Stella Adams Care plan PDF

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Stella Adams ihuman care plan. Stella Adams ihuman care plan...

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Miami Dade College Benjamin Leon School of Nursing NUR 2310L: Pediatric Nursing Pediatric History, Assessment, and Plan of Care Student’s Name Amanda Calas Patient’s Initials SA

Date: 02/22/2021

Age: 17 y/o

DOB: N/A

Race/Ethnicity: N/A

Admitting medical diagnosis: Possible post-streptococcal glomerulonephritis Chief complaint: Malaise and brownish colored urine History of present illness: Patient went to the emergency room due to malaise and dark color urine. She presented to her PCP’s office 3 days ago after several days of fever and severe sore throat. A rapid strep test was positive. She has had four doses of a ten-day course of amoxicillin. Patient noticed the discolored urine this morning and when it did net clear up, her mother brough her to the ER. Past medical, surgical and psychiatric or behavioral problems history: No surgeries, “the usual cough, colds and tummy aches, nothing remarkable “

Patient’s/Parent’s Understanding of Present Illness: N/A VS and Pain level (indicate pain scale used) BP: 140/86 RR: 22 HR: 104 BPM T: 101.2 F ORAL O2: 98% ROOM AIR Baseline (or normal values for age) HR: 80-10 BPM. RR: 12-20 BP: 90

DECREASED GFR

DAY 1

POSITIVE

NEGATIVE

PROTEINURIA

Amoxicillin 500mg PO BID

Binds to bacterial cell wall, causing cell death.

Indications: Genitourinary infections, works against streptococci bacteria. Side effects: seizures, rash, CDAD (Clostridioides difficile associated diarrhea) anaphylaxis.

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Use cautiously in severe renal impairment. Monitor bowel function. Observe for signs and symptoms of anaphylaxis.

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Essential for nervous, muscular and skeletal systems Act as an activator in the transmission of nerve impulses and contraction of cardiac, skeletal and smooth muscle. Regular Insulin Lowers blood 10 IU IV glucose by ONCE stimulating glucose uptake in skeletal muscle and fat and inhibiting hepatic glucose production. Calcium Gluconate 10% 10 ml IV ONCE

Dextrose 50% 25 grams IV Once

Dextrose Oral Liquid 15 grams PRN

Dextrose 30 grams PO

Emergency treatment of hyperkalemia and hypermagnesemia Side effects: cardiac arrest, nausea, vomiting, constipation, phlebitis.

Control of hyperglycemia but also for hyperkalemia treatment. Side effects: hypoglycemia, swelling, erythema, hypokalemia.

Provide calories. Prevention and treatment of hypoglycemia

IV: treatment of hypoglycemia

Provide calories. Prevention and treatment of hypoglycemia

IV: treatment of hypoglycemia

Provide calories. Prevention and treatment of hypoglycemia

IV: treatment of hypoglycemia

Side effects: inappropriate insulin secretion, hypokalemia, glycosuria.

Side effects: inappropriate insulin secretion, hypokalemia, glycosuria.

PRN

Side effects: inappropriate insulin secretion, hypokalemia, glycosuria.

Inhibits synthesis of Acetaminophen prostaglandins that may serve as 650 PO Q6

Mild to moderate pain Fever Side Effects:

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Monitor BP, HR, and ECG frequently Assess IV for patency.

Monitor periodically for symptoms of hypoglycemia like tingling in hands and feet, chills, anxiety etc. Monitor body weight. Assess hydration status. Monitor intake and output. Monitor IV site for phlebitis.

Assess hydration status. Monitor intake and output. Monitor IV site for phlebitis. Assess hydration status. Monitor intake and output. Monitor IV site for phlebitis. Asses for rash If overdose occurs, Acetadote

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For pain 1-4/10 or fever 101.4F

mediators of pain and fever, primarily in the CNS.

hepatoxicity, renal failure, muscle spasms, atelectasis, nausea, vomiting, rash.

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is the antidote.

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Textbook picture: Include the etiology, pathophysiology, signs/symptoms, medical treatment, and prognosis for your client on the left (textbook) and compare to your client on the right (client). Textbook Client Patient was diagnosed with AKI secondary to postEtiology and Pathophysiology streptococcal glomerulonephritis. Acute renal failure also called acute renal injury, may be caused by prerenal or postrenal factors as well as actual kidney damage. Prerenal ARF is a result of decreased perfusion to an otherwise healthy kidney in association with a systemic condition. Hypovolemia secondary to dehydration is generally the cause, however, alterations in renal vasculature or cardiac function may also precipitate prerenal ARF. This is the most common type of ARF in infants and young children. Signs and Symptoms: Upper/lower extremity edema Nausea, vomiting, lethargy, edema, gross hematuria, Hematuria oliguria, hypertension, hyperkalemia, hyponatremia, and Hypertension hypocalcemia Hyperkalemia Dark urine, headache, fatigue, crackles, gallop heart Dark urine rhythm. Medical Treatment: Nursing care focuses on preventing complications, maintaining fluid balance, administering medications such as diuretics, meeting nutritional needs, preventing infection and providing emotional support to the child and family. Prognosis: Prognosis depends on the cause of ARF. When renal failure results from drug toxicity or dehydration, the prognosis is generally good. However, ARF that results from diseases such as hemolytic-uremic syndrome or acute glomerulonephritis may be associated with residual kidney damaged.

Patient is receiving calcium gluconate to correct the hyperkalemia, also receiving normal saline to prevent dehydration.

This patient acute kidney injury was caused by glomerulonephritis but according to ihuman, patient was discharged home after several days and regained normal renal function.

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Nursing Plan of Care Student’s Name Amanda Calas Date: 02/22/2021 Patient’s Initials: SA Age: 17 y/o Gender: Female Medical diagnosis: Intrarenal Acute Kidney Injury (AKI)

Diet: Regular Activity: As tolerated VS/Pain level (scale used) Numerical. BP: 140/86 HR: 104 bpm RR: 22 Temperature: 101.2 F Oral O2: 98% on room air Pain: 4/10 headache Throat Pain: 02/10 Immunizations: Up to date as per CDC Guidelines . Brief/significant Medical History Only: Member stated nothing remarkable, the usual coughs, colds, and tummy aches. Assessment Data Subjective data (must use quotes): Patient report “malaise and a brownish colored urine”, “puffy feet and hands” “Pain 4/10 (headache) and 02/10 (throat pain)” Objective data: Hyperkalemia Leukocytosis Elevated BUN and Creatinine Decreased GFR Hematuria Tachycardic Febrile Tonsils enlarged with white exudate. Upper/lower extremity edema Hypertensive Pharynx reddened.

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Nursing diagnosis (NANDA, R/T, and AEB): Excess fluid volume related to compromised regulatory mechanism secondary to acute renal failure as evidence by peripheral edema and elevated BUN and Creatinine. Expected Outcomes (must be SMART): Short term: The patient will have equal or very similar values of intake and output, BUN and creatinine will be within normal ranges (BUN: 8-21 Creatinine: 0.5-1.1), as well as vital signs, within 24 hours-48 hours. Long Term: Restore kidney function to an optimal state. Patient will maintain hydration and be free from infection or chronic kidney damaged. Nursing Actions: Assess: The nurse will assess intake and output and monitor vital signs every 4 hours and notified any significant changes to HCP. Rationale: An assessment provides baseline information for monitoring changes and evaluating the effectiveness of therapy.

-Assist: The nurse will assist the child to do position changes every 2 hours. Rationale: Frequent position changes lessens pressure on body parts and prevents the accumulation of fluid in the dependent areas.

-Administer: The nurse will administer diuretics as prescribed. Rationale: Diuretics decreases plasma volume and edema by causing diuresis.

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-Provide: The nurse will provide elevation of the edematous body part/ parts while the child is in bed or sitting in a chair. Rationale: Helps move fluid away from dependent body parts through gravity.

-Consult: The nurse will consult a dietician to develop a meal plan low in sodium, potassium, and protein that includes preferred foods as allowed. Rationale: A proper diet plays a vital part in controlling the symptoms, maintaining nutrition, and in the management of the disease.

Teach: The nurse will teach the patient and family members about glomerulonephritis and acute kidney injury, including its signs and symptoms, diagnostic, and management. Rationale: Provides an understanding of the disease which increases compliance with treatment regimen.

Evaluations of Nursing Actions (What was the outcome of the Nursing Actions performed): After 24-48 hours of nursing interventions, patient’s intake and output have very similar values, upper/lower extremity edema is almost non-existent and lab values are within a normal range (BUN, creatinine, WBC, GFR) as well as vital signs. The nurse will continue to monitor and assess patient. Patient and family members demonstrated understanding of the disease by repeating all possible signs and symptoms and management of the condition. Also, they were able to verbalize what a diet low in sodium and potassium consists of.

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Evaluations of Outcomes (Did you achieve the short and/or long-term goals you set for your client?): Kidney function is restored. Fluid, electrolyte, and acid-base balance is restored and maintained. BUN, creatinine, BP, WBC and GFR are within a normal range. Peripheral edema resolved.

Modifications of Plans (If you did not achieve your goal, how or what would you modify in your nursing actions and/or goals):

No modifications suggested since goals were achieved.

List additional appropriate Nursing diagnosis: 1- Ineffective renal perfusion related to hypovolemia, sepsis, or drug 2- Imbalanced Nutrition less than body requirement related to anorexia, nausea, vomiting, and catabolic state.

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