1
LAGUARDIA COMMUNITY COLLEGE
City University of New York
SCR 210
NURSING PROCESS TOOL
Student Name: Louise Margaret Tomas
Clinical Date: 05/08/2008
Biographical Data : Client’s Initials: E.J
Room: 303 Bed 1 Sex: F Age: 89 years old
Religion: Catholic Occupation: Retired
Cultural/Ethnic Background: African American
Admitting Date: 05/01/08
Reason for Admission: Possible Sacral
Osteomylelitis
Data - Label S for Subjective, O for Objective
R
E
S
T
&
A
C
T
I
V
I
T
Y
A. Rest: (Usual, alterations assoc. with
illness/hospitalization)
Hours of sleep each night – Unable to access because client
is confused and not responding (S)
Difficulty falling asleep; early awakening; nap during
day; Client was observed napping during the day. (O)
manifestations of sleep deprivation Assistive measures:
warm milk, medication, etc. - No assistive measures were
observed. (S)
B. Activity
Degree of mobility of all joints; condition of joints – Client
is immobile so unable to demonstrate. Client feels pain while
moving joints (O)
Ability to flex and extend limbs against graduated
resistance- Unable to Flex and extend limbs against
graduated resistance(O)
Hand grasp- bilateral; coordination - Pt. demonstrates
normal coordination and bilateral ability to grasp my hands.
(O)
Ability to stand, assistance needed; posture, gait, balance
–Pt is on complete bed rest so not able to stand, complete
assistance needed for ADL’s so I couldn’t assess her posture
and gait. Might be very poor gait.(O)
Assistance needed to transfer, stand, walk and use of
assistive devices (cane, crutches, walker, wheelchair)Unable to access because pt is on complete bed rest(O)
Ability to perform ADL : Pt need complete assistance for
Data Analysis
Admitting Diagnosis: Possible Sacral
Osteomylelitis
Secondary Diagnosis: Not Applicable
Surgical Procedure: None
Date: N/A
Health History: Sacral Decubiti;
Dementia; Hypertension
(Provide reference)
Rest:
As people get older tend to take longer to fall
asleep, awaken more easily and frequently, and
spend less time in deep sleep. Older people are
more likely to be awakened because of
environmental factors such as noise, pain,
nocturia.
(Brunner & Suddarth, pg. 235)
Pain
Chronic pain (chest, joint) clients may interfere
with sleep, fatigue and muscle tension and may
also affect ADL function. Immobilized body parts
produce discomfort or suffering. Once clients
suffers from pain there can be serious impairment
of functional status, mobility, ADL, social
activities and activity tolerance may be reduced.
(P&P p 1236)
Immobility
Reduced mobility will slowly decrease
endurance, strength; muscle mass and this long
term immobility can develop contracture. (P&P p
1427-1429)
Activity:
Intact musculoskeletal and neurologic systems are
Nursing Diagnosis
Risk for disturbed sleep
pattern related to
hospital environment and
joint pain.
Risk for disuse syndrome
related to immobility,
decrease muscle strength,
decrease ROM
Activity intolerance
related to joint pain and
muscle weakness as
evidence by client
exhibiting a pained look
on her face when I was
flexing her lower
extremities.
2
ADL’s (O)
Restrictions imposed by health problems/therapeutic
modalities- Client has been put on bed rest since she is
confused. (O)
Other factors that may affect mobility: Fatigue, weakness
(O)
E
L
I
M
I
N
A
T
I
O
N
A. Urinary
Voiding (Usual, alterations associated with illness and
hospitalization) Client has a Foley catheter in place. (O)
Frequency, urgency, dysuria
- Could not assess since client was confused and
unresponsive. (O).
Urine: quantity, color, clarity, odor, Sp. G.- Pt has
catheter bag and it has 300cc, yellowish in color
Lab: urinalysis: BUN: 15 (norm= 8-20 mg/dL);
creatinine: 0.8 (norm= 0.6-1.2 mg/dL);
Assistive devices (indwelling, external catheter) Structural
adaptations; urinary diversions: Pt has foley catheter(O)
Retention/bladder distention- No distention observed. (O)
Other factors that may affect normal urinary elimination
- HTN, medications, sedentary lifestyle. (O)
B. Bowel
Evacuation patterns (Usual, alterations associated with
illness & hospitalization) – Unable to assess.
Last BM – 05/08/2008 (O)
Stool: quality, color, consistency, presence of blood,
mucusStool was brown soft and mushy in texture; no mucus or
blood was observed. (O)
Assistive measures: laxative, enemas, suppositories -
essential for maintenance of safe mobility and
performance of ADL’s.
Age–related changes that affect mobility include
alterations in bone remodeling, leading to
decreased bone density, loss of muscle mass,
deterioration of muscle fibers and cell
membranes, and degeneration in the function and
efficiency of joints.
(Brunner & Suddarth, pg. 235)
FUNCTIONAL INCONTINENCE
Functional incontinence is involuntary ,
unpredictable passage of urine in a client with
intact urinary and nervous system. Changes in
environment; sensory, cognitive, or mobility
deficits. Symptoms include urge to void that
causes loss of urine before reaching appropriate
receptacle. (P&P, p. 1394)
Age and Immobility
People may have special problems with
incontinence because of physical limitations and
environmental barriers. Older persons with
restricted mobility have greater chances of being
incontinent because of their inability to reach
toilet facilities in time. (P&P, p. 1329) and also
lose muscle tone in the perineal floor and anal
sphincter. Although the integrity of the external
sphincter may remain intact, older adults may
have difficulty controlling bowel evacuation and
are at risk for incontinence. (P&P, p. 1377)
Self-care deficit related
to pain, and weakness as
evidenced by complete
assistance is needed in
performing in ADL’s
Impaired urinary
elimination related to
immobility, age,
decreased muscle tone as
evidenced by client is in
complete bed rest and
has Foley catheter.
3
None. (O)
Bowel sounds- Presence of normal bowel sounds (b/w 520/min) in all 4 quadrants. (O)
Abdomen: distension, firmness, tendernesss - The
abdomen is firm but not distended or tender. No protrusions
nor distortions noted (O)
Structural adaptations; Ostomies - Pt has no ostomies. (O)
Other factors that may affect normal bowel elimination Nutrition, medications and inadequate exercise.
Urinary:
About one third of elderly people show no
decrease in renal function. Therefore, changes in
renal function may be a combination of aging and
pathological conditions such as hypertension.
Older adults who take medications may
experience serious consequences due to decline in
renal function because of impaired absorption,
decreased ability to maintain fluid and electrolyte
balance, and decreased ability to concentrate
urine.
(Brunner & Suddarth pg. 233)
Immobility and constipation
Clients confined to bed are often constipated.
Physical activity promotes peristalsis, whereas
immobilization depresses peristalsis. Weakened
abdominal and pelvic floor muscle impairs the
ability to increase intraabdominal pressure and to
control the external sphincter. muscle tone may
be weakened or that impairs nerve transmission
so patient are more prone to constipate.(P&P p
1337)
Diet, Age and Constipation
Regular daily food intake helps maintain a
regular pattern of peristalsis in the colon. Fiber,
the indigestible residue in the diet, provides the
bulk of fecal material. Diet with low residue
which move more slowly through the intestinal
tract and can’t create sufficient residue of waste
products to stimulate the reflex for defecation.
With aging, stool passes through the intestines
at a slower rate and the perception of stimuli that
produce the urge to defecate often
Risk for constipation r/t
immobility, age
medication, diet, low
fluid intake
4
diminishes.(P&P p 1377)
A
C
C
E
P
T
A
N
C
E
A
C
C
E
P
T
A
N
C
E
Affect:
withdrawn, sad, cheerful, angry, blank
expression- Client is confused and unresponsive to questions.
(O)
Ability to communicate (verbal & non-verbal) – Client
was not able to communicate. (O)
Barriers to communication: language, facility, aphasia,
tracheotomy/E.T. tube, perceptual impairments,
developmental disorders, etc.- Client is confused and
unresponsive. (O)
Primary language /ability in English- English (O)
Understanding of health status/reason for hospitalizationUnable to assess.
Any manifestation of anxiety/describe behavior- Unable to
assess.
Coping mechanisms used- Unable to assess.
Self concept/body image; self esteem- Unable to assess.
Family
constellation/role
within
family;
living
arrangements; significant others – Unable to assess.
Stage of growth and development: achievement of
developmental tasks; give evidence- Unable to assess.
Family situation: recent changes or crises - Unable to
assess.
Hobbies- Unable to assess. (O)
Level of education – Unable to assess.(O)
Cultural/ethnic influences – Unable to assess (O)
Formal religion; spiritual needs- Unable to assess. (O)
Economic situation (socioeconomic status) - Unable to
assess. (O)
Occupation: specific role – Unable to assess.
Support systems: church groups, AA, etc. Unable to
assess. (O)
Patterns of sexual function (alterations associated with
illness) - Unable to assess. (O)
Stress and coping:
Common stressors of old age include normal
aging changes that impair physical function,
activities and appearance; disabilities from
chronic illness; social and environmental losses
related to income and decreased ability to
perform previous roles and activities; and deaths
of significant others.
(B & S, pg. 229)
Anxiety
Anxiety may increase or decrease the ability of a
person to pay attention. Anxiety is uneasiness or
uncertainty resulting from anticipating a threat or
danger. When faced with change or the need to
act differently, a person feels anxious when there
in no one to take care them. (P&P, p. 456)
Powerlessnes related to
hospitalization and
limited mobility as
evidenced by pt unable to
perform ADL’S.
Anxiety related to
situational crisis
(hospitalization and
illness) as evidenced by
client’s nonverbal
complaint of pain and
discomfort.
5
Menstrual history and pattern- Unable to assess. (O)
Reproductive history/disorders; menopause historyUnable to assess. (O)
Urethral, vaginal discharge- None recorded in chart. (O)
S
A
F
E
T
Y
S
A
F
E
T
Y
Allergies: Manifestation- Penecillin and Tynenol
Stage of consciousness: alert, confused, drowsy, lethargic,
stuporous, and comatose –
Client is confused and lethargic. (O)
Orientation: person, place, time Unable to assess. (O)
Ability to recognize & respond to environmental
hazardsUnable to assess. (O)
Memory: immediate, recent, remoteRecent: Unable to assess (O)
Immediate: Unable to assess. (O)
Remote: Unable to assess. (O)
Pupillary response: PERRLA
- Pt pupils are equal, round and respond to light. (O)
Senses: taste, touch, smell, pain, sight, hearingTaste: Unable to assess. (O)
Touch: Client sensed when she was touched; but moving her
head towards the person who touched her. (O)
Pain: Pt feels pain when we are giving her AM care, mostly
on the lower extremities(S)
Sight: Unable to assess; but no assistive devices were
observed
Hearing: Client moved head towards my voice when I spoke
to her. (O)
Assistive devices: glasses, lens, hearing aid – None were
observed. (O)
Risk for fall
“ Risk for falls is significantly higher in older
clients “ balance and mobility problems” “
sensory impairment”(visual and hearing problem)
(P&P pg 966)
Hospitalization:
An illness that requires hospitalization or a
change in lifestyle is an imminent treat to wellbeing. Older people admitted to the hospital are at
high risk for disorientation, confusion, change in
level of consciousness, and other symptoms of
delirium as well as fear and anxiety.
(Brunner & Suddarth, pg. 248)
Risk for injury r/t altered
vision, poor gait,
unknown environment
and age .
Disturbed sensory
perception r/t altered
vision AEB client’s
confused state.
Risk for infection r/t IV
Intravenous Infusions:
There are numerous hazards that a pt. can infusing in left arm and
encounter when receiving IV therapy due to the Foley catheter.
introduction of microorganisms. These include
local complications like phlebitis, infiltration,
hematoma or clotting of the needle and systemic
6
S
A
F
E
T
Y
Symmetry of facial expressions, tongue, smileSymmetrical facial expressions, tongue. (O)
Condition of hair, nails, mucous membranes of mouth,
nose, and conjunctiva, tongueHair: clean, gray. (O)
Nails: Clean, intact, and no cracking on fingernails but toe
nails are dry and thickened.(O)
MM of mouth, nose, conjunctiva & tongue: pink, intact, and
moist. (O)
Condition of skin: describe wounds, stages of decubiti,
I.V. sites, dressings, scars, rashes, nodules, ecchymosis –
Client had a IV line infusing in her Left arm. (O)
Stage IV sacra; decubiti ulcer (8x10 cm; 3cm depth). (O)
Other factors that may affect skin integrity – Immbobility.
(O)
Condition of breasts: symmetry, contour, puckering,
nipple discharge, gynecomastia- Pt breasts are symmetrical
with no abnormalities seen on assessment. (O)
Comfort status: itching, burning, nausea, hunger, pain
(character, location, onset, duration, relief measures)Unable to assess. (O)
Other factors that may affect comfort status –
Hospitalization; immobility; (O)
Fluid status: IV type and rate, medication added -1000 ml
0.45% NaCl at 50 cc/hr; 5%dextrose
I&O: Date: 03/11/08: Intake : IV: not recorded PO: ?
S
A
F Output : Urine: 300cc; Other: none
E 05/07/08 Intake: IV: 1000 cc PO: 300 cc of water and 80%
of lunch
T
Output: Urine:
Y
Skin turgor, rapid weight gain or loss, condition of
mucous membranes of mouth- Skin turgor is normal. The
MM of the mouth is pink and intact. No weight changes
reported. (O)
Other factors that may affect fluid and electrolyte status –
Medications, nutrition (O)
complications which are more serious like
infections.
(Brunner & Suddarth pg. 290)
Skin:
With aging changes in appearance and function of
the skin include: thinner dermis, decreased
subcutaneous fat, decreased blood supply, loss of
resiliency and wrinkling. The skin becomes drier
and susceptible to injury and infection.
(Brunner & Suddarth pg. 233)
Dry feet nails
A normal healthy nail is transparent, smooth, and
convex, with pink nail bed and translucent white
tip. Disease can cause changes in the shape,
thickness and curvature of the nail.(P&P p. 695).
Some people have dry feet because of a decrease
in sebaceous gland secretion, dehydration, pf
epidermal cells and poor condition of footwear. If
foot or mails problems stay unresolved the client
can easily become disabled and risk for infection
on cracked nails (Brunner & Suddarth p. 1013)
Fluid and electrolyte imbalance:
Illnesses, trauma, surgery and medications can
affect the body’s ability to maintain fluid
electrolyte and acid-base balance. Tissue trauma
causes fluids and electrolytes to be lost from
damaged cells. Medications and other diseases
can also result in abnormal losses of electrolytes
and fluid loss or retention.Older adults have
decreased thirst sensation which may affect their
oral intake of fluids. Their kidneys have
decreased glomerulus’s filtration rate and the
Risk for deficient fluid
volume
r/t
age,
medication, loss of fluids
through
abnormal
routes(indwelling tubes)
and deviation affecting
access of fluids .
7
S
A
E
F
T
Y
Lab data and Diagnostic tests:
Lab: electrolytes:
Na: 142(135-145 mEq/L);
K: 4.1 (3.5-5.5 mEq/L);
Cl: 107 (96-108 mEq/L);
Ca: 9.1 (8.5-11.0 mg/dl) ;
Albumin:2.7 ( 3.5-4.9g/dl);
Bilirubin: Not recorded. (0.1-1.2 mg/dl);
Alk. Phosphatase: Not recorded(30-110 u/l)
WBC: 8.2 (norm= 5.0-11.0);
culture reports: total cholesterol: Not recorded; LDL: Not
recorded (norm= < 130mg/dL); HDL: 48 (norm= 3585mg/dL); triglycerides: Not recorded. (norm= 40150mg/dL); liver function test, etc.- N/A
Other significant lab data (include significant data not
specified, such as serum levels of drugs, endocrine testes,
etc.) N/A
Diagnostic tests results (scans, MRI, echo, etc.) – N/A
Risks Associated with Diagnostic and Therapeutic
Modalities (Some examples include anticipation of
common problems identified with: perioperative care,
use of restraints, nasogastric tube feeding, blood therapy,
total parenteral nutrition, chest tubes, central lines,
surgical procedures, etc.)- - Pt at risk for infection due to
invasive medical procedures (IV on L arm and Foley
catheter.(O).
Body temperature patterns x 2 days05/01/2008: 97.6 F
05/02/2008: 97.1 F
Recent exposure to infections- IV site on L arm and foley
catheter(O)
Manifestations of active infection- swelling, redness, pain
on old IV site.(O)
Immunization: inquire about status including TD,
Hepatitis B, Flu, and Pneumococcal-No records of
immunization in the charts.
number of filtering nephrons. These changes may
mean that in the presence of sodium depletion or
overload the older adult may not able to maintain
homeostasis and the imbalance instead can be
worsened. Medications can cause fluid and
electrolytes imbalance. Nurses can closely
examine laboratory values and knowledge of the
clients about side effects and adherence to
medication schedule.(P&P,1149). All clients with
cathetrization should have 2000-5000 ml oral or
IV intake .A high fluid intake produces large
amount of urine that flashes the bladder and keps
the catheter fre of sediment.( Brunner & Suddarth
,1350)
Foley catheter
Catheterization of the bladder involves
introdusing a rubber or plastic tube through the
urethra and into the bladder.The catheter provides
continuose flow of urine if client is unable to
control
micturation
or
those
with
obstructions.Bladder catheterization carries risk
of UTI,blockege and thrauma to the urethra.When
inserting the indwelling catheter closed urinari
drainage system is maintained to prevent
infections.The bag should be hang on the bed
frame not touching the floor below the level of thr
bladder.Urine in the bag can become midium for
bacteria and infection is likely to develop if thr
urine flows back in the bladder.Break in the
system can lead to infection .Sites at risk are the
site of catheter insertion,the drainage bag ,the
tube junctionand the junction between the tube
and the bag.(P&P,1350)
8
Medications: major risks associated with side
effects/interactionVitamin C 1000mg PO daily
Cozaar 50mg PO daily
Atenol 50 mg PO daily
Gentomyacin 1000 mL IVPB
O
X
I
G
E
N
A
T
I
O
Alcohol and/or unprescribed drug use: Unable to assess.
Discharge Planning: )
1. Where will the client be going after discharge?
Unable to assess. (O)
2. If returning to home, inquire about home
environment:
adequate space, stairs to climb, cooking
facilities, hazards. N/A
3. Ability to manage health problem, knowledge base,
motivation, constraints, role of significant others, teaching
needs, affordability of medications, supplies and
equipment.
Unable to assess. (O)
4. Medical follow-up: understands need for,
transportation to PMD, clinic, and labs. Need complete
assistance.
5. Anticipated need for referral: Social Worker, Visiting
Nurse, and other Home Care Services. Unable to assess.
(O)
Chest pain, describe- Unable to assess. (O)
Nails, lips skin, mucus membranes: color/temperature Pt. nail beds, lips and MM are pink and intact. Skin is cold to
touch, clammy and diaphoretic. (O)
Capillary refill: upper extremities:
4 seconds (O)
Pulse - rate, rhythm, quality (rate pattern x 2 days)05/01/2008: 88
05/02/2008: 74
The respiratory system changes throughout the
aging process and it is important for nurses to be
aware of these changes when assessing patients .
Nurses should be aware that the older adult is at
risk for aspiration, and infection related to these
changes.
(Brunner & Suddarth p728)
LABS:
Impaired gas exchange
r/t
alveolar-capillary
membrane changes AEB
abnormal breathing rate,
dyspnea and restlessness
9
N
O
X
Y
G
E
N
A
T
I
O
N
O
X
Y
G
E
N
A
T
I
O
N
Rhythm was
Compare apical / radial pulses - Apical: 76 Radial: 77
Peripheral pulses: presence, volume, compare bilaterally
(brachial, radial, femoral, political, posterior tibia, dorsal
pedals) – All peripheral pulses are present but very weak (O)
Homan's sign- Negative (O)
Edema: degree and location/measure abdominal girth
p.r.nPt has no edema. (O)
Distention of neck veins- No distension of neck veins
noticed. (O)
Blood pressure pattern x 2 days05/01/2008: 163/82
05/02/2008: 172/88
Other factors that may effect the cardiovascular system –
immobility, non productive cough(O)
Activity tolerance – Client is bed bound. (O)
Orthopnea- Client is in semi-fowlers. (O)
Shape of chest- Chest symmetrical ,normal(O)
Respiration-rate, rhythm, depth, patterns, use of
accessory muscles, symmetry of chest movements, rate
pattern x 2 days05/01/2008: 18
05/02/2008: 18
There is symmetry of chest movements. (O)
Breath sounds: clear, course, crackling, wheezing- clear
breath sound s. (O)
Location of adventitious sounds – none. (O)
Cough:
frequent, infrequent, dry, loose, barking,
productive, etc.Client was not observed coughing. (O)
Sputum: color, tenacity, amount, color- Client had no
sputum. (O)
Assistive measures: oxygen therapy (kind), tracheotomy,
ventilator with E.T. tube, etc. – N/A
History of smoking tobacco/marijuana:
amount,
RBC: cellular component of blood involved in
transport of oxygen and carbon dioxide.
Hemoglobin: iron-containing protein of RBCsdelivers oxygen to tissues. Decreased level of
hemoglobin reflects the presence of fewer than
normal RBCs in circulation. As a result, the
amount of oxygen delivered to tissues is also
diminished.
Hematocrit: Is percentage of total blood volume
consisting of RBCs. Decreased hematocrit may
indicate anemia or acute massive blood loss.
PT and APTT: Indicates time taken for clotting to
occur. Lengthen PT and PTT may indicate risk
for bleeding.
Albumin: In the blood, albumin acts as a carrier
molecule and helps maintain blood volume and
blood pressure.
(Brunner & Suddarth p1045, Taber’s p66, p1796)
) Cardiac output in the older adults may be
affected by increased arterial wall tension and
moderate myocardial hypertrophy due to an
increased systoloc blood pressure(P&P,1069).
If left ventrical failure is significant the amount
of blood ejected from left ventrical drops and
decreases cardiac output.Assesment fundinggs
may include decreased activity
tollerance,breatlessness,dizziness and confusion
as a result of tissue hypoxia.(P&P,1078)
Lack of movement and exercise places clients at
higher risk for reparatory complications. The
most common respiratory complications are
Ineffective breathing
patern r/t
anxiety,decreased
energy/fatigue as
evidence by use of
accesory muscle to
breath and deapth of
breating
Decreased cardiac output
r/t altered stroke volume
AEB
clammy
skin,
altered peripheral pulses
prolonged capillary refill
and confusion
10
durationUnable to assess.
Other factors that may affect the respiratory system –
Medication, HTN,
Lab: RBC count: 3.23 (norm= 4.0-5.50); Hgb.: 10.1
(norm= 12-15.g/dL); Hct.: 29.3 (norm= 35-47);
Platelet: 449 (norm=150-450);
ABG's: Ph: 7.45 (7.35-7.45)
Pco2: 37.1(35-45)
PO2: 80.2 (75-100)
HCO3: 24.4(22-26)
cardiac enzymes: Unable to assess. (O),
; PT: Not recorded(norm= 11-12.5); APPT: Not recorded.
(norm=); INR: 2.9(norm= 3.0-4.5); Guaiac Tests: no
record
Pulse oximetry results: 96% (O);
EKG report: Normal Sinus Rhythm; performed on
x-ray/lung scans: None recorded in chart.
pulmonary function tests: N/A
atelectasis (collapse of alveoli) and hypostatic
pneumonia (inflammation of the lung from stasis
or pooling of secretions). Both decreases
oxygenation, prolong recovery, and add to the
client’s discomfort. (P&P 1428)Encourage early
ambulation after surgery walking causes client to
assume a position that do not restrict expansion of
the lungs and stimulates an increased RR
.(P&P,1638)
General appearance: muscular, wasted, emaciated, obese,
well nourished-Client is emaciated. (O)
Height and weight patterns of gain or loss- Not able to
determine
Weight: compare current weight with ideal weight- lb (O)
Condition of teeth & gums, ability to chew and swallowClient’s gums were pink and spongy; gag reflex was present.
Client had no teeth and no dentures were observed. (O)
Usual eating patterns: describe the patient’s usual diet for
breakfast, lunch and dinner on a week day and on a
weekend day; identify usual number of servings of CHO,
protein, milk, vegetables, fruits and fats on a regular day
and frequency of intake of fast foods, fried foods, deserts,
etc.- observation of lunch only: client is on soft mechanical
cardiac diet. (O)
N Intake of caffeine, alcohol, sodium, processed foods, fiber-
With clients need assistance with feeding it is
important to protect client’s safety, independence
and dignity. The nurse should asses client ‘s risk
for aspiration. Client with more risk for aspiration
needs more assistance with feeding. Position
client in upright seating position. this client
should not use a straw .In addition the rate of
feeding is slower and more frequent chewing and
swallowing through the meal is need
it(P&P,1296-1298)
The American Heart association dietary
guidelines are intended to reduce risk factors for
the development. Dietarian therapy following
myocardial infarction includes initial reduction in
kilocalories ,soft textured foods and amounts of
fats ,sodium, and cholesterol that conform to
N
U
T
R
I
T
I
O
N
U
Risk for ineffective
airway clearance r/t pain
and immobility.
Feeding self-care deficit
r/t weakness, muscoloskeletal
impairment,
fatigue as evidence by
inability to ingest food
safely ,inability to chew
and complete a meal
Nutrition less than body
requirements
r/t
to
excessive
intake
in
relation of metabolic
need AEB weight less
than 10 % under ideal for
11
T
R
I
T
I
O
N
Client was observed eating 85% of lunch. (O)
Cultural/religious preferences Not able to determine
Alterations in eating patterns associated with illness &
hospitalization- Client is not able to feed self; assistance is
needed. (O)
Diet ordered/knowledge of compliance- .- Cardiac pureed
diet ,no salt
Appetite: assess usual intake and the last 2 days- Client
eats 80% of her meals. (O)
Lab: total protein:, serum albumin: also consider
relationship of Hgb. to nutritional statusGlucose levels – blood:, urine glucose:, acetone in urine:
Assistive measures for nutrition (i.e. tube feedings, TPN,
etc.)- N/A
Are current nutritional needs being met in terms of
calories, protein, vitamin, calcium, etc.?
Provide
objective data to support your decision. If feeding by
nasogastric, gastrostomy tubes or TPN: estimate caloric
intake for 24 hours
# 1 Priority Nursing Diagnosis
Ineffective tissue perfusion r/t decreased
hemoglobin concentration in blood, decreased
Hct, substance abuse aeb confusion, memory
impairment and extremity weakness
# 2 Priority Nursing Diagnosis
Impaired gas exchange r/t alveolar-capillary
membrane changes AEB tachycardia, decreased
carbon dioxide
AHA recommendations. Magnesium and folic
acid appeared to be important for primary
prevention .
Nursing intervention for hypertension ,coronary
artery disease and CHF include weight reduction
and limiting fat and salt intake.(P&P,250)
Caloric intake to the point of obesity overloads
the cells of the body with lipids .By requiring
more energy to maintain the extra tissue obesity
place a strain on the body’s cardiovascular
system(Brunner & Suddarth p101)
Outcomes
-
In 48 hrs, client will demonstrate adequate
tissue perfusion aeb increased strength in
extremities, able to remember recent events,
loss of confusion
Outcomes
-Pt lung fields maintain clear and remain free
of signs of respiratory distress by the end of
hospital stay.
height and frame
Implementation
1)Assess skin color and temperature, vital signs,
capillary refill and mental status.
2) Teach the client to recognize signs and
symptoms of ineffective tissue perfusion such as
change in skin color and temperature.
3) Administer 2 L oxygen nasal cannula
Implementation
1. Monitor respiratory rate, depth, pattern and
breathe sounds q2h.
12
-Pt will maintain adequate oxygenation and
gas levels within normal parameters during
hospital stay.
-Pt will have adequate peripheral perfusion
during hospital stay.
2. Administer supplemental O2.
3. Teach client to cough and deep breathing
exercise q2 hours.