In: Nursing
Case 2 (Ms. Brown continued, I need answers typed please I posted case 1 in the end if you need it).
Patient: Brown, Francine
DOB: 04/25/44
Medical Record Number: 09052016
Allergies: NKA
Precautions: Fall
Height: 5’ 2”
Weight: 60.4 kg
Ms. Brown condition improves, and she is discharged home after her admission to the hospital for her CVA. She has residual right-sided weakness in her arm and leg and a right-sided visual field cut. Ms. Brown is prescribed the following daily medications: metoprolol, warfarin, simvastatin, and furosemide.
Ms. Brown lives alone in an apartment and was set up with visiting nurse services and home physical therapy. She uses a walker to ambulate. The nurse notices that Ms. Brown drags her right foot when ambulating. Ms. Brown reports that she tires easily has been unable to complete her ADL’s aside from toileting and brushing her teeth.
What is a priority nursing diagnoses for Ms. Brown?
Set an outcome (goal statement) for this diagnosis.
What interventions would you take to meet this nursing outcome?
Fast forward one week: Write an evaluative statement for your nursing diagnosis. (You can embellish the story however you’d like.)
if you need case 1 here it is
Case 1
Patient: Brown, Francine
DOB: 04/25/44
Medical Record Number: 09052016
Allergies: NKA
Precautions: Fall
Height: 5’ 2”
Weight: 60.4 kg
Your patient, Ms. Brown, is admitted to the hospital after a CVA (Stroke) secondary to irregular heartbeat. She also has a history of HTN and hyperlipidemia. Ms. Brown lives alone and was found down on the floor by her neighbor. It was estimated she had been down on the ground for around 14 hours.
Ms. Brown is unable to walk at this time and is confined to her bed. She has a poor appetite and eats only bites at each meal. She has several episodes of bladder and bowel incontinence daily.
What are your primary concerns for Ms. Brown? Word two of these concerns as nursing diagnoses (one actual & one risk for)
Nursing Diagnosis statement actual (3 parts):
Nursing Diagnosis statement potential or “risk for” (2 parts):
Select an outcome (goal statement) for one of the nursing diagnosis selected from above.
What nursing interventions would you perform to treat these concerns? What interprofessional team members could you involve in the care of Ms. Brown?
Nursing diagnosis and interventions for a patient admitted with CVA are :-
Nursing diagnosis - Risk for development of pressure sores related to bed ridden status
Outcome -to prevent the development of pressure sores related to immobility
Nursing interventions are:-
- Assess the vitals of the patient
- Assess the patient for any pressure sores mainly the prone areas as the patient is bed ridden chances of pressure sores are high
- Change the position of patient every two hourly
- Use of comfort devices for positioning to maintain the correct position.
- Avoid moisture as it increases chances of sores and a area for bacterial growth.
- provide back care with powder to avoid moisture and for prevent breakdown of skin
- provide diet rich in protein and vitamin C for proper and timely healing of tissues
- maintain hydration status of the patient.
- use of air mattress to avoid pressure sores
-appropriate use of Braden score,if any pressure sores are there and also providing prompt sore care to the patient
2. Nursing diagnosis- Impaired mobility related to stroke as evidenced by bed ridden status of patient
Outcome - to improve the mobility status of the patient
Nursing interventions are :-
- Assess the vitals of the patient
- Help the patient to change there position
- Help the patient in activity of daily living
- Use of devices for to enhance mobility
- Providing emotional support to the patient
- Assess the patient for bed sores related to immobility
3. Risk for development of DVT related to immobility
Outcome - to prevent development of deep vein thrombosis and early identification of thrombosis to avoid complications like Pulmonary embolism.
Nursing interventions are :-
- assess the vitals of the patient
- assess the legs and other sites for signs of thrombosis like swelling, warmth, redness,
- advice the patient to keep the legs elevated
- advice and help the patient in doing range of motion exercise to prevent thrombosis
- assisting the patient to change position two hourly
- use of compression stockings as advised
- use of intermittent pneumatic compression devices to avoid vein thrombosis
4. Risk of fall related to altered mobility and mental status related to cerebrospinal vascular accident
Outcome - to prevent fall and associated complications
Nursing interventions are:-
- Assess the vitals of the patient
- Make the patient orient to the surrounding environment by using calenders ,clocks, pictures
- Keep the side rails up all time
- keep the floors dry especially of washroom
- proper lighting of the patient's room
- keep the height of bed low
- Don't leave the patient alone
- Assisting the patient while getting off of bed and vice-versa for washroom etc
5. Nursing diagnosis- Incontinence (urinary and fecal ) related to trauma to the centres controlling Bowe and bladder movement
Outcome - to prevent complications related to incontinence such as bed sores , infections etc
Nursing interventions are :-
- Assess the vital signs of the patient
- Assess the voluntary and involuntary reflexes
- Catheterization of the patient to avoid bed wetting and infections and pressure sores
- Use of diapers as the patient is unable to walk to the washroom
- Providing perineal care once a shift and also after every voiding movement to avoid risk for pressure ulcers and infections
Therapeutic interpersonal relationships will be used within the team members and would involve doctors ,nurses dieticians physiotherapist , nursing assistant will be included in the care of the patient.