Med- Surg Papper:Topic- Cirrhosis Patient Information: Age-58 Mobility- Wheel Chair Diet-Regular Allergies- Penicillin, Hydrocortisone, corticosteroids, Vancomycin, hydrochloride. Level of care- Medical Care Current Diagnoses Acute Kidney injury Alcohol Abuse Insomnia Cirrhosis **** Type 2 diabetesmellitus Dyslipidemia GI bleed Vit B12 deficiency Possible Lymphoma Auto immune hemolytic Anemia Barrelts Esophagus Cerebrovascular accident with right side weakness Hypertension MEDICATIONS: Insulin lispro x3 Acetaminophen x2 Acetylsalic Acid x1 ( on Hold) Allopurinol x1 Amlodipin Besylate x1 Baclofen x1 Cyanocobalamin x1 Folic Acid x1 Multivitamin x1 Polyethylen Glycol x1 Vit D3 x1 Atorvatatin Calcium x1 Melatonin x1 Insulin Glargine Lantus x1 Gravol x1 Prednisone 1 HISTORY 2 sons and 1 daughter Seperated from Husband Unable to discriminate between what is safe and what is not + family takes advantage of her Decreased hearing on the right side ear Wearing glasses No significant emotional concerns Grade 8 education Worked as cook Mild symptoms of anxiety(depression) Surgical procedures with date: Dec. 14, 2014- open reduction internal fixation of right tib/fib. March 16,2016- open reduction internal fixation of right ankle Minimal assistant in feeding Risk for altered skin integrity Risk for elopement Unsafe smoker Objective 1. Client will take meds as prescribed 2. Client has increased ability to perform ADL 3. Client will live live in a safe and sanitary environment 4. Client will dress appropriately ( to go smoke) 5. Client will experience maximized functional potencial 6. Client will maintain a nutritionally appropriate diet. Occasional history of substance abuse ; e.g previously , family members have taken client out to drink alcohol and have left her in the community. Vital Sign; P-63 O2-98 BP-147/78 Weight- 89.2 PAPER MUST INCLUDE THE FOLLOWING: An introduction of the client including the patient demographics and background included any pertinent information. Only Discuss 1 of your clients major PMHX. (CIRRHOSIS). Briefly mention any comorbid illnesses that are relevant to the situation. For example if you are discussing Atrial fibrillation, a remote past history of hernia repair is not important whereas a clotting disorder would be. For the Main disorder only (CIRRHOSIS), Include: o appropriate treatments o medications o diagnostics o nursing assessments o expected patient presentation ? Identify all subjective and objective data The care plan portion must be presented using a Landscape chart format in this order: Assessment, Nursing diagnosis, Goals, Intervention, Rationale and Evaluation. Example: o It shall include: ? 2 appropriate nursing diagnoses ? 2 (S.M.A.R.T.) goals per diagnosis. ? A minimum of 3 (S.M.A.R.T.) nursing interventions that directly apply to each nursing diagnosis & goal ? Choose and identify one PRIORITY intervention for each goal based on what is relevant to the status of the client. ? Interventions must be supported by scientific rationale that has come from an academic, reliable source. ? Evaluate if the client was able to meet the goal based on the Nursing interventions that were chosen. **Please do not forget to identify priority interventions for the goals.
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