Question

Create a nursing care plan with 2 nursing diagnosis, one short term goal for each diagnosis, per diagnosis 5 interventions with rationale, and evaluation for the following patient.

75 y/o day #3 F nx HTN, DM, CAD/MI, CVA X2 W/ recent admission who presented as a notification for AMS & hypotension with unknown last know well. Noted to be hypothermia normotensive following limited commands not responding verbally withdrawing pain improved with IV bolus and warming blanket. Concern for transient AMS possibly infection source vs. medication induced syncope episode (polypharmacy hypoglycemia) vs. new stroke be seizure d/o.

Answer 1

1.Nursing diagnosis:altered mental status related to hypothermia

Short term goal:::To keep patients body temperature above 35 degrees Celsius

Nursing interventions:1)regulate the environment temperature or relocate the client to warm environment.keep the patient and linen dry-rationale:This will give gradual warming of the body.

2)control the heat source depends on patients physical response----rationale::body temperature should not be raised more than few degrees per hour.otherwise complications like hypotension,dyrythimia can occur.

3)cover the patient with warm blankets::::it provides passive method for rewarming .

4)give warm intravenous fluid:it produces a heat source

5)provide extra heat source such as heat lamp or radiant warmer:::it will raises the core temperature and improves circulation.

evaluvation::hypothermia is corrected and patient get oriented

2.Nursing diagnosis:::Hypotension related to fluid volume deficit secondary to altered levels of consciousness

short term goals:::to correct patients intake same as output

Nusing interventions::

1)monitor patients vitals frequently To know about hydration status and cardiac output

2.intravenous Ns should be administered To correct hypotension due to dehydration

3)check level of consciousness --to make sure that patient get improved or not

4)foot end of bed should be elevated---to ease the blood flow to the heart and improve circulation

5)administer dopamine infusion according to doctors order ----to increase cardiac output,heart rate,and heart contractility .

Evaluvation...patient b.p get improved after correcting fluid volume deficit .patient is conscious oriented