Nursing care Plan Help!!

An 85 year old female patient was admitted to the hospital as a result of a fall . Early tests show that she may have had a mild CVA and now has right sided paresis with expressive aphasia. Vital signs are: BP 130/72; TPR: 101 degree's F; 110; 26. Additionally, she wears hearing aid's, but left them at home. The nurses' notes state that she is confused and that her speech is slurred and difficult to understand. She is on a pureed diet, but has only been eating about 20% of her meals indicating that she is just not hungry. Her intake and output for the past 24 hours is 800 cc of oral intake and 700 cc's of concentrated urine output. According to family members, she has not had a bowel movement for 5 days. There is a reddened area on her coccyx area. Also, she is running a low grade fever of 100 degrees orally and has a WBC of 11,500.

1. What are possible reasons for elevated temperature, pulse and respiration?

2. What relationship is there between hearing loss and confusion?

3. What is a pureed diet and why would it be ordered for this patient?

4. What is the normal intake and output for a 24 hour period?

5. What is the significance of the patient not having a bowel movement for 5 days?

6. What is the nursing care for a patient with a reddened area on a bony prominence?

Using the above information; put together ONE cluster of related informatio

n:

cluster:

In the example: Skin integrity impaired Next choose a nursing diagnosis that most closely aligns to your

Using one of your care plan pages for developing a nursing diagnoses:

1) Do one nursing diagnosis for your identified cluster.

2) Identify the goal statement and 2 outcome criteria

3) Plan 3 nursing interventions (with scientific rationale)