Tuesday, June 29, 2010

Care Plan with comments by Dr. A.

Hi Victoria, Good work, see the few comments.

Dr. A

Sharon A. Aronovitch, PhD, RN
Faculty, ADN Program

Previous Message:
Please review the careplan and documentation. Thanks! Vickie

27 y/o male who, over the last year, has steadily gained weight, especially around his waist. After being diagnosed with Cushing’s Disease he attempted weight loss with a variety of OTC “remedies”. As a result he has liver failure and has been admitted for a liver biopsy. Has acute ascites, which is causing some dyspnea. Oxygen 2lpm NC. His extremities are atrophied. Has some abdominal pain, last rated 4/10 and constant. Fentanyl ordered PRN for pain. VS: AP, BP, R, oral temp, SpO2 IV: D5NS 65 ml/hr I&O: Restrict oral fluid to 300 ml during PCS Mobility: OOB to chair with assist, ambulate down hall x1 as tolerated with assist AOCs: Abdominal assessment – girth measured at level of umbilicus Respiratory management – IS x10 qhour PVA – lower extremities Comfort management

CP #1
Ineffective Breathing Pattern r/t decreased lung expansion AEB dyspnea
Patient will report ability to breath comfortably during PCS
1. Administer oxygen as ordered at 2lpm NC
2. Encourage patient perform IS x10 per hour
CP #2
Excess Fluid Volume r/t compromised regulatory mechanism AEB ascites
Patient will explain measures that are to be followed to treat excess fluid volume, especially fluid restrictions.
1. Restrict PO fluid intake to 300 ml uring PCS
2. Measure girth at umbilicus

CP # 1 – Rationale: According to Maslow adequate ventilation is a basic physiological need. With out effective breathing patterns oxygenation will be impaired and further complications can occur such as pneumonia .

Fluid management:
IV site right forearm without inflammation or edema, D5/NS infusing via pump at 65 ml/hour. Oral mucosa moist and pink, reviewed fluid restriction and I&O procedure with patient. Understanding verbalized.
Abdominal Assessment: {Abdominal girth is no longer a critical element.}
Curtain pulled for privacy, patent denied need to void, Head of bed at 30 degrees due to dyspnea and knees flexed 45 degrees. Abdominal girth 58 inches at umbilicus. Abdomen rounded and firm all quadrants. Bowel sounds active all 4 quadrants, Patient rates pain in ribs and general abdominal area at a constant 4 on a scale of 0-10. Not increased with palpation.
{This is an assessment for musculoskeletal management: Bilateral lower extremities noticeably atrophied. } Pedal pulses palpated bilaterally, skin warm to touch, capillary refill <3 seconds on bilateral toes, wiggles toes bilaterally, acknowledges light touch on dorsal and planter aspects of bilateral feet.
Reported patient’s pain to RN and medicated with fentanyl by RN. Assisted patient to left side and provided back rub. Mouth care and facial wash accepted. Patient stated, “I feel better now”
Respiratory Management:
Oxygen maintained at 2 lpn via NC. Head of bed in semi-fowler’s position skin on nares and ears intact with no redness noted. Assisted patient to fowler’s position, Lung sounds decreased bilaterally posterior upper and lower lobes. Performed IS x 10 repetitions. Reassessed lungs with {The correct term is clear.} normal breath sound upper bilateral lobes and right lower lobe, left lobe remains abnormal. No sputum expectorated.
Assisted patient to side of bed and dangled x1 minute. Assisted with ambulation in hall 50 feet, with nasal o2 tank. Returned to room and sat in chair. Tolerated activity with slight dyspnea. Patient stated, “Boy that really takes a lot of effort”

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