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
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.