Question

The patient is 70 years old. She is suffering from dementia. The woman is currently undergoing depression as well as anxiety. She is confused. She has decided to relocate from t plaza (where she has been for three months) to our place because of the deterioration of her medical condition. She has undergone unusual mental alteration. She had moved to new place so as to receive care as she wasn’t able to look after herself while in her apartment. The woman reveals to me that she has experienced intermittent diarrhea over the past one week. In addition, she has had chills. She experienced neither fever nor abdominal pain however. Whenever she urinates, there is tingling. The patient doesn’t however have hematuria. Not even the urinary frequency. It unfolds to me that the patient‘s PO intake has considerably declined as she has been occasionally nauseous too, once including vomiting. The conjunctiva are non-injected, with pupils equal and round. The patient is not hard of hearing, ears and nose have a normal external appearance, oropharynx is clear and mucus membranes appear dry. The neck is supple, has no masses. The heart has a regular rate and rhythm, there are no pathologic abdominal aortic pulsations and there is no jugular venous distention. Normal effort for respiration and the lungs are clear to auscultation bilaterally. The abdomen is soft, nontender, non-distended, and there are no palpable masses and no pathological hepatosplenomegaly. Bowel sounds were present. There is no clubbing, cyanosis or ischemia. There are no bony deformities pathologic asymmetry or masses. These is trace lower extremity edema. Patient can ambulate with a walker. The skin has no rashes pathologic indurations/nodules/tightening on the exposed areas. She has also had insomnia, GERD, IBS, kidney stones and acute kidney injury, and small bowel obstruction (resolved without surgery).

Base on the patient assessment please help me to write care plan with three patient problem and

Patient Problem includes:
1. Nursing diagnosis 

2. Supporting evidence (subjective and objective data) 3. One SMART* goal. 

4. Minimum of 3 EB* interventions.

What lab need to do for this patient

Answer 1

1 Nursing Diagnosis for GERD

Imbalanced nutrition less than body requirements related to inability to intake enough food because of reflux possibly evidenced by nausea and vomiting.

Subjective data

• Nausea often with vomiting.

Objective data

• Vomiting

Desired goal

Patient will ingest daily nutritional requirements i accordance to her activity lrevel and metabolic needs.

Nursing interventions

• Accurately measure the patients weight and height.
• Obtain a nutrirtional history.
• Encourage small frequent meals of high calories and high protein foods.

2 Bowel incontinence related to lack of voluntary sphincter control secondary to cerebrovascular accident as evidenced by patient unable to control passage of stool.

Subjective data

Patient verbalizes diarrhea.

Objective data

The patient has started to experience the inability to control his bowel movements.

Nursing interventions

• The nurse will encourage and help the patient develop a daily bowel program based on the patients wants and needs.
• The nurse will assess the patients bowel movements and frequencies daily.
• The nurse will assess the patient feelings regarding self-control of bowel movements daily.

Desired outcomes

• Report reduction in frequency of stools return to more normal stoolconsistency.
• Identify or avoid contributing factors.

Altered urinary elimination related to mechanical obstruction possibly evidenced by tingling.

Subjective data

Patient verbalizes of tingling but no haematuria.

Objective data

Urinine tests

Desired outcomes

Void in normal amounts and usual pattern

Experience no signs of obstruction

Nursing intervention

Record Intake and output and characteristics of urine

Determine patients normal voiding pattern and note variations

Encourage the patient to walk if possible.