Meds:
Coumadin, (blood thinner) Simvastatin (statin)
Meds:
Coumadin, (blood thinner) Simvastatin (statin)
Outcome: Pt. will demonstrate effective swallowing without aspiration or chocking while eating q shift.
Outcome: Pt. will demonstrate effective swallowing without aspiration or chocking while eating q shift.
Risk factors: Age (79), HTH, and previous stroke
Risk factors: Age (79), HTH, and previous stroke
Labs: PT/INR 15.0/1.14, Hgb 10.9,HCT 32
Labs: PT/INR 15.0/1.14, Hgb 10.9,HCT 32
Interventions:
Elevate the HOB 45-90 degrees for meals, perform good oral hygiene, monitor weight, check mouth for food pocketing
Interventions:
Elevate the HOB 45-90 degrees for meals, perform good oral hygiene, monitor weight, check mouth for food pocketing
Outcome: Pt. will remain free of skin breakdown by end of shift
Outcome: Pt. will remain free of skin breakdown by end of shift
Nursing Dx: Impaired swallowing R/T weakness and right sided hemiplegia AEB drooling and difficulty swallowing
Nursing Dx: Impaired swallowing R/T weakness and right sided hemiplegia AEB drooling and difficulty swallowing
Outcome: Pt. will participate as much as possible in ADL’s by end of shift
Outcome: Pt. will participate as much as possible in ADL’s by end of shift
Interventions: Complete Braden scale assessment q shift, monitor skin condition, turn & reposition q 2 hrs., minimize exposure to moisture, assess nutritional status.
Interventions: Complete Braden scale assessment q shift, monitor skin condition, turn & reposition q 2 hrs., minimize exposure to moisture, assess nutritional status.
Interventions:
Provide rest between activities, encourage participation with ADL’s, collaborate with PT and OT
Interventions:
Provide rest between activities, encourage participation with ADL’s, collaborate with PT and OT
Nursing DX: Impaired physical mobility R/T right sided hemiplegia & weakness AEB difficulty repositioning and limited range of motion
Nursing DX: Impaired