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94 y/o Male, Assessment, Diagnostics, Factors Impacting Discharge, Tests I…

- - - - Impaired Skin Integrity
        
        Client-Focused Outcomes
        
        Client will experience timely timely healing healing of wounds without complications and will demonstrate effective wound care before discharge
        
        Interventions
        
        Nurse will assess skin turgor, sensation and circulation (Ackley et al., 2019)
        
        Nurse will assess skin for changes in color, redness, warmth, swelling, and any other signs of infection (Ackley et al., 2019)
        
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    - - Risk for Infection
        
        Client-Focused Outcomes
        
        Client will remain free from symptoms of infection during hospital stay
        
        Interventions
        
        Nurse will observe and report any signs of infection (Ackley et al., 2019)
        
        Nurse will observe and report laboratory values that show signs of infection (Ackley et al., 2019)
        
        1 more item...
    - - Risk for Electrolyte Imbalance
        
        Client-Focused Outcomes
        
        Client will maintain normal serum potassium, sodium, magnesium and calcium during hospital stay
        
        Interventions
        
        Nurse will review laboratory data and report deviations to the provider (Ackley et al., 2019)
        
        Nurse will monitor heart rate and rhythm (Ackley et al., 2019)
        
        1 more item...
    - - Decreased Cardiac Output as evidence by reduced ejection fraction
        
        Client-Focused Outcomes
        
        Client will demonstrate adequate cardiac output as evidence by blood pressure, pulse rate and rhythm during hospital stay
        
        Interventions
        
        Nurse will check and closely monitor the clients peripheral pulses (Ackley et al., 2019)
        
        Nurse will assess oxygen saturation both at rest and during activity (Ackley et al., 2019)
        
        1 more item...
    - - Urinary Retention related to enlargement of the prostate as evidence by urinary frequency
        
        Client-Focused Outcomes
        
        Client will report a change in hesitancy, dribbling, frequency, and bladder fullness to the nurse during hospital stay
        
        Interventions
        
        Nurse will encourage the client to void every 2-4 hours when the urge to void is present (Ackley et al., 2019)
        
        Nurse will palpate the suprapubic area to feel for a distended bladder (Ackley et al., 2019)
        
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- - - - HR: 70
        
        RR: 16
        
        O2 Sat: 99% RA
        
        Temp: 98.9
  - - - Hgb: 10.0 L
        
        Hct: 31.3 L
        
        Plt Count: 164
- - - - INR: 1.6
        
        Heparin Anti-Xa: 0.46
        
        aPTT: 29.4
  - - - Chloride: 107
        
        BUN: 52 H
        
        Creatinine: 2.3 H
        
        GFR: 27 L
        
        Ca: 8.8
        
        Mg: 1.9
        
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- - - - Medications
        
        Acetaminophen 650 mg PO Q4H PRN
        
        Carvedilol 3.125 mg PO BIWFOOD SCH
        
        Cholecalciferol 1,000 Unit PO Daily SCH
        
        Cyanocobalamin 2,000 mcg PO BEDTIME
        
        Heparin Sodium (Heparin Bolus 100 Unit/MI Bag) 0 Unit IV Protocol PRN
        
        2 more items...
        
        Home Meds
        
        Coumadin
        
        Torsemide (Holding)
- - - - Prostate-specific antigen test
        
        BNP lab
        
        ESR and CRP test
        
        lipid profile