Nursing Care Plan: Hypertension and Hypothyroidism

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Questions and Answers

What should care providers do if there are shared spaces?

Ensure the space is well-ventilated and open windows

Limit the use of shared spaces to only one person

Avoid using the space altogether

Sanitize properly in between uses (correct)

What type of mask is preferred for care providers transporting an individual?

Surgical mask

N95 respirator (correct)

Cloth mask

No mask is required

How long should individuals wash their hands with soap and water?

30 seconds

20 seconds (correct)

15 seconds

10 seconds

What should be done if soap and water are not available for hand hygiene?

Use an alcohol-based hand sanitizer with at least 60% alcohol Signup and view all the answers

When should individuals wash their hands?

After using the bathroom and before eating or preparing food Signup and view all the answers

What should care providers do with gloves after contact with the individual?

Discard them immediately after use Signup and view all the answers

What is the recommended action for an individual covering coughs and sneezes?

Cover with a tissue and dispose of it in a trash can Signup and view all the answers

What is advised if masks are not soiled and supplies are short?

Reuse them Signup and view all the answers

What is the first step when removing personal protective equipment after interacting with a COVID-19 affected individual?

Remove and dispose of gloves Signup and view all the answers

What should be done immediately after disposing of gloves?

Wash hands with soap and water or use alcohol-based sanitizer Signup and view all the answers

When should soap and water be used for handwashing?

When hands are visibly dirty Signup and view all the answers

What items should not be shared with other people in the home during a COVID-19 outbreak?

Dishes and utensils Signup and view all the answers

How should laundry items contaminated with body fluids be handled?

Immediately remove and wash them with gloves Signup and view all the answers

What is recommended for cleaning and disinfecting high-touch surfaces in a sick room?

Routinely clean and disinfect every day Signup and view all the answers

What should be done with laundry once it is washed?

Dry thoroughly using the warmest temperatures recommended Signup and view all the answers

What precaution should be taken after using the bathroom by a sick person?

Wait as long as possible before cleaning Signup and view all the answers

Which high-touch surface is NOT mentioned as requiring cleaning and disinfecting?

Air conditioning units Signup and view all the answers

Which of the following is a requirement for individuals to discontinue home isolation if they have COVID-19?

They must have had no fever for at least 72 hours. Signup and view all the answers

What is recommended to ensure safe and effective use of household disinfectants?

Keep the surface wet for several minutes. Signup and view all the answers

What precaution is NOT advised when using household cleaning products?

Storing the product in a warm place Signup and view all the answers

Which of the following should be used as much as possible in an individual's room?

Disposable products Signup and view all the answers

In order to ensure infection control, what measure is suggested regarding care providers?

Assign the same care providers consistently. Signup and view all the answers

If a person with COVID-19 has symptoms, how many days must pass since their symptoms first appeared before they can consider leaving isolation?

10 days Signup and view all the answers

What should be done if a high-touch surface is visibly dirty before disinfecting?

Clean it with soap and water or another detergent. Signup and view all the answers

What is the primary issue addressed in the individual care plan?

Disturbed sleep pattern Signup and view all the answers

Which approach aims to create a suitable environment for sleep?

Limit staff interruptions during sleep hours Signup and view all the answers

What should be done if the client has more than 2 days in a row of less than 4 hours of sleep?

Notify the MD for further instructions Signup and view all the answers

Which goal is associated with the disturbed sleep pattern care plan?

Achieve optimal amounts of sleep within 3 months Signup and view all the answers

What might indicate the need for further evaluation and management regarding the client's insomnia?

Frequent interruptions in daily activities Signup and view all the answers

What is the rationale behind increasing daytime physical activities in the care plan?

To help establish a regular sleep pattern Signup and view all the answers

Which factor is NOT mentioned in the care plan as part of promoting better sleep?

Daytime screen time restriction Signup and view all the answers

What should be done if the client has insomnia and shows self-injurious behavior?

Monitor the client closely Signup and view all the answers

What should be monitored to identify signs of aspiration pneumonia?

Low grade fever and dehydration Signup and view all the answers

Which of the following are initial signs of choking?

Coughing and gagging Signup and view all the answers

What is the appropriate action if an individual begins to vomit during a choking incident?

Assist them to an upright position Signup and view all the answers

Which of the following is a part of the goal for managing the risk of constipation?

To have a minimum of 1 bowel movement every 3 days Signup and view all the answers

What should be encouraged to help prevent constipation?

Increased dietary fiber Signup and view all the answers

What should be documented following a possible aspiration or choking incident?

Temperature, respirations, and heart rate Signup and view all the answers

What action should be taken if an airway is blocked due to choking?

Call 911 and initiate the Heimlich maneuver Signup and view all the answers

How much fluid intake should be encouraged to help prevent constipation, assuming no medical contraindications?

2000-3000 mL/day Signup and view all the answers

What nutritional supplement is being taken to increase protein intake?

Protein powder Signup and view all the answers

What behavior increases the risk for imbalanced nutrition in the client?

Self-gagging behavior Signup and view all the answers

What is the goal of the care plan regarding skin integrity?

To be free from skin breakdown Signup and view all the answers

What should be monitored closely as part of the client’s care plan?

Episodes of vomiting Signup and view all the answers

What schedule should be followed for checking and changing incontinent briefs?

Every 2 hours or as needed Signup and view all the answers

Which of the following is a proposed approach to managing the client's risk for imbalanced nutrition?

Establish a consistent daily routine Signup and view all the answers

What is the main intended outcome for the client within the next 3 months regarding skin integrity?

Freedom from skin breakdown Signup and view all the answers

What type of dietary supplement is Thick-It used for in the client's care plan?

Swallowing aid Signup and view all the answers

Study Notes

Care Plan - Alteration in Health Status D/T Hypertension

Problem: Hypertension (high blood pressure)
Goal: Maintain blood pressure within an acceptable range.
Approach(es):
- Monitor blood pressure as prescribed by a doctor.
- Monitor for symptoms like shortness of breath, cyanosis, increased weakness, confusion, headaches, chest pain, nosebleeds, and low blood pressure.
- Take blood pressure before administering medication.
- Hold medication if systolic blood pressure is below 100 mmHg.
- Administer medication as ordered by a doctor.
- Specific medications: Lisinopril 2.5 mg BID for high blood pressure and Inderal (Propranolol) to normalize pulse. Hold either medication if systolic pressure is under 100 mmHg or pulse is under 80.

Care Plan - Alteration in Health Status D/T Hypothyroidism

Problem: Hypothyroidism (underactive thyroid gland)
Goal: Maintain Thyroid Stimulating Hormone (TSH) within normal limits.
Approach(es):
- Monitor TSH levels through lab work as ordered by a doctor.
- Administer medication as directed by a doctor.
- Specific medication: Levothyroxine QD.

Care Plan - COVID-19 Care

Problem: Positive COVID-19 test.
Goal: Individual will be free of symptoms and fully recover from COVID-19.
Approach(es):
- Follow CDC recommendations for COVID-19.
- Administer medications as ordered by the physician.
- Monitor for symptoms (fever, cough, congestion, etc.)
- If symptoms worsen notify a doctor immediately.
- Keep the individual isolated to prevent spread of infection.
- Follow infection control protocols (handwashing, mask-wearing, etc.)
- Ensure healthcare providers wear appropriate PPE (personal protective equipment).
- Monitor oxygen saturation and report any values below 90%.
- Follow guidelines regarding isolation discontinuation.

Care Plan - Disturbed Sleep Pattern

Problem: Disturbed sleep pattern due to neurological dysfunction.
Goal: Achieve optimal sleep by establishing a regular sleep pattern.
Approach(es):
- Maintain consistent daily schedule for retiring and arising.
- Ensure a conducive sleep environment (quiet, comfortable, temperature control).
- Limit staff or other interruptions during sleep hours.
- Discourage daytime naps unless necessary to meet sleep requirements.
- Increase daytime physical activity to promote sleep.
- Administer medication if insomnia is worsening.

Care Plan - High Risk for Injury D/T Client Injuring Self

Problem: High risk for injury due to self-injurious behavior related to various diagnoses.
Goal: Reduce or prevent self-injury within three months.
Approach(es):
- Maintain a calm and supportive approach to address the client's needs
- Implement appropriate safety measures to prevent self-harm, ensuring the environment is safe
- Administer medication as prescribed to manage behavior
- Closely monitor for self-injury episodes and implement appropriate interventions (e.g., blocking techniques, redirection)
- Monitor for any worsening of symptoms and report to the RN or doctor immediately.
- Provide medications for the diagnosed conditions (e.g., for autism, anxiety, SIB and tantrums).

Care Plan - Impaired Verbal Communication

Problem: Difficulty expressing needs due to cognitive impairment.
Goal: Successfully meet the client's needs and wants using appropriate communication methods.
Approach(es):
- Anticipate the client's needs based on nonverbal cues.
- Encourage communication attempts and acknowledge successes.
- Communicate clearly in simple terms.
- Use gestures and objects to help enhance communication.
- Report significant changes in condition to the doctor.

Problem: Potential side effects from psychotropic medications.
Goal: Minimize adverse side effects from medications while managing the diagnosed conditions.
Approach(es):
- Monitor for side effects like tremors, involuntary muscle movements, decreased appetite, etc.
- Document and report any observed side effects to healthcare professionals.
- Administer medication as prescribed by the physician.
- Regularly assess medication effectiveness and adjust as needed.

Care Plan - Risk for Aspiration

Problem: Risk of aspiration pneumonia.
Goal: Consume meals safely without aspiration.
Approach(es):
- Monitor for signs and symptoms of choking or aspiration pneumonia.
- Report any signs of choking or aspiration pneumonia immediately.
- Instruct the client to eat slowly and chew food thoroughly.
- Ensure client consumes small bites and takes small sips of liquids.
- Monitor for abnormal temperature, respiration, and heart rate.
- Document all assessments and follow up with RN/Administration or doctor

Care Plan - Risk for Constipation

Problem: Risk of constipation due to medication and diagnosis/condition.
Goal: At least one bowel movement every 3 days for 3 months.
Approach(es):
- Monitor bowel movements.
- Encourage adequate fluid intake.
- Ensure a balanced diet with adequate fiber content.
- Administer meds as directed for constipation.

Care Plan - Risk for Imbalanced Nutrition

Problem: Risk of insufficient nutrition due to decreased appetite and related issues.
Goal: Maintain weight within 10% of ideal body weight within three months.
Approach(es):
- Monitor daily food and fluid intake and weight.
- Engage client in mealtime so they can feel encouraged to eat.
- Encourage fluids and monitor for dehydration.
- Administer medications as ordered and monitor for medication side effects.
- Provide a positive mealtime environment.

Care Plan - Risk for Imbalanced Nutrition R/T Client's SIB of Gagging and Vomiting

Problem: Risk of insufficient nutrition due to self-injurious behavior of gagging and vomiting.
Goal: Prevent gastrointestinal bleeding and aspiration.
Approach(es):
- Consistent daily routine.
- Monitor for vomiting, potential bleeding & client safety.
- Alert RN / medical staff of vomiting episodes.

Care Plan - Risk for Impaired Skin Integrity

Problem: Impaired skin integrity due to bowel and bladder incontinence.
Goal: Prevention of skin breakdown within three months.
Approach(es):
- Repositioning q 2 hours PRN
- Keeping the individual clean and dry.
- Maintaining good skin hydration and lubrication.
- Monitoring for signs of skin breakdown.
- Reporting any skin irritations to healthcare professionals immediately.

Care Plan - Self-Care Deficit

Problem: Self-care deficits due to diagnosis.
Goal: Safely perform self-care activities with appropriate assistance within three months.
Approach(es):
- Provide verbal and physical assistance as needed for ADLs.
- Establish consistent routines and adequate time frames for tasks.
- Monitor client's ability to complete tasks and adjust support as needed.

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Description

This quiz focuses on the nursing care plans for managing hypertension and hypothyroidism. It covers monitoring techniques, medication administration, and understanding of vital signs. Test your knowledge on maintaining health status in patients with these conditions.