Patho & Care Plan #1 - CSC SNA Web Resources

DS is unable to communicate how she resolved Erikson's final developmental level, Integrity vs. Despair. She has family members that visit her regularly and provide her with her own gowns. Her relatives continued inolvement indicates that she was able to maintain a close relationship earlier in her life. She has been in the nursing home for over a decade and was in a long term care facility prior to transfer. DS is 98 years old and has had a great deal of time to resolve this conflict positively to the side of integrity.

I. Description: Dementia is an organic brain syndrome in which the individual loses intellectual fuctioning. (Rush, 241) It affects the ability to remember, think, and perform activities of daily living (ADLs). (Kindig, 3 ) Individuals with dementia experience confusion and are not always oriented to person, place, time and/or situation. The disorientation leads to lack of orderly thought, impaired decision making, and confusion. (Anderson, 383) Another possible facet of dementia is hallucinations. By definition, hallucinations may be seen, heard, felt, tasted or smelled. (Rush, 391) DS is unoriented to person, place, time and situation. She is unable to perform any ADLs. She does not indicate that she is experiencing hallucinations.

Dementia developes gradually over months or years and can be thought of as chronic brain failure. The most common type of dementia is Alzheimer\'92s Disease, it accounts for 50-90% of dementias. Small strokes causes Multi Infarct Disease (MID) which accounts for 5-10% of the cases of dementia. About 15% of dementias are mixed, caused by both Alzheimer's and MID. (Kindig, 3, 18)

II. Etiology: Approximately 4 million people in the United States (1993) are afflicted with a dementing illness. Any process that destroys the nerve cells of the brain can cause dementia. The incidence of dementia increases with old age. (Kindig, 2, 21) DS has been treated for a brain tumor on two occasions and she is 98 years old. Sometimes dementia is secondary to another condition and can be reversed by treating the underlying problem. (Kindig, 22) The criteria for diagnosing dementia has been outlined by the American Psychiatric Association. Impairment of long and short term memory must be present. At least one of the following must be present: impaired judgement, impaired abstract thinking, change in personality, and impaired brain function. These problems must be severe enough to interfere with work, social interactions and relationships. The person cannot have delerium at the time of diagnosis and the problems cannot be brought about by a psychiatric problem. (Kindig, 21-22) Alzheimer's disease is the most common type of dementia and it is usually described as having three stages. The first is the "Forgetful Stage" because memory problems are usually the first symptom. It''s common for them to forget appointments or birthdays and to ask the same questions over and over. Family members find reminders helpful and usually dismiss the behaviors as old age. It is also common for them to exhibit increased frustration, anxiety, depression, difficulty concentrating or finding the right word, and poor judgment. Some individuals will blame others for the unexplained discrepancies that they experience when things are misplaced or they feel frustrated. (Kindig, 57-58) The "Confusional Stage" is the second stage of Alzheimer''s disease and memory loss is much more profound. Reminders are no longer helpful and complex tasks are increasingly difficult. Individuals are able to follow simple instructions, but need constant supervision and a familiar environment. Safety is a major concern during this stage, it's not unusual for them to wander off, mix up medications or drive unsafely. Other symptoms include: neglect of appearance and hygeine; rapid mood changes including fear, anger, restlessness, agitation, and anxiety; depression or apathy; suspicion of others; sleep disturbances; loss of bladder control; and difficulty of swallowing. (Kindig, 58-59) During the final or "Terminal Stage" memory loss and confusion are very severe. They no longer recognize family, lose the coordination necessary for walking, and lose control of the muscles that control elimination. It's common for the person to lose the ability to swallow food or fluids and they become dehydrated and malnutritioned. Eventually they become bedridden and depend upon others for all of their care. Symptoms from earlier stages increase in severity and hallucinations, seizures, and compulsive acts may begin to occur. (Kindig, 59-60) DS is unable to get out of bed, swallow food, is incontenant and has seizures. She takes Dilantin 2.0cc GT qid to help control her seizures.

III. Signs/Symptoms: Dementia affects all people differently, but there are several symptoms that are most common. Individuals generally have have problems with recent and remote memory, and there seems to be greater difficulty recalling more recent events. Tasks that require coordination of several different areas of the brain are sometimes difficult for people with dementia. Personalities may be changed and it becomes increasingly difficult to understand ideas, use sound judgement and solve arithmetic problems. (Kindig, 19-20) DS does not have recent or remote memory recall and is unable to perform any tasks.

A medical evaluation for someone that may have a dementing illness consist of three basic elements: history, physical examination and laboratory studies. \par \tab The history of memory loss is usually difficult for the affected person to relate and it is obtained from family members. Details are gathered about the course of the memory loss and it's probable causes. DS is not able to communicate any memory recall. \par \tab The medical evalutation includes physical examination, labs and diagnostic tests. The physical assessment includes weight; standing and lying blood pressure; 30 question memory test; checking the ear canals and the backs of the eyes; heart and lung sounds; abdominal palpation; arm and leg reflexes; ability to feel a pin, light touch, and vibration; balance; walking ability; and strength. (Kindig, 31-32) DS is unable to ambulate and her strenght is 1+/10+. She has a PEG tube, contractures in her lower extremities, and her eyes open to firm touch.

The laboratory studies include blood tests for conditions that can alter the functining of the brain: anemia, infection, altered thyroid function, B-12 deficiency, and syphilis. Urine is tested for sugar, protein, blood and infection. (Kindig, 33) DS's lab results suggest anemia, but they could also reflect the blood loss that she experienced when she was admitted to the hospital on 23 Oct 98 for gastrointestinal (GI) bleeding. She has a Foley catheter and experiences frequent urinary tract infections.

Imaging studies will most likely be ordered the first time the person is evaluated for memory loss. These tests may include a computerized axial tomography (CAT) or magnetic resonance imaging (MRI) of the brain to indentify strokes, tumors, bleeding, compression or other abnormalities. (Kindig, 34-35) DS has been treated for a brain tumor on two seperate occasions.

Lumbar punctures may be done to examine the cerebrospinal fluid for infection. Electroencephalograms are not routine, but may be useful in the investigation of seizures and to differentiate between delerium and dementia. A neuropsychologist may be asked to administer a standardized to test to that compares how well an individuals brain functions in comparison to others in the same age group. (Kindig, 36-37) DS is being medicated for seizures.\par The only way to definitively diagnose Alzheimer\'92s disease is to look at brain tissue. This is done after death and usually for research statistics. (Kindig, 38)

IV. Medical Treatments: Dementia is caused by rapid death of nerve cells has no cure or treatment. It is the goal of most care givers to preserve safety, comfort, self respect, and encourage pleasure in \'93the little things\'94 in life. (Kindig, 3-23) There are certain medical conditions that are underlying causes that can be reversed. Sometimes correction of this problem can cure dementia. Other times there may be no change in condition or partial improvement. (Kindig 3-23)

DS has been treated for brain tumors and had a percutaneous endoscopic gastrostomy tube place to prevent nutritional deficiencies. She continues to have dementia. DS's physician has prescribed her 1 mg ergoloid mesylates twice a day for senile dementia. It may help with brain activity be increasing cerebral metabolism and blood flow. (Skidmore-Roth, 409)

V. Nursing Implications:
1. Staff should be aware of DS's dementia and reminded to speak slowly and clearly, identify themselves, address her by name, and acknowledge her feelings. (Kindig, 137)
2. DS's environment should be well lit, equipped with objects to orient her to time, and have personal items.
3. Focus on what the client is able to do rather than their limitations. Provide honest encouragement to do things that have little risk of failure. (Kindig, 65)
4. Understand that daily tasks will gradually take more time to do and allow the extra time. Be patient and do not rush the client. (Kindig, 65-66)
5. Allow the person to make choices. Narrow the possible choices if it is necessary to prevent agitation or frustration. (Kindig, 65, 67)
6. Stay calm, people with dementia are highly sensitive to the mood of those around them. (Kindig, 65)
7. Be aware of early fatigue and short attention span. Provide a quiet environment for resting. (Kindig, 65, 94)
8. Assess the client for eating difficulties: pain from dental problems, vision problems that make it hard to see the food, restlessness at meal time, remind of meal time if necessary. (Kindig, 69-70)
9. Bowel incontenance may be helped by: regular exercise, avoiding overuse of laxatives, drinking 6-8 glasses of fluid/day, eating a balanced diet that includes fiber. Maintaining a regular toileting schedule, especially after meals, will also help with bowel incontinence. (Kindig, 95)
10. Plan activities during the time of day that the individual is most receptive and has the most energy. (Kindig, 90) Morning activities may be best since it is common for clients to experience "sundowning," increased restlessness, agitation and confusion during the late afternoon, evening and during the night. (Kindig, 145)
11. Always be aware of possible safety risks in the patient\'92s environment. If there is a risk that can be elimated, eliminate it. Using the same safety precautions that you use with children is a good guide. (Kindig, 102-103)
12. Due to memory problems, the client is at risk for over/under medication. Remind caregivers and family members to assess symptoms that may indicate a need for prn medications and treatments. Never assume that they are taking their mediation properly.
13. Loss of strength, balance, and coordination put clients at risk for falls and fall related injuries. (Kindig, 114)
14. Clients may have a tendency to get lost or wander off. It is very important to make sure that they have some sort of identification. Medic Alert bracelets and necklaces are ideal. (Kindig, 115)
15. Watch for changes in emotional status. Be able to differentiate what can/should be treated and what is part of the disease process.
16. Clients may have a decreased ability to tolerate noise. (Kindig, 135)
17. Clients may have a decreased ability to express feelings, ideas, or needs. They may also have difficulty understanding what others are saying to them. (Kindig, 135)
18. Always convey a sense of security and support. (Kindig, 138)
19. Use touch, unless it might be interpretted as an attack. (Kindig, 138)
20. Look for reasons behind unusual behaviors, do not just dismiss it as part of the illness. (Kindig, 152)
21. It is essential to teach family and caregivers the items that I have listed. Understanding the affects of the disease and knowing what to expect will better prepare them for situations that might arise.

DS had two brain tumors, an inexact term to describe any intracranial masses. General symptoms are caused by an increase in intracranial pressure. They include headache, vomitting without nausea, and retinal changes. Another side effect of brain tumors is convulsions similar to those experienced with epilepsy. (Egan, 259) DS has seizures, sudden breif attacks of altered consciousness, motor activity, or sensory phenomena. Some but not all recurrent seizure patterns are due to epilepsy. (Egan, 657) DS has an order for 2.0 cc Dilantin four times a day to help decrease the occurence and severity of her seizures. Seizure precautions should be taken with DS to ensure that she is not injured during an episode.
DS had a heart attack or myocardial infaction (MI). They are caused by partial or complete occlusion of one or more of the coronary arteries. Symptoms include prolonged, heavy pressure or squeezing pain in the center of the chest behind the sternum. Pain may be localized or spread into the head, back, arm, shoulder and hand. There can also be nausea, vomitting, sweating, and shortness of breath. (Egan, 1257-1258) DS is takes 60 mg Lasix every twelve hours for fluid edema, it helps lower the blood volume and decreases the heart's work load. She also takes 81 mg of aspirin daily at bedtime to increase the time it takes for her blood to clot. (Skidmore-Roth)
Duodenal ulcers refer to damaged mucous membrane of the duodenum, the first part of the small intestine, and is usually accompanied by generation of pus. Sometimes there is a bleeding sore that creates danger of perforation. Duodenal ulcers heal slowly because irritatiing fluids, food and digestive juices are always passing over them. (Egan, 583) DS is fed Osmolite 60cc/h continuously through her percutaneous endoscopic gastrostomy tube (PEG-tube), there is a constant presence of food and constantly production of stomach acid. Pain is the most common symptom and usually occurs after meals. (Egan, 1435) Sometimes the first Since DS is continusously fed, her pain may be constant. Her physician has prescribed 20mg Prilosec daily for duodenal ulcers. Prilosec supresses gastric secretions.
Nausea and vomitting, (N/V) are also symptomatic of duodenal ulcers. (Egan, 1435) The medications prescribed for DS's N/V are110 mg Reglan every six hours and 2.5 mg phenergan suppositories every four hours as needed. All of DS\'92s medications can cause nausea.
Sometimes the first symptom of an ulcer is hemorrhage. Vomitus and stools should be checked for blood. (Egan, 1435) DS has experienced GI bleeding and her most recent episode was on 23 Oct 98. Her last bowel movement was on 9 Nov 98 and it was black in color, indicating the continued presence of blood in her stools. Her physician has prescribed her 81 mg of aspirin daily at bedtime. Aspirin decreases platelet aggregation and could increase her bleeding.
DS has anemia, her blood's hemoglobin content is less than what is required to meet his body's oxygen demands. (Egan 96-98) Her physician has prescribed her 325 mg Fesol as needed twice a day for anemia. The abnormal lab values that indicate DS has anemia can also be indicative of hemorrhage or recent blood loss. She was hospitalized for GI bleeding on 23 Oct 98.
DS experiences chronic constipation, difficult or infrequent bowel movements. A common cause of constipation is not eating enough vegetable fiber. (Rush, 213) Straining to defecate and constipation can contribute to hemorrhoid development and DS has a history of GI bleeding. (Anderson, 749) Her physician has ordered 30cc MOM on Monday, Wednesday and Friday mornings for constipation. The Feosol that has been prescribed for DS's anemia may increase her constipation. She has a physicians order for a soap suds enema twice a week as needed to help evacuate her bowels.
Osteoarthritis is the most common form of arthritis in elderly clients. As the cartilage lining in a joint deteriorates the connecting surfaces of the joint rub together and become rough. (Rush, 52-53) Weight bearing joints, like the hip, knee and spine, are most commonly effected. Non-steroidal anti-inflammatory drugs (NSAIDs) are useful in treating the pain and inflammation of affected joints. (Rush, 52-53) NSAIDs can cause ulcers and their use is contraindicated for DS. At this time, she does not have an order for pain medication. Range of motion exercises are written to be performed four times a day and should help maintain joint mobility.

DRUG ORDER: Ergoloid Mesylates 1mg; 1 tab GT tid Generic: ergoloid NORMAL DOSE: PO/SL 1 mg tid, may increase to4.5-12.0 mg/day IS ORDER SAFE? Yes REASON FOR GIVING: Senile Dementia; may increase cerebral metabolism and blood flow PRE-ADMINISTRATION ASSESSMENT: Weight daily; peripheral edema in feet, legs; check B/P & pulse regularly; neurological status (LOC, blurring vision, N/V, tingling in extremities); Toxicity (dysnea, hypo/hypertension; rapid, weak pulse, delirium, N/V, bradycardia) IMPLICATIONS FOR ADMINISTRATION: With or after meals to avoid GI symptoms. Store in well closed container at room temperature. POST-ADMINISTRATION EVALUATION: Decreased forgetfulness, increased mental alertness and ability for self care. REFERENCE: Skidmore-Roth, 409	DRUG ORDER: Lasix 60mg; (1) 40 mg tab & (1) 20 mg tab GT q12h for fluid edema (1/9/97) Generic: furosemide NORMAL DOSE: PO 20-80 mg/day in AM; may give another dose in 6 h, up to 600 mg/day IS ORDER SAFE? Yes REASON FOR GIVING: Edema; inhibits reabsorption of Na & Cl at proximal & distal tubule and in loop of Henle. PRE-ADMINISTRATION ASSESSMENT: Signs of metabolic alkalosis (drowsy, restless); Signs of hypokalemia (postural hypotension, malaise, fatigue, tachycardia, leg cramps, weakness); Rashes; Temperature; Confusion; Hearing (tinnitus and loss); Weight & I&O to determine fluid loss; Respirations (rate, depth, rhythm, sounds); B/P; Electrolytes (K, Na, Cl, BUN, Glucose, CBC, serum creatinine, blood pH, ABG's, uric acid, Ca Mg); Skin turgor; Edema; Mucous membranes. IMPLICATIONS FOR ADMINISTRATION: In AM to avoid interference with sleep if using as diuretic. K+ replacement if K+ <3. PO with food if nausea, may decrease absorption slightly. Tablets may be crushed. POST-ADMINISTRATION EVALUATION: improvement in edema of feet, legs, sacral area REFERENCE: Skidmore-Roth, 486-488
DRUG ORDER: Prilosec 20 mg; 1 tab GT daily for duodenal ulcer Generic: omeprazole NORMAL DOSE: NORMAL DOSE: PO 60mg/day; may increase to 120 mg IS ORDER SAFE? Yes REASON FOR GIVING: Duodenal ulcers; suppresses gastric secretions. PRE-ADMINISTRATION ASSESSMENT: GI symptoms (bowel sounds qh8, abdomen for pain, swelling, anorexia); Hepatic enzymes (AST SGOT, ALT SGPT, alk phosphatase) IMPLICATIONS FOR ADMINISTRATION: Before eating; swallow capsule whole; do not break crush or chew. POST-ADMINISTRATION EVALUATION: Absence of epigastric pain, swelling, fullness REFERENCE: Sidmore-Roth, 750-751 *Prilosec capsules should not be broken, crushed or chewed, so this medication is not compatible for G-tube.	DRUG ORDER: ASA; 81 mg aspirin, 1 tab per GT HS post MI NORMAL DOSE: 325-650 mg/day or bid IS ORDER SAFE? REASON FOR GIVING: Prophylaxis of MI; decreases platelet aggregation. PRE-ADMINISTRATION ASSESSMENT: Liver [AST (SGOT), ALT (SGPT), bilirubin, creatinine]; Renal (BUN urine creatinine); Blood (CBC, Hct, Hgb, Pro Time); I&O for decrease; Edema in feet, ankles, hands; Fever; Pain (location, duration,type,intensity); Vision (blurring,halos) IMPLICATIONS FOR ADMINISTRATION: Give crushed or whole, chewable may be chewed. Don't crush enteric coated. Give 30 min before or 2 h after meal; with food to decrease gastric symptoms. POST-ADMINISTRATION EVALUATION: Decreased pain, inflammation, fever. (Not taking for those reasons.) REFERENCE: Skidmore-Roth, 139-141 *Aspirin can cause GI bleeding, N/V. Aspirin has an anemia precaution. Aspirin has toxic effects with furosemide. DS's chart indicates that she has GI bleeding, N/V and anemia, she also takes furosemide. Aspirin can cause increased bleeding and DS was admitted for GI bleeding on 10/23/98. Thrombocytopenia is a side effect of aspirin and DS's platelet count was low at 126.
DRUG ORDER: Phenergan suppository; 12.5mg (R) q4h Generic: NORMAL DOSE: 10-25 mg; may repeat 12.5-25 mg q4-6h IS ORDER SAFE? REASON FOR GIVING: Nausea PRE-ADMINISTRATION ASSESSMENT: I&O ratio: urinary retention, frequency, dysuria. CBC during long term therapy: blood dyscrasias. Cardiac & respiratory status. Decreased effect of anti-coagulants, can cause dry mouth IMPLICATIONS FOR ADMINISTRATION: With meals for GI symptoms; absorption may slightly decrease. POST-ADMINISTRATION EVALUATION: absence of nausea REFERENCE: Skidmore-Roth 850-852 *Phenergan can decrease the effect of anti-coagulants. DS takes aspirin for it's anti-coagulant properties.Phenergan can cause a dry mouth and DS has no oral fluid intake.	DRUG ORDER: Feosol; 325 mg GT prn bid for anemia Generic: ferrous fumerate/ferrous gluconate/ferrous sulfate NORMAL DOSE: PO- fumerate 200 mg tid-qid; gluconate 200-600 tid, sulfate 0.75-1.5 g/day divided into 3 doses IS ORDER SAFE? REASON FOR GIVING: Anemia; replaces iron stores needed for RBC development. PRE-ADMINISTRATION ASSESSMENT: Blood studies, elimination, causes of iron loss or anemia. Can cause false positive for occult blood & constipation IMPLICATIONS FOR ADMINISTRATION:* between meals for best absorption, after meals for GI symptoms Swallow tablet whole, do not crush or chew. POST-ADMINISTRATION EVALUATION:* improvement in Hbg, Hct, reticulocytes, decreased fatigue and weakness. REFERENCE: Skidmore-Roth, 452-454 *Feosol can cause a false positive for occult blood and DS has a history of GI bleeding. It can also cause constipation and DS has chronic constipation. Can't be crushed for GT administration.
DRUG ORDER: Dilantin 2.0cc GT qid; seizures 8am, 12pm, 4pm, 8pm Generic: Phenytoin NORMAL DOSE: after loading dose; 300 mg/day or divided tid IS ORDER SAFE? Yes REASON FOR GIVING: Generalized tonic and clonic seizures; head trauma; migraines; ventricular dysrhythmia PRE-ADMINISTRATION ASSESSMENT: Blood studies; mental status; respiratory depression; blood dyscrasias.can cause nausea, vomiting, anemias IMPLICATIONS FOR ADMINISTRATION:* Take in divided doses with or after meals to decrease adverse effects. May turn urine pink. Oral care needed to prevent gingival hyperplasia. POST-ADMINISTRATION EVALUATION: Decreased severity of seizures & ventricular dysrhythmia. REFERENCE: Skidmore-Roth, 807-809 *Dilantin can cause N/V, and anemias. DS has episodes of N/V and has been diagnosed with anemia. Incidents or severity may increase.	DRUG ORDER: MOM 30cc; M-W-F qam per GT for constipation Generic: Magnesium Salts NORMAL DOSE: 30-60 ml hs IS ORDER SAFE? REASON FOR GIVING: Laxative for constipation; draws fluid into colon and increases osmotic pressure. PRE-ADMINISTRATION ASSESSMENT: I&O ratio: decreased urinary output. Cramping, Mg toxicity N/V, thirst, confusion, decreased reflexes can cause rectal bleeding IMPLICATIONS FOR ADMINISTRATION:* with 8 oz water POST-ADMINISTRATION EVALUATION: decreased constipation REFERENCE: Skidmore-Roth, 615-616 Milk of Magnesia can cause rectal bleeding. DS was hospitalized on 23 Oct 98 for rectal bleeding.
DRUG ORDER: Reglan 10mg; q6h Generic: metoclopramide NORMAL DOSE: 10 mg qid (before meals and hs) IS ORDER SAFE? REASON FOR GIVING: prevention of N/V induced by delayed gastric emptying and GERD PRE-ADMINISTRATION ASSESSMENT: Mental status; GI Complaints; N/V; EPS checks can cause constipation IMPLICATIONS FOR ADMINISTRATION:* ??? POST-ADMINISTRATION EVALUATION: ??? REFERENCE: ??? *Reglan can cause constipation and DS already has constipation.	DRUG ORDER: Generic: NORMAL DOSE: IS ORDER SAFE? REASON FOR GIVING: PRE-ADMINISTRATION ASSESSMENT: IMPLICATIONS FOR ADMINISTRATION: POST-ADMINISTRATION EVALUATION: REFERENCE:

DATE	TEST	NORMAL VALUES	OBTAINED VALUE	IMPLICATIONS FOR NURSING CARE WITH REFERENCE
10/28/98	GLUCOSE	70-105 MG/DL	133 H	The normal values indicate this to be a random blood glucose. Results can vary with the time of the last meal. Critical values are <40 or >700 mg/dL. (Jaffe, 596-599) Before changes in diet or medication are made, a FBS should be done.
10/28/98	BUN	7-18 MG/DL	16
10/28/98	CREATININE	0.6-1.3 MG/DL	0.7
10/28/98	SODIUM	130-146 MMOL/L	134
10/28/98	POTASSIUM	3.5-5.0 MMOL/L	5.0
10/28/98	CHLORIDE	98-109 MMOL/L	109
10/6/98	SGOT (AST)	13-30 IU/L	21
10/6/98	ALKALINE PHOSPHATE	42-98 IU/L	86
10/6/98	BILI TOTAL	0.2-1.2 MG/DL	0.4
10/6/98	CALCIUM	8.4-10.2 MG/DL	8.2 L	Hypocalcemia may be caused by hypoparathyroidism, total parathyroid removal, or poor calcium absorption. It may also occur with Cushing's syndrome, kidney failure, acute pancreatitis and peronitis. It can lead to numbness & tingling or spasms of the face, arms, and legs; muscle twitching or cramping; tetany; seizures; and irregular heartbeats. (Moore, 337) DS is diagnosed with seizures.
10/6/98	TOTAL PROTEIN	6.0-8.3 G/DL	7.3
10/6/98	ALBUMIN	3.7-5.3 G/DL	3.6 L	Decreased albumin levels may occur in the following disorders: malnutrition, nephritis/nephrosis, diarrhea, plasma loss from burns, hepatic disease, hypogammaglobulinemia, peptic ulcer, acute cholecystitis, sarcoidosis, collagen diseases, systemic lupus erythematosus, rheumatoid arthritis, essential hypertension, metastatic cancer and hyperthyroidism. (Moore, 385) DS has arthritis and ulcers
10/28/98	CALCIUM OSMOLALITY	270-300 MOSM/KG	271
10/28/98	CO2	23-33 MMOL/L	22 L	Decreased CO2 levels are common in metabolic acidosis. Levels may also decrease in respiratory alkalosis. (Moore, 335)
10/28/98	ANION GAP	6-16	3 L	The level of anions (not including Cl- and HCO3) in the blood. (Egan, 111) A low value suggests that the HCO3 level is higher than normal. Increased HCO3 levels in the blood is alkalosis. (DeLaune, 1044, 1048)
10/28/98	WBC	3.8-11.0 X 10^3	8.8 X 10^3
10/28/98	RBC	4.00-5.20 X 10^6	3.91 X 10^6 L	A low count may indicate anemia, fluid overload, or severe bleeding. (Moore, 282) A low result may indicate anemias, hyperthyroidism and leukemias. (DeLaune, 617) DS has been diagnosed with anemia.
10/28/98	HGB	12.0-16.0 G/DL	10.5 L	A low result may indicate anemia, recent hemorrhage, or fluid retention. (Moore, 290) DS has been diagnosed with anemia.
10/28/98	HEMATOCRIT	36.0-46.0 %	31.0
10/28/98	MCV	80.0-100.0 FL	88
10/28/98	MCH	26.0-34.0 PG	29
10/28/98	MCHC	31.0-37.0 G/DL	33.0
10/28/98	RDW	11.5-14.5 %	15.7 L	Red blood cell distribution is low due to decreased number or RBCs. RBC's were lost in GI bleeding and DS is anemic. Increased protien in her diet will aid in RBC production. (Corbett, 38-39)
10/28/98	PLATELET COUNT	130-400 x 10^3 UL	126 L	Thrombocytopenia (low platelet count) can be caused by bone marrow problems (cancer, leukemia, infection; folic acid or Vit B-12 deficiency; pooling of platelets in spleen; increased platlet distruction due to drugs or immune disorders; or mechanical injury to platelets.
10/28/98	NEUTROPHILS	40.0-74.0 %	63.3
10/28/98	LYMPHOCYTES	23.0-61.0 %	28.7
10/28/98	MONOCYTES	2.0-8.0 %	7.1
10/28/98	EOSINOPHILS	0.0-6.5 %	0.1
10/28/98	BASOPHILS	0.0-1.5 %	0.9
10/28/98	NEUTROPHIL ABS#	1.90-8.00	5.58
10/28/98	LYMPH ABS#	0.90-5.20	2.53
10/28/98	MONOCYTES ABS#	0.16-1.00	0.63
10/28/98	EOSINOPHIL ABS#	0.00-0.80	0.01
10/28/98	BASOPHILS ABS#	0.00-0.20	0.08
10/28/98	BASOP ANISOCYTOSIS	-	1+A
10/23/98	DILANTIN	10.0-20.0 UG/ML	5.0 L	Medication to decrease the frequency/severity of DS's seizures. The physician should be consulted, her medication may need increasing.
10/23/98	APTT	23.2-31.8 SEC	19.9 L	The clotting time is faster than normal. The physician should be consulted about any necessary changes in DS's medication. (Corbett, 320-321)
10/23/98	PRO TIME	10.4-12.8 SEC	12.0
10/23/98	INTERNATIONAL NORMALIZED RATIO	2.0-3.0	1.1 L
10/6/98	TROPONIN T	<0.4 NG/ML	<0.3
10/6/98	CKMB	0.0-4.9 NG/ML	3.5	Does not suggest myocardial injury.
9/21/98	COLOR (URINE)	STRAW	YELLOW
9/21/98	APPEARANCE (URINE)	CLEAR	CLEAR
9/21/98	GLUCOSE URINE	NEG	NEG
9/21/98	BILIRUBIN	NEG	NEG
9/21/98	KETONE	NEG	NEG
9/21/98	SPEC GRAVITY	1.005-1.030 MG/DL	1.010
9/21/98	BLOOD URINE	NEG	NEG
9/21/98	PH	5.0-9.0	7.5
9/21/98	PROTEIN URINE	NEG MG/DL	NEG
9/21/98	UROBILINOGEN	0.2-1.0 MG/DL	0.2
9/21/98	NITRITE	NEG	NEG
9/21/98	LEUKOCYTE URINE	NEG	LARGE	Suggests infection, treated with Cipro for one week. No symptoms at this time, labs have not been repeated.
9/21/98	RED CELLS	/HPF	RARE/HPF
9/21/98	WHITE CELLS	-/HPF	TNTC/HPF
9/21/98	EPITHELIAL CELLS	/HPF	RARE/HPF
9/21/98	BACTERIA	POS>10,000BAC	LARGE	Suggests infection, treated with Cipro for one week. No symptoms at this time, labs have not been repeated.
9/21/98	SGPT (ALT)	10-35 IU/L	27
9/21/98	ALKALINE PHOS	42-98 IU/L	74
9/21/98	BILI, TOTAL	0.2-1.2 MG/DL	0.4
9/21/98	BILI, DIRECT	0.0-0.2 MG/DL	0.1
10/26/98	TYPE BLOOD	A, B, AB, O	A
10/26/98	RH	NEG, POS	NEG
10/26/98	INDIRECT COOMBS TEST		NEG

Additional Labs & Diagnostic Tests
10/26/98, COLONOSCOPY WITH SNARE POLYPECTOMY- Extensive arteriovenous malformations of the right colon. Could have contributedto bleeding. Extensive diverticulosis of left colon. Could have contributed to bleeding. Colon polyps. One snared and retrieved. Doubtful cause of bleeding.
10/23/98, ECG - Undetermined rhythm, suspect atril fibrillation with controlled ventricular response with premature ventricular complexes/aberrantly conduct beats. Nonspecific ST abnormality. Abnormal ECG when compared with ECD of 6 Oct 98. Nonspecific T wave abnormality improved in anteriolateral as per above.

DATE	TREATMENT	RATIONALE WITH REFERENCE	EVALUATION OF CLIENT'S REFERENCE
11/2/98	Diet: Osmolite 60cc/h continuous pump	-PEG tube placed to ensure adequate nutritional intake (DeLaune, 1120) -"Continuous feeding keeps the gastric volume small, minimizing residual volume & reducing the risk of aspiration pneumonia Bloating, nausea, abdominal distention, & diarrhea are less likely to occur. (DeLaune, 1126)	-DS's lab values (low RBC, low HGB, and low Hematocrit) suggest anemia. An increase in dietary protein may be beneficial to this condition. (The labs were done while DS was hospitalized for GI bleeding. These low levels may also be a result of recent hemorrhage. ) -Continuous feeding helps minimize/prevent these problems. DS has a firm distended abdomen and experiences N/V. -Check residual q2h when administrating water. If over 75cchold for 2h. When there is a large residual, the patient is more likely to regurgitate formula through the gastric sphincter into the esophagus and from there it may be aspirated into the lungs, causing aspiration pneumonia. (Ellis, 707) -DS has been prescribed 10mg Reglan to prevent N/V inducedby delayed gastric emptying.
7/1/92	Tube Maint: Flush GT with 100cc water q2h	-A minimum intake of 1500 ml is essential to balance urinary output and the body's insensible water loss. (DeLaune, 1049) -Keeps tube free of impediments and maintains patency. (DeLaune, 1049)	-DS's urine is yellow and has a very strong odor. Her 9/21/98 labs indicated an abnormally high amount of bacteria and WBCs, increasing the need for fluid intake. Staff related that DS cannot always tolerate her water. Water should be administered 50cc/h until it is better tolerated.
12/28/92	Tube Maintenance: Nurses may change G-tube prn	-A clean tube should be inserted when the current tube is no longer patent or harboring possible microorganisms. (Ellis, 704)	-On 11/11/98, the 20 Fr G-tube was replaced with a 20 Fr G-tube. An attempt was made to place a 30 Fr G-tube in hopes that it would stop formula and stomach secretions from leaking out around the tube and irritating the tissue that surrounds it's exit site on the abdomen.
5/9/91	Tube Maintenance: Check placement of G-tube 2 times/shift	-Checking placement ensures that feeding is going into the stomach. (DeLaune, 1129)	-Site red and irritated, formula and stomach secretions draining and soaking dressing. Dressing changed by folding gauze on side of tube (not cutting a notch) to eliminate small pieces of gauze from further irritating site. On 11/11/98 an attempt was made to place a 30 Fr G-tube, but a 20 Fr was placed. A skin barrier was applied and the dressing was changed.
9/9/96	Tube Maintenance: PEG tube care prn with Bactroban	-Bactroban interferes with bacterial protein synthesis and is used for skin infections, wounds, minor burns, skin grafts, primary pyodemas. (Skidmore-Roth, 1084)	-The PEG tube site is very red and irritated. Formula and digestive juices irritate the skin and make it very tender. Apply Bactroban when site is cleaned and dressing is changed. - Check drainage when giving water and change dressing prn.
3/1/93	May suction prn	-Clear secretions the client cannot remove by coughing. (DeLaune, 805)	-DS didn't have a cough or require suctioning. She gagged and acted as if she might vomit during G-tube replacement and a basin was provided for her.
11/4/91	Half soap suds enema X 2 weekly prn	-Cleanse the lower bowel to assist in the evacuation of stool, flatus, or to instill medication. (DeLaune, 1173)	-DS has been diagnosed with constipation. Her last bowel movement was black on 10/9/98.
no date	Routine vital signs	Routine vital signs are accessed for changes that may indicate adverse effects of meds, illness, infection, or patient progress. Axillary Temperature: 95.8-95.4 F (Estes, 211) Pulse: rate 60-100/minute, strength-volume 2+/3+, rhythm regular (Estes, 208-211) Respirations should be 16-20/minute, pattern regular, depth (not shallow), and bilaterally equal. (Estes 207-208) Blood Pressure 100-160 systolic and 60-90 diastolic. (Estes, 216)	-DS's vital signs were within the ranges listed. Pulse and respirations were initially high, but went down in <5 minutes. I must have startled her when I woke her up. Axillary temperature was 98.6 F on 11/10/98. DS's pulse brachial pulse was 84/min on 11/11/98, regular rate and 2+/3+. Rechecked in 5 minutes: 74/min. She was asleep when I approached her and must have been startled. DS's respirations were 28/min on 11/11/98. Pattern was regular with a bilaterally equal chest rise of 1.5". LCTA. Rechecked in 5 minutes 20/min. She was asleep when I approached her and must have been startled. DS lying B/P on her left arm was 124/72 on 11/11/98.
no date	May crush meds as necessary	-If the patient is unable to swallow pills the medicine may be crushed for administration.	-DS is unable to swallow medications and all are ordered to be given through her G-tube. Some of his medications are in liquid form. The ones in tablet from must be finely crushed and dissolved in water for administration. (Ellis, 705) Prilosec and Feosol should not be crushed or chewed. Contact physician about incompatibility of current prescription.
no date	Lab: Dilantin level q 6months	-Test results indicate a patient's progress and can be the basis for planning or altering therapy and nursing care. (Ellis, 215) -Dilantin is toxic at levels of 30-50mcg/ml. (Skidmore-Roth, 807-808)	-Dilantin is prescribed to decrease the severity and frequency of DS's seizures. -DS's Dilantin level was 5.0mcg on 10/23/98. That result is low. The normal range on the lab slip is 10/20mcg/ml. Since the is low, the occurrence of seizures should be investigated and the physician should be contacted about her current dosage.
10/6/98	Oxygen at 2L/M n/c prn SOB	-Improve oxygen uptake and delivery. (DeLaune, 817)	-On 11/11/98 DS's respirations were 28. I reassessed in 5 min and they were 20. No oxygen was administered.
no date	Passive ROM X 4 during bath and repositioning *Nothing specifies how often she should be turned. She should be turned q2h.	-Joints that have not been sufficiently moved can begin to stiffen within 24 hours and will eventually become immovable. Tendons and muscles can be affected as well. Strong flexor muscles contract in a permanent position of flexion (contracture). ROM exercises can prevent joint stiffening and contractures (Ellis, 525) -Correct positioning contributes to comfort and rest and prevents muscle strain. Change of position prevents decubitus ulcers and contractures and it improves muscle tone, respiration, and circulation. (Ellis, 329)	-DS has contractures in her lower extremities. Her knees are pulled toward her chest, hips are at a 90 degree angle. Her feet are kept close to her buttocks and the left is usually under the right. It is difficult to move her legs laterally as well. During exercises her knees are extended to 45-60 degrees. -She also has a tendency to keep her arms close and hands in fists. -Vigilant adherence to her ROM exercise schedule can prevent contractures from occurring or getting worse. -ROM exercises were performed during bed bath. Hands and feet emerged in warm water facilitated relaxation. - A pillow is usually placed between her feet and buttocks. -DS's contractures make positioning difficult, but it is VERY important that she be repositioned to prevent further skin beakdown on her left foot or other areas.
4/10/97	Bed rails up X 2 to prevent falls.	-Side rails are raised to prevent the patient from falling or rolling out of bed.	-DS's bed rails are raised at all times. There were no falls.
no date	Give 0.5 ml influenza virus vaccine each year in October	-Elderly are at risk for infection due to a weakened immune response. Vaccinations reduce risk of viral illness.	-DS's flu shot was given in October.
8/14/98	Foley catheter shift 11-7 shift with soap and water.	-Decrease risk of infection; secretions build up and are an optimum location for bacterial growth, bacteria can move up the outside of the catheter and infect the urinary tract. (Ellis, 126)	-DS still has urinary tract infections, she was treated for one in October. -Ensuring that DS gets adequate water is essential. If she is unable to tolerate her water 100ccq2h, 50ccqh may be more tolerable. -Recommend cleaning DS's catheter 3/day instead of 1/day.
5/15/91	Resident is physically or mentally unable to sign residents bill of rights, family may sign.	-Legally the client must be mentally competent to give consent for medical procedures. (DeLaune, 238)	-DS is not mentally capable of understanding her condition or choices. There was no need to contact family to make choiceswhile DS was under my care.
no date	No Code	-A physicians order in the record that states caregivers NOT perform CPR or other life saving measures if cardiac arrest occurs. (DeLaune, 242)	-There were no situations that warranted CPR.
no date	No Life Support	-A physicians order in the record that states caregivers NOT use life support equipment to prolong life. (DeLaune, 242	-There were no situations that warranted life support.
no date	Seizure precautions	-Keep airway patent, tongue may obstruct. -Prevent injury by: protecting head, removing harmful objects. -Lay on side to decrease risk of aspirating stomach contents/saliva. (Price, 881)	-DS did not have any seizures in my presence.

Diagnostic Divisions	Nursing Problems	Diagnoses	Maslow's Priorities
Activity/Rest	bedfast withdrawn/lethargic flaccid muscles too weak to support head ROM limited X4 strength 1+/10+ contractures lower extremities eyes open to touch	Activity intolerance r/t immobility. Activity intolerance r/t weakness. Disuse syndrome. Look at criteria for activity intolerance.	1 1
Ego Integrity	Widow Sedentary lifestyle; immobile withdrawn dementia of Alzheimer's type
Food/Fluid	PEG tube Osmolite 60cc/h continuous 100 cc water/q2h; not tolerated well N/V history of erosive esophagitis dysphagia lips dry and cracked mucous membranes dry npo No teeth or dentures Foley catheter urine, strong odor frequent UTI r/t Foley catheter duodenal ulcer Edema dx-chart; None Meds cause edema Meds cause N/V Med-Lasix 60 mg q12h Med-Reglan 10mg q6h Med-Phenergan supp 12.5mg q4h Med-Prilosec 20mg/day Lab-Anion Gap 3 Low Lab-Albumin Serum 3.6 Low Lab-Calcium 8.2 Low Lab-Glucose (Random) 133 High	Alteration in nutrition r/t dysphagia. Risk for fluid volume deficiet r/t dysphagia.	1 2
Hygiene	All ADLs are dependent 1-2 person assist with ADLs skin dry, flaky scalp flaky	Self-care deficit, feeding r/t dysphagia. Self-care deficit, bathing/hygiene r/t weakness. Self-care deficit, toileting r/t weakness.	1 1 1
Neurosensory	Cataracts OU blind OU seizures Med-Dilantin 2.0 cc qid, seizures No orientation X3 Lab-Glucose (Random) 133 High Glasses needed (missing) Dysphagia Speech unintelligible Memory loss, recent & remote Posturing- arms to chest	Visual sensory alteration r/t altered status of eyes. Altered thought process r/t disorientation.	2 2
Pain/Comfort	grimace while turning/repositioning
Respiration	recurrent pneumonia Oxygen 2L/M prn dysphagia PEG tube	Risk for aspiration pneumonia r/t dysphagia.	2
Safety	elderly at risk for infection Decreased circulation in left foot 1/2"X1/2" open, L, little toe 1/2"X1" black, L great toe 90% of little toe black Impaired vision & cataracts OU Bed rails up X 2. dx-arthritis dysphagia PEG tube ecchymosis on both upper arms 1" circles, redness from pressure rash, left chest below clavicle large dark moles strength 1+/10+ immobile flaccid muscles ROM limited X 4 contractures in lower extremities	Risk for injury r/t weakness. Impaired physical mobility r/t weakness. Risk for impaired skin integrity r/t immobility.	2 1 2
Social Interaction	widowed nursing home spends all time in bed/in room no verbal communication opens eyes to touch
Teaching/Learning	dementia of Alzheimer's type severely impaired cognitive skills parents died of heart disease

*1-PHYSIOLOGICAL; 2-SAFETY/SECURITY; 3-LOVE/BELONGING; 4-SELF-ESTEEM; 5-SELF-ACTUALIZATION

ASSESSMENT

NURSING DIAGNOSIS

NURSING LONG TERM GOAL/OUTCOME CRITERIA

NURSING INTERVENTIONS

RATIONALE FOR CHOSEN INTERVENTIONS WITHREFERENCE

EVALUATION

-1-2 person assist with ADLs
-Foley catheter
-urine, strong odor
-frequent UTI r/t
-Foley catheter
-Lasix 60 mg q12h
-PEG tube
-Osmolite 60cc/h continuous
-100 cc water/q2h; not tolerated well
-N/V
-history of erosive esophagitis
-dysphagia
-lips dry and cracked
-mucous membranes dry
-npo
-elderly at risk for infection
-immobility
-contractures
-duodenal ulcer
-Edema dx-chart; None
-Meds cause edema
-Meds cause N/V
-Med-Lasix 60 mg q12h
-Med-Reglan 10mg q6h
-Med-Phenergan supp
12.5mg q4h

Risk for Infection r/t a site for organism invasion secondary to Foley catheter.

The client will have no UTI's in one week, AEB:

1.No blood in urine.

2. Absence of bacteria in urine.

The nurse will:

1. I&O

2. Give 1440cc Osmolite/day (60cc/h)

3. Give 1200 cc water/day (100cc q2h).

4. Clean perineal area and catheter tubing each shift.

5. Keep the catheter bag off the floor.

6. Keep the catheter bag below the level of the bladder at all times.

7. Empty the catheter bag every shift or prn.

1. Intake and output should be relatively equal. (Ellis, 197) Assess functioning of the catheter. (Ellis, 126)

2. Nutrients are needed to supply the body with energy to fight infection.

3. Constant flow of fluid tends to inhibit the movement of microbes up the tubing. (Ellis, 126)

4. Decrease risk of infection; secretions build up and are an optimum location for bacterial growth, bacteria can move up the outside of the catheter and infect the
urinary tract. (Ellis, 126)

5. If it touches the floor there are micro-organisms that can get on the outside of the bag and move up the tubing. (Ellis, 126)

6. Prevents potentially contaminated urine from moving back up the tubing and into the bladder. (Ellis, 126)

7. Prevent overfill and urine backing up into the bladder. (Ellis, 126)

1. The goal was partially met: all interventions were carried out, but urine wasnot tested for blood.

2. The goal was partially met:all interventions were carried out, but urine was not tested for bacteria.

-PEG tube
-Osmolite 60cc/h cont.
-100 cc water/q2h; not tolerated well
-N/V
-history of erosive esophagitis
-dysphagia
-lips dry & cracked
-mucous membranes dry
-npo
-No teeth/ dentures
-Foley catheter
-urine, strong odor
-frequent UTI r/t -Foley catheter
-duodenal ulcer
-Meds cause N/V
-Med-Lasix 60 mg q12h
-Edema dx-chart; -None
-Meds cause edema
-Med-Prilosec 20mg/day
-Lab-Anion Gap 3 Low
-Lab-Albumin Serum 3.6 Low
-Lab-Calcium 8.2 Low
-Lab-Glucose (Random) 133 High

Risk for fluid volume deficit r/t dysphagia.

The client will have a fluid intake of no less than 2640cc/day in one week, AEB:

1. Intake of 1440cc Osmolite/ day (60cc/h) via GT.

2. Intake of 1200cc water/day (100cc q2h) via GT.

3. Moist mucous membranes.

4. Lips smooth and free from cracks.

5. Absence of vomiting.

6. Urine odor not strong.

The nurse will:

1. Check placement before giving water.

2. Check residual before giving water.

3. Give 100cc water q2h.

4. Administer prescribed med- icines for N/V.

5. Elevate head of bed 30-45 degrees at all times.

6. Record I&O.

7. Weigh client daily.

8. Osmolite at room temperature.

1. Auscultation of a "whooshing" sound assists in confirmation of placement. (Nettina, 567) Checking placement ensures that the feeding is going into the stomach. (DeLaune, 1129)

2. Checks placement and digestion of previous feeding. (Ellis, 707)

3. Flushes tube, ensures patency, additional water is usually needed by the person receiving tube feeding. (Ellis, 705)

4. Reglan 10mg q6h and Phenergan suppository 12.5 mg q4h for nausea. (Skidmore-Roth)

5. Prevents aspiration. (Nettina, 567-569)

6. Fluid intake should approximately equal fluid output. Anything significantly unequal should be reported. (Ellis, 197)

7. A change in daily weights may indicate fluid retention or dehydration. (Ellis 197)

8. Serving tube feedings at refrigerator temperature can cause cramping. (Ellis, 706)

1. Goal met. 60cc/h Osmolite was tolerated. Residual < 10cc.

2. Goal met. Residual <10cc and 100cc water q2h was tolerated.

3. Goal not met. Mucous membranes dry.

4. Goal not met. Interventions were carried out, but lips are still dry, cracked, and peeling.

5. Goal met. Client did not vomit.

6. Goal not met. Interventions were carried out, but urine still has strong odor.

Anderson, K. (1998). Mosby's Medical, Nursing, & Allied Health Dictionary. St. Louis, Missouri: Mosby-Yearbook, Inc.

Corbett, J.V. (1996). Laboratory Tests & Diagnostic Procedures with Nursing Diagnoses. Norwalk, Connecticut: Appleton & Lange.

DeLaune, S. & Laudner, K. (1998). Fundamentals of Nursing Standards and Practice. Albany, New York: Delmar Publishers.

Egan, E.J. (1997). Taber's Cyclopedic Medical Dictionary. Philadelphia, Pennsylvania: F.A. Davis Company.

Ellis, R.J.; Nowlis, E.A. & Bentz, P.M. (1996). Modules for Basic Nursing Skills, Volume I. Philadelphia, Pennsylvania: Lippincott-Raven Publishers.

Ellis, R.J.; Nowlis, E.A. & Bentz, P.M. (1996). Modules for Basic Nursing Skills, Volume II. Philadelphia, Pennsylvania: Lippincott-Raven Publishers.

Estes, M.E.Z. (1998). Health Assessment & Physical Examination. Albany, New York: Delmar Publishers.

Jaffe, M. (1997). Davis's Laboratory and Diagnostic Test Handbook. Philadelphia, Pennsylvania: F.A. Davis Company.

Janus, R., (1998). The World Book Rush-Presbyterian-St Luke's Medical Center Medical Encyclopedia. Chicago, Illinois: World Book, Inc.

Moore, S. B. (1996). Everything You Need to Know about Medical Tests. Springhouse, Pennsylvania: Springhouse Corporation.

Nettina, S. (1991). The Lippencott Manual for Nursing Practice. Philadelphia, Pennsylvania: Lippencott-Raven Publishers.

Price, S.A. (1997). Pathophysiology: Clinical Concepts of Disease Processes. St. Louis, Missouri: Mosby-Yearbook, Inc.

Skidmore-Roth, L. (1999). Mosby's 1999 Nursing Drug Reference. St. Louis, Missouri: Mosby-Yearbook, Inc.

POINTS POSSIBLE	POINTS EARNED	GRADE: _X_ Satisfactory (>74.9%) GRADE: ___ Unsatisfactory (<74.9%) 74.9% = 149.8 POINTS
5	5	PART A: Data Base 1. Legible, use terminology appropiately, correct spelling and grammar
5	5	2. Developmental Level
20	20	3. Pathophysiology (Description, etiology, signs/symptoms, medical treatment, nursing implications, use two (2) references. Excellent
25	24	4. Complete assessment
10	10	5. Lab & Diagnostic Studies (results, nursing implications, reference) Great!
15	14	6. Medication Worksheets (Results, nursing implications, reference)
10	10	7. Medical Treatments (Include rationale, evaluation, reference) Excellent!
5	4	8. Data Analysis (Matches assessment, Prioritized according to Maslow, Appropriate Nursing Diagnosis)
5	5	6. Reference Sheet Appropirate references cited correctly
100	97	TOTAL PART A
12/12	12/12	PART B: Care Plan (2 required) 1. Assessment: a. subjective data b. Objective data (includes applicable meds, labs, diagnostic studies, and treatment)
6/6	6/6	2. Nursing diagnosis: a. Relivant/Valid b. Correct format (2 - part)
6/6	6/6	3. Goal a. Client centered b. Realistic Attainable c. Addresses nursing diagnosis d. Time for achievement
6/6	6/6	4. Outcome Criteria (minimum of 2 per goal): a. Measureable b. Clearly specific
12/12	12/12	5. Interventions: a. Appropriate number to meet goal (5-6) b. Specific (What, when, how often, how long, where) c. Creative d. Individualized e. Rationale (supports interventions; reference) f. Relevant to goal/outcome criteria
3/3	3/3	15. Rationale: a. Principle support intervention b. Reference
5/5	5/5	16. Evaluation: a. Relevant to started intervention or expected outcome b. Objective/subjective data
100	100	TOTAL PART B
100	97	TOTAL PART A
200	197	TOTAL POINTS

Treatable Causes of Dementia	Irreversible Dementia
medication side effects major depression hypothyroidism low B-12 level severe nutritional deficiencies brain infections (ie. syphilis) consuming large amounts of alcohol over several years brain tumors bleeding around/in the brain high level exposure to certain poisons	Parkinson's disease Pick's disease Huntington's disease Jacob-Creutzfeldt disease (Kindig, 22-23)