Question 3641

Question Answered step-by-step Sensory PerceptionJenna, partnership student nurse received report from the day shift RN she is working with for the new admission to the short-term rehabilitation unit at Samson Hospital: Mr. Tim Carson is an 83-year-old male with a left middle cerebral artery stroke. He has a history of hypertension for 25 years and insulin-dependent diabetes mellitus (IDDM) for 3 years, hyperlipidemia, and he wears reading glasses and bilateral hearing aids. Prior to the stroke, he was very active, working daily as a volunteer reader/assistant at a local elementary school, driving, worked in his garage tinkering on old cars, and enjoyed being with his family as much as possible cooking on the grill. He walked daily for 3 miles. He saw his pcp every 3 months for checkups. He enjoyed all foods, especially chips. His mother lived to be 90 with a history of HTN and two strokes. His father had two bka’s due to DM and chronic kidney disease-was on dialysis. He lived to be 84.1.     EBP: Etiology: What lifestyle factors, genetic predisposition, or other diseases contributed to the development of the disease/health problem the patient has?2.      EBP: Patho: Describe the pathophysiology of this disease/problem3.     EBP: What signs or symptoms would you assess for or expect to see? List at least 5 symptoms.4.     EBP: What labs would you follow and why? What are they indicating and what are normal values? What lab values would you expect to see with this disease process?5.     EBP: What diagnostic testing has been done or would you anticipate and why? What are you looking for with this testing?6.     EBP: What medications would you anticipate being ordered for this patient for his conditions? What do they do/Mechanism of Action? What are major side effects to monitor for if any? List at least 5 medications.7.     EBP: What interventions if any would you anticipate and why for his care?  List at least 5 interventions.8.     EBP: What complications would you assess for, either of the disease or of the treatment? How would these complications manifest (signs/symptoms)?9.     Teamwork: Who would be on the collaborative care team, including specialty medical service and how would nursing interact with them? List at least 5 team members.10.  Patient-centered: How would you ensure the patient’s comfort during their admission? List at least 3 interventions.11.  Patient safety: How would you ensure patient safety during their admission?   List at least 4 interventions.12.  Quality improvement: What quality indicators or CMS core measures would be influencing care and documentation? (CLABSI, CAUTI, falls)-look up on QSEN criteria and CMS core measures. List two indicators and how they influence care/documentation.13.  Informatics: What would be critical to ensure is charted so that the interdisciplinary team can utilize the EHR to monitor and direct care?14.  Patient-centered: What discharge teaching would you provide to the patient? Concisely summarize what specifically you would tell them in layman’s terms. (I.e. “amlodipine is a calcium channel blocker it is to treat high blood pressure you would take your blood pressure with a machine, call your PCP if your top number systolic is less than 100 mmHg, do not stop taking blood pressure medications abruptly as it can lead to rebound hypertension”).15.  Patient-centered: What psychosocial issues, patient concerns or preferences, or cultural issues that need to be addressed?~Caremap with 3 diagnoses (ONE risk for only).(#1 being the most urgent diagnosis/need for pt. care by the RN) (be sure to include related to and aeb in correct way for actual diagnosis and risk for-do not need related to-just aeb after the risk for… aeb);-supporting data (signs and symptoms, patient statements);-pt. goals.-RN interventions.-citations (where you got your info-e.g. your careplanning book, website)Reference: Nursing Care Plans Diagnosis, Interventions, & Outcomes. Authors: Meg Gulanick, Judith L. Myers Health Science Science Nursing NUR 100 Share QuestionEmailCopy link Comments (0)

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