Question

Discharge Plan Assignment Case: Cindy, 13, with poor nutritional intake, Bulimia Nervosa. Recently lost his father to alcoholism. lives with her mother in a private home. Has insurance coverage through mother. Resides in New York, Brooklyn, Zip code 11205.

A client scheduled for discharge back to their community New York, Brooklyn, Zip code 11205 from the acute care setting.

As the Community Health Nurse assigned to be the Case Manager for this client, you will be required to prepare a discharge plan of care for the client (template provided). Plan of care must focus on Primary,

Secondary and Tertiary levels of prevention for management of the client while in the community, resources and knowledge of the resources available within the community.

Students provided with a discharge plan template.

Points allotted as follows:

Identification of 3 Priority Nursing Diagnoses for care in the community – 12% Identification of Primary, Secondary and Tertiary levels of prevention appropriate for age, gender and diagnosis – 6% Setting S.M.A.R.T objectives for continuity of care in the community setting – 2.0% identify the health care agencies within the community (11205) that you would most likely collaborate with to ensure that your client receives optimal care in the community setting – 5.0%

Answer 1

#. Nursing diagnosis :-

1. Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic needs.

May be related to :-

Inadequate food intake; self-induced vomiting

Chronic/excessive laxative use

Possibly evidenced by :-

Body weight 15% (or more) below expected or may be within the normal range (bulimia)

Pale conjunctiva and mucous membranes; poor skin turgor/muscle tone; edema

Excessive loss of hair; increased growth of hair on the body (lanugo)

Amenorrhea

Hypothermia

Bradycardia; cardiac irregularities; hypotension

Desired Outcomes :-

Client will verbalize understanding of nutritional needs.

Client will establish a dietary pattern with caloric intake adequate to regain/maintain an appropriate weight.

Client will demonstrate weight gain toward the individually expected range.

Nursing Interventions with Rationale :-

For Bulimia Nervosa:

Supervise the patient during mealtimes and for a specified period after meals (usually one hour).

- Prevents vomiting during or after eating.

Identify the patient’s elimination patterns.

- To prevent self-induced vomiting.

Assess her suicide potential.

- Among patients with bulimia nervosa, warning signs include having more co-morbid psychiatric symptoms and reporting a history of sexual abuse.

Outline the risks of laxative, emetic, and diuretic abuse for the patient

- Bulimic patients may include abuse of laxatives, emetics, and diuretics.

2. Risk for Deficient Fluid Volume: At risk for experiencing vascular, cellular, or intracellular dehydration.

May be related to :-

Inadequate intake of food and liquids

Consistent self-induced vomiting

Chronic/excessive laxative/diuretic use

Possibly evidenced by (actual)

Dry skin and mucous membranes, decreased skin turgor

Increased pulse rate, body temperature, decreased BP

Output greater than input (diuretic use); concentrated urine/decreased urine output (dehydration)

Weakness

Change in mental state

Hemoconcentration, altered electrolyte balance

Desired Outcomes :-

Client will maintain/demonstrate improved fluid balance, as evidenced by adequate urine output, stable vital signs, moist mucous membranes, good skin turgor.

Client will verbalize understanding of causative factors and behaviors necessary to correct the fluid deficit.

Nursing Interventions with Rationale

Monitor and record vital signs, capillary refill, status of mucous membranes, skin turgor.

- Indicators of the adequacy of circulating volume. Orthostatic hypotension may occur with the risk of falls and injury following sudden changes in position.

Note amount and types of fluid intake. Measure urine output accurately.

- Patient may abstain from all intake, with resulting dehydration; or substitute fluids for caloric intake, disturbing electrolyte balance.

Discuss strategies to stop vomiting and laxative and diuretic use.

- Helping patients deal with the feelings that lead to vomiting and laxative or diuretic use will prevent continued fluid loss. Note: Patient with bulimia has learned that vomiting provides a release of anxiety.

Identify actions necessary to regain or maintain optimal fluid balance (specific fluid intake schedule).

- Involving the patient in the planning to correct fluid imbalances improves chances for success.

Review electrolyte and renal function test results.

- Fluid, electrolyte shifts, decreased renal function can adversely affect a patient’s recovery or prognosis and may require additional intervention.

- Administer and monitor IV