Anemia-careplan for adult

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MIAMI DADE COLLEGE - MEDICAL CENTER CAMPUS - SCHOOL OF NURSINGNUR 1025L: Fundamentals Nursing Clinical

Students Name: Francisco J Ortiz Date:_07/15/13_ Clients Initials: ____ IH ___ Admission Date:_04/01/2013

Age: 91yr DOB: ______08/28/1921_____ Sex: Male X Female Race/Ethnicity: WHITE/______________Support System: _____son _________________________________________________________ Religion: _Catholic

MEDICAL HISTORYALLERGIES: _NKA_Admitting Medical Diagnosis (es): DMII; Fracture of humerus; dementia; hypertension; lipoidmetabolic disorder, iron deficiency; anemia

Chief Complaint: abnormal lab

History of Present Illness: Pt is a 91 yr old female historyfrom nursing home history of GI bleeding.Pt was sent back to the hospital because of low HH

Past Medical History (include past surgical history):Significant hypertension ,Dementia, asthma, DMII and hyperlipidemia; No alcohol abuse, no drugabuse

Clients (Parents)Understanding of Illness: patient has dementia and cannot recollect informationgiven

Stage of Development: Erickson Ego Integrity vs. Despair _ Freud: According to Freud, the genital

stage lasts throughout adulthood. He believed the goal is to develop a balance between all areas oflife. Piaget _ Formal Operational

____Special Developmental Considerations: N/AHeight: 162.56 cm Weight: 50 kg Placement in Growth Chart: _N/AImmunizations: Patient refused flu vaccine

VITAL SIGNSTime Taken: ______1000_________ Activity: ______________ Position: ____wheel chair__________

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T_36.4 P96 R 19 BP _129/68Baseline (Normal Age for Age):T_ 36.137.8 P_60 -100 R_12-20_ BP120/80 _

NUTRITIONDiet: REGULAR Food Preferences:_EXTRA SYRUP IN BREAKFAST, COFFEE AFTER LUNCH, COOKIEAFTER DINNERNutritional Requirements: (Cal/Kg/Day): 2100 CAL/KG/DAY Total Calories per Day: _1900___________Fluid Requirements (Ml/Kg/Day): __________________________________ ________________Total Fluids per Day:_______________________________

Special Treatments: ____________N/AMedications atHome:_N/A_____________________________________________________________________________________________________________________________________________________________________________________________________________

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Medication(s) Worksheet

NAMECLASSIFICATI

ON

DOSE/ROUTE/FREQUENCY SAFE RANGE

MECHANISMOF ACTION

INDICATIONS SIDEEFFECTS

NURSINGCONSIDERATIONS

AND PATIENTEDUCATION

Prilosec 20mg daily by mouth Binds to anenzyme ongastric parietalcells in thepresence ofacidic gastricpH, preventingthe finaltransport ofhydrogen ionsinto the gastriclumen.

GERD/maintenance of healingin erosiveesopha- gitis.Duodenal ulcers(with or withoutanti-infec- tivesfor Helicobacter

pylori). Short-term treat-ment of activebenign gastriculcer.Pathologichypersecretoryconditions,includingZollinger-El-lison syndrome.Reduction ofrisk of GIbleeding incritically illpatients.

CNS:dizziness,drowsiness,fatigue,headache,weakness.CV: chestpain. GI:abdominalpain, acidregurgitation,constipation,diarrhea,flatu- lence,nausea,vomiting.Derm:itching,rash. Misc:allergicreactions.

A Assess patientroutinely forepigastricorabdominal pain anfrank or occult bloin the stool, emesor gastric aspirate

Monitor CBC withdifferentialperiodically duringtherapy.

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Norvasc 10mg 1 tab PO Inhibits thetransport ofcalcium intomyocardialand vascularsmoothmuscle cells,resulting inin- hibition ofexcitation-contractioncoupling andsubsequentcontraction.

Indications:Aloneor with otheragents in themanagement ofhypertension,angina pectoris,and vasospastic(Prinzmetals)angina.

CNS:headache,dizziness,fatigue. CV:peripheraledema,angina,bradycardia,hypotension, palpita-tions. GI:gingivalhyperplasia,nausea.Derm:flushing.

Monitor blood pressureand pulse before therapy,during dose titration, andperiodically duringtherapy. Monitor ECGperiodically duingprolonged therapy.

Celexa 10mg 1 tab PO Selectivelyinhibits thereuptake ofserotonin inthe CNS.

Depression. CNS:NEUROLEPTICMALIGNANTSYNDROME,SUICIDAL

THOUGHTS,

apathy,

confusion,drowsiness,insomnia,weakness,agitation,amnesia,anxiety.

Assess for suicidaltendencies, especiallyduring early therapy anddose changes. Restrictamount of drug availableto patient. Risk may be

increased in children,adolescents, and mayminimize dry mouth. If drymouth persists for morethan 2 wk, consult healthcare professionalregarding use of salivasubstitute

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Namenda 10mg 1 tab PO Binds to CNSN-methyl-D-aspartate(NMDA) re-ceptor sites,preventingbinding ofglutamate,an excitatoryneurotransmitter.

Moderate tosevereAlzheimersdementia.

CNS:dizziness,fatigue,headache,sedation.CV:hypertension. Derm:rash. GI:weight gain.GU: urinaryfrequency.Hemat:anemia.

Assess cognitive function(memory, attention,reasoning, language,ability to perform simpletasks) periodically duringtherapy.

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Amaryl 4mg 1 tab PO (with

breakfast)Lower bloodglucose bystimulatingthe releaseof insulinfrom thepancreasandincreasingthesensitivity toinsulin atreceptorsites. Mayalso de-creasehepaticglucoseproduction.

Control of bloodglucose in type2 diabetesmellitus whendiet therapyfails. Requiresomepancreaticfunction.

CNS:dizziness,drowsiness,headache,weakness.GI:constipation, cramps,diarrhea,drug-inducedhepatitis,heartburn, qappetite,nausea,vomiting.Derm:photosensitivity, rashes.

Observe for signs andsymptoms ofhypoglycemic reactions(sweating, hunger,weakness, dizziness,tremor, tachycardia,anxiety).

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Zestril 10mg 1 tab PO ACEinhibitorsblock theconversionofangiotensin Ito thevasoconstrictorangiotensinII. ACEinhibitorsalso preventthedegradationofbradykininand othervasodilatoryprostaglandins. ACEinhibitorsalso qplasma reninlevels and pal-dosteronelevels. Netresult issystemicvasodilation.

Alone or withother agents inthemanagement ofhypertension.

CNS:dizziness,drowsiness,fatigue,headache,insomnia,vertigo,weakness.Resp:cough,dyspnea.CV:hypotension,chest pain,edema,tachycardia.Endo:hyperuricemia

Hypertension: Monitorbloodpressure and pulsefrequently during initialdose adjustment andperiodically duringtherapy. Notify healthcare professional ofsignificant changes.

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Ferrous sulfate 65mg tab with breakfast An essentialmineralfound inhemoglobin,myo- globin,and manyenzymes.Enters theblood-stream andistransportedto theorgans ofthe re-ticuloendothelial system(liver,spleen, bonemarrow),where it isseparatedout andbecomes

part of ironstores.

Prevention/treatment of iron-deficiencyanemia

CNS: IM, IVSEIZURES,dizziness,headache,syn- cope.CV: IM, IVhypotension,hypertension,tachycardia.GI: nausea;PO,constipation,dark stools,diarrhea,epigastricpain, GIbleeding;

Assess nutritional statusand dietary history todetermine possible causeof anemia and need forpatient teaching.

Assess bowel function forconstipation or diarrhea.Notify health careprofessional and use

appropriate nursingmeasures should theseoc- cur.

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Zocor 20mg 1 tab PO nightly Inhibit anenzyme, 3-hydroxy-3-methylglutaryl-co-enzyme A(HMG-CoA)reductase,which isrespon- sibleforcatalyzingan earlystep in thesynthesis ofcholesterol.

Adjunctivemanagement ofprimaryhypercholes-terolemia andmixeddyslipidemias.

CNS:dizziness,headache,insomnia,weakness.CV: chestpain,peripheraledema.EENT:rhinitis;lovastatin,blurredvision.Resp:bronchitis.

Obtain a dietary history,especially with regard tofat consumption.

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Aspirin 81mg daily PO Inhibits thesynthesis ofprostaglandins that mayserve asmediators ofpain andfever,primarily inthe CNS.Has nosignificantanti-inflammatory propertiesor GItoxicity.

Mild pain. Fever. GI: HEPATICFAILURE,HEPATOTOXICITY

(overdose).GU: renalfailure (highdoses/chronic use). He-mat:neutropenia,

pancytopenia,leukopenia.Derm: rash,urticaria.

Assess overall healthstatus and alcohol usagebefore administeringacetaminophen. Patientswho are malnourished orchronically abuse alcoholare at higher risk ofdeveloping hepato-toxicity with chronic useof usual doses of thisdrug.

Assess amount,frequency, and type ofdrugs taken in patientsself-medicating,especially with OTCdrugs. Prolonged use ofacetaminophen increasesthe risk of adverse renaleffects. For short-termuse, combined doses ofacetaminophen andsalicylates should not

exceed therecommended dose ofeither drug given alone.

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PATHOPHYSIOLOGY-BRIEF TEXTBOOK PICTURE WITH CLIENT COMPARISONDefinition, Etiology, Incidence, Pathophysiology, Diagnostic tests, Signs & symptoms, Medical

treatments

Textbook Client

Pathology- Incidence of anemia reflect the presence of bone

marrow failure or excessive loss of red blood cells or both.Bone marrow failure can occur due to nutritionaldeficiencies, toxic exposures, tumor, or mostly due to

unknown causes. Red blood cells can be lost through

hemorrhage or hemolysis (destruction) in the latter case, theproblem can be caused by the effects of red blood cells that

do not correspond to the resistance of normal red blood cellsor due to several factors outside the red blood cells that

causes red blood cell destruction.Red blood cell lysis (dissolution) occurs mainly in the

phagocytic system or in the reticuloendothelial system,

especially in the liver and spleen. As a byproduct of this

Patient has lab levels indicative of Low Iron anemia

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process the bilirubin that is formed in phagocytes will enter

the bloodstream. Any increase in red blood cell destruction(hemolysis) immediately reflected by increasing plasma

bilirubin (normal concentration of 1 mg / dl or less; levels of1.5 mg / dl result in jaundice in the sclera.

Anemia is a blood disease characterized less low levels of

hemoglobin (Hb) and red blood cells (erythrocytes). Thefunction of the blood is carrying food and oxygen to all

organs of the body. If the supply is less, then the intake ofoxygen will be less. As a result, can inhibit the work of the

vital organs, the brain One. The brain consists of 2.5 billionbioneuron cells. If capacity is lacking, then the brain will belike computer memory is weak, slow catch. And if it is

damaged, can not be repaired (Sjaifoellah, 1998).

Classification- Anemias can be classified by cytometric

schemes (i.e., those that depend on cell size and hemoglobin-content parameters, such as MCV and MCHC),

erythrokinetic schemes (those that take into account the ratesof rbc production and destruction), and

biochemical/molecular schemes (those that consider the

etiology of the anemia at the molecular level.

Etiology- The most common cause of anemia is deficiency of

nutrients required for the synthesis of red blood cells, such asiron, vitamin B12 and folic acid. The rest is the result of a

variety of conditions such as hemorrhage, geneticabnormalities, chronic disease, drug toxicity, and so on.

Patient anemias related to poor nutrition

Statistics-

7% of children aged 1-2 had anemia in the US 1999-2000

(MMWR, NCHS, CDC)

12% of women aged 12-49 had anemia in the US 1999-

2000 (MMWR, NCHS, CDC)

174,600 nursing home residents had anemia in the US

1999 (National Nursing Home Survey, NCHS, CDC)

10.7% of nursing home residents had anemia in the US1999 (National Nursing Home Survey, NCHS, CDC)

Patient lies within the range of those 23% of females havinganemia

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3.4 million cases in the US (Mayo Clinic)

1.3% of population self-reported having anemia inAustralia 2001 (ABS 2001 National Health Survey,

Australias Health 2004, AIHW)

0.3% of male population self-reported having anemia in

Australia 2001 (ABS 2001 National Health Survey,

Australias Health 2004, AIHW)

2.3% of female population self-reported having anemia in

Australia 2001 (ABS 2001 National Health Survey,Australias Health 2004, AIHW)

217,000 women self-reported having anemia in Australia2001 (ABS 2001 National Health Survey, Australias Health2004, AIHW)

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DIAGNOSTIC TESTS

Test(i.e. X-Ray, MRI, EEG, EKG)

RESULTSDate, Result, Significance

N/A

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Laboratory values

CHEMISTRYPROFILE

NORMALVALUES

CLIENTSVALUES

HEMOTOLOGY

NORMALVALUES

CLIENTS VALUES

DATE DATE

DATE DATE DATE

DATE

SODIUM 135-145

Meq/L

142

5/10/13

WBC 3.8-10.8

K/uL

4.82

5/10/13

POTASSIUM 3.5- 5.1mEq/L

4.55/10/13

RBC 3.80-5.20 2.06*L5/10/13

CHLORIDE 98-108mEq/L

1095/10/13

HGB 11.8-15.4g/dl

12.15/10/13

CO2 19-34 23.05/10/13

HCT 41-50 38*L5/10/13

CALCIUM 8.2-10.3mg/dL

7.75/10/13

MCV 79.4-94.8fL

90.75/10/13

GLUCOSE 70-105mg/dL

110(H)**5/10/13

MCH

BUN 7-25 mg/

Dl

36 (H)**

5/10/13

MCHC 25.6-32.2

pg

27.8

5/10/13CREATININE 0.6-1.2

mg/dL1.15/10/13

PLATELETS 11.5-15.0%

16.65/10/13

PHOSPHORUSCHOLESTEROL

DIFFERENTIAL

TOTALPROTEIN

6.4-8.9g/dL

6.45/10/13

NEUTROPHILS

ALBUMIN 3.5-5.0g/dL

3.485/10/13

SEGMENTS

ALBUMIN/GLOBULIN RATIO

2.975/10/13

BANDS

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AST (SGOT) 13-39 U/L 235/10/13

LYMPHOCYTES

ALT (SGPT) 7-52 U/L 155/10/13

EOSINOPHILS

TOTALBILIRUBIN

0.3-1.0mg/dL

BASOPHILS

AMYLASE MONOCYTES

LIPASECOAGULATION

STUDIESPTT

SODIUM 135-145Meq/L

1425/10/13

WBC 3.8-10.8 K/uL 4.825/10/13

POTASSIUM 3.5- 5.5mEq/L

4.55/10/13

RBC 3.80-5.20 2.06*L5/10/13

CHLORIDE 98-108mEq/L

1095/10/13

HGB 11.8-15.4g/dl 12.15/10/13

CO2 19-34 23.05/10/13

HCT 38*L5/10/13

CALCIUM 8.2-10.3mg/dL

7.75/10/13

MCV 90.75/10/13

GLUCOSE 70-105mg/dL 110(H)**5/10/13

MCH

BUN 7-25 mg/Dl

36 (H)**5/10/13

MCHC 27.85/10/13

CBC BMP

Hgb Na+

Cl-

BUNWBC Plts Glucose

Hct K+ HCO3 Creatinine

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URINALYSISCOLOR YELLOWAPPEARANCE CLEARSP. GRAVITY 1.010 MISCELLANEOUS

TESTPH 4.8 TEST NORMAL

VALUESCLIENTS VALUES

DATE DATE DATEGLUCOSE NORMA

L

URINE

CULTURE

PENDI

NG

07/17/1

3KETONE NEGATIVE

OCCULT BLOODPROTEIN NEGATI

VEBILRUBIN NEGATI

VEUROBILINOGEN NORMA

LNITRITE NEGATI

VELEUCOCYTE NEGATI

VE

CASTWBCRBCCRYSTALSSQUAMOUSCELLS/ EPITHELIALCELLS

Relate the clinical significance of abnormal lab values above:

GLUCOSE(HIGH)- INDICATIONS:- Symptoms of elevated glucose levels include abdominal pain, fatigue, muscle cramps,nausea, vomiting, polyuria, and thirst. Possible interventions include sub- cutaneous or IV injection of insulin with continuous glucose

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monitoring.

BUN(HIGH)- INDICATIONS:-A patient with a grossly elevated BUN may have signs and symptoms including acidemia,agitation, confusion, fatigue, nausea, vomiting, and coma. Possible interventions include treatment of the cause, administration of

intravenous bicarbonate, a low-protein diet, hemodialysis, and caution with respect to prescribing and continuing nephrotoxic

medications.

RBC(LOW)- INDICATIONS:-Low RBC count leads to anemia. Anemia can be caused by blood loss,

decreased blood cell production, increased blood cell destruction, or hemodilution.

HCT (LOW)- INDICATIONS:- High Hct leads to polycythemia. Polycythemia can be caused bydehydration, decreased oxygen levels in the body, and an overproduction of RBCs by the bonemarrow. Dehydration from diuretic use, vomiting, diarrhea, excessive sweating, severe burns, ordecreased fluid intake decreases the plasma component of whole blood, thereby increasing the ratioof RBCs to plasma, and leads to a higher than normal Hct. Causes of decreased oxygen includesmoking, exposure to carbon monoxide, high altitude, and chronic lung disease, which leads to amild hemoconcentration of blood

Head to Toe AssessmentGeneral Appearance:The pt is resting comfortably in no acute distress. No weight loss or gain. No feverHead & Hair: Norm cephalic and atraumatic

Face: Norm cephalic and atraumatic

Eyes: Norm cephalic and atraumaticEars: Norm cephalic and atraumaticNose: Turbinates bright red and swollen, mucous pink, no swellingLips/Mouth/Throat: No cracking/ lesions on lips, mouth is clean and free from debris, mild breath odor.

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Neck:Chest/Breast:Clear to palpation and auscultation lateral chest is larger than anterior/posterior diameter.Lungs:Clear to auscultation; no abnormal sounds heard.Heart:Normal rhythm sounds heart at the fine precordial points.Abdomen/Kidneys:Normal bowel sounds, no masses, lumps, or tenderness found.Genitalia (Internal Exam Deferred): N/ARectum (Internal Exam Deferred): N/AExtremities:No edema clubbing or cyanosisBack: no deformities

R.O.M.: Limited range of motion. Patient is in the wheelchair bound.Document findings on next page

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Plan of Care

Priority Nursing Diagnosis: Nursing Diagnosis: Imbalanced Nutrition Less Than Body Requirements

Risk Nursing Diagnosis: Risk of Enhance tissue perfusionSupporting Data: Patient reports of decreased exercise or activity tolerance

Subjective: Patient states I am tiredObjective: patient labs show abnormal lab levels after analysis

Expected Outcome (Goals)

Long Term: Provide patient nutritional/fluid needs to avoid further complication before discharge.

Short Term: After 1hr disease process/prognosis and therapeutic regimen will be understood by patient.

Nursing InterventionsNursing Actions Scientific Principle

and/or RationaleEvaluation Modification of Plan of

CareMonitor vital signs:Auscultate breath sounds,

heart rate and rhythm,respirations q 4 hours.

Respiratory systemmay become

decompensated.Tachycardia andchanges in bloodpressure may bepresent because ofpain, anxiety andreduced cardiacoutput.

BP is 129/68 Lungsounds are clear to

auscultation, respiratoryrate is between 20 to 24breaths per minute andpulse is at 96

Assess peripheral pulses,capillary refill, skin turgor,and mucous membranes q

Indicators of level ofhydration andadequacy of circulating

Mucous membrane aremoist, capillary refill isless than 2 seconds and

If skin turgor +2 call doctorfor order of IV fluids forhydration.

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4 hours. volume. skin turgor has increased

Monitor laboratory studies, e.g.,Hb/Hct and RBC count, arterial

blood gases (ABGs).

Identifies deficiencies inRBC components affecting

oxygen transport and

treatment needs/response totherapy.

Pt labs will showimprovement if othertreatments are workinge.g. iron supplement

Note changes in balance,gait disturbance, andmuscle

weakness.

May indicate

neurological changesassociated withvitamin B12 deficiency,affecting client safetyand increasing risk ofinjury.

Patient showed signs of

improved musclestrength after consumingmeals

Elevate head of bed, as

tolerated.

Enhances lungexpansion to maximizeoxygenation forcellular uptake. Note:May be contraindicated

if hypotension ispresent.

Pt tolerated head rest at

45 degrees and 90

degress

May have to be discontinued if

hypotension is present or noted

Assist client to prioritizeADLs and desiredactivities. Alternate restperiods with activityperiods.

Promotes adequaterest, maintains energylevel, and alleviatesstrain on the cardiacand respiratorysystems.

The patientverbalizes understandingof priority learning needs.

Change environment towhere pt will have

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Review nutritional history,including food preferences.

Identifies deficienciesand suggests possibleinterventions. Note:Daily meal diary overperiod of time may benecessary to identify

anemia related tonutrient deficienciessuch as no meat in dietiron and vitamin B12deficiency, or few leafyvegetables in dietfolic acid deficiency.

Patient toleratedambulating from chair tobed after a short rest

Encourage questionsbefore and after eachteaching.

Questions facilitateopen communicationbetween patient andhealth careprofessionals, andallow verification ofunderstanding of giveninformation and theopportunity to correctmisconceptions

The patient askedquestions regarding herregimen, diet andconcerns when injectingherself.

Suggest bland diet, low inroughage, avoiding hot,spicy, or very acidic foods,as indicated

When oral lesions arepresent, pain mayrestrict type of foodsclient can tolerate.

Pt ate puree food thatwas tolerate forconsumption

Ask doctor if TPN is apossible suggestion for I/O

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Encourage or assist withgood oral hygiene beforeand after meals; use soft-bristled toothbrush forgentle brushing. Providedilute, alcohol-free

mouthwash if oral mucosais ulcerated.

Enhances appetite andoral intake. Diminishesbacterial growth,minimizing possibilityof infection. Specialmouth-care techniques

may be needed iftissue is fragile,ulcerated, or bleedingand pain is severe

Pt demostrated use oforal hygiene after Iperformed task

Review individuals targetblood glucose levels assoon as possible.

Although this rangevaries per person, theideal range for theadult diabetic isconsidered to be 80 to120 mg/dL. (Doengespg 418)

Patient understood thattheir normal blood sugarlevels are between 70 to100 milligrams perdeciliter.

Monitor laboratory studies,such as Hgb/Hct, bloodurea nitrogen

(BUN), prealbumin andalbumin, protein,transferrin, serum

iron, vitamin B12, folicacid, TIBC, and serum

Aids in establishingdietary plan to meetindividual needs.Evaluateseffectiveness oftreatment regimen,including dietary

sources of needed

Pt BUN level becamestable after treatment

If level are still low aftertreatment consult withdoctor for other treatment

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electrolytes. nutrients.

Review clients dietaryprogram; compare withrecent intake before end ofshift.

Identifies deficits anddeviations fromtherapeutic plan, whichmay precipitate

unstable glucose anduncontrolledhyperglycemia.(Doenges pg 412)

The patient complieswith the new way ofteaching nutritionalintake and insulin

pattern.

Monitor laboratory studies, e.g.,

Hb/Hct and RBC count, arterialblood gases (ABGs).

Identifies deficiencies inRBC components affectingoxygen transport and

treatment needs/response totherapy.

CARE PLAN RUBRICStudent: ___________________________________ Date: ______________________

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CATEGORIES POSSIBLE POINTS

YOURPOINTS

COMMENTS

SUBJECTIVE DATA(Relevant and timely and quotedfrom patient)

10

OBJECTIVE DATA(Includes vital signs, physicalassessment findings, diagnostictests and procedures, relevantmedications, etc.)

10

NURSING DIAGNOSIS(NANDA, R/T, AEB)

20

GOAL(Condition, Time Frame,Parameters, and must be realistic)

20

INTERVENTIONS ANDRATIONALES(Assess, Assist, and Teach)

20

EVALUATION OF CARE PLAN(Evaluate each nursing action foreffectiveness)

10

MODIFICATION OF CARE PLAN(Modify patient care plan based onpatients response to interventions)

10

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*TOTAL SCORE:

*Student must obtain score of > 77% in order to obtain a grade of S on the weekly care plan.

Reviewed with student: ______________________________ Date: ___________________Signature

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Anemia-careplan for adult

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