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 please help one more problem of nursing diagnosis

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

Patient problems

Dementia

It leads to depression and anxiety

Lower extremities edema

Insomnia

Kidney stone

Acute kidney injury

Small bowel obstructions

Unable to take over oral

Nausea and vomiting

Tingling sensation while urinated

Intermittent diarrhoea

Confused state etc..

NURSING DIAGNOSIS

Subjective data :

Patient says that , " am not able to remember my daily activities ".

Objective data :

As evidenced by patient had depression and anxiety and confused by mental status examination.

Goal ;

Patient recover from the dementia or patient able to do their daily activities .

NURSING interventions

Communicate with simple sentence as per their sensory ability or level of understanding

Providing skill training like personal care ( dressing , bathing , combing , eating etc)

Provide assistive technology is a broad term defining any item , piece of equipment ...

Provide an group therapy and discussion

Promote un scheduled time planning to them

Arrange all the articles as same as daily in their room for easy remembering the things...