Andrene93

GMR is glucose i thought that was universal my bad.....Glucose meter reading (GMR) *smh...........it's 21.9mmol (millimoles)....It's a real patient and yes we use NANDA

Manifestations: UGIB- distended abdomen, pepsi colored urine. Complex partial seizure- restlessness, confusion. Aspiration pneumonia- poor mobility Nursing diagnosis: Risk for fluid volume deficit related to upper gastric bleeding, Risk for impaired communication related to acute confusion, Risk for oxygen depletion related to changes in mental status Goals: I think further is where I am having problems.

Age: 63 years old Date of Admission: Feb. 16, 2014 Time of Admission: 5:35 am Physical Appearance upon Admission: elderly female, obvious evidence of restlessness Prior to admission: Patient was brought in by her son who stated that she was having episodes of trembling and being confused. Medical History: Patient states that she had a stroke in 2011. Also, she has been diagnosed with high cholesterol, diabetes and hypertension all over 15 years. Ms. Marriot states that she also has sinusitis which is flared by her encounter with dust. Home Environ: Ms. Marriot states that she has indoor running water and other bathroom facilities. Upon Admission (Diagnosis): complex partial seizure, Aspiration Pnuemonia, Upper gastrointestinal bleed. Upon admission, Ms. Marriot was observed for 48 hours, at hourly intervals. [TABLE] [TR] [TD]Date[/TD] [TD]Time/Hrs.[/TD] [TD]Deduction/Results[/TD] [/TR] [TR] [TD]17/2/14[/TD] [TD]3-7pm[/TD] [TD]No seizure activity noted[/TD] [/TR] [TR] [TD]17/2/14[/TD] [TD]8-12pm[/TD] [TD]No seizure activity noted[/TD] [/TR] [TR] [TD]17/2/14[/TD] [TD]12-12am[/TD] [TD]No seizure activity noted[/TD] [/TR] [TR] [TD]18/2/14[/TD] [TD]3-7am[/TD] [TD]No seizure activity noted[/TD] [/TR] [TR] [TD]18/2/14[/TD] [TD]8am-12pm[/TD] [TD]No seizure activity noted[/TD] [/TR] [TR] [TD]18/2/14[/TD] [TD]12pm-8pm[/TD] [TD]No seizure activity noted[/TD] [/TR] [TR] [TD]18/2/14[/TD] [TD]7am-3pm[/TD] [TD]No seizure activity noted[/TD] [/TR] [/TABLE] This information was acquired from Ms. Marriot's docket at the UHWI. Additional information: Ms. Marriot has an IV to the right hand, she needs no assistance with meals, her GMR is 21.9 m/mol and her BP is 138/72mmHg. On Feb 16, 2014 a CT Brain scan was done and there was no evidence of intracranial activity. At present, Ms. Marriot is on insulin, panadol (1g, PO), augmentin (1.2g IV). She also has an upper gastrointestinal bleed.

Patient is a 63 yr old woman who upon admission was diagnosed with complex partial seizure and aspiration pneumonia. 1. identify 3 relevant clinical manifestations relating to the client's diagnosis and briefly give the pathophysiology 2. list 3 priority nursing diagnoses (2 actual and 1 risk) appropriate to the selected client using the maslow's hierachy for each diagnosis 3.formulate an outcome for each diagnosis 4. provide nursing interventions with rationale for each nursing diagnosis 5. develop a plan for the evaluation of each outcome All I need is guidance in doing this please!!!!