Mini Care Plan

Nicholas Ortiz
RM 206 AGE 65 MD INITIALS ADM DATE 10/28/10 SURGERY DATE None
PATIENT INITIALS H,D DX Pleural Effusion, Acute Renal Failure, Anemia, Infected INSE
DIET ADA 1 OPERATION None
ALLERGIES NKA ACTIVITY None IV’S Hep Lock SPECIMENS NEEDED OB Stool X3
VS 0/275 I/O, 98.2 T, 61 P, 18 RR, 136/61 BP, 0/10 Pain, 95% 02Sat (RA) WT 201 lbs.
LABS DONE TODAY Na 137, K 4, Cl 106, BUN 54H, Gluc. 86, Crea 2.27H, Ca 8L, AST 2H, ALT 13L, Protein 5.8L,
Albumin 2.7L, Globulin 3.1, Alb/Glob 0.9L, Alk Phosph. 69, Bulirubin 0.2, MCH C 34.2, C02 25, PLT 194, Nuetro 63, RDW
14.5, MCV 86.3, MCH 29.5, WBC 4.9, RBC 3.53L, Lymph 26, BGM 10.4 L, HCT 30.4, Mono 10H
TX None
MD ORDERS NEEDED None EQUIPMENT Tele, Cane, Hep-Lock, 02Sat, Bed Alarm
SPECIAL INSTRUCTIONS Check OB 3x day, Check for Housing (Homeless), Son is present but disabled, Snack at 1900
DEVELOPMENTAL STAGE Generativity Vs. Stagnation
CULTURAL/RELIGIOUS/SPIRITUAL CONSIDERATIONS Christian (No special needs)

MEDS
Protoneix 40 mg PO q24
Heparin 5000 U SQ Bid
Bumex 0.5 mg IV q24
SPA 12.5 Gm IV before
Bumex q12
Morphine Sulfate 4mg IV
Morphine 1-2 mg IV q3hrs prn
q3hrs prn
Vicodin 5/500 PO 1-2 tabs
Lantus 25 U SQ q day
q3hrs prn
Tylenol 650 mg PO q4hrs
Zofran 4 mg IV q4hrs prn

NURSING DIAGNOSIS EXPECTED OUTCOME/GOAL NURSING INTERVENTIONS

Excess fluid volume related to
acute renal failure as evidence
by pitting edema 1+ and pleural
effusion (2.2L liquid in lungs
removed).
Client will display appropriate
urinary output (>30 ml/hr) w/
stable v/s and absence of edema
by discharge.
Assess skin, face, and dependent areas of edema. Evaluate
degree of edema. Throughout my shift.
Record I/O, include IV antibiotic additives, liquid med. Ice
chips, and frozen treats. Measure GI losses and estimate
insensible losses, such as diaphoresis. Throughout my shift.
Monitor urine specific gravity during assessment.
Monitor HR, BP and CVP throughout my shift.
Auscultate lung and heart sounds q 2hrs.

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Doenges 8th p 542