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Bowel Plan?Pt understands bypass of anal sphincter and collection pouch is necessary for BMNeurological – A&O x 4; cranial nerves II-XII intact; no tremors noted; pt follows verbal commands
8Musculoskeletal – all extremities symmetrical and WNL; no edema noted; steady gait; pt can ambulate unassistedPt reports chronic lower back pain of unknown origin; Morse Fall Scale 15 (no risk)Genitourinary - WNL; no foley present; pt denies burning/pain upon voidingUrinary continence?Pt is continentToileting plan?Pt can use restroom independentlyNursing Diagnosis #1: Imbalanced Nutrition: Less than Body RequirementsRelated to (RT):acute renal failure, inability to procure adequate amounts of food and ileostomy.As evident by (AEB):Increased BUN and serum creatinine, hyperkalemia, decreased hemoglobin and hematocrit, decrease in serum calcium with increased in serum phosphate, and patient statement of being homeless.Planning/Desired Outcome(s): Patient achieves optimal nutritional status and nutrient intake.Implementation/Nursing intervention(s):Rationale Evaluation/Patient ResponseAssess for possible cause of a decreased appetite or gastrointestinal discomfortUremia manifestations include GI disturbances related to the accumulation of toxins and altered intestinal motility (Gulanick & Myers, 2014, p. 797).Pt has ostomy bag RLQ.Assess the patient’s actual oral intake; obtain calorie counts as necessaryThis provides accurate measurement of nutritional intake (Gulanick & Myers, 2014, p. 797). Pt will ingest adequate caloric intake during shift. Monitor serum albumin levelSerum albumin indicates the degree of protein depletion (3.8-4.5g/100mL is normal) (Gulanick & Myers, 2014, p. 797). Pt’s serum albumin level will stay within normal range.
9Provide referral to community nutritional resources as indicated.Many transient patients are unable to acquire adequate amounts of food required to meet the body’s metabolic demands (Gulanick & Myers, 2014, p. 135).Pt will be provided with information on community nutritional programs and homeless shelters. Adjust the potassium and phosphorus restrictions as indicatedIn ARF, the kidney is unable to excrete potassium and phosphorus. Dietary restriction is needed to keep serum levels within normal limits (Gulanick & Myers, 2014, p. 798).Pt will be compliant with dietary restrictions.Offer antiemetics as prescribedControlling nausea may improve the patient’s appetite and food intake (Gulanick & Myers, 2014, p. 798).Pt will verbalize the need for antiemetic. Administer antacid and H2-receptor-blocking agentsThese drugs reduce gastric acidity and prevent mucosal ulcerations. Antacids should not contain aluminum and magnesium because the patient with ARF cannot excrete aluminum or magnesium, and hypermagnesemia would develop (Gulanick & Myers, 2014, p. 798).