Question

CASE STUDY Grace Kennedy is a 73 y/o white female admitted to your nursing home. Your behavioral assessment reveals: BP: 96/70 P: 110 & R GO-100 T: 100 (po) Ht: 5'5” Wt: 94 lbs

Answer 1

Ineffective behavior due to internal and external environmental stimuli due to lack of social support after her husband's death and daughter angry. Ineffective behavior can restrict patient energy intake, increase fear into emotional stress and social isolation, etc.
Nursing diagnosis:
-Deficit fluid volume(concentrated dark, amber urine, and increased specific gravity and dry skin and pale, skin breakdown in coccyx and elbows and decreased turgor)
-Imbalance nutrition(due to poor intake of food, patient feel weak and dizzy, fallen twice at home and become underweight)
-Ineffective coping(due to depression, loneliness)
-situational low self-esteem ( due to statement I knew I'd get sick and I look so old and worn out)
goal:
-Promote weight restoration
-increase fluid volume
-Improve human response and increase communication
-Promote adaptation with the external environment
- Create common awareness
-Make self-awareness
-Promote individual coping
Nursing intervention:
Deficit fluid volume:
-Encourage patient to drink enough amount of fluids.
-provide intravenous fluids for maintaining hydration status
-Plan daily activity to increase the patient energy level
Imbalanced nutrition:
-Make a healthy diet to improve her nutrition status
-create a pleasant environment to improve eating
-Refer to the dietician for a diet plan with balanced nutrition.
Ineffective coping:
-allow the patient to express her feeling, fear with gentle physical touch.
-Make a supportive environment it enhances coping
-Provide counseling and refer the patient for social therapy.
Situational low self-esteem:
- Encourage the patient to express their past and current achievement.
-Assess the patient feeling with loved one with active listening skills and never an argument.
-create a positive environment, belief, and ideas about her and refer to professional counseling.