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 foul-odored 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 should include addressing her dehydration and pneumonia, managing her high blood sugar level and incontinence, implementing a comprehensive skin care plan, and addressing her immobility.

Step-by-step explanation:

A nursing care plan for Mrs. D should include several components to address her current issues. First, her dehydration and pneumonia should be treated with intravenous fluids and appropriate antibiotics. Close monitoring of her vital signs, oxygen saturation, and respiratory status is essential. In addition, her high blood sugar level should be managed through regular blood glucose monitoring, insulin administration, and dietary adjustments. Her incontinence should be managed with frequent toileting and the use of absorbent pads. A comprehensive skin care plan is crucial to prevent and treat pressure ulcers. This should include regular repositioning, keeping the skin clean and dry, using specialized pressure-relieving devices, and applying appropriate wound care products. Finally, her immobility should be addressed with a range of motion exercises, physical therapy, and assistive devices to minimize the risk of complications such as blood clots and muscle wasting.