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CLC: Home Visit with Sallie Mae Fisher

Identify, prioritize, and describe at least four problems.
Provide substantiating evidence (assessment data) for each problem identified.
Identify and describe at least four medical and/or nursing interventions. (Mara)
Ineffective breathing pattern related to CHF as evidenced by dyspnea and 24 respirations/min.
N/I: Assess SpO2.
N/I: Follow up/ call Delivery Company about supplemental oxygen prescribed for dyspnea prn.
N/I: Encourage pt. to take breaks after each activity.
N/I: Teach and encourage use of supplemental oxygen and risk of not getting sufficient oxygen. Explain that having low oxygen levels can contribute to her feeling that her “mind so cloudy”.
            Poor appetite r/t upset stomach as evidenced by loss of weight 14lbs in 1 week.
            N/I: Daily Weight
            N/I: Determine daily calorie requirement realistic and adequate. Consult a Dietician.
N/I: Teach individuals to use flavorings to help improve the taste and smell of food (lemon, mint, clove, cinnamon, rosemary)
N/I: Eat with others, local elderly community centers, a neighbor
N/I: Supplemental drinks: ensure, etc. to supplement diet.
Nanda Nursing Interventions (2009). Nanda Nursing Interventions: Nursing Interventions
            for Imbalanced Nutrition Less than Body Requirements. Retrieved May 26, 2014,
            interventions-for-imbalanced.html
Dehydration r/t poor oral hydration as evidenced by poor skin turgor with skin tenting and dry mucous membranes.
N/I: Administer antiemetic if ordered.
N/I: Encourage oral intake of 180ml or 6 oz. of fluid with medications.
N/I: Teach pt. about risk of orthostatic hypotension, dizziness, or change in mental status r/t dehydration.
N/I: Place fluids of pt.’s choice within arm reach to encourage oral intake.
Galanes, S., & Gulanick, M. (2012). EHS: Nursing Diagnosis Care Plans, 4/e – Fluid
            Volume Deficit – Hypovolemia; Dehydration. Retrieved May 26, 2014, from
            ick21.html
Risk for lonliness as evidenced by pt. stating “don’t care since Woody died”.
N/I: Encourage pt. to maintain contact with others through telephone.
N/I: Encourage pt. to go outside to get stimulation. Ex: take a short walk outside.
N/I: Assist client in identifying why she feels so lonely.
N/I: Ask daughter/grandchildren to come by periodically for a short while once per week.
Saunders Elsevier (2012). EHS: Nursing Care Planning Guides – Care Planner:
            Diagnosis: Risk for loneliness. Retrieved May 26, 2014, from
            d=52