Question

Simulated Patient’s Name in EHR: Anne Newton

Brief History: This is an 84-year-old female admitted two days ago with a diagnosis of Adult Failure to Thrive, dehydration, and weight loss. The patient has dementia/advanced Alzheimer’s disease, and dysphagia due to a previous stroke. She was receiving intermittent PEG tube feedings at home, which have continued since her admission. Orders have been written for her to be started on continuous tube feedings today. You are the nurse on the 7a-7p shifts and will be initiating the continuous enteral feedings. Ms. Newton is currently alert, agitated, and oriented times one (person). 02 @2L/min. via nasal cannula is in place.

Diagnosis: Adult Failure to Thrive, Dehydration, advanced Alzheimer's Disease

Allergies: Ciprofloxacin, Aspirin

Activity: OOB to chair with assistance

Vital signs: every 4 hours with O2 sat

Oxygen 2L nasal cannula

IV- Saline lock, flush as per protocol

Enteral feedings via PEG: Jevity 1.2 cal/mL - 250 ml/45 minutes every 4 hours for 48 hours then begin

continuous Enteral feeding Jevity 1.2 cal/mL @ 50mL/hr via kangaroo pump Check for residual every 4 hours, hold for gastric residual > 200 mL

Monitor I&O

Daily weights

Fingerstick blood glucose every 6 hours

Labs: Basic metabolic panel, CBC with diff, PT/PTT, INR, serum albumin, ABG in am.

Serum glucose every 24 hours

X ray: Flat plate abdomen done in ED prior to admission to floor

Alert, oriented times one (person). Exhibits periods of agitation. Requires frequent reorientation. Nasal 02 @2LPM via N/C in place. O2 sat 95%. Lungs clear bilaterally. IV lock to right arm patent, dressing clean, dry and intact – no signs infiltration or phlebitis. PEG tube clamped – dressing clean, dry and intact. Abd. soft, sunken, non-tender. BS + X 4 quadrants. Receiving Jevity intermittent feedings q 4 hrs for past 48 hrs. No complaints of nausea, pain or fullness. Gastric residuals 75-100 mL. Soft brown BM X 2 this shift. Voiding small amounts amber urine. Continuous enteral feeding to begin today. Labs drawn and sent as ordered. Daughter at bedside.

Pt. alert, oriented X1 (person). Frequent reorientation required. Continues to have periods of extreme agitation, and c/o hunger. Daughter at bedside throughout evening. 2 L O2 via nasal cannula for O2 sat 95%. Skin pink, warm, dry. Lungs clear bilaterally. Peripheral IV lock 20gX1" to right antecubital fossa; flushed per protocol; transparent membrane dressing clean, dry, intact; site negative for redness, swelling, warmth. PEG tube clamped. Site without redness, swelling or drainage; site cleansed, DSD applied. Abd. soft, sunken, non-tender. BS+ X 4 quadrants. No complaints of nausea, pain or fullness. Receiving intermittent Jevity feedings q 4 h; gastric residuals 100-125 mL. Formed brown BM X 1. Voiding small amounts amber urine.

84-year-old female admitted for failure to thrive, dehydration, weight loss, dementia/advanced Alzheimer’s disease. H/O stroke, dysphagia.Pt. is poor historia. Daughter is guardian, at bedside providing information. Pt. alert, oriented X1 (person). Started on 2 L O2 via nasal cannula for O2 sat 93%. Skin pink, warm, dry. Lungs clear bilaterally. Peripheral IV lock inserted 20gX1" to right antecubital fossa; flushed per protocol; transparent membrane dressing clean, dry, intact; site negative for redness, swelling, warmth. PEG tube in place - site healed. no redness, swelling or drainage noted; site cleansed, DSD applied. Abd. soft, sunken, non-tender. BS+ X 4 quadrants. No complaints of nausea. pain or fullness. Receiving intermittent Jevity feedings q 4 h; gastric residuals 100-125 mL. No BM. Voided X 3 dark amber urine.

Fingerstick BG Monitoring q 6 h

4/15 13:00 - 82 A. Speed RN

4/15 19:00 - 80 A. Speed RN

4/16 01:00 - 92 A. Speed RN

4/16 07:00 - 90 I. Smith RN

4/16 13:00 - 100 I. Smith RN

4/16 19:00 - 110 A. Speed RN

4/17 07:00 - 100 A. Speed RN

1) Patient’s Diagnosis: Give a brief summary of the pathophysiology of the patient’s medical diagnosis (rephrase in your own words):

2) Assessment of the Patient: What assessment findings have already been documented regarding this patient in the electronic medical record? What would your priority assessment be?

3) List at least three possible nursing diagnoses for this patient:

Answer 1

1, Adult failure to thrive
It occurs in older adults with loss of appetite, weight loss, inactive, lack of social activity, memory loss, etc. it causes dehydration, difficulty in performing a daily activity, bed wetting, malnutrition, depression and cognitive impairment. history of stroke, dysphagia, and historia increased the inability to do the work and eat.
2, Assessment findings:
Skin: pinks, warm and dry
Abd soft, sunken and nontender
Voided X3 dark amber urine
This indicates the patient is in severe dehydration. this should be given more priority to avoid dehydration to restore rehydration.
3, nursing diagnosis:
-Deficit fluid volume due to loss of appetite and dysphagia
-The risk for fall due to impaired physical mobility and advanced Alzheimer's disease
-Impaired gas exchange due to previous stoke and inactivity.