LA County Medical Center School of Nursing - Rx Yearbook (Los Angeles, CA)

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CLINICAL NURSING WORKSHEET Dates of Care 2-17, 2-18 1971 Nursing Problem Emphasis lclassl O2!CO2 Amitting Diagnosis Chronic alcoholism, G-I bleeder, cirrohosis of the liver, RXO esophageal va rices, seizu re disorder, CVA Final Diagnosis Cirrohosis of liver, esophageal va rices, CVA, seizure disorder Patient's initial 81 PF if A.S. Age 45 years Sex Male . Developmental Task lpredictedl Level Dependency vs lndependency Nursing Problems land needsl I. lmmobilityz leftsided hemiparesis KNO aphasia, eyesight difficulty. Unable to support wt. on L. side or move extremities Able to contract muscles in affected hand, arm and leg, has sensation A. Difficulty carrying out ADL B. More prone to URI and pneumonia C. More prone to constipation and bladder stasis D. Tends to be dependent Cthe more you do for him the more demanding he seems to becomej E. More prone to skin breakdown CHas reddened areas on buttocksb Relate Knowledge fCite Sourcel Respiratory complications plague the disabled. , ,The pt. who has suffered a CVA with resultant paralysis is prone to hypostatic pneumonia Beland, p. 832 Skin breakdown is always a matter of grave concern to the paralyzed pt. , , Lack of sensation andfor motor paralysis chances of skin breakdown. Prolonged pressure over bony prominence causes a lack of circulation which is the etiology of a pressure sore. Beland, p. 828 Decreased mobility and lack of exercise can create problems of stasis Cperistalsis and bladder tone decreasedb

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CUURT DEW. No man is an island entire of itself, every rnan is a piece of the continent, a part ofthe main. .. Any man's death diminishes l am involved in mankind. me, because John Donne Occupational Therapy 'I7

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Careplans Are a Drag Nursing Intervention Assist pt. with ADL where indicated, but encourage him to do as much for himself as possible Place articles of care within easy reach ton unaffected sidebg e.g. urinal, h20, call bell. Provide with assistive devices if helpful, eg trapeze, siderails up for safety and movement assistance. PT Position on side q 2 hrs. Provide with blow glove: instruct how to use and encourage coughing and deep breathing q hr. Encourage fluids Up in chair BID as ordered ROM-passive and active. Instruct how to do exercises and encourage to do Backcare at least BID with alcohol, silicone spray to buttocks as ordered Results I found the pt responded very well to instruction on exercises and coughing and deep breathing and carried out my suggestions with little encouragement. The pt. seemed to be less dependent on me when l provided articles of care near his bedside and encouraged him to function as much as he could on hid own. He, however, remained very demandingg perhaps I underestimated his helplessness. PT might be helpful in showing the pt ways in which he can carry out his ADL with his disability. Any problems urine qcontrol or abnormal lab workyl