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91 y.o. female/DNR/sulfa & levofloxacin allergy (Allergic reaction:…
91 y.o. female/DNR/sulfa & levofloxacin allergy
Allergic reaction: red rash
Nursing Diagnoses
Risk for Ineffective respiratory function/Fatigue/Risk for Injury
Assess for the presence of an optimal decrease in pain with periods of fatigue or respiratory depression is minimal
Assist patient with repositioning
Auscultate lung fields Q4H, increase the frequency if any abnormal breath sounds heard
Restrict environmental stimuli
Promote sufficient nutritional intake
Provide comfort such as judicious touch/massage
Acute Renal Failure
Nursing Diagnoses
Excess Fluid Volume
Risk for Decreased Cardiac Output
Risk for Imbalanced Nutrition: Less than Body Requirements
Risk for Infection
Risk for Deficient Fluid Volume
Deficient Knowledge
Interventions:
I&O's/ Monitor urine specific gravity
Daily weights
Assess patient for edema and evaluate degree
Monitor HR, BP, and JVD
Auscultate lung and heart sounds
Assess LOC
Administer/ check for fluid restrictions
Monitor diagnostic studies: BUN/CR/Na/K/Hb/Hct/Chest X-ray
Administer meds as ordered
Assess color of skin, mucus membranes, and nail beds. Note capillary refill time
Provide frequent small feedings
Offer frequent mouth care
PMH:
Activity intolerance
Fall risk
Acute excacerbation of COPD
Fluid vol. deficit/overload
Acute on chronic right knee pain Hyperglycemia
Acute renal failure
HTN
backache
infection
breathing pattern impairment
low back contusion w/L1 compression fx
CHF
mobility impairment
croupy cough
restless
dehydration
skin integrity impairment
dyspnea
tissue integrity impairment
SOB w/COPD + CHF
Tests: EKG: possibly recent anteroseptal infarct/Chest X-RAY: No acute infiltrate/effusion is identified
Abornmal labs:
Sodium
146
Potassium
149
Creatinine
87
90
Calcium
1.5
1.7
A/G Ratio
1.2
eGFR (Non-African American)
33
WBC
16.9
15.7
Hemoglobin
15.4
Hematocrit
46.7
RDW
Platelet Count
93
Neutrophils
79
Lymphs
11
Monocytes
1.01
Neutrophils, absolute
13.86