Nursing Care Plan Essays - RTT, Amiodarone, ACE Inhibitor

Nursing Care Plan Course: NUR 1210L Instructor: Dates of Care: 12, 13, 19 & 20 Sept 96 Date Submitted: 11/15/96 Student Names: Anthony Bernardi, SN/SPJC HOLISTIC NURSING CARE PLAN STUDENT Anthony Bernardi GRADE DATE November 15, 1996 Clients Clinical Picture (5) (Initial Cephacaudal assessment) Textbook Description of Diagnosis (5) Summary of Clients Progress (5) Completion of Holistic NCP Tool (30) NURSING DIAGNOSIS (15) GOALS (10) INTERVENTIONS (10) RATIONALES (5) EVALUATIONS (10) REFERENCES (5) TABLE OF CONTENTS SUBJECT PAGE # ? Cover Page 1 ? Grading Point Scale 2 ? Table of Contents 3 ? Summary Page 4 ? Clients Clinical Picture (Cephacaudal Assessment) 5 ? Medical Diagnosis 6 ? Textbook Description of Disease 6-12 ? Treatments and Procedures 13 ? Summary of Caregiver Progress Notes 14 ? Diagnostic Values Out Of Normal Range Clinical Implications 16 ? Radiology 17 ? Medications 18-52 ? Holistic Nursing Care Plan Form 53-62 ? List of Nursing Diagnosis 65 ? Five Nursing Diagnoses 66-70 ? References 71 CLIENT CLINICAL PICTURE: Please see attached Cephacaudal Assessment (Pages 5) MEDICAL DIAGNOSIS: Current diagnosis:Necrotizing pneumonia, cachexia secondary to malnutrition / infection, hypothroidism, NIDDM, empyema RUI, Aspergilloma, RUI, and depression. HX: HTN, atrial fibrillation, COPD, asthma TEXTBOOK DESCRIPTION OF DIAGNOSIS: See attached Disease Process Description (pages 6-12-) SUMMARY OF CAREGIVER PROGRESS NOTES: See attached Caregiver Progress Notes (page 14-15) CLIENT CLINICAL PICTURE Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for atypical chest pain and hemoptysis. V/S BP 114/51, P 84, R 24, T 97.4. He seems alert and oriented x 3 and cheerful. Bowel sounds present x 4. Pt. has a red area on his coccyx. Silvadene treatments have been started. Pt. Has a fungal lung infection with a pleural suction drainage tube inserted in his chest . Pt is extremely thin with poor skin turgor with a diagnosis of cachexia ( wasting) secondary to malnutrition and infection. Patient is no known allergies to drugs but is allergic to aerosol sprays disinfectants and dust.. Advanced directives on chart. Code status DNR. Primary physician Dr. R, Thoracic surgeon Dr. L. Psychology Dr.W. There is PT, OT Dietary and Infectious Disease consults when necessary. He lives with his wife who he has been married to for 56 years. His son and his daughter come to visit him. He does not smoke. He wears dentures but did not bring them. He dose not use a hearing aid but he does have a hearing deficit. Pt. is able to do all his ADLs with limited assistance. He wants to get better and leave the HSP. Pt. Stated 90 days is to long to be here. Pt. States that he is concerned about caring for his tube site when he goes home and does not feel that his wife can do this for him. Diet: Pureed Hi protein, low fat, anti-dumping with Calorie count (all meals) and drink supplements between meals. TPN @ 79cc/hr 12hr around the clock through PICC line MEDICAL DIAGNOSIS: Empyema, Hemoptysis, Necrotizing pneumonia, Aspergillosis (Aspergillus fumigatus) cachexia secondary to malnutrition/infection, hypothyroidism, Diabetes Type II melitius , and depression. PATHOPHYSIOLOGY HEMOPTYSIS: Expectoration of blood arising from the oral cavity, larynx, trachea, bronchi or lungs (Tabors, 17th ed. 1989 p.879) CACHEXIA SECONDARY TO MALNUTRITION/INFECTION : The state of ill health, malnutrition, and wasting It may occur in any chronic diseases, certain malignancies and advanced pulmonary tuberculosis. (Tabors, 17th ed. 1989 p.287) NECROTIZING PNEUMONIA: Aspiration pneumonia. Aspiration pneumonia is frequently called necrotizing pneumonia because of the pathologic changes in the lungs. It usually follows aspiration of material in the mouth into the trachea and subsequently the lungs. The aspirated material. Either food, water, or vomitus, is the triggering mechanism for the pathology of this type of pneumonia. If the aspirated material is an inert substance (e.g. barium or nonacid stomach contents), the initial manifestation is usually caused by obstruction of airways. When the aspirated materials contain gastric acid, there is chemical injury to the lung parenchyma with infection as a secondary event usually 48 to 72 hours later. The infecting organism is usually one of the normal oropharyngeal flora. The clinical manifestations proceed as those of a classic pneunococcal or streptococcal pneumonia. Fungi may also be a cause of pneumonia. These infections are not transmitted from person to person, and the patie nt does not have to be placed in isolation. The clinical manifestations are similar to those of bacterial pneumonia. Skin and serology tests are available to assist in identifying the infecting