Developing a nursing care plan Directions: Utilize

Developing a nursing care plan Directions: Utilize the Millie Larsen Case Study and formulate one actual priority patient problem with supporting assessment data that demonstrates that this is a priority problem. The following need to be completed: Actual patient problem Related to Evidenced by the problem Expected Outcome area. The three nursing interventions need to include 1) one assessment type action, 1) one physical intervention that the nurse would perform, and 1) one patient teaching intervention. Give rationales explaining why each intervention will help alleviate or resolve this problem. For the evaluation step of this nursing care plan, you will need to speak to what & how you would evaluate your interventions’ effectiveness in meeting the desired patient goal/outcome, as if you carried this out. Identify the scientific reason for choosing this diagnosis based on Millie’s clinical condition. Summarize the overall degree of achievement of meeting the outcome. Can use this area to describe if modification or revision necessary. Situation: Patient Millie Larson Last hospitalization was from a clinic visit several weeks ago. She has history of hypertension, glaucoma, elevated cholesterol levels, osteoarthritis of knee, stress incontinence, osteoporosis and diabetes mellitus. Millie was at the clinic for routine examination and medication follow up. She was taking several anti-hypertensive and anti-diabetic medications, along with diuretics, and analgesics. During the follow up visit, Millie provided important details of how she views her current life situation. Millie stated that she had not felt right and was hoping that within this visit, she could obtain information about her health and what she might be able to do so that she could feel better. Testing and exam had found Millie to be dehydrated with some mild electrolyte imbalances. She was admitted to the hospital, swabbed for influenza, and placed on droplet precautions until testing is completed. Two hours later, Millie was found to be confused and pulling on the intravenous line that was inserted for necessary fluid replacement. The RN put Millie on “fall precautions” and obtained an order for soft restraints to keep Millie from pulling out the IV line. The provider also ordered a urine sample for testing to be obtained via straight catheterization if Millie is unable to void on her own. Update: Millie has now been hospitalized for several days and has developed a fever of 102 F with some productive coughing and difficulty breathing. She is also complaining of some pleuritic chest pain when she tries to take a deep breath. Her respiratory rate has increased to 26 breaths per minute, and her heart rate is 60, blood pressure is 98/66 mm Hg, O2 saturation is 90% on 6 L/min oxygen via nasal cannula. When the nurse assessed Millie’s lung sounds, she heard rhonchi and scattered crackles. A chest X-ray was obtained, and Millie is diagnosed with hospital-acquired pneumonia. A complete blood count was drawn, and the results show that Millie’s white blood cell count is 22,000. New orders have been obtained from the provider, and Millie is to be transferred to a Special Care Unit (SCU) to monitor her condition more closely. Blood and sputum cultures have been obtained, normal saline is infusing, and the higher dose of ciprofloxacin (Cipro) is being given. She was given a respiratory treatment by the RT and has not received any pain medication at this time. Millie still has a Foley catheter in place, and her urinary tract infection has resolved, but the provider still wants to strictly monitor her intake and output. Millie is lethargic and appears very ill and still is not eating well or taking in oral fluids as the provider would like. Her intake has only been 300 mL IV fluids, 50 mL oral intake plus sips, and output of 200 mL clear yellow urine.

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