Question

FOR EACH ASSESSMENT PLEASE INCLUDE A NURSING INTERVENTION THAT WOULD BE EMPLOYED TO TREAT AILMENT.

Gastrointestinal Assessment and Intervention: (include ordered diet)

Assessment: Patient is on a general diet. Patient did not eat her breakfast; she ate 25% of lunch and 25% of her dinner. Patient’s abdomen was distended and ascites was present. Hypoactive bowel sounds present in all 4 quadrants. Patient given protonix for gastric mobility at 0900. Patient had loose brown/yellow bowel movements 4 X in the commode. Patient was on lactulose, which was discontinued in the AM.

****Interventions:

Endocrine Assessment and Intervention: Assessment: Patient has a hx of DM II. Accuchecks every 6 hours and on a sliding scale. Patient’s glucose was 170 at 1200 and was given Insulin aspart 3 units at 1200. Patient has a history hypothyroidism; synthroid 50 mcg was given on an empty stomach at 0900. Patient does not exhibit diaphoresis, nervousness, or change in skin color. No signs of heat or cold intolerances.

****Interventions:

Reproductive Assessment and Intervention:

Patient had two children 36 and 40 years ago.

**Interventions:

Vascular Access Assessment and Intervention

Assessment: Patient has an IV in her left hand and another IV in her right brachial. Dressing dry and intact. No continuous IV fluids running at this time. No signs of infiltration, redness or phlebitis at either IV site. Patient stated burning at left hand IV site during potassium chloride infusion, infusion lowered and heat pack given.

Interventions:

Safety Assessment and Intervention:

Assessment:

Patient is at a high risk for falls. Three-side rails are up and the bed is in the lowest position. Bed alarm is on. Call light is with in reach. Turn patient every two hours to prevent skin break down. Ensure HOB is 30-45 degrees.

**Interventions

Psychosocial Assessment and Interventions:

Assessment:

The patient lives in a house in Chicago with her son Tommy. She has two grandchildren that came to visit her at the bedside. She was a former smoker and alcoholic. She stated that she currently drinks one mixed drink of vodka each day. Her husband passed away 15 years ago and that’s when her drinking got bad. She stated, “I’m not as bad of a drinker as my father was.” She stated that she enjoys cooking because it makes her feel happy, however has not been able to cook as much because of her limited mobility and pain.

**Interventions

Answer 1

Gastrointestinal assessments

Nursing intervention

• Assess the bowel sounds and bowel movement to get baseline information
• Provide soft and bland diet for easy digestion
• Provide fluid replacement orally and intravenously as per order to balance fluid loss and electrolyte balance if any .This can also prevent dehydration

Endocrine assessment

Nursing intervention

• Monitor blood glucose as per order, to keep a track and plan for care
• Administer insulin as per sliding scale
• Assess the patient for any signs and symptoms of hypoglycemia
• Provide diabetic diet
• Administer synthyroid tablet in empty stomach early in the morning because there should be a gap of at least one hour between mediation and breakfast and four hours for other medications

Reproductive assessments

• Assess for any signs reproductive issues like abnormal discharge ,lower abdomen pain ,back pain ,etc., and plan for care
• Teach the women about the preferences menopausal symptoms and its management
• Provide general health education on the care of reproductive organs against infection

Vascular access assessment

• Assess for any leaks ,tenderness ,swelling ,infiltration to plan for care
• In case of swelling, remove the IV line and reinsert a new line at different site as per requirement
• Application of ice to reduce pain and swelling at the edematous region

Safety assessments

Nursing intervention

• Bed at the lowest level
• Four rails up when patient is on bed
• Ensuring the present CD of a relative or care giver when there is high risk of fall
• Ensure patient is in visible area next to nursing station

Psychosocial assessments

Nursing intervention

• Pain management through medications ,comfort devices and diversions therapy
• Improving mobility by assistive device if necessary
• Encourage to do ROM to improve muscle strength and enhance mobility
• Provide psychological support.