Alert & Oriented x3

Allergic to Tetracycline

Independent, Uses walker

Bruises on arms from past blood tests otherwise skin intact and same colour

History of Anemia, Atrial fibrillation, breast cancer, Chronic kidney disease, Femoral condyle fracture, Peptic ulcer disease, upper gastrointestinal bleed, gastric ulcer, and h. pylori infection

Vital Signs

Hr – 82 Reg

Rr – 14

BP – 115/69

Temperature – 37.1

Spo2 – 94%

Pain denied

Pedal pulses present

MEDICATIONS

–        Edoxaban (Lixiana) TAB 30mg, oral, daily

–        Folic Acid TAB 1mg, oral, daily

–        Multivitamin with minerals (Centrum) TAB 1, oral, daily

–        Nicotine (Habitrol, Nicoderm) 21mg, 24hr patch 1, TD, daily

–        Pantoprazole Magnesium (Tecta), delayed release, tab 40mg, oral BID before meals

–        Thamine (vitamin B1) TAB 100mg, oral, daily

–         Titropium bromide (Spiriva Respimat), inhaler 2 puffs

PRN

–        Acetaminophen (Tylenol) suppository 650mg, rect, q4

–        Acetaminophen (Tylenol) suppository 650mg, oral, q4h

–        Melatonin sublingual (SL) TAB 3mg, nightly

–        Ondasetron (Zofran) 2mg/mL injection IV 4mg, q8h

–        Ondasetron (Zofran) 2mg/mL injection Subcut 4mg, q8h

–        Ondasetron TAB 4mg, oral, q8h

Subjective

“My veins are small that’s why they find them hard to find”

Risk for electrolyte imbalance as evidenced by history of chronic kidney disease and Acute Kidney Injury

Goal

Short term – Educate patient on benefits of healthy diet and fluid intake especially after physical activity. Give recommendations to reduce the risk of electrolyte imbalance as well as negative or side effects associated with it the day prior to discharge and ensure they receive a paper copy of the information that is legible and easy to understand.

Long term – Encourage movement of the patient after sitting and lying for ling hours and slowly develop an exercise plan specifically for the patient by the 3rd month and by the end the of the year have patient be consistent with exercise plan.

Nursing Interventions

–          Organize a focus teaching session explaining the benefits of healthy diet and fluid intake especially after physical activity.

–          Prepare a paper copy of the content cover for easy access to information that may be forgotten keeping in mind clients demographic

–          Test understanding of a patient, for instancing by asking question to ensure content cover is well understood.

1.     Identify current activity levels

2.     Add physical activities with daily care/routine

3.     Consult with a physiotherapist to produce an exercise plan appropriate for the patient.

Rationale

–          It is important for patients to understand their conditions as it can help increase the patients interest for recovery.

–          Creating a paper copy of information covered will allow for patients to go back and check information cover helping with the remembrance of important points

–          Test patient understanding will allow the nurse to truly know whether patient has understood or if changes are needed in the nurse’s delivery of the information. If the patient has not understood the content, then they have not been truly educated.

1.     By identifying current activity levels, we can find the amount of movement needed for the patient to improve overall health without exerting themselves.

2.     Starting with minimal movement during daily activities can make integrating to an exercise plan easier for the patient.

3.     A physiotherapist can help suggest exercises that will be beneficial to the patient.

Short Term – Not met, patient was discharged before education could be provided

Long term – Not met, unable to contact a physiotherapist to organize an exercise plan/