoys watching cooking networks. Pathophysiology: The primary pathophysiology of stoke is an underlying heart or blood vessel disease. The secondary manifestations in the brain are the result of one or more of these underlying diseases or risk factors.
The primary pathologies include hypertension, atherosclerosis leading to coronary artery disease, dyslipidemia, heart disease, and hyperlipidemia. The two types of stroke that result from these disease states are ischemic and hemorrhagic strokes. A stroke is the sudden onset of weakness, numbness, paralysis, slurred speech, aphasia, problems with vision and other manifestations of a sudden interruption of blood flow to a particular area of the brain. The ischemic area involved determines the type of focal deficit that is seen in the patient.
S/S: Weakness or total inability to move a body part, numbness, loss of sensation, tingling or other abnormal sensations, decreased or loss of vision, language difficulties, inability to recognize or identify sensory stimuli and loss of memory. Treatment: The most effective treatment for stroke is intravenous rtPA. This medicine works to dissolve the clot causing the stroke. If received within 3 hours of the first stroke symptoms, the drug can help prevent permanent problem. Nursing diagnosis pertaining to primary diagnosis Impaired cerebral tissue perfusion 1. Risk for ineffective airway clearance
2. Impaired physical mobility 3. Risk for impaired verbal communication 4. Risk for disturbed sensory perception (tactile) References: 1. PATHOPHYSIOLOGY REFERENCE: PATHOPHYSIOLOGY OF A CVA/STROKE. RETRIEVED 11/19/2013 HTTP://WWW. AMEPC. ORG/CVA 2. MEDICATION REFERENCE: SKIDMORE, L. (2011). NURSING DRUG REFERENCE. ST. LOUIS, MI. ELSEVIER. MOLBY 3. LAB AND DIAGNOSTIC REFERENCE: LEFEVER, J. K. (2011). HAND BOOK OF LABORATORY AND DIAGNOSTIC TESTS, NJ. PRENTICE HALL 4. NURSING DIAGNOSES REFERENCE: GULNICK, M. AND MYERS, J. (2011). NURSING CARE PLANS, DIAGNOSES, INTERVENTIONS, AND OUTCOMES.
CHICAGO, ILLINOIS. ELSEVIER Vital Signs: 0830 Temp 98. 2 Pulse 66 Respirations 17 Blood Pressure 144/88 Pain Level 4 Medications Medication Name (trade & Generic names) Dosage Is this a safe dose? Frequency Route (how do you give it? ) Classification and Primary Action of Medication (Why is this patient receiving this drug and what is the therapeutic class? ) Nursing Implications/Side Effects (What should the nurse do prior to giving any medication and especially this medication and what are the side effects common to this drug? ) Famotidine (Pepcid) 20mg Adult 300mg QD
PO Antiulcer agent Inhibits the action of the H2 receptor site located primarily in gastric parietal cells. Nursing implications -Asses for epigastric or abd pain with occult blood in stool. -Administer with meals or immediately there after Side effects CNS: confusion, dizziness, drowsiness. CV: arrhythmias. Mirtazapine (Remeron) 15mg Adult 15mg/day QD PO Antidepressants used for major depressive disorder Nursing implications -Assess mental status-orientation and mood -may be given as a single dose at bedtime to minimize excessive drowsiness or dizziness Side effects
-CNS: Suicidal thoughts, drowsiness, abnormal dreams. Resp: dyspnea, cough ASPIRIN (Bayer ASA) 81MG Adult 50-325MG QD – AM PO Anticoagulant Used to prevent clots Nursing implications -Take medication w/food -Do not crush Side effects -Upset stomach and heart burn -Easy bruising/bleeding -Dizziness HYDROMORPHOE (DILAUDID) 2mg Adult 2-5MG BID PO Opioid agonists For pain Nursing implications: -Give 30 minutes prior to wound care. -Assess bowel function routinely. Side Effects: -Drowsiness -Feeling faint and weak -Abnormally low BP Furosemide (Lasix) 40mg Adult dose 20-80mg/day BID
PO Diuretic Used to reduce edema due to heart failure Nursing implications -Asses fluid status/monitor electrolytes -Monitor I/O Side effects -CNS: blurred vision EENT: hearing loss, tinnitus -GI: Anorexia, constipation, dry mouth Labs and Diagnostic Tests Test Name (ex. Chemistry, hematology/Na+, K+, Hct, Hgb, xray, cultures) Normal Values (What is the reference range? ) Lab Value (What is the patient’s result? ) Analysis of the lab result (what are the possible reasons for this patient? ) Nursing Considerations (What might you anticipate for this value? ) POTASSIUM 3. 5-5.
1 3. 5 Potassium is drawn to detect presence of hypo – and hyperkalemia. Observe for signs of hypokalemia Record I/O’s. Polyuria can cause excessive loss of potassium CREATININE 0. 50-. 090 1. 44 Creatinine is drawn to diagnose renal dysfunction. Compare BUN and creatinine levels. If both are increased there is a high probability of kidney disease. Limit beef and poultry if the serum creatinine level is very high CHLORIDE 98-107 101 Chloride is drawn to check chloride levels in relation to potassium, sodium, acid-base balance. Encourage the client with deficit to drink fluids
containing sodium and chloride Inform the health care provider when the client is receiving IV D5 continuously. A chloride deficit could occur. Practical Nurses’ DOCUMENTATION: PRACTICAL NURSES DOCUMENTATION Nursing Diagnosis GIVEN BY INSTRUCTOR Desired Patient Outcomes Practical Nursing ACTIONS And CONSIDERATIONS scientific rationale evaluation 1. Impaired cerebral tissue perfusion related to a stroke as evidenced by altered mental status and changes in papillary reactions Patient will maintain optimal cerebral tissue perfusion with NIHSS score of less than 4 during her stay at coral bay Assess PT’s neurological status using NIHSS scale
This information is used to determine the effects of stroke and identify life threatening complications. NIHSS is a standardized assessment of conscious, vision, sensory and motor responses, speech and language function. Pt will remain free of neurological deficits and maintain and stable BP. 2. Risk for ineffective airway clearance related to a stoke as evidenced by dysphagia Patient will maintain clear, open airway as evidenced by normal breath sounds normal rate and depth of respirations, and ability to cough secretions after treatment during her stay at coral bay.
Assess for dysphagia Impaired swallowing may occur with stroke. The use of a formal dysphagia screening protocol significantly decreases the risk for aspiration pneumonia. Patient will maintain airway patency 3. Impaired physical mobility related to a stroke evidenced by decreased muscle strength, control or mass 4. Risk for impaired verbal communication related to a stroke evidenced by speech deficits. 5. Risk for disturbed sensory perception (Tactile) related to a stroke as evidenced by loss of position sensors and in ability to sense deep pressure, pain and temperature.
Patient will perform physical activity independently or within limits of activity restrictions, during her stay at coral bay. Patient will effectively communicate her basic needs, as well as maximize remaining communication ability, during her stay at coral bay Patient will remain free of skin injuries including pressure ulcers. Assess for the ability to move and change positions, to transfer and walk, to perform ROM to all joints, for fine muscle movement, and for gross muscle movement. Assess patient’s verbal communication ability. Assess patient’s ability to sense light touch, pinpricks and temperature.
There may be differing degrees of involvement on the affected side. Paralysis, Paresis and sensory loss are contralateral to the side of the brain affected by the stroke. The patients with expressive forms of dysphasia will have difficulty finding words. Speech will be non-fluent, with the use of single words or short phrases to communicate ideas. Early assessment determines the level of alteration and identify specific areas of risk Patient demonstrates use of adaptive techniques that promote ambulation and transferring. Patient demonstrates ability to communicate clearly. Patient’s skin remains intact.

Warning! This essay is not original. Get 100% unique essay within 45 seconds!

GET UNIQUE ESSAY

We can write your paper just for 11.99$

i want to copy...

This essay has been submitted by a student and contain not unique content

People also read