Sacral Case Study Care Plan

8/2/2019 Sacral Case Study Care Plan

1/12

COMMUNITY COLLEGENURSING PROCESS TOOL

Student Name:

Clinical Date:

Biographical Data : Clients Initials: E.J

Room: 303 Bed 1 Sex: F Age: 89 years old

Religion: Catholic Occupation: Retired

Cultural/Ethnic Background: African American

Admitting Date: 05/01/08Reason for Admission: Possible Sacral

Osteomylelitis

Admitting Diagnosis: Possible Sacral

Osteomylelitis

Secondary Diagnosis: Not Applicable

Surgical Procedure: None

Date: N/AHealth History: Sacral Decubiti;

Dementia; Hypertension

Data - Label S for Subjective, O for Objective Data Analysis (Provide reference) Nursing Diagnosis

R

E

S

T

&

A

C

T

I

V

I

T

Y

A. Rest: (Usual, alterations assoc. with

illness/hospitalization)

Hours of sleep each nightUnable to access because client

is confused and not responding (S)

Difficulty falling asleep; early awakening; nap during

day; Client was observed napping during the day. (O)

manifestations of sleep deprivation Assistive measures:warm milk, medication, etc. - No assistive measures were

observed. (S)

B. ActivityDegree of mobility of all joints; condition of jointsClientis immobile so unable to demonstrate. Client feels pain while

moving joints (O)

Ability to flex and extend limbs against graduated

resistance- Unable to Flex and extend limbs against

graduated resistance(O)

Hand grasp- bilateral; coordination - Pt. demonstrates

normal coordination and bilateral ability to grasp my hands.

(O)

Ability to stand, assistance needed; posture, gait, balancePt is on complete bed rest so not able to stand, complete

assistance needed for ADLs so I couldnt assess her postureand gait. Might be very poor gait.(O)

Rest:As people get older tend to take longer to fall

asleep, awaken more easily and frequently, and

spend less time in deep sleep. Older people are

more likely to be awakened because of

environmental factors such as noise, pain,

nocturia.

(Brunner & Suddarth, pg. 235)

PainChronic pain (chest, joint) clients may interfere

with sleep, fatigue and muscle tension and may

also affect ADL function. Immobilized body parts

produce discomfort or suffering. Once clients

suffers from pain there can be serious impairment

of functional status, mobility, ADL, social

activities and activity tolerance may be reduced.

(P&P p 1236)

ImmobilityReduced mobility will slowly decrease

endurance, strength; muscle mass and this long

term immobility can develop contracture. (P&P p

Risk for disturbed sleep

pattern related to

hospital environment and

joint pain.

Risk for disuse syndrome

related to immobility,

decrease muscle strength,

decrease ROM

Activity intolerance

related to joint pain and

muscle weakness as

evidence by client


2/12

Assistance needed to transfer, stand, walk and use of

assistive devices (cane, crutches, walker, wheelchair)-Unable to access because pt is on complete bed rest(O)

Ability to perform ADL : Pt need complete assistance for

ADLs (O)Restrictions imposed by health problems/therapeuticmodalities- Client has been put on bed rest since she is

confused. (O)

Other factors that may affect mobility: Fatigue, weakness

(O)

1427-1429)

Activity:Intact musculoskeletal and neurologic systems are

essential for maintenance of safe mobility andperformance of ADLs.Agerelated changes that affect mobility includealterations in bone remodeling, leading to

decreased bone density, loss of muscle mass,

deterioration of muscle fibers and cell

membranes, and degeneration in the function and

efficiency of joints.


exhibiting a pained look

on her face when I was

flexing her lower

extremities.

Self-care deficit related

to pain, and weakness as

evidenced by complete

assistance is needed in

performing in ADLs

E

L

I

M

IN

A

T

IO

N

A. Urinary

Voiding (Usual, alterations associated with illness andhospitalization) Client has a Foley catheter in place. (O)

Frequency, urgency, dysuria- Could not assess since client was confused and

unresponsive. (O).

Urine: quantity, color, clarity, odor, Sp. G.- Pt has

catheter bag and it has 300cc, yellowish in color

Lab: urinalysis: BUN: 15 (norm= 8-20 mg/dL);

creatinine: 0.8 (norm= 0.6-1.2 mg/dL);Assistive devices (indwelling, external catheter) Structuraladaptations; urinary diversions: Pt has foley catheter(O)

Retention/bladder distention- No distention observed. (O)

Other factors that may affect normal urinary elimination- HTN, medications, sedentary lifestyle. (O)

B. Bowel

Evacuation patterns (Usual, alterations associated with

FUNCTIONAL INCONTINENCE

Functional incontinence is involuntary ,

unpredictable passage of urine in a client with

intact urinary and nervous system. Changes in

environment; sensory, cognitive, or mobility

deficits. Symptoms include urge to void that

causes loss of urine before reaching appropriate

receptacle. (P&P, p. 1394)

Age and Immobility

People may have special problems with

incontinence because of physical limitations and

environmental barriers. Older persons with

restricted mobility have greater chances of being

incontinent because of their inability to reach

toilet facilities in time. (P&P, p. 1329) and also

Impaired urinary

elimination related to

immobility, age,

decreased muscle tone as

evidenced by client is in

complete bed rest and

has Foley catheter.


3/12

illness & hospitalization)Unable to assess.

Last BM05/08/2008 (O)

Stool: quality, color, consistency, presence of blood,

mucus-

Stool was brown soft and mushy in texture; no mucus orblood was observed. (O)

Assistive measures: laxative, enemas, suppositories -None. (O)

Bowel sounds- Presence ofnormal bowel sounds (b/w 5-

20/min) in all 4 quadrants. (O)

Abdomen: distension, firmness, tendernesss -The

abdomen is firm but not distended or tender. No protrusions

nor distortions noted (O)

Structural adaptations; Ostomies - Pt has no ostomies. (O)

Other factors that may affect normal bowel elimination -Nutrition, medications and inadequate exercise.

lose muscle tone in the perineal floor and anal

sphincter. Although the integrity of the external

sphincter may remain intact, older adults may

have difficulty controlling bowel evacuation and

are at risk for incontinence. (P&P, p. 1377)

Urinary:About one third of elderly people show no

decrease in renal function. Therefore, changes in

renal function may be a combination of aging and

pathological conditions such as hypertension.

Older adults who take medications may

experience serious consequences due to decline inrenal function because of impaired absorption,

decreased ability to maintain fluid and electrolyte

balance, and decreased ability to concentrate

urine.

(Brunner & Suddarth pg. 233)

Immobility and constipation

Clients confined to bed are often constipated.

Physical activity promotes peristalsis, whereasimmobilization depresses peristalsis. Weakened

abdominal and pelvic floor muscle impairs the

ability to increase intraabdominal pressure and to

control the external sphincter. muscle tone may

be weakened or that impairs nerve transmission

so patient are more prone to constipate.(P&P p

1337)

Risk for constipation r/t

immobility, age

medication, diet, lowfluid intake


4/12

Diet, Age and Constipation

Regular daily food intake helps maintain a

regular pattern of peristalsis in the colon. Fiber,

the indigestible residue in the diet, provides the

bulk of fecal material. Diet with low residuewhich move more slowly through the intestinal

tract and cant create sufficient residue of wasteproducts to stimulate the reflex for defecation.

With aging, stool passes through the intestines

at a slower rate and the perception of stimuli that

produce the urge to defecate often

diminishes.(P&P p 1377)

A

CC

E

P

T

A

N

C

E

Affect: withdrawn, sad, cheerful, angry, blankexpression- Client is confused and unresponsive to questions.

(O)

Ability to communicate (verbal & non-verbal) Client

was not able to communicate. (O)

Barriers to communication: language, facility, aphasia,

tracheotomy/E.T. tube, perceptual impairments,developmental disorders, etc.- Client is confused and

unresponsive. (O)

Primary language /ability in English- English (O)

Understanding of health status/reason for hospitalization-Unable to assess.

Any manifestation of anxiety/describe behavior- Unable to

assess.

Coping mechanisms used- Unable to assess.

Self concept/body image; self esteem- Unable to assess.

Family constellation/role within family; livingarrangements; significant othersUnable to assess.

Stage of growth and development: achievement of

Stress and coping:Common stressors of old age include normal

aging changes that impair physical function,

activities and appearance; disabilities from

chronic illness; social and environmental losses

related to income and decreased ability to

perform previous roles and activities; and deaths

of significant others.

(B & S, pg. 229)

Anxiety

Anxiety may increase or decrease the ability of a

person to pay attention. Anxiety is uneasiness or

uncertainty resulting from anticipating a threat or

danger. When faced with change or the need to

act differently, a person feels anxious when there

in no one to take care them. (P&P, p. 456)

Powerlessnes related to

hospitalization and

limited mobility as

evidenced by pt unable to

perform ADLS.

Anxiety related to

situational crisis

(hospitalization and

illness) as evidenced by

clients nonverbalcomplaint of pain and

discomfort.


5/12

A

C

C

E

PT

A

N

C

E

developmental tasks; give evidence- Unable to assess.

Family situation: recent changes or crises - Unable to

assess.

Hobbies- Unable to assess. (O)

Level of educationUnable to assess.(O)Cultural/ethnic influencesUnable to assess (O)

Formal religion; spiritual needs- Unable to assess. (O)

Economic situation (socioeconomic status) - Unable to

assess. (O)

Occupation: specific roleUnable to assess.

Support systems: church groups, AA, etc. Unable to

assess. (O)

Patterns of sexual function (alterations associated with

illness) - Unable to assess. (O)

Menstrual history and pattern- Unable to assess. (O)Reproductive history/disorders; menopause history-Unable to assess. (O)

Urethral, vaginal discharge- None recorded in chart. (O)

S

A

F

E

T

Y

Allergies: Manifestation- Penecillin and Tynenol

Stage of consciousness: alert, confused, drowsy, lethargic,stuporous, and comatoseClient is confused and lethargic. (O)

Orientation: person, place, time -Unable to assess. (O)

Ability to recognize & respond to environmental

hazards-Unable to assess. (O)

Memory: immediate, recent, remote-

Risk for fall

Risk for falls is significantly higher in older

clients balance and mobility problems sensory impairment(visual and hearing problem)

(P&P pg 966)

Risk for injury r/t altered

vision, poor gait,

unknown environment

and age .


6/12

S

A

F

E

T

Y

S

A

F

E

T

Y

Recent: Unable to assess (O)

Immediate: Unable to assess. (O)

Remote: Unable to assess. (O)

Pupillary response: PERRLA

- Pt pupils are equal, round and respond to light. (O) Senses: taste, touch, smell, pain, sight, hearing-Taste: Unable to assess. (O)

Touch: Client sensed when she was touched; but moving her

head towards the person who touched her. (O)

Pain: Pt feels pain when we are giving her AM care, mostly

on the lower extremities(S)

Sight: Unable to assess; but no assistive devices were

observed

Hearing: Client moved head towards my voice when I spoke

to her. (O)Assistive devices: glasses, lens, hearing aidNone were

observed. (O)

Symmetry of facial expressions, tongue, smile-Symmetrical facial expressions, tongue. (O)

Condition of hair, nails, mucous membranes of mouth,

nose, and conjunctiva, tongue-Hair: clean, gray. (O)

Nails: Clean, intact, and no cracking on fingernails but toe

nails are dry and thickened.(O)

MM of mouth, nose, conjunctiva & tongue: pink, intact, andmoist. (O)

Condition of skin: describe wounds, stages of decubiti,

I.V. sites, dressings, scars, rashes, nodules, ecchymosisClient had a IV line infusing in her Left arm. (O)

Stage IV sacra; decubiti ulcer (8x10 cm; 3cm depth). (O)

Other factors that may affect skin integrityImmbobility.

(O)

Condition of breasts: symmetry, contour, puckering,

Hospitalization:An illness that requires hospitalization or a

change in lifestyle is an imminent treat to well-

being. Older people admitted to the hospital are at

high risk for disorientation, confusion, change inlevel of consciousness, and other symptoms of

delirium as well as fear and anxiety.


Intravenous Infusions:There are numerous hazards that a pt. can

encounter when receiving IV therapy due to the

introduction of microorganisms. These includelocal complications like phlebitis, infiltration,

hematoma or clotting of the needle and systemic

complications which are more serious like

infections.


Skin:With aging changes in appearance and function of

the skin include: thinner dermis, decreased

subcutaneous fat, decreased blood supply, loss ofresiliency and wrinkling. The skin becomes drier

and susceptible to injury and infection.


Dry feet nails

A normal healthy nail is transparent, smooth, and

convex, with pink nail bed and translucent white

tip. Disease can cause changes in the shape,

Disturbed sensory

perception r/t altered

vision AEB clients

confused state.

Risk for infection r/t IV

infusing in left arm and

Foley catheter.

Risk for deficient fluid

volume r/t age,

medication, loss of fluidsthrough abnormal

routes(indwelling tubes)

and deviation affecting

access of fluids .


7/12

S

A

F

E

TY

S

A

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F

T

Y

nipple discharge, gynecomastia- Pt breasts are symmetrical

with no abnormalities seen on assessment. (O)

Comfort status: itching, burning, nausea, hunger, pain

(character, location, onset, duration, relief measures)-

Unable to assess. (O)Other factors that may affect comfort status

Hospitalization; immobility; (O)

Fluid status: IV type and rate, medication added -1000 ml

0.45% NaCl at 50 cc/hr; 5%dextrose

I&O: Date: 03/11/08: Intake : IV: not recorded PO: ?

Output : Urine: 300cc; Other: none05/07/08 Intake: IV: 1000 cc PO: 300 cc of water and 80%

of lunch

Output: Urine:Skin turgor, rapid weight gain or loss, condition ofmucous membranes of mouth- Skin turgor is normal. The

MM of the mouth is pink and intact. No weight changes

reported. (O)

Other factors that may affect fluid and electrolyte statusMedications, nutrition (O)

Lab data and Diagnostic tests:

Lab: electrolytes:Na: 142(135-145 mEq/L);

K: 4.1 (3.5-5.5 mEq/L);Cl: 107 (96-108 mEq/L);

Ca: 9.1 (8.5-11.0 mg/dl) ;

Albumin:2.7 ( 3.5-4.9g/dl);

Bilirubin: Not recorded. (0.1-1.2 mg/dl);

Alk. Phosphatase: Not recorded(30-110 u/l)

WBC: 8.2 (norm= 5.0-11.0);

culture reports: total cholesterol: Not recorded; LDL: Not

recorded (norm= < 130mg/dL); HDL: 48 (norm= 35-

thickness and curvature of the nail.(P&P p. 695).

Some people have dry feet because of a decrease

in sebaceous gland secretion, dehydration, pf

epidermal cells and poor condition of footwear. If

foot or mails problems stay unresolved the clientcan easily become disabled and risk for infection

on cracked nails (Brunner & Suddarth p. 1013)

Fluid and electrolyte imbalance:Illnesses, trauma, surgery and medications can

affect the bodys ability to maintain fluidelectrolyte and acid-base balance. Tissue trauma

causes fluids and electrolytes to be lost fromdamaged cells. Medications and other diseases

can also result in abnormal losses of electrolytes

and fluid loss or retention.Older adults have

decreased thirst sensation which may affect their

oral intake of fluids. Their kidneys have

decreased glomeruluss filtration rate and thenumber of filtering nephrons. These changes may

mean that in the presence of sodium depletion or

overload the older adult may not able to maintain

homeostasis and the imbalance instead can beworsened. Medications can cause fluid and

electrolytes imbalance. Nurses can closely

examine laboratory values and knowledge of the

clients about side effects and adherence to

medication schedule.(P&P,1149). All clients with

cathetrization should have 2000-5000 ml oral or

IV intake .A high fluid intake produces large

amount of urine that flashes the bladder and keps


8/12

85mg/dL); triglycerides: Not recorded. (norm= 40-

150mg/dL); liver function test, etc.- N/A

Other significant lab data (include significant data not

specified, such as serum levels of drugs, endocrine testes,

etc.) N/ADiagnostic tests results (scans, MRI, echo, etc.)N/A

Risks Associated with Diagnostic and Therapeutic

Modalities(Some examples include anticipation of

common problems identified with: perioperative care,

use of restraints, nasogastric tube feeding, blood therapy,

total parenteral nutrition, chest tubes, central lines,

surgical procedures, etc.)- - Pt at risk for infection due to

invasive medical procedures (IV on L arm and Foley

catheter.(O).

Body temperature patterns x 2 days-05/01/2008: 97.6 F

05/02/2008: 97.1 F

Recent exposure to infections- IV site on L arm and foley

catheter(O)

Manifestations of active infection- swelling, redness, pain

on old IV site.(O)

Immunization: inquire about status including TD,

Hepatitis B, Flu, and Pneumococcal-No records of

immunization in the charts.

Medications: major risks associated with side

effects/interaction-

Vitamin C 1000mg PO daily

Cozaar 50mg PO daily

Atenol 50 mg PO daily

Gentomyacin 1000 mL IVPB

the catheter fre of sediment.( Brunner & Suddarth

,1350)

Foley catheter

Catheterization of the bladder involvesintrodusing a rubber or plastic tube through the

urethra and into the bladder.The catheter provides

continuose flow of urine if client is unable to

control micturation or those with

obstructions.Bladder catheterization carries risk

of UTI,blockege and thrauma to the urethra.When

inserting the indwelling catheter closed urinari

drainage system is maintained to prevent

infections.The bag should be hang on the bed

frame not touching the floor below the level of thrbladder.Urine in the bag can become midium for

bacteria and infection is likely to develop if thr

urine flows back in the bladder.Break in the

system can lead to infection .Sites at risk are the

site of catheter insertion,the drainage bag ,the

tube junctionand the junction between the tube

and the bag.(P&P,1350)


9/12

Alcohol and/or unprescribed drug use: Unable to assess.

Discharge Planning: )

1. Where will the client be going after discharge?

Unable to assess. (O)2. If returning to home, inquire about home

environment: adequate space, stairs to climb, cookingfacilities, hazards. N/A

3. Ability to manage health problem, knowledge base,

motivation, constraints, role of significant others, teaching

needs, affordability of medications, supplies and

equipment.Unable to assess. (O)

4. Medical follow-up: understands need for,

transportation to PMD, clinic, and labs. Need completeassistance.

5. Anticipated need for referral: Social Worker, VisitingNurse, and other Home Care Services. Unable to assess.

(O)

O

X

I

G

E

N

A

T

I

O

N

Chest pain, describe- Unable to assess. (O)

Nails, lips skin, mucus membranes: color/temperature -Pt. nail beds, lips and MM are pink and intact. Skin is cold to

touch, clammy and diaphoretic. (O)

Capillary refill: upper extremities:

4 seconds (O)Pulse - rate, rhythm, quality (rate pattern x 2 days)-05/01/2008: 88

05/02/2008: 74

Rhythm was

Compare apical / radial pulses - Apical: 76 Radial: 77

Peripheral pulses: presence, volume, compare bilaterally

(brachial, radial, femoral, political, posterior tibia, dorsalpedals)All peripheral pulses are present but very weak (O)

The respiratory system changes throughout the

aging process and it is important for nurses to be

aware of these changes when assessing patients .

Nurses should be aware that the older adult is at

risk for aspiration, and infection related to thesechanges.

(Brunner & Suddarth p728)

LABS:

RBC: cellular component of blood involved in

transport of oxygen and carbon dioxide.

Hemoglobin: iron-containing protein of RBCs-

delivers oxygen to tissues. Decreased level of

hemoglobin reflects the presence of fewer than

Impaired gas exchange

r/t alveolar-capillary

membrane changes AEB

abnormal breathing rate,

dyspnea and restlessness


10/12

OX

Y

G

E

N

A

T

I

O

N

O

X

YG

E

N

A

T

I

O

N

Homan's sign- Negative (O)

Edema: degree and location/measure abdominal girth

p.r.n-Pt has no edema. (O)

Distention of neck veins- No distension of neck veinsnoticed. (O)

Blood pressure pattern x 2 days-05/01/2008: 163/82

05/02/2008: 172/88

Other factors that may effect the cardiovascular system immobility, non productive cough(O)

Activity toleranceClient is bed bound. (O)

Orthopnea- Client is in semi-fowlers. (O)

Shape of chest- Chest symmetrical ,normal(O)

Respiration-rate, rhythm, depth, patterns, use of

accessory muscles, symmetry of chest movements, rate

pattern x 2 days-05/01/2008: 18

05/02/2008: 18

There is symmetry of chest movements. (O)

Breath sounds: clear, course, crackling, wheezing- clear

breath sound s. (O)

Location of adventitious soundsnone. (O)

Cough: frequent, infrequent, dry, loose, barking,

productive, etc.-Client was not observed coughing. (O)

Sputum: color, tenacity, amount, color- Client had no

sputum. (O)

Assistive measures: oxygen therapy (kind), tracheotomy,ventilator with E.T. tube, etc.N/A

History of smoking tobacco/marijuana: amount,

duration-

normal RBCs in circulation. As a result, the

amount of oxygen delivered to tissues is also

diminished.

Hematocrit: Is percentage of total blood volume

consisting of RBCs. Decreased hematocrit mayindicate anemia or acute massive blood loss.

PT and APTT: Indicates time taken for clotting to

occur. Lengthen PT and PTT may indicate risk

for bleeding.

Albumin: In the blood, albumin acts as a carrier

molecule and helps maintain blood volume and

blood pressure.

(Brunner & Suddarth p1045, Tabers p66, p1796)

)Cardiac output in the older adults may be

affected by increased arterial wall tension and

moderate myocardial hypertrophy due to an

increased systoloc blood pressure(P&P,1069).

If left ventrical failure is significant the amount

of blood ejected from left ventrical drops and

decreases cardiac output.Assesment fundinggs

may include decreased activity

tollerance,breatlessness,dizziness and confusion

as a result of tissue hypoxia.(P&P,1078)

Lackof movement and exercise places clients at

higher risk for reparatory complications. The

most common respiratory complications are

atelectasis (collapse of alveoli) and hypostatic

Ineffective breathing

patern r/t

anxiety,decreased

energy/fatigue as

evidence by use ofaccesory muscle to

breath and deapth of

breating

Decreased cardiac output

r/t altered stroke volume

AEB clammy skin,

altered peripheral pulses

prolonged capillary refill

and confusion


11/12

Unable to assess.

Other factors that may affect the respiratory systemMedication, HTN,

Lab: RBC count: 3.23 (norm= 4.0-5.50); Hgb.: 10.1

(norm= 12-15.g/dL); Hct.: 29.3(norm= 35-47);Platelet: 449 (norm=150-450);

ABG's: Ph: 7.45 (7.35-7.45)

Pco2: 37.1(35-45)

PO2: 80.2 (75-100)

HCO3: 24.4(22-26)

cardiac enzymes: Unable to assess. (O),

; PT: Not recorded(norm= 11-12.5); APPT: Not recorded.

(norm=); INR: 2.9(norm= 3.0-4.5); Guaiac Tests: no

record

Pulse oximetry results: 96% (O);EKG report: Normal Sinus Rhythm; performed on

x-ray/lung scans: None recorded in chart.

pulmonary function tests: N/A

pneumonia (inflammation of the lung from stasis

or pooling of secretions). Both decreases

oxygenation, prolong recovery, and add to the

clients discomfort. (P&P 1428)Encourage early

ambulation after surgery walking causes client toassume a position that do not restrict expansion of

the lungs and stimulates an increased

RR .(P&P,1638)

Risk for ineffective

airway clearance r/t pain

and immobility.

N

U

T

R

I

T

I

O

N

General appearance: muscular, wasted, emaciated, obese,well nourished-Client is emaciated. (O)

Height and weight patterns of gain or loss- Not able to

determine

Weight: compare current weight with ideal weight- lb (O)

Condition of teeth & gums, ability to chew and swallow-Clients gums were pink and spongy; gag reflex was present.Client had no teeth and no dentures were observed. (O)

Usual eating patterns: describe the patients usual diet for

breakfast, lunch and dinner on a week day and on a

weekend day; identify usual number of servings of CHO,

protein, milk, vegetables, fruits and fats on a regular day

and frequency of intake of fast foods, fried foods, deserts,etc.- observation of lunch only: client is on soft mechanical

With clients need assistance with feeding it is

important to protect clients safety, independenceand dignity. The nurse should asses client s riskfor aspiration. Client with more risk for aspiration

needs more assistance with feeding. Position

client in upright seating position. this clientshould not use a straw .In addition the rate of

feeding is slower and more frequent chewing and

swallowing through the meal is need

it(P&P,1296-1298)

The American Heart association dietary

guidelines are intended to reduce risk factors for

the development. Dietarian therapy following

myocardial infarction includes initial reduction in

Feeding self-care deficit

r/t weakness, muscolo-

skeletal impairment,

fatigue as evidence by

inability to ingest food

safely ,inability to chewand complete a meal

Nutrition less than body

requirements r/t to

excessive intake in

relation of metabolic


12/12

N

U

T

R

IT

I

O

N

cardiac diet. (O)

Intake of caffeine, alcohol, sodium, processed foods, fiber-Client was observed eating 85% of lunch. (O)

Cultural/religious preferences Not able to determine

Alterations in eating patterns associated with illness &hospitalization- Client is not able to feed self; assistance is

needed. (O)

Diet ordered/knowledge of compliance- .- Cardiac pureed

diet ,no salt

Appetite: assess usual intake and the last 2 days- Client

eats 80% of her meals. (O)

Lab: total protein:, serum albumin: also consider

relationship of Hgb. to nutritional status-

Glucose levels blood:, urine glucose:, acetone in urine:

Assistive measures for nutrition (i.e. tube feedings, TPN,etc.)- N/A

Are current nutritional needs being met in terms of

calories, protein, vitamin, calcium, etc.? Provide

objective data to support your decision. If feeding by

nasogastric, gastrostomy tubes or TPN: estimate caloric

intake for 24 hours

kilocalories ,soft textured foods and amounts of

fats ,sodium, and cholesterol that conform to

AHA recommendations. Magnesium and folic

acid appeared to be important for primary

prevention .Nursing intervention for hypertension ,coronary

artery disease and CHF include weight reduction

and limiting fat and salt intake.(P&P,250)

Caloric intake to the point of obesity overloads

the cells of the body with lipids .By requiring

more energy to maintain the extra tissue obesity

place a strain on the bodys cardiovascularsystem(Brunner & Suddarth p101)

need AEB weight less

than 10 % under ideal for

height and frame

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Sacral Case Study Care Plan