An 82 yo W F admitted 2/20/10 for diarrhea and volume depletion. Recent Dx of colon cancer and VRE. R colectomy with hernia repair. Hx of asthma, COPD, diabetes, eosinophilc pneumonia, HTN, osteoporosis, DJD, polymyalgia rhematica, GERD, carotid artery stenosis, rotator cuff injury, degenerative disk disease, anxiety, sciatica, fibromyalgia, hyperlipidemia, obesity, fibroid tumor removal, breast reduction, and heart catheter. MEDS: Sennosides-docusate, Candesartan Cilexetil, Insulin, Hydrocodone, Heparin, Prednisone, Lyrica, Pantoprazole. ALLERGIES: All NSAIDS, Amoxicillian, Avelox, Celebrex, Cipro, Enbril, Erythromycin, Lasix, Macrobid, Mobic, Sulfa, Tetracycline, Vioxx, Arthrotec, Sulfate, Cymbalta. 22G Catheter D5 ½ 20KCl 100 cc/hr. Abdominal incision open to air. VS Q4. Nasal Cannula 2L. Fall precautions. Up to chair with assistance. Full liquid diet. Vitals: T 97, P 74, BP 108/64, O2 97%. Pain level=5, desires a 2. Aching pain at abdominal incision and in R shoulder. WBC=10.8, RDW=15.4, Neut=6.8, CO2=33, Glucose=117. Breathing unlabored & even. Lung sounds diminished bilaterally. Productive cough with thin yellow sputum. Regular heart rate. No presence of murmors. Radial pulse=2+ bilaterally. Pedal pulses=1+ bilaterally. Cap refill 3-4 sec. 1+ edema in feet bilaterally. Skin fleshtoned, warm, dry and smooth. Skin intact except for surgical incision. Turgor <2 sec. Braden score=19. Pt. PERLLA. Pt. awake, alert, and oriented. LOC X3. Will be transferring to an extended care facility. Daughter very involved in patient’s life.OPT Model of Clinical ReasoningInterventions Rationale1. Continue to administer Hydrocodone and other pain medication to control pain level, while observing for any change in behavior.2. Assess the client daily for appropriateness of activity. Gradually increase activity, allowing patient to assist with positioning and transferring. Progress from sitting, to standing, to ambulation. 3. Teach patient proper technique for using a walker and encourageuse with ambulation.4. Perform passive and active range of motion (ROM) at leasttwice a day to increase mobility and assess muscle strength.5. Instruct patient on techniques of controlled conscious breathing, including pursed-lip breathing techniques to decrease dyspnea. Monitor O2 saturation during activity and provide supplemental O2 to keep O2 saturation at an adequate level (above 90%).References:Ackley, B.J., & Ladwig, G.B. (2008). Nursing Diagnosis Handbook. (8th ed.) St. Louis: Mosby Elsevier.Vincent, K.R., Braith, R.W., Feldman, R.A., Kallas, H.E., & Lowenthal, D.T. (2002). Improved cardiorespiratory endurancefollowing 6 months of resistance exercise in elderly men and women. Archives of Internal Medicine 162(6), 673-678.1. “Administer a nonopiod if pain is thought to be mild and an opiod if pain is thought to be moderate to severe”(Ackley & Ladwig, 2008, p. 545).2. “Always have client dangle at the bedside before trying standing to evaluate for postural hypotension. These methods can help prevent falls” (Ackley & Ladwig, 2008, p. 119).3. “Assistive devices can increase mobility by helping the client overcome limitations” (Ackley & Ladwig, 2008, p. 120).4. “Resistance exercise for the elderly greatly increased their aerobic capacity, possibly from increased skeletal muscle strength” (Vincent, Braith, Feldman, Kallas, & Lowenthal, 2002, p. 677).5. “A systemic review found that inspiratory muscle training was effective in increasing endurance of the client and decreasing dyspnea. The use of oxygen improves cardiac function, exercise capacity, and tolerance of ADLs” (Ackley & Ladwig, 2008, p. 120).Activity Intolerance 10-Pain level = 5-Hx of COPD and asthma.-Needs assistance with ambulation to chair and ADLs.-Pt. verbalizes weakness and fatigue with activity.-Limited ROM.-CO2=33-BP=108/64-Mobility deficit.-2L nasal cannulaAltered Bowel Pattern 6-Pt. reports having uncontrollable diarrhea for more than 3 weeks.-Full liquid diet.-Hypoactive bowel sounds r/t surgery.-Colectomy with removal of R colon and hernia repair.Risk for Falls 3-Pt. reports weakness and fatigue with activity.-Needs assistance x1 with ambulation.-Hx of osteoporosis.-Pt. reports weak muscle tone and strength.-Limited ROM. Impaired Physical Mobility 8-Needs assistance x1 with ambulation to chair.-Pt. reports weakness and decreased strength.-Recent rotator cuff injury.Self-Care Deficit 3-Needs assistance x1 with ambulation and ADLs.-Pain level=5-Pt. reports weakness/fatigue with ADLs.-Limited ROM in both arms r/t rotator cuff injury.Impaired Nutrition 6-Hx of colon cancer, and recent colectomy.-Severe diarrhea > 3 weeks.-Pt. ate only 25% of breakfast and lunch.-Full liquid diet.-Pt. verbalizes weakness.-Unable to digest food or absorb nutrients.Pain 4 -Pain level= 5, desires 2.-Pt. reports aching, dull pain in R shoulder and around abdominal incision.Pt. states, “I am so used to being in pain.”-Hx of fibromyalgia, osteoporosis, and colon cancer.-Recent rotator cuff injury.Fluid Volume Deficit 4-excessive diarrhea with watery stool-dry skin-dry mucous membranes-1+ pedal pulses-Pt. verbalizes weakness.Diarrhea and Volume DepletionRisk for Infection 3 -Surgical incision on midline of abdomen, open to air.-raw anus r/t constant diarrhea-WBC= 10.8, Neut.= 6.8-Impaired
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