Chronic renal failure, Arthritis, Generalized Pain, Dysuria, Anemia, HTN, GERD, Early Stage Dementia, Anxiety, Osteoporosis

Medical Diagnoses: Chronic renal failure, Arthritis, Generalized Pain, Dysuria, Anemia, HTN, GERD, Early Stage Dementia, Anxiety, Osteoporosis

Assessment	Nursing DX/Clinical Problem	Client Goals/Desired Outcomes/Objectives	Nursing Interventions/Actions/Orders and Rationale	*I	Evaluation
					Goals	Interventions
Subjective “My hip is hurting from when I broke it.” Objective: Client does not ambulate.	Problem Chronic Pain	Long Term: Client will function with minimal interference from pain, rated as 3 or less on a scale o f 0-10 within 2 months. Client will function with minimal interference from medication side within one week..	Tell the client to report pain location, intensity and quality when experiencing pain. Assess and document the intensity of the pain with each new report of pain and at regular intervals. Systematic ongoing assessment and documentation provide the direction for pain treatment plans ; adjustments are based on the client’s response. (Nursing Diagnosis Handbook, Ackley and Ladwig, pg. 613)	N/A	The client will report pain at less than three on a scale of 0-10.	The nurse will help the client by repositioning to avoid pressure on the healing hip, administer medications as indicated by pain level and call physician to change medication if pain is unrelieved by prior intervention.s
	R/T Progression of joint deterioration, injury, surgical procedure, and chronic kidney disease	Short Term: Use pain rating scale to identify current level of pain intensity, and determine comfort/function goal.	Ask the client to describe past and current experiences with pain and the effectiveness of the methods used to manage the pain, including experiences with side effects, typical coping responses and the way the client expresses pain. A study revealed that barriers can affect a client’s willingness to report pain and use analgesics. Many harbored fears and misconceptions regarding the use of analgesics, management of side effects and risk of addiction.	N/A
	AEB as evidenced by patient self report of pain level.

*I = Implementation. Check those interventions/actions/orders that were implemented

Name/Dose	Why does resident receive?	Major Side Effects	Nursing Implications
Lorazepam 0.25 mg, every 8 hours, PRN.	Anxiety	Anterograde amnesia, drowsiness, sedation, dizziness, weakness, unsteadiness, disorientation, depression, sleep disturbances, restlessness, confusion, and hallucinations	Supervise ambulation of older patients for at least 8 hours after administration to prevent falling and injury.
Premarin-0.625 mg/1 gm cream	Vaginal dryness, itching and burning	Vaginal discomfort or pain, itching, breast pain, vaginitis	Monitor for and report any vaginal bleeding, assess for relief of symptoms
Metoprolol XL 25 mg once daily	Hypertension	Erythematous rash, fever, headache, muscle aches, sore throat, laryngospasm, respiratory distress, dizziness, bradycardia, fatigue, insomnia, mental depression, Raynaud’s phenomena, nausea, heartburn, dry mouth and mucous membranes, hypoglycemia, SOA	Take apical pulse and BP prior to administration, report significant changes, monitor I&O, daily weight, auscultate daily for pulmonary rales, withdraw drug if patient exhibit mental depression, can progress into catatonia.
Acetaminophen -500 mg PRN q 4	Pain	Neglible with recommended dosage, rash	Monitor for s/s of hepatotoxicity.
Maalox 30 mL q6 PRN	GERD	Chalky taste, constipation, diarrhea, increases thirst, stomach cramps	Monitor for s/s of allergy, monitor bowel elimination
Hydrocodone 5/500 PRN q6, not to exceed 4 gm per 24 hours	Pain	Dry mouth, constipation, nausea, vomiting, light-headedness, sedation, dizziness, drowsiness, euphoria, dysphoria	Monitor for effectiveness of pan relief, monitor for n/v, especially in ambulatory patients, monitor respiratory status and bowel elimination
Senna 8.6 mg	Constipation	Strong cramping and griping pains in the abdomen, electrolyte imbalance (loss of potassium) and loss of body fluids, nausea, rash, swelling of the fingertips, weight loss, and dark pigmentation in the colon	Monitor for effectiveness of bowel relief, monitor for electrolyte imbalances, monitor for n/v, monitor for rash
Furosemide 10 mg	Hypertension/Renal Failure	Hypotension, dizziness with excessive diuresis, hypovolemia, dehydration, hyponatremia, hyperglycemia, anemia	Monitor BP during periods of diuresis, monitor I&O ratio and pattern, monitor for dehydration and hypovolemia, monitor glucose, monitor for electrolyte imbalances
Ferrous Sulfate 325 mg	Anemia	Nausea, heartburn, anorexia, constipation, diarrhea, epigastric pain, abdominal distress, black stools.	Monitor HgB and reticulocytevalues during therapy. Monitor bowel movements.
Ibuprofen 400 mg	Pain	Headache, dizziness, light- headedness, anxiety, emotional lability, fatigue, drowsiness, confusion, depression, aseptic meningitis, dry mouth, GERD, v/n/d, acute renal failure, GI bleeding	Monitor for effectiveness, periodic Hgb, renal and hepatic function and auditory and ophthalmic examinations. Monitor for GI distress and S/s of GI bleeding.
Calcium Carbonate	Indigestion/hyperphosphatemia	Constipation or laxative effect, acid rebound, n/v, flatulence	Monitor for bowel functio, determine serum and urine calcium, observe for s/s of hypercalcemia