Question

Arter deciding the 3 most urgent needs , and writing a 3 needs care plan answer these questions

1. What is the first action you'd take immediately?

2. Would you contact this patient's provider (MD, NP)? What information would you consider is essential to report?

3. What other comfort measures would you offer this gentleman?

Care Plan Assignment for clinical Please read the patient's profile and assessment, then write a 3 needs care plan and answer the questions posed. Mr. J., a 72 yr old retired construction worker, is your patient for the second day in a row. You took care of him through a 12 hr shift yesterday. He was admitted during that shift from the ER, with dyspnea and fatigue. He lives alone, has 3 grown children who are loving and involved. He is a widower. He retired at age 65, and spends his spare time doing charity work for his church, playing with his grandchildren, and playing cards weekly with some of his former work friends. He takes Zocor 10mg daily for mildly elevated lipids, Lasix 20 mg daily, and Metoprolol 25 mg daily for mild hypertension and occasional tachycardia. When admitted yesterday, he was alert, fatigued, easily aroused, BP 116/75, HR 82, Resp 18. He is 5'10", 180 lbs. No allergies. He doesn't drink alcohol, quit smoking in 1977. He had an IV infusing, N/S 50ml/hr in his left arm, was taking fluids po and ate fairly well with some encouragement. He denied pain. 02 sat was 93% on room air. Labs were pending. This morning, you enter his room and find him lethargic and a bit difficult to arouse. He vaguely remembers you from yesterday. His lips and mucus membranes are dry and cracked. Skin turgor poor. Hasn't voided since he went to sleep at 9pm. IV intact and patent. V/S-T 100.4 orally, HR 98. Resp 22, moist non productive cough at times. 02 sat 89% on room air. He is refusing food and fluids. Labs-CBC - WBC 13.4, HGB 10.5, HCT 30, PLT 100, Liver enzymes WNL, Electrolytes-K+ 2.3, NA 125, remainder unremarkable. Urine analysis shows 3+ bacteria, culture pending. CXR-streaks at bilateral bases. Phys Assessment- Pale, restless, elderly gentleman in mild distress, color pale, skin turgor poor with tenting noted. No skin breakdowns noted. Eyes-PERLA, oral exam shows dry, cracked mucus membranes, Breath sounds- crackles are heard at bilateral bases and accessory muscle use is noted. Abd soft, no tenderness.

plan/plan; intervention; rationale and evaluation

Answer 1

1.Maintain oxygenation. : Report the physicisn as per order start oxygen therapy.

2. Contact the patient provider, report the physician about,

• Altered vital signs and patient health status.
• Lab findings
• Assessment findings.

3.

• provide comfortable position that is fowler's position to lessen breathing difficulty.
• Measures to decrease body temperature : cold compress, antipyretics as per doctors order, frequent monitoring
• Maintain oxygenation as per doctor's order.
• Provide psychological support.
• Assess skin integrity.
• IV infusion to maintain hydration.
• Nutritional support as per doctor's order. (Parentral nutrition )

Nursing careplan

Assessment (Objective data)	Nursing diagnosis	Goal	planning	Rationale	Evaluation
Spo2-89%,dyspnea, Poor skin turgor, restless.crackles on auscultation.	Ineffective breathing pattern related to hypoxia	The patient will maintain nornal breathing pattern.	1.Assess the health status. .2.Maintain oxygenation. 3.provide comfortable position. 4.Administer medication as per doctor's order 5.Teach effective breathining	1.provide baseline data. 2.assess need for intervention 3.promote breathing pattern 4.Reduce dyspnea and cough 5.Improve breathing pattern.	The patient maintain normal breathing pattern
Incresed body temperature about 100.4, WBC 13.4 and 3+ bacreria present in urine analysis	Impaired thermoregulation related to infection	The patient will maintain normal body temperature.	1.assess the vital signs of the patient. 2.promote rest. 3.Administer medication as per doctor's order. 4.Promote hydration level 5.provide cold compress to the patient	1.Identify current health status. 2.Lessen the fatigue 3.Reduce body temperature 4.Avoid dehydration 5.Reduce body temperature	The patient maintain normal temperature
Not voided since last night	Impaired urinary eliminatin related to urinary retension	The patient will maintain normal urination	1.Assess the urinary elimination pattern 2.monitory intake and output chart 3.Insert urinary catheter as per doctor's order. 4.Administer medication as per doctor's order.	1.provides badeline data 2.Identify the need for intervention 3.Drain the urine 4.maintain urine output	The patient maintain normal urine output