Assignment Directions: Utilize the Millie Larsen Case Study and formulate one actual patient problem with supporting assessment data that demonstrates that this is a priority problem. List the assessment data under either subjective (what Millie might state) and/or objective (what is reported within the case study such as test results) data. Write at least one goal/outcome that you plan for Millie to reach and develop at least 3 nursing interventions to help Millie reach that goal/outcome. The three nursing interventions need to include 1) one assessment type action, 1) one physical intervention that the nurse would perform, and 1) one patient teaching intervention. Give rationales explaining why each intervention will help alleviate or resolve this problem. For the evaluation step of this nursing care plan, you will need to speak to what & how you would evaluate your interventions' effectiveness in meeting the desired patient goal/outcome, as if you carried this out. This form needs to be filled in and submitted by the due date. There should be no blank spaces in order for you to obtain full credit for this assignment.
Continuation for Millie Larson Unfolding Case Study:
Millie has been hospitalized for several days now and has developed a fever of 102 F with some productive coughing and difficulty breathing. She is also complaining of some pleuritic chest pain when she tries to take a deep breath. Her respiratory rate has increased to 26 breaths per minute, and her heart rate is 60, blood pressure is 98/66 mm Hg, O2 saturation is 90% on 6 L/min oxygen via nasal cannula. When the nurse assessed Millie's lung sounds, she heard rhonchi and scattered crackles. A chest X-ray was obtained, and Millie is diagnosed with hospital-acquired pneumonia. A complete blood count was drawn, and the results show that Millie's white blood cell count is 22,000.
New orders have been obtained from the provider, and Millie is to be transferred to a Special Care Unit (SCU) to monitor her condition more closely.
New orders include:
- Obtain sputum specimen and blood cultures.
- Oxygen at 6-8 Liters high flow nasal cannula to keep O2 sat at or above 92%
- Normal saline intravenous solution at 100 mL/hr
- Ciprofloxacin (Cipro) 400 mg intravenous mini bag every 12 hours
- Acetaminophen 650 mg oral every 6 hours prn for fever greater than 101F
- Tramadol hydrochloride 50mg (oral) every 4-6 hours PRN for pain
- Albuterol respiratory nebulizer treatments q 4 hours and prn
- Respiratory monitoring per acute protocol
Millie still has a Foley catheter in place, and her urinary tract infection has resolved, but the provider still wants to strictly monitor her intake and output. Millie is lethargic and appears very ill and still is not eating well or taking in oral fluids as the provider would like. Her intake has only been 300 mL IV fluids, 50 mL oral intake plus sips, and output of 200 mL clear yellow urine.