Nursing Care Plan Report Help

INTRODUCTION:

This care plan is a detailed health assessment of a 76 year old, Alice McCallum.  She was brought to hospital confused and weak. In this care plan, two of her physiological conditions will be discussed. Risk of falls is a potential problem that might occur if preventive measures are not taken, while on the other hand, metabolic acidosis is an actual existing problem that needs immediate attention. This report addresses the pathophysiology that links the conditions to the occurring signs and symptoms. It also lists the nursing interventions and desired outcomes required as a source of treatment for the two.

 

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RISK OF FALLS:

Elderly patients have a high risk of falls due to various reasons such as dehydration, disturbed neurological conditions, medication, malfunctioning of organs, age (Ambrosea et al., 2013). Mrs. McCallum is at risks of falls due to the hyponatremia i.e. loss of salts from the body (Gunathilake et al., 2013). She was taking a diuretic Bendroflumethazide to control hypertension. This drug releases water from the body to treat oedema and high blood pressure. This might have caused loss of salts from the body which led to an electrolyte imbalance and to hyponatremia (Liamis et al., 2016).

 

PATHOPHYSIOLOGY:

  • Bilateral muscle spasm: There is a strong imbalance in the electrolytes of the patient. There is a decrease in the salt electrolyte as a result the salt-potassium gradient that powers the calcium ions are unable to function properly. Brain sends ATP to muscles causing release of calcium ions for muscles contraction. Without sodium gradient, calcium ions stays in the myofibrils and causes the muscles to stay contracted causing muscle spasms. This will lead to risk of fall.
  • Muscle weakness: Muscle weakness is also termed as myopathy (Sasaki et al., 2007).  Hyponatremia induced myopathy is very common, as loss of sodium causes skeletal muscle disruptions. Presence of sodium and calcium balance is necessary for healthy muscle function. With the decrease in sodium electrolyte, calcium electrolyte gets elevated in the cell. This poses a direct threat, as elevated calcium will damage the sarcoplasm and causing cell death and loss of muscle function
  • Confusion: when there is a decrease in the sodium level, water enters the cells and causes swelling. When this happens in the brain, it causes a dangerous condition called cerebral edema. This causes brain to swell which leads to confusion, altered mental state (Zieschang et al., 2016).
  • High heart rate and low blood pressure: continuous tachycardia without treatment might result in cardiac problems (Cavusoglu et al., 2019). With the loss of sodium, arginine vasopressin gets activated. It increases the water absorption, thus forcing heart muscles to contract increasingly. This causes increased heart rate. Sodium reduction causes increase production of rennin, increase aldosterone, adrenal and non adrenal which not only increases heart rate but also lower blood pressure (Graudal et al., 2016)

INTERVENTIONS:

Certain nursing interventions are employed to prevent the risk of falls. These interventions cannot be 100% effective till the underlying disease is treated. Following are the list of management efforts that can assure patient’s well being.

  • Discuss with other health care professionals such as physicians and pharmacists, to plan and evaluate such medications that might increase the risk of falls (Sluisveld et al., 2012). Nelleke et al.,(2012) in his study, concluded how interaction between the whole medical staff is necessary for effective patient health management.

 Reason: This is due to the fact that some medicines such as diuretics in this case, causes decrease amount of salt in the body that increases the fall risk. Discussion with the prescribing team will aid in proper assessment of the dosage, side effects and contraindications (Milos et al., 2014).

  • Encourage patient to join an exercise and training program that will ensure physical activity and will decrease the risk of falls (Sherrington et al., 2011). Physical therapist will aid in this intervention. A planned physical activity for diabetic and hypertensive patients is required here.

Reason: Physical activity improves bone density and muscle movement. This will reduce the incidence of falls and will limit the injury attained due to it (Cadore et al., 2013).

  • With the assistance of occupational therapist ,plan a gait technique for practice and ambulation (Szanton et al., 2014)

Reason: Assistive gait devices and techniques will provide stability in positioning and movement (Duchêne et al., 2014). Devices such as cranes, walkers etc will provide support and dependency that will lower the risk of falls.

  • In case of confusion and delirium, reality orientation can be used to help patient focus (Day et al., 2011). This technique requires familiar surroundings, things and people to remove confusion.

Reason:  Through this technique of focusing on time place and surroundings, patient will be able to focus and remember. This will aid in calming down the patient

  • Educating patient on how to ambulate at home.

Reason:  this will aid in relieving anxiety and minimize the risk of falls

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OUTCOMES:

  • Patient’s resistance to fall is one of the main goal. Educating patient and caregivers through above mentioned interventions.
  • GCS should be 15 and stable. Frequent checks after every few hours to obtain a stable reading are important. GCS is measured through checking the eye activity, verbal response and motor relexes.
  • Patient is expected to have a normal heart beat. Heart rate should be monitored every hour or 2 till it reach below 100 bpm. After stability is achieved, it will be monitored every 4 hours with the help of heart rate monitor or manually.
  • Blood pressure should be 130/80 mm Hg as required in diabetics. it should be checked every hour for the first 4 hours and then later every 4 hours when it is stable
  • Patient should be taking proper nutrition that is according to her health circumstances.
  • Electrolyte should be properly balanced especially sodium. Sodium should be within the range of 136-145mmol/L. it can be checked through blood test (Waikar et al., 2011)

METABOLIC ACIDOSIS:

Metabolic acidosis is a physiological condition. It is caused due to sudden decrease in the sodium bicarbonate and an increase in the acidity. This imbalance causes a decrease in pH, making the body acidic.  Metabolic acidosis in this patient is caused due to hyperlactatemia. Patient is suffering from sepsis which causes a rise in lactic acid leading to accumulation (Maciel et al., 2010). This condition has given rise to many signs and symptoms: weakness, confusion, poor oral intake, weight loss, and increase in WOB, low urine output etc.

 

PATHOPHYSIOLOGY:

  • Weakness and drowsiness: Patient is suffering from weakness and drowsiness which is due to the low oxygen level in the brain. To balance the pH of the body, compensatory mechanism initiates, that causes increase in PCO2. With the severity of metabolic acidosis, oxygen becomes inadequate causing slowing down of brain function, weakness and drowsiness.
  • High respiratory rate and SpO2: Metabolic acidosis has a direct effect on the respiratory system. It causes a decrease in the pH of the arterial blood resulting in stimulation of receptors that increases ventilator drive. It causes sudden fast and deep breathing as a compensatory mechanism to balance the pH. This causes an increase in respiratory rate and decrease in SpO2 level.
  • Poor oral intake: Loss of appetite in metabolic acidosis is a common symptom. Metabolic acidosis affects the bone health and protein balance. As a result it causes an imbalance in nitrogen, a sudden increase in the degradation of protein and oxidation of amino acids. This further causes loss of appetite. This is followed by prominent effect on gastrointestinal system which causes vomiting, abdominal pain and nausea.
  • Confusion: Short of oxygen causes improper functioning of the brain leading to confusion and disorientation. GCS score is 13, which confirms that memory part of the brain is not functioning properly (Mendu et al., 2015).
  • Tachycardia: Severe acidity or academia causes decrease myocardial contractility which leads to decline in overall cardiac output. Further compensatory mechanism might cause hypokalemia as the acidosis is corrected. This causes ventricular fibrillation which further causes ventricular tachycardia. High heart rate is the starting signal for deterioration and should be treated to promote health (Kraut et al., 2016).
  • High lactic acid i.e. greater than 4.7mmol/L is the reason for acidic pH. Due to sepsis, there is malfunctioning of systems in the body, as a result lactic acids starts getting accumulated. This trips the acid base balance and causes metabolic acidosis

INTERVENTIONS:

Nursing interventions are effective in managing the physiological conditions and protecting the patient from fatal consequences (Henneman et al., 2012).

  • Monitor heart rhythm continuously (Liu et al., 2011). Every hour or two till stability is achieved

Reason: high acidity results in life threatening cardiac condition due to decrease cardiac contractility.

  • Observe respiratory rate for any alteration in the depth of breathing and SpO2 to gain picture of the situation.

Reason: with the increase in acidity in the body, compensatory mechanism will be active. Over compensation of acid might result in respiratory depression. This is usually caused by hypokalemia.

  • Encourage oral hygiene with sodium bicarbonate and lemon (Adeva-Andany et al., 2014)

Reason: Till the underlying cause is treated, mild handling of acidosis is encouraged. This will provide a protective shield for the mouth and will improve oral intake. It will reverse the effect of acid.

  • Administer the prescribed medication i.e. sodium bicarbonate cautiously at the required interval

Reason: this will reverse the acidity in the patient’s body, but too much of it might cause metabolic alkalosis (Kim et al., 2013). Therefore it should be monitored and administered carefully.

  • Assisting physicians in the treatment and management of the underlying disease

Reason: this condition can only be properly treated with the treatment of underlying condition such as sepsis. This will promote acid base balance and will further reverse patient’s situation.

  • Monitoring the GCS scale and checking the neurological effects such as confusion, disorientation etc.

Reason: hypoxia causes such effects and therefore requires constant monitoring and documentation.

  • In coordination with dietitian, a healthy diet is planned based on American Diabetes Association (American Directors, ND)

OUTCOMES:

  • Sodium bicarbonate is within normal level of 23-28mmol/L. This can be measured through ABG (arterial blood gas) test (Patel et al., 2018). It can be done every 10 minutes to check the pH of the patient
  • Respiratory rate is normal and less than 25 breathes per minute and progressing towards the limit18- 20. At first, it should be measured every 1 or 2 hours till stable number is achieved and then measured every 4 hours. It can be done manually or through respiratory monitors
  • SpO2 is above 95% in patient and stable. This is measured every hour or every 2 hours till stability is achieved. It can be easily measured with the help of pulse oximetry.
  • pH level is normal i.e. 7.3 to 7.4. it can done every 10 minutes till stability is attained.
  • Lactic acid level is within range (0.67-1.8 mmol/L). it should be measured after every 3 hours due to sepsis infecton. After stability is achieved it should be measured after every 6 hours
  • Patient is properly educated on the illness and the procedure
  • Diet plan is followed by the patient that aids in acquiring a healthy weight.

CONCLUSION

This report provided in-depth evidence based knowledge on the two physiological conditions namely, risk of falls and metabolic acidosis. It provided the required information i.e. pathophysiology of symptoms, nursing interventions and outcomes.

REFERENCES:

Anne Felicia Ambrosea, G. P. (2013). Risk factors for falls among older adults: A review of the literature. Maturitas , 51-61.

Catherine Sherrington, A. T. (2011). Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. NSW Public Health Bulletin , 78-83.

Damodara Rao Mendu, M. F. (2015). D-lactic acidosis mediated neuronal encephalopathy in acute lymphoblastic leukemia patient: An under diagnosis. Clinica Chimica Acta , 90-91.

Directors, A. B. (ND). Nutrition. Retrieved april 26, 2020, from American Diabetes Assocation: https://www.diabetes.org/nutrition

Duchêne, R. J. (2014). A New Device to Assess Gait Velocity at Home. In R. J. Duchêne, XIII Mediterranean Conference on Medical and Biological Engineering and Computing 2013. Springer, Cham.

Eduardo Lusa Cadore, L. R.-M. (2013). Effects of Different Exercise Interventions on Risk of Falls, Gait Ability, and Balance in Physically Frail Older Adults: A Systematic Review. Rejuvenation Research , 105-114.

Elizabeth A. Henneman, A. G. (2012). Surveillance: A Strategy for Improving Patient Safety in Acute and Critical Care Units. Critical Care Nurse , e9–e18.

George Liamis, T. D. (2016). Thiazide–associated hyponatremia in the elderly: what the clinician needs to know. Journal of Geriatric Cardiology , 175–182.

Hyun Jeong Kim, Y. K. (2013). Effect of Sodium Bicarbonate Administration on Mortality in Patients with Lactic Acidosis: A Retrospective Analysis. PloS one .

Jeffrey A.Kraut, N. E. (2016). Lactic Acidosis: Current Treatments and Future Directions. American Journal of Kidney Diseases , 473-482.

Jenny Day, I. H. (2011). Orientation strategies during delirium: are they helpful? Journal of Clinical Nursing , 3285-3294.

Maciel, A. &. (2010). Metabolic Acidosis in Sepsis. Endocrine, metabolic & immune disorders drug targets , 252-7.

María M. Adeva-Andany, C. F.-F.-B.-Q.-M. (2014). Sodium Bicarbonate Therapy in Patients with Metabolic Acidosis. The Scientific World Journal .

Mit P Patel, A. A. (2018). Use of sodium bicarbonate and blood gas monitoring in diabetic ketoacidosis: A review. World J Diabetes , 199–205.

Nan Liu, Z. L.-B. (2011). Patient Outcome Prediction with Heart Rate Variability and Vital Signs. Journal of Signal Processing Systems , 265–278.

 

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