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PLEASE READ THE CASE STUDY AND ANSWER THE QUESTIONS TO THE BEST OF YOUR ABILITY: Mr....

PLEASE READ THE CASE STUDY AND ANSWER THE QUESTIONS TO THE BEST OF YOUR ABILITY:

Mr. Jackson is 86 years old. He is admitted to HUMC for congested heart failure. He also has a history of renal failure and goes for dialysis on Mondays, Wednesdays and Friday. He has an AV fistula in his right hand. He also has a history of diabetes, hypertension and depression.

He is allergic to shrimp. He is a nonsmoker. He lives with his wife and two sons.

He is on a renal, low sodium, low cholesterol diet.

He is positive for clostridium difficile.

He suffered a stroke while he was in the hospital and now has left sided weakness.

12. How will you evaluate the nursing care that was provided after the care plan and implementation of his conditions?

Solutions

Expert Solution

Answer :

1 ) mpaired Physical Mobility is characterized by the following signs and symptoms that you can use in the assessment part of your nursing care plan:

  • · Inability to move purposefully within the physical environment, including bed mobility, transfers, and ambulation
  • · Inability to perform action as instructed
  • · Limited ROM

Goals and Outcomes

The goals of interventions are to avoid the hazards of immobility, prevent dependent disabilities, and assist the patient in restoring, preserving, or maintaining as much mobility and functional independence as possible, as evidenced by the following indicators:

  • Patient performs physical activity independently or within limits of disease.
  • Patient demonstrates measures to increase mobility
  • Patient demonstrates the use of adaptive devices to increase mobility

Nursing Assessment

Rationales

Check for functional level of mobility.

· Level 1: Walk, regular pace, on level indefinitely; one flight or more but more short of breath than normally

· Level 2: Walk one city block or 500 ft on level; climb one flight slowly without stopping

· Level 3: Walk no more than 50 ft on level without stopping; unable to climb one flight of stairs without stopping

· Level 4: Dyspnea and fatigue at rest

Understanding the particular level, guides the design of best possible management plan.

Evaluate patient’s ability to perform Activities of Daily Living efficiently and safely on a daily basis.

· 0 – Completely independent

· 1 – Requires use of equipment or device

· 2 – Requires help from another person for assistance, supervision, or teaching

· 3 – Requires help from another person and equipment or device

· 4 – Is dependent, does not participate in activity

Restricted movement influences the capacity to perform most activities of daily living. Safety with ambulation is a significant matter. Determines strengths or insufficiency and may give information regarding recovery. This helps out in preference of actions since different methds are used for the following: flaccid and spastic paralysis.

Assess for impediments to mobility

Identifying barriers to mobility (e.g., chronic arthritis versus stroke versus pain) guides design of an optimal treatment plan.

Assess the strength to perform ROM to all joints.

This assessment provides data on extent of any physical problems and guides therapy. Testing by a physical therapist may be needed.

Assess input and output record and nutritional pattern.

Pressure ulcers build up more rapidly in patients with a nutritional insufficiency.

Monitor nutritional needs as they relate to immobility.

Good nutrition also gives required energy for participating in an exercise or rehabilitative activities.

Evaluate the need for assistive devices.

Correct utilization of wheelchairs, canes, transfer bars, and other assistance can enhance activity and lessen the danger of falls.

Assess presence or degree of exercise-related pain and changes in joint mobility.

Examines development or recession of complications. May require to delay augmenting exercises and hold until further healing occurs.

Assess the safety of the environment.

Blockages such as throw rugs, children’s toys, and pets can further control and limit one’s ability to ambulate harmlessly.

Assess the emotional response to the disability or limitation.

Acceptance of temporary or more permanent limitations can vary broadly between individuals. Each person has his or her personal interpretation of acceptable quality of life.

Consider the need for home assistance (e.g., physical therapy, visiting nurse).

Obtaining suitable support or help for the patient can ensure a safe and proper progression of activity.

Assess the patient’s or caregiver’s understanding of immobility and its implications.

The risk for effects of immobility such as muscle weakness, skin breakdown, pneumonia, constipation, thrombophlebitis, and depression are also to be considered in patients with temporary immobility.

Note for progressing thrombophlebitis (e.g., calf pain, Homan’s sign, redness, localized swelling, a rise in temperature).

Prolonged bed rest or immobility allows clot formation in the impaired physical mobility nursing diagnosis.

Check for skin integrity for signs of redness and tissue ischemia (especially over ears, shoulders, elbows, sacrum, hips, heels, ankles, and toes).

Routine inspection of the skin (especially over bony prominences) will allow for prevention or early recognition and treatment of pressure ulcers.

Note elimination status (e.g., usual pattern, present patterns, signs of constipation).

Immobility promotes constipation, decreasing the motility of the gastrointestinal tract.

Nursing Interventions for Impaired Physical Mobility

Intervention of this condition includes prevention of dependent disabilities, restoring mobility when possible, as well as maintaining or preserving the existing mobility. Special patient care includes changing position, exercises, nutrition and giving a safe environment, etc. We look in detail at the nursing care plan for Impaired Physical Mobility:

Nursing Interventions

Rationales

Assist patient for muscle exercises as able or when allowed out of bed; execute abdominal-tightening exercises and knee bends; hop on foot; stand on toes.

Adds to gaining enhanced sense of balance and strengthens compensatory body parts.

Present a safe environment: bed rails up, bed in a down position, important items close by.

These measures promote a safe, secure environment and may reduce risk for falls.

Establish measures to prevent skin breakdown and thrombophlebitis from prolonged immobility:

· Clean, dry, and moisturize skin as necessary.

· Use anti embolic stockings or sequential compression devices if appropriate.

· Use pressure-relieving devices as indicated (gel mattress).

This is to prevent skin breakdown, and the compression devices promote increased venous return to prevent venous stasis and possible thrombophlebitis in the legs.

Execute passive or active assistive ROM exercises to all extremities.

Exercise enhances increased venous return, prevents stiffness, and maintains muscle strength and stamina. It also avoids contracture deformation, which can build up quickly and could hinder prosthesis usage.

Provide foam or flotation mattress, water or air mattress or kinetic therapy bed, as necessary.

These equipment decrease pressure on skin or tissues that can damage circulation, potentiating risk of tissue ischemia or breakdown and decubitus formation.

Promote and facilitate early ambulation when possible. Aid with each initial change: dangling legs, sitting in chair, ambulation.

These movements keep the patient as functionally working as possible. Early mobility increases self-esteem about reacquiring independence and reduces the chance that debilitation will transpire.

Show the use of mobility devices, such as the following: trapeze, crutches, or walkers.

These devices can compensate for impaired function and enhance level of activity. The goals of using such aids are to promote safety, enhance mobility, avoid falls, and conserve energy.

Help out with transfer methods by using a fitting assistance of persons or devices when transferring patients to bed, chair, or stretcher.

Learning the proper way to transfer is necessary for maintaining optimal mobility and patient safety.

Let the patient accomplish tasks at his or her own pace. Do not hurry the patient. Encourage independent activity as able and safe.

Healthcare providers and significant others are often in a hurry and do more for patients than needed. Thereby slowing the patient’s recovery and reducing his or her confidence.

Give positive reinforcement during activity. Patients may be unwilling to move or initiate new activity because of fear of falling.

This is to boost the patient’s chances of recovering and to increase his or her self-esteem.

Provide the patient of rest periods in between activities. Consider energy-saving techniques.

Rest periods are essential to conserve energy. The patient must learn and accept his her limitations.

Give medications as appropriate.

Antispasmodic medications may reduce muscle spasms or spasticity that interferes with mobility; analgesics may reduce pain that impedes movement.

Help patient in accepting limitations.

Let the patient understand and accept his or her limitations and abilities. Assistance, on the other hand, needs to be balanced to prevent the patient from being unnecessarily dependent.

Encourage resistance-training exercises using light weights when suitable.

Strength training and other forms of exercise are believed to be effective in maintaining independent living status and reduced the risk of falling in older adults.

Help patient develop sitting balance and standing balance.

This helps out in retraining neuronal pathways, promoting proprioception and motor response.

Turn and position the patient every 2 hours or as needed.

Position changes optimize circulation to all tissues and relieve pressure.

Keep limbs in functional alignment with one or more of the following: pillows, sandbags, wedges, or prefabricated splints.

This avoids footdrop and too much plantar flexion or tightness. Maintain feet in dorsiflexed position.

Encourage coughing and deep-breathing exercises. use suction as necessary. Make use of incentive spirometer.

Coughing and breathing prevent buildup of secretions. Incentive spirometry increases lung expansion.

Present suggestions for nutritional intake for adequate energy resources and metabolic requirements.

Correct nutrition is necessary to keep sufficient energy level. The patient will need adequate, properly balanced intake of carbohydrates, fats, proteins, vitamins, and minerals to provide energy resources.

Encourage a diet high in fiber and liquid intake of 2000 to 3000 ml per day unless contraindicated.

Liquids maximize hydration status and avoid hardening of stool. It also decreases risk of skin irritation or breakdown.

Set up a bowel program (e.g., adequate fluid, foods high in bulk, physical activity, stool softeners, laxatives) as needed. Note bowel activity levels.

Sedentary lifestyle contributes to constipation. A variety of interventions will promote normal elimination.

Offer diversional activities. Observe emotional or behavioral reactions to immobility.

Forced immobility may heighten restlessness and irritability. Diversional activity helps in refocusing attention and promotes coping with limitations.

Explain to the patient the need to call for help, such as call bell and special sensitive call light.

In impaired physical mobility, this intervention allows patient to have a sense of control and lowers fear of being left alone.

Set goals with patient or Significant Other for cooperation in activities or exercise and position changes.

This enhances sense of anticipation of progress or improvement and gives some sense of control or independence.

Reinforce principles of progressive exercise, emphasizing that joints are to be exercised to the point of pain, not beyond.

“No pain, no gain” is not always true! Pain occurs as a result of joint or muscle injury. Further damage is expected if inappropriate movement is continued.

Teach patient or family in maintaining home atmosphere hazard-free and safe.

A safe environment will help prevent injury related to falls. Home modification can help the patient maintain a desired level of functional independence and reduce fatigue with activity.

Give explanation 2about progressive activity to patient.

Providing small, attainable goals helps increase self-confidence and reduces frustration.

Risk for Decreased Cardiac Output

Nursing Diagnosis

· Risk for decreased cardiac output

Risk factors may include

· Fluid overload (kidney dysfunction/failure, overzealous fluid replacement)

· Fluid shifts, fluid deficit (excessive losses)

· Electrolyte imbalance (potassium, calcium); severe acidosis

· Uremic effects on cardiac muscle/oxygenation

Possibly evidenced by

· Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

· Maintain cardiac output as evidenced by BP and HR/rhythm within patient’s normal limits; peripheral pulses strong and equal with adequate capillary refill time.

Nursing Interventions

Rationale

Monitor BP and HR.

Fluid volume excess, combined with hypertension (common in renal failure) and effects of uremia, increases cardiac workload and can lead to cardiac failure. In ARF, cardiac failure is usually reversible.

Observe ECG or telemetry for changes in rhythm.

Changes in electromechanical function may become evident in response to progressing renal failure and accumulation of toxins and electrolyte imbalance. Peaked T wave, wide QRS, prolonged PR interval is usually associated with hyperkalemia. Flat T wave, peaked P wave, and appearance of the U waves usually indicate hypokalemia. Prolonged QT interval may reflect calcium deficit.

Auscultate heart sounds.

Development of S3/S4 is indicative of failure. Pericardial friction rub may be only manifestation of uremic pericarditis, requiring prompt intervention and possibly acute dialysis.

Assess color of skin, mucous membranes, and nail beds. Note capillary refill time.

Pallor may reflect vasoconstriction or anemia. Cyanosis is a late sign and is related to pulmonary congestion and/or cardiac failure.

Note occurrence of slow pulse, hypotension, flushing, nausea and vomiting, and depressed level of consciousness.

Use of drugs (like antacids) containing magnesium can result in hypermagnesemia, potentiating the neuromuscular dysfunction and risk of a respiratory or cardiac arrest. Use aluminum-hydroxide-based antacid.

Monitor for GI bleeding by guaiac testing all stools for blood.

Gastrointestinal bleeding is a known complication of renal failure; however, its pathogenesis remains uncertain. Some have attributed gastrointestinal bleeding to the effects of uremia on the gastrointestinal mucosa; others have suggested that uremia may affect platelet adhesiveness, which may explain the prolonged gastrointestinal bleeding seen in patients with renal failure. In addition, the role of heparinization and the widespread use of antiplatelet agents in patients on dialysis have been implicated in the etiology of gastrointestinal bleeding.

Investigate reports of muscle cramps, numbness of fingers, with muscle twitching, hyperreflexia.

Neuromuscular indicators of hypocalcemia, which can also affect cardiac contractility and function.

Maintain bed rest or encourage adequate rest and provide assistance with care and desired activities.

Reduces oxygen consumption and cardiac workload.

Monitor laboratory studies:

· Potassium.

During oliguric phase, hyperkalemia is present but often shifts to hypokalemia in diuretic or recovery phase. Any potassium value associated with ECG changes requires intervention. Note: A serum level of 6.5 mEq or higher constitutes a medical emergency.

· Calcium.

In addition to its own cardiac effects, calcium deficit enhances the toxic effects of potassium.

· Magnesium.

Dialysis or calcium administration may be necessary to combat the CNS-depressive effects of an elevated serum magnesium level.

Administer and/or restrict fluids as indicated.

Cardiac output depends on circulating volume (affected by both fluid excess and deficit) and myocardial muscle function.

Provide supplemental oxygen if indicated.

Maximizes available oxygen for myocardial uptake to reduce cardiac workload and cellular hypoxia.

Administer medications as indicated:

· Inotropic agents: digoxin (Lanoxin)

May be used to improve cardiac output by increasing myocardial contractility and stroke volume. Dosage depends on renal function and potassium balance to obtain therapeutic effect without toxicity.

· Calcium gluconate

Serum calcium is often low but usually does not require specific treatment in ARF. Calcium gluconate may be given to treat hypocalcemia and to offset the effects of hyperkalemia by modifying cardiac irritability.

· Aluminum hydroxide gels (Amphojel, Basaljel)

Increased phosphate levels may occur as a result of failure of glomerular filtration and require use of phosphate-binding antacids to limit phosphate absorption from the GI tract.

· Glucose and/or insulin solution

Temporary measure to lower serum potassium by driving potassium into cells when cardiac rhythm is endangered.

· Sodium bicarbonate or sodium citrate

May be used to correct acidosis or hyperkalemia (by increasing serum pH) if patient is severely acidotic and not suffering from fluid overload.

· Sodium polystyrene sulfonate (Kayexalate) with or without sorbitol.

Exchange resin trades sodium for potassium in the GI tract to lower serum potassium level. Sorbitol may be included to cause osmotic diarrhea to help excrete potassium.

Prepare for/assist with dialysis as necessary.

May be indicated for persistent dysrhythmias, progressive HF unresponsive to other therapies.

Risk for Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis

  • · Nutrition: imbalanced, risk for less than body requirements

Risk factors may include

  • · Protein catabolism; dietary restrictions to reduce nitrogenous waste products
  • · Increased metabolic needs

Possibly evidenced by

  • Renal diet low sodium low cholesterol diet

Desired Outcomes

  • · Maintain/regain weight as indicated by individual situation, free of edema.

Nursing Interventions

Rationale

Assess and document dietary intake.

Aids in identifying deficiencies and dietary needs. General physical condition, uremic symptoms (nausea, anorexia), and multiple dietary restrictions affect food intake.

Provide frequent, small feedings.

Minimizes anorexia and nausea associated with uremic state and/or diminished peristalsis.

Give patient/SO a list of permitted foods or fluids and encourage involvement in menu choices.

Provides patient with a measure of control within dietary restrictions. Food from home may enhance appetite.

Offer frequent mouth care or rinse with diluted acetic acid solution. Give gums, hard candy, breath mints between meals.

Mucous membranes may become dry and cracked. Mouth care soothes, lubricates, and helps freshen mouth taste, which is often unpleasant because of uremia and restricted oral intake. Rinsing with acetic acid helps neutralize ammonia formed by conversion of urea.

Weigh daily.

The fasting or catabolic patient normally loses 0.2–0.5 kg/day. Changes in excess of 0.5 kg may reflect shifts in fluid balance.

Monitor laboratory studies: BUN, albumin, transferrin, sodium, and potassium.

Indicators of nutritional needs, restrictions, and necessity for and effectiveness of therapy.

Consult with dietitian support team.

Determines individual calorie and nutrient needs within the restrictions, and identifies most effective route and product (oral supplements, enteral or parenteral nutrition).

Provide high-calorie, low to moderate protein diet. Include complex carbohydrates and fat sources to meet caloric needs and essential amino acids

The amount of needed exogenous protein is less than normal unless patient is on dialysis. Carbohydrates meet energy needs and limit tissue catabolism, preventing keto acid formation from protein and fat oxidation. Carbohydrate intolerance mimicking DM may occur in severe renal failure..

Maintain proper electrolyte balance by strictly monitoring levels.

Medications and decrease in GFR can cause electrolyte imbalances and may further cause renal injury.

Restrict potassium, sodium, and phosphorus intake as indicated.

Restriction of these electrolytes may be needed to prevent further renal damage, especially if dialysis is not part of treatment, and/or during recovery phase of ARF.

Administer medications as indicated:

· Iron preparations

Iron deficiency may occur if protein is restricted, patient is anemic, or GI function is impaired.

· Calcium carbonate

Restores normal serum levels to improve cardiac and neuromuscular function, blood clotting, and bone metabolism. Note: Low serum calcium is often corrected as phosphate absorption is decreased in the GI system. Calcium may be substituted as a phosphate binder.

· Vitamin D

Necessary to facilitate absorption of calcium from the GI tract.

· B complex and C vitamins, folic acid

Vital as coenzyme in cell growth and actions. Intake is decreased because of protein restrictions.

Risk for Infection

Nursing Diagnosis

  • · Risk for Infection

Risk factors may include

  • · Depression of immunologic defenses (secondary to uremia)

Possibly evidenced by

  • Positive for clostridium difficile

·

Nursing Interventions

Rationale

Promote good hand washing by patient and staff.

Reduces risk of cross contamination.

. Use aseptic technique when caring and manipulating IV and invasive lines. Change site dressings per protocol. Note edema, purulent drainage.

Limits introduction of bacteria into body. Early detection of developing infection may prevent sepsis.

Provide routine catheter care and promote meticulous perineal care. Keep urinary drainage system closed and remove indwelling catheter as soon as possible.

Reduces bacterial colonization and risk of ascending UTI.

Encourage deep breathing, coughing, frequent position changes.

Prevents atelectasis and mobilizes secretions to reduce risk of pulmonary infections.

Assess skin integrity.

Excoriations from scratching may become secondarily infected.

Monitor vital signs.

Fever (higher than 100.4°F) with increased pulse and respirations is typical of increased metabolic rate resulting from inflammatory process, although sepsis can occur without a febrile response.

Monitor WBC count with differential.

Although elevated WBCs may indicate generalized infection, leukocytosis is commonly seen in ARF and may reflect injury within the kidney. A shifting of the differential to the left is indicative of infection.

Obtain specimen(s) for culture and sensitivity and administer appropriate antibiotics as indicated.

Verification of infection and identification of specific organism aids in choice of the most effective treatment. Note: A number of anti-infective agents require adjustme

Nightingale answered 2 years ago
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