NR 226 - Nursing Care Plan & Assessment Data

NR 226 - Nursing Care Plan & Assessment Data Current Physician/Health Care Provider Orders (Prescriptions for Care) ITEM TYPE THIS RESIDENT’S ORDERS RATIONALE Diet Mechanical soft, regular liquids, no alcohol Patient has poor dentition and is an aspiration risk from CVA Activity May participate as tolerated Due to hemiparesis, patient may not be able to tolerate long periods of activity I/O Not monitored in patient's medical chart None-not monitored in chart due to admission to hospice VS Checked every 10 days by a hospice provider None-recorded to keep a running record of patient decline. Accu-Cheks None None Foley None None NG None None PEG/PEJ tube None None Wound Care / Dressing Change None None Respiratory Treatments None None Tracheostomy None None Suctioning None None Chest Tube None None Special Equipment Hoyer lift required for transfer Patient is unable to support body weight Medications due to right side paralysis and muscle atrophy Lab orders None Since patient is on hospice, these are not tests that are required for this patient Other None None Rehab Services Activity or Treatment Plan & Schedule Rationale Physical Therapy Balance assessment, transfer methods Rehabilitation of gait and muscle weakness Speech Therapy Unspecified dysphagia; discontinued 2/13/13 due to hospice admission Assessment of patient's ability to speak and swallow reflexes to check for aspiration risk Occupational Therapy ADL evaluation, wheelchair management from 1/23/13- 2/21/13; discontinued due to hospice admission Evaluation of patient’s ability to care for oneself and the amount of care needed to perform ADLs. IV Access: Type None Site: None Last Dressing Change None Last Tubing Change: None Reason for IV access None IV fluids and meds None Most recent Imaging Findings: (CXR? CT? MRI?) Within the last six months. Type of Imaging (X-Ray, CT, MRI, etc) Body Area Imaged Reason for testing and results of test None None N/A None None N/A Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?) Within the last six months. Date Lab Test Results Norms Comments 12/25/1 2 TSH 0.99 0.4-3.0 mIU/mL Thyroid function is low-patient diagnosed with hypothyroidsim 3/12/13 C. diff by lamp Positive Negative Semi-solid stool N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Other recent, significant procedures or tests (EKG, etc) Within the last six months. Date Test Reason for testing and results of test Resident’s Developmental Stage according to Erikson: Integrity versus Despair Your assessment of this resident’s response to the opportunities and potential conflicts of this stage: In this stage, the adult will accept responsibility for their life and come to terms with death. Based on the relevant and limited information in her chart, I believe that MW has sufficiently accepted this stage by making decisions regarding her care prior to her illnesses making her unable to do so by appointing bother power of attorney Medications and durable power of attorney. Because she is unable to speak, it is difficult to determine if MW has a sense of fulfillment with her life. List one of the resources you used to learn more about this resident’s diagnoses: (APA format) Staff, Mayo Clinic. "Dementia." Mayo Clinic. Mayo Foundation for Medical Education and Research, 16 Apr. 2013. Web. 26 May 2013. "Alzheimer's Disease and Dementia." Alzheimer's Disease and Dementia. Alzheimer's Association, 2013. Web. 26 May 2013. Based on the information on these pages and your assessment of this resident, what is your FIRST or PRIORITY concern? (“What worries you the most about this resident?”) Based on the information provided in MW's chart, my priority concern is wound prevention. Since this patient is immobile and spends her time in either bed or in a wheel chair, pressure ulcer prevention would be my primary concern. I would implement a plan to make sure that MW is repositioned frequently and propped with pillows to ensure that she is not leaning onto her right side (hemiparesis) for too long of a duration. Total of four medications that relate to a primary medical diagnosis. Adverse reactions: 2 common, 2 lifethreatening. Nursing considerations and teaching should include if applicable antidote, VS to check prior to medication, food restrictions. Brand Name and Generic Name Normal Dosage Ranges Contraindications Namenda (Memantine) 5 mg initial Maximum of 20 mg daily Use