Nur 513 Week Six Case Study

Topics: Nursing care plan, Health care, Nursing Pages: 6 (867 words) Published: March 5, 2014
Case Study Care Plan

NUR 513
02/24/14

Case Study Care Plan
Admitting Diagnosis: R/O CHF, R/O DVT

FALL RISK STATUS
LEVEL THREE SCORE: (45 and higher) 45 (RED LEAF SIGN)
Patient is identified as a severe fall risk.
Place autumn red leaf sign over bed.
Q 1hr observation with toileting and comfort rounds (This should include positioning as indicated, offering fluids, snacks when appropriate and ensuring patient is warm and dry).
Bedside mat on floor at side of bed
Hill-Room low bed
Evaluation by Interdisciplinary Team
For patient at risk for head injury * Consult Rehab Medicine for helmet
Injury prevention room when available

*** NURSING DIAGNOSIS and CARE PLAN PRIORITIZATION***
Patient is: geriatric (80 and older)
Plan has been discussed with: Patient, Family, Treatment team members
I have applied concepts of age specific care to establishing alert and priorities for care.

PROBLEM: ALTERATION IN RESPIRATORY STATUS R/T SOB Priority 1

The Initial Assessment done by Nursing indicates the following plan of care:
Select target date for review of problem: Feb 24, 2014
Problem status: Problem ongoing review 24 hours

Goals:
Attains/maintains ABG's/pulse oximetry within normal range
Has normal respiratory rate/breathing pattern
Has decreased abnormal breath sounds
Has decreased use of accessory muscles
Remains afebrile

Interventions:
Measure Intake and Output
Q4H

Take B/P
Q8H

Monitor cardiac rhythm
Q4H

ABG'S/pulse oximetry
Q4H and PRN

Provide mouth care daily
Elevate head of bed 60 Degrees

Out of bed Q Shift

PROBLEM: DECREASED CARDIAC OUTPUT R/T Poor Perfusion Priority 2

The Initial Assessment done by Nursing indicates the following plan of care:
Select target date for review of problem: Feb 24, 2014
Problem status: Problem ongoing review 24 hours

Goals:
Maintains cardiac output
Document as ordered
Returns to and maintains NSR or pacing rhythm document as ordered
Maintains therapeutic levels of anti-arrhythmic agents

Interventions:
Measure Intake and Output
Q4H

Take B/P
Q8H

Monitor cardiac rhythm
Q4H

Out of bed Q Shift

PROBLEM: FLUID VOLUME DEFICIT R/T Electrolyte imbalance Priority 3

The Initial Assessment done by Nursing indicates the following plan of care:
Select target date for review of problem: Feb 24, 2014
Problem status: Problem ongoing review 24 hours

Goals:
Maintains fluid/electrolyte balance
Maintains balanced Input and output

Interventions:
Assess skin turgor and oral mucous membranes
Q4H

Assess for presence/amount of edema
Q4H

Intake and Output - Include patient and significant other in recording I&O
Q8H

PROBLEM: PAIN R/T Decreased Cardiac Output Priority 4

The Initial Assessment done by Nursing indicates the following plan of care:
Select...
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