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Care Plan

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Submitted By trusnak
Words 1566
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J. A. Care Plan
Tamara Parker
South College

Medical Dx: Depression Allergies: Demerol, Oxycodone
Hx: 91 y/o female brought to Shannondale from Blount Memorial with multiple fractures which she sustained from falling out of her bed. Patient suffers from chronic back pain and has hx of osteoporosis, muscle weakness, glaucoma, hyperlipidemia, kyphoplasty with bone fusion, back fusion, stemi, OA, and depression.

|Neuro: |GU: |
|Alert and oriented x3. Little confusion |No bowel movement since 3/2/16. Urine x1. |
| | |
|EENT: |MS: |
|PERRLA, normocephalic, presbyopia. |Generalized weakness, uses wheelchair, needs little assistance with ADL’s. |
| | |
|Resp: |Integumentary: |
|Lungs CTA, respirations are 20, symmetric chest expansion. |Warm and dry to touch, slight bruising on bilat lower extremities. |
| | |
|CV: |Misc: |
|HRRR, pulse 62, b/p 154/68. | |
| | |
|GI: |Tests/Procedures: |
|Soft, non-tender, non-distended, BS+ x4. | |
| | |

Patient Laboratory Findings: None in the last 30 days.

Medication Sheet

Client initials: J. A. Date: March 3, 2016 Student: Tamara Parker
Allergies: Demerol, Oxycodone

|Medication (generic and |Amount |Frequency |Safe range |Mechanism of Action |Major side effects |Nursing interventions |
|trade name) |/dose | | | | | |
|Colace |100 mg |Daily |50–400 mg in 1–4 |Promotes incorporation of water|mild cramps, diarrhea |Advise patient not to use laxatives when |
|(ducusate sodium) | | |divided doses |into stool, resulting in softer| |abdominal pain, nausea, vomiting, or |
| | | | |fecal mass | |fever is present. |
|Aspirin |81 mg |Daily |81-325 |Reducing platelet aggregation |GI bleed, anaphylaxis, edema, |Advise pt to report signs of unusual |
| | | | | |epigastric distress, abd pain |bleeding of gums, bruising, or black |
| | | | | | |tarry stools |
| Toprol XL |25 mg |Daily |25 mg, 50 mg, 100 |Decreased frequency of attacks |bradycardia, hf, pulmonary edema, |Take apical pulse before administering |
|(metoprolol succinate | | |mg |of angina pectoris. |fatigue, weakness, anxiety, | |
| | | | | |depression, dizziness, drowsiness, | |
| | | | | |insomnia, memory loss, mental status | |
| | | | | |changes | |
|Milk of Magnesia (magnesium|30 cc |HS |30–60 mL |Laxative |Diarrhea, flushing, sweating |Assess patient for abdominal distention, |
|hydroxide) | | | | | |presence of bowel sounds, and usual |
| | | | | | |pattern of bowel function. |
|Paxil |10 mg |HS |10-50 mg |Depression |neuroleptic malignant syndrome, |Assess for suicidal tendencies |
| | | | | |suicidal thoughts, anxiety, | |
| | | | | |dizziness, drowsiness, headache, | |
| | | | | |insomnia, weakness, agitation, | |
| | | | | |serotonin syndrome | |
|Lipitor |10 mg |HS Every other day|10 mg, 20 mg, 40 |Reduction of lipids/cholesterol|rhabdomyolysis, hypersensitivity |Obtain a diet history, especially with |
| | | |mg, 80 mg |reduces the risk of myocardial |reactions including angioneurotic |regard to fat consumption |
| | | | |infarction and stroke sequelae |edema | |
South College Nursing Care Plan

|Nursing Diagnosis |Client Goals and Evidences |Nursing Interventions, Rationale with Source |Evaluation |
|Risk for falls r/t generalized muscle | | | |
|weakness AEB recent fall. | | | |
| | | | |
| |Resident will not sustain a fall |Place items used by resident within easy reach, such as |Goal met as evidence by resident did not sustain a fall |
| |during my shift, 0630-1230. |the call light, water, and telephone. Stretching to reach|during my shift, 0630-1230. |
| |Resident will wear nonskid socks/shoes|items from bedside tables that are out of reach can |Goal met as evidence by resident wore nonskid shoes during |
| |during my shift, 0630-1230. |disrupt the residents balance and contribute to falls |my shift, 0630-1230. |
| | |(Gulanick, Myers, pg66). | |
| | |Encourage appropriate lighting, especially at night. | |
| | |Using a night-light helps the resident increase | |
| | |visibility if the resident has to get up at night | |
| | |(Gulanick, Myers, pg66). | |
| | |Encourage the resident to wear non-skid shoes or slippers| |
| | |when ambulating. Nonskid footwear provides sure footing | |
| | |for the resident with diminished foot and toe lift when | |
| | |walking (Gulanick, Myers, pg66). | |
| | | | |
| | | | |
|Subjective data: | | | |
| | | | |
|Resident said that it was hard for her| | | |
|to do some things due to her fractures| | | |
|from her recent fall. | | | |
| | | | |
| | | | |
|Objective data: | | | |
| | | | |
|Noticed that it was hard for her to do| | | |
|some of her ADL’s due to being sore. | | | |
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South College Nursing Care Plan

|Nursing Diagnosis |Client Goals and Evidences |Nursing Interventions, Rationale with Source |Evaluation |
|Activity intolerance r/t chronic pain | | | |
|AEB hx of chronic pain. | | | |
| | | | |
| |Resident will experience the least | |Goal partially met as evidence by resident thanked me for |
| |amount of pain possible while |Refrain from performing nonessential procedures. |helping her ambulate to the bed. She said that it was a lot |
| |ambulating during my shift, 0630-1230.|Residents with limited activity tolerance need to |easier for her when she had help. |
| |Will provide the resident with |prioritize tasks (Gulanick, Myers, pg10). |Goal met as evidence by I repeatedly encouraged the resident|
| |encouragement while performing ADL’s |Encourage verbalization of feelings regarding |while she was performing her morning ADL’s during my shift, |
| |during my shift, 0630-1230. |limitations. Acknowledgement that living with activity |0630-1230. |
| | |intolerance is both physically and emotionally difficult | |
| | |to cope with (Gulanick, Myers, pg10). | |
| | |Promote a positive attitude regarding abilities. | |
| | |Appropriate supervision during early efforts can enhance | |
| | |confidence (Gulanick, Myers, pg10). | |
| | | | |
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|Subjective data: | | | |
| | | | |
|Resident said that she needed help to | | | |
|finish getting dressed bc “it hurt to | | | |
|bend over and put her pants on”. | | | |
| | | | |
|Objective data: | | | |
| | | | |
|Noticed that it was hard for the | | | |
|resident to get her pants on. | | | |
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South College Nursing Care Plan

|Nursing Diagnosis |Client Goals and Evidences |Nursing Interventions, Rationale with Source |Evaluation |
| | | | |
|Risk for constipation r/t medication | | | |
|regimen. | | | |
| | | | |
| |Resident will be as active as |Encourage a daily fluid intake of 2000 to 3000 ml/day, in|Goal met as evidence by resident did most of her morning |
| |physically able during my shift, |not contraindicated medically. Adequate fluid is |ADL’s during my shift, 0630-1230. |
| |0630-1230. |necessary to keep the fecal mass soft (Gulanick, Myers, |Goal met as evidence by resident drank most of her fluids on|
| |Resident will increase fluid intake |pg51). |her breakfast tray during my shift, 0630-1230. |
| |during my shift, 0630-1230. |Encourage physical activity and regular exercise. | |
| | |Ambulation promotes peristalsis (Gulanick, Myers, pg52). | |
| | |Encourage a regular time for elimination. Many people | |
| | |defecate following the first daily meal or coffee, as a | |
| | |result of the gastrocolic reflex (Gulanick, Myers, pg52).| |
| | | | |
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|Subjective data: | | | |
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|Resident did not address | | | |
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|Objective data: | | | |
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|Resident has not had a bowel movement | | | |
|since March 2, 2016. | | | |
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South College Department of Nursing
Medical Diagnosis Sheet

Borderline personality disorder (BPD) is a serious mental illness marked by unstable moods, behavior, and relationships. The Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) listed BPD as a diagnosable illness for the first time in 1980. Most people who have BPD suffer from problems with regulating emotions and thoughts, impulsive and reckless behavior, and unstable relationships with other people. People with this disorder also have high rates of co-occurring disorders, such as depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides (www.nami.org). Scientists generally agree that genetic and environmental factors are likely to be risk factors for BPD but research is still in the very early stages. Studies on twins with BPD suggest that the illness is strongly inherited. Another study shows that a person can inherit his or her temperament and specific personality traits, particularly impulsiveness and aggression. Scientists are studying genes that help regulate emotions and impulse control for possible links to the disorder. Social or cultural factors may increase the risk for BPD (www.nami.org). According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms: extreme reactions; a pattern of intense and stormy relationships with family, friends, and loved ones; distorted and unstable self-image or sense of self; impulsive and often dangerous behaviors; recurring suicidal behaviors or threats or self-harming behavior; intense and highly changeable moods; chronic feelings of emptiness and/or boredom; inappropriate, intense anger or problems controlling anger; having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality. BPD usually begins during adolescence or early adulthood. Some studies suggest that early symptoms of the illness may occur during childhood (www.nami.org). Unfortunately, BPD is often underdiagnosed or misdiagnosed. A mental health professional experienced in diagnosing and treating mental disorders—such as a psychiatrist, psychologist, clinical social worker, or psychiatric nurse—can detect BPD based on a thorough interview and a discussion about symptoms. A careful and thorough medical exam can help rule out other possible causes of symptoms. BPD is often viewed as difficult to treat. However, recent research shows that BPD can be treated effectively, and that many people with this illness improve over time.

BPD can be treated with psychotherapy, or "talk" therapy. In some cases, a mental health professional may also recommend medications to treat specific symptoms. No medications have been approved by the U.S. Food and Drug Administration to treat BPD. One study done on 30 women with BPD showed that omega-3 fatty acids may help reduce symptoms of aggression and depression (www.nami.org).

My patient does not have this but I was running out of options and BPD always interested me.

REFERENCES

Borderline Personality Disorder. (n.d.). In National Institute of Mental Health. Retrieved March 4, 2016, from http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
[pic]
River, NJ: Prentice Hall. Gulanick, M. & Myers, J. L. (2013). Nursing care plans: Nursing diagnosis and intervention. (8th ed.) St. Louis, MO: Mosby/Elsevier.

Sanoski, B. & Vallerand, A. H. (2014). Davis’s drug guide for nurses (with CD-ROM). (14th ed.). Philadelphia, PA: F. A. Davis.

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...Nursing for Health and Wellbeing 2012 Patient Name: Jake Anderson Student Name: Linda Nguyen Student Number: 17532189 Nursing Issue: Development, risk of delayed due to poor nutrition and inefficient social interaction as evidence by Jake’s limited speech and often refuses to eat lunch. Goal/s: To promote a healthy nutritional intake and increase social interactions to prevent delayed physical and psychological development. INTERVENTION | RATIONALES FOR INTERVENTIONS | 1. Full health assessment. (Crisp & Taylor, 2010). 2. Assess ADL’s. (Holland, Jenkins, Solomon & Whittam, 2009). 3. Assess activity level. (Holland, Jenkins, Solomon & Whittam, 2009). 4. Refer to Occupational Therapist. (Crisp & Taylor, 2010). 5. Refer to dietician. (Crisp & Taylor, 2010) 6. Refer to motherless mother social group located in Blacktown. (Crisp & Taylor, 2010). 7. Provide strategies for Sally to read to Jake. (Crisp & Taylor, 2010). 8. Provide strategies for Sally to assess safety in her own home. (Crisp & Taylor, 2010). 9. Teach Sally the importance of listening attentively. (Holland, Jenkins, Solomon & Whittam, 2009). | 1. A full health assessment is required to assess the degree of malnourishment in Jake and to obtain a full and complete picture of his current health status, based on the height and weight that has been examined. This will aid in developing strategies which will assist Sally in promoting Jakes...

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