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Description

Medical Dx/ Reason for Admission/history/Age Age 54, Female Past Medical History Cerebral Hemorrhage, pancreatitis, pyelonephritis, used crack cocaine, hypertension, both kidney transplant, CKD.

Signs and Symptoms

Outcomes

Objective: AAox3, Capillary refill less than 2 sec., pulses are diminished, Upper, and lower extremities are. BP 118/74, PulOx 99, HR 74, Resp 18, Pulse 68, Temp 98.2 Labs: Calcium is 11.7-high, Hgb-10, BUN-8, Creatine0.2 Subjective Pain level is 0/10. Feeling tired and wants to sleep. Do not want to eat.

Short Term Goal 1.Patient calcium level will be check 11.7 once a day, by the end of the shift. 2.Patient will be able to eat at least 40% of meal, by the end of the shift Long Term Goal 1.Patient will be able to have more energy and eat at least 50% of her meal by the end of discharge. 2. Patient’s calcium levels will be within the normal range by the end of discharge.

Reason for Admission Hypercalcemia, Chest pain, chronic pancreatitis

Evaluation

Nursing Diagnosis Electrolyte imbalance r/t high calcium level of 11.7 as evidenced by feeling tired, weak, fatigue and only wants to sleep.

Nursing Interventions/ Rationales Nursing Interventions Assess: Vital Signs Labs values (calcium, BUN, WBC, Hgb, Creatine)/IV rehydration

Diet/ Fluid I&O Do: Monitor, HR, BP, Pulse and Oxygen/ Monitor Lab values once a day/IV rehydration Monitor I&O/Diet

1.No patient’s calcium level is not below 11.7. by the end of the shift. 2.No, patient doesn’t eat 40% of her meal by the end of the shift. 3. Yes, patient have more energy and eat 50% of her meal by the discharge. 4. Yes, patient’s calcium level is between 8.610.3 by the discharge.

Rationales for Nursing Interventions Assess: Reflect essential body functions, monitoring of vital signs is to check the level of physical function. Determine a patient's overall health and well-being, monitor kidneys, RBCs, WBCs (any present Infection), Calcium (high calcium can cause bone to be weaker. Also, high calcium creates a susceptibility to cardiac arrest) Prevention of malnutrition and dehydration which can give more complication to the patient’s body. Do: Prevention of heart complication due to high calcium, any abnormality that patient can experience. Help determine a diagnosis, plan treatment, check to see if treatment is working. Goal is to have equal I&O. Too much input can lead to fluid overload. Too much output can cause dehydration. Prevent malnutrition.

Teach: Feeling dizzy, weak and palpitations

Teach: report any of the symptoms to the provider to prevent any further complications. Reduces the risk of progression of any more health problems Ambulation as tolerated Helps to prevent DVT, any pressure ulcer and circulation promotion. Encourage fluid intake of 3-4 liters per day/adequate diet/protein snacks Reduces dehydration and malnutrition Ref: Mariann. M. Harding, Jeffrey Kwong, Dottie Roberts,Debra Hagler, Courtney Reinisch. (2020). Lewi's Medical-Surgical Nursing Assessment and Managment of Clinical. St. Louis: Elsevier...