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Brief Background: 77 y.o. grandmother brought from retirement home last night for altered mental state.

Assessment Problem Statement Goals Actions Evaluation


Observations:
Thin to
emaciated elderly
woman
BMI 17.4
Vital signs:
T 99.6, P 102, R 24,
BP 108/52
Examination:
Dry, tacky
mucous membranes
Crusted saliva
adhering to lips
Incontinent of a
small amt. amber
urine
Jugular veins do
not distend (much)
when patient is
supine
LBM unknown
Labs:
Chemistries:

Hypernatremic
hypovolemia
(dehydration)
RT
(likely) inadequate
intake (plus
fever?)
AEB
Elevated Na+, BUN
and Creatinine
Concentrated urine










W/in 24
hours pts Na
+
,
Creatinine and
BUN will trend
toward normal
Pt. will
void moderate
to large
amounts 4
times in next
24 hours











Collaborative actions:
5% dextrose 0.45%
normal saline IV at 75
ml/hour.
Independent Nursing Actions
Good oral care now
and q4-8 hours and prn
Offer thickened
liquids with each hourly
rounding (sit pt. 90 degrees)
Check briefs and
change if wet hourly
If no urine in 6hrs
bladder scan
Weigh daily












Not
drinking. MD
IV rate to
100/hour
for 10 hours
Feeding
tube
inserted
Na
+
149, K
+
3.8, Cl
-
115, HCO
3
-
18,
BUN 25,
Creatinine 2.2
Mg
2+
1.5, PO
4
-
2.5,
Albumin 2.9
Heme:
Hgb 14, Hct 45,
WBC 14,000 (90%
neutrophils),
platelets 207,000
UA:
Leukocyte esterase
and nitrite positive.

Neuro checks:
AAOx1 (maybe)
and does not follow
commands
Non-verbal
Moves all
extremities
PEERL



Threat to
physiological
safety
RT
bladder infection
AEB
UA results,
neutrophilia and
fever





Impaired nutrition
RT
Debility (?)
dementia (?)
and/or dentition
(?)
AEB
BMI, Low serum
albumin, Mg
2+
and
PO
4
-


W/in 24
hours after
first dose of
antibiotic
white count
and fever will
trend toward
normal






W/in 1
week pts
weight will
increase by 2
pounds
W/in 1
week pt. calorie
intake will be
at goal
W/in 2
days patient
Collaborative actions:
Rocephin 1.0 Gm IV
q24h.

Independent Nursing Actions:
Vital signs q4h and
prn
Note color and rough
amount of urine each time
briefs changed.





Insert NG tube
Dietary consult
Administer thiamine,
B vitamins and
multivitamins as ordered.
Begin Gevity feedings
at 20 ml/hour and
gradually increase to 60
ml/hour over the week
until at goal rate
Speak to MD re: stool












Threat to safety
RT
altered sensorium
AEB
Does not follow
commands, not
oriented to
surroundings or
circumstances

will be having
bowel
movements.



W/in 1
week (as
metabolic
issues and
infection
improve) pt.
will be
oriented and
follow
commands.
softener.


Neuro checks q4h and
prn
ROM exercises q4h
and prn
Sequential stockings
Specialty mattress
Turn q2h
HOB up at least 45
o
while tube feedings
running.