Question

Mrs. D is an 80-year-old woman from a nursing home. She is admitted to the hospital for dehydration and pneumonia. Her past medical history includes a cerebrovascular accident (CVA), dementia, and diabetes. On admission, she has a blood sugar of 30 mmol/L (Normal Values: 4-7 mmol/L), Na of 160 mmol/L (Normal Values: 135-145 mmol/L), WBC of 15 x 10-9/L (Normal Values: 4-11 x 10-9/L), and albumin level of 10 g/L (Normal Values: 35-50 g/L). She does not speak but responds to painful stimuli by moaning. She is diaphoretic and incontinent of both urine and stool. She is immobile and requires assistance for positioning. She is not eating and she is on IV fluids. Mrs. D also has a cavity on her sacrum measuring 8 cm x 6 cm x 5 cm with undermining of 3 cm at 3 o’clock. The wound is draining large amount of foulodored greenish exudate. There is erythema noted around the wound measuring 3 cm. She also has a non-blanchable reddened area on both her hips. Vital Signs on admission: BP: 80/65 HR: 118 Respirations: 22 Temperature: 104 F MAKE A NURSING CARE PLAN.

Answer 1

A nursing care plan for Mrs. D involves immediate stabilization for severe dehydration, blood sugar regulation, infection control, nutritional support, specialized wound care, and pressure ulcer prevention.

Step-by-step explanation:

Nursing Care Plan for Mrs. D

Mrs. D is an elderly woman with a complex health condition, including dehydration, pneumonia, and a history of cerebrovascular accident (CVA), dementia, and diabetes. Based on her clinical presentation, the following nursing care plan aims to address her acute and critical needs:

• Immediate stabilization: Given her severe dehydration and hypotension (BP 80/65), aggressive fluid resuscitation is required to support her blood pressure and perfusion.
• Blood sugar regulation: With a blood sugar level of 30 mmol/L, she needs insulin therapy and frequent monitoring to bring her glucose levels within a normal range.
• Infection control: Her high sodium level (Na 160 mmol/L), increased white blood cell count (WBC 15 x 10-9/L), and fever indicate a severe infection likely linked to pneumonia. Antibiotic therapy and monitoring of infection markers are crucial.
• Nutritional support: As she is not eating and her albumin level is very low (10 g/L), nutritional assessment and support, potentially in the form of enteral or parenteral nutrition, may be required.
• Wound care: The sacral cavity with greenish exudate and surrounding erythema needs meticulous wound care to prevent further infection and aid in healing.
• Pressure ulcer prevention: Regular repositioning and skin care are necessary due to the non-blanchable reddened areas on her hips and her immobility.

This care plan should be frequently reassessed and adjusted according to Mrs. D's evolving clinical status.