Nursing Care Plan

Nursing Care Plan

CLIENT CLINICAL PICTURE

Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for " atypical chest pain and hemoptysis". V/S BP 114/51, P 84, R 24, T 97.4. He seems alert and oriented x 3 and cheerful. Bowel sounds present x 4. Pt. has a red area on his coccyx. Silvadene treatments have been started. Pt. Has a fungal lung infection with a pleural suction drainage tube inserted in his chest . Pt is extremely thin with poor skin turgor with a diagnosis of cachexia ( wasting) secondary to malnutrition and infection. Patient is no known allergies to drugs but is allergic to aerosol sprays disinfectants and dust.. Advanced directives on chart. Code status DNR. Primary physician Dr. R, Thoracic surgeon Dr. L. Psychology Dr.W. There is PT, OT Dietary and Infectious Disease consults when necessary. He lives with his wife who he has been married to for 56 years. His son and his daughter come to visit him. He does not smoke. He wears dentures but did not bring them. He dose not use a hearing aid but he does have a hearing deficit.

Pt. is able to do all his ADL's with limited assistance. He wants to get better and leave the HSP. Pt. Stated' 90 days is to long to be here". Pt. States that he is concerned about caring for his tube site when he goes home and does not feel that his wife can do this for him.

Diet: Pureed Hi protein, low fat, anti-dumping with Calorie count (all meals) and drink supplements between meals. TPN @ 79cc/hr 12hr around the clock through PICC line

MEDICAL DIAGNOSIS: Empyema, Hemoptysis, Necrotizing pneumonia, Aspergillosis (Aspergillus fumigatus) cachexia secondary to malnutrition/infection, hypothyroidism, Diabetes Type II melitius , and...

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...trol. Home health aide / RN needs to understand this after discharge.

OUTCOME/GOAL STATEMENT: Short Term: Pt will verbalize feelings of concern regarding at home maintenance of self with SO prior to discharge. Long Term: (after discharge) Pt will work with home health care giver to relief frustration and avoid further depression.

Bibliography:

REFERENCES:

Brunner, L.S. & Suddarth, D. S Textbook of Medical- Surgical Nursing, 1988 6th ed. J. B. Lippincott Company, Philadelphia

Doenges, M. E. & Moorhouse, M. F. Nursing Care Plans 3rd ed. 1993 F.A. Davis Company, Philadelphia

Fischbach, Frances, A Manual of Laboratory & Diagnostic Tests, 4th ed., J. B. Lippincott Company, Philadelphia

Lewis, S.M. & Collier, I.C. Medical Surgical Nursing, 4th ed. Mosby Company, St. Louis.

Mosby Company. Folio Bound Drug Views 1994 St. Louis