Question An RN on the surgical floor at a VA hospital has a patient that had

Question An RN on the surgical floor at a VA hospital has a patient that had surgery for a stage four sacral pressure ulcer and is 48 hours post-op. His condition has been stable since his surgery. Cyrus Cantrell is a white, 70-year-old, Vietnam combat veteran who is a T-8 paraplegic. Mr. Cantrell’s wife was his primary caregiver until her death 6 months ago. Since that time, his daughter has provided care. However, she also has a full-time job and two children, so her time is limited. Plus, dealing with his indwelling foley catheter, bowel program, and personal hygiene upsets her, and so she has performed these activities as quickly as possible.In addition to his paralysis and pressure ulcer, Mr. Cantrell has:Chronic pain related to his spinal cord injuryType 2 diabetes, controlled with oral hypoglycemicsChronic bronchitis, mild emphysemaHistory of depressionHistory of UTIs from indwelling foley catheterHis current medications are:amitriptyline 75mg qd poGabapentin 600mg tid poOxycontin 5mg prn poMetformin 500mg tid with meals poAlbuterol inhaler prnCiprofloxacin 500 q12h IVpulse: 105He also has normal saline at KVO rate and 2l oxygen via nasal cannula.His daughter has been visiting him after work every day, bringing her children when possible.AssessmentVitalsWhen checking his vitals before breakfast at the beginning of the shift, the RN finds:BP: 100/60RR: 18Oxygen saturation: 94% on 2l oxygen via nasal cannulaTemperature: 37°CBlood glucose: 515As she gathers vitals, the RN speaks to Mr. Cantrell. He is just waking up, and is pretty groggy and confused as the RN works with him. After a few minutes, he does not seem to be getting more coherent, and his speech is slurred, so the RN decides to assess him for delirium as she changes his wound dressing. The RN knows from interacting with him over the past couple of days, from discussions with his daughter, and from his chart, that he has no previous cognitive impairment or history of dementia. His pre-surgery Mini-Mental State Examination (MMSE) score was 29/30.2 CARE PLANS, 1 PHYSICAL AND 1 PSYCHOSOCIALImage transcription textRoom # Age: Sex: Admission Date:Student: Cultural/Ethnic Activity: Diet:Date: Background: Diagn… Show more… Show more Health Science Science Nursing NUR 230 Share QuestionEmailCopy link Comments (0)

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