Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download better example
Document related concepts
Transcript
1 DEMOGRAPHIC DATA Name: student name Name: J.Y. Diagnostic testing Age: 57 Today’s Objective: Assess a patient diagnosed with sepsis Ultra Sound of the Abdomen: view of ascites due to cancer prior to removal of fluid (10/10/2016); complications of sepsis study (9/27/2016) Allergies: Adhesive tape, Benadryl Date and location: October 13, 2016 – October 14, 2016 MMH Ht: 185 cm Wt: 113 kg BMI : 33 Race: White MEDS Metronidazole 500 mg Oral Q8H – antiinfective for treatment of septicemia Piperacillin 3/Tazobacutm 0.375/Isotonic Injection IV piggybacak infuse over 30 minutes -- broad spectrum antiinfective for treatment of infection Bumetanide 2 mg Oral BID – loop diuretic for treatment of edema secondary to CHF Insulin Lispro 5 unit dose (sliding scale) –treatment for diabetes mellitus type 2 Insulin Glargine 40 units – treatment for diabetes mellitus type 2 Metolazone 5 mg oral/daily – diuretic, antihypertensive to decrease edema and decrease blood pressure (essential HTN) Pantoprazole 40 mg oral/daily – protein pump inhibitor to maintain normal gastric acid Morphine 5 mg Q4H PRN – PAIN Reference Skidmore-Roth, L. (2015). Mosby's drug guide for nursing students. St. Louis: Elsevier Mosby. Medical diagnosis: Sepsis, Diabetic Foot Ulcer, Severe Thrombocytopenia Past medical hx: Bacteremia, Chronic kidney disease, stage 3, Diabetes Mellitus type 2, Essential Hypertension, Infection due to enterococcus, liver excision sp trisegment hapatectomy and cholecystectomy due to cancer that metastasized to the liver, primary malignant neoplasm of descending colon, pure hypercholesterolemia, secondary malignant neoplasm of the liver, CHF CT Head/Brain: Rule out further metastasis to brain due to confusion DIET Moderate Carbohydrate 1300 calories Brief medical hx: patient was admitted to the hospital on 9/26 for sepsis due to gangrene after coming into the ER c/o shortness of breath Address use of tobacco, alcohol or illicit drugs:Denies any history of tobacco, alcohol or illicit drug use Pathophysiology Sepsis- the presence of infection systemic manifestations; infectious organisms have entered the bloodstream Widespread inflammation (SIRS) with increased infectious organism – infection escaping local control COLLABORATIVE CARE Wound Care – every Monday, Wednesday, and Friday to maintain wound vac care to left foot Physical therapy consult (10/14) – Consult for equiptment needed for home care; assess ADL status Occupational therapy consult (10/14) – evaluate patients need for home equipment; evaluate capabilities for adaptation to achieve tasks and independence to prevent disability when discharged Inflammation leads to extensive hormonal, tissue, and vascular changes Oxidative stress impair oxygenation and tissue perfusion WBCs produce pro-inflammation cytokines (IL-1) (IL-6) (TNF-A) causing widespread vasodilation and blood pooling (elevated WBC with infection) Increased respiratory rate compensatory to impaired oxygenation and perfusion Inappropriate clotting leads to hypoxia and reduces organ function Reference (APA) - Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology. St. Louis, Mo: Elsevier. 2 HEENT & Sensory Eyes Denies Problems: _____ `Glasses: X Itching / Burning: ____ Photophobic: _____ Lens implant(s): _____; (left/right/both) Contact lenses: _____ Diplopia: _____ Blind Spots:_____ Glaucoma:____ Ears Denies Problems: _____ Hearing Loss: _____ Hearing Aid: _____ Earache: _____ Right:_____ Left:_____ Bilateral_____ Nose Denies Problems:_____ Nose Bleed:_____ Blindness:_____ Cataracts:_____ Tinnitus: __X Drainage:_____ Hearing Aids: _____________ Sinus Drainage/Congestion:_ X____ Implant: _________ Olfactory loss:_______________ Mouth & Throat Denies Problems: _____ Dentures: _none Upper:_____ Lower:_____ Bridge:_____ Loose / Missing teeth: __X Mouth Sores: _none____ Lips :_pink, no cracking__ Cares for own teeth/dentures:__self___ Tongue:_____ Throat: _uvula is midline, no exudates, no inflammation, no tonsil enlargement; patient denies any problems with throat__ Condition of teeth & gums: _____poor dentition__________________ Comments: No additional comments INTEGUMENT Skin Warm: __X__ Cool:_____ Hot: _____ Dry: _X_ Moist: _____ Itching: _____ Rash: _none present___ Change in Pigmentation: _______no changes seen, pigmentation is even_________________ Bruising: _none seen____ Rash/Lesion: _blister to right inner thigh____ Hair loss: _no significant changes__ Nail Changes: _____ Pattern Changes: _unable to shower without assistance________ Turgor Elastic: _____ Loose: __X___ Tented: _____ Taut: _____ Mucus Membranes Dry: _____ Moist: __X__ Pink: _X__ Other:_____________________________________________ Self-Care Comments: patient has tattoos to bilateral forearms, old stitches to left lower leg, red blisters to left shin RISK ASSESSMENT FOR PRESSURE SORES (RAPS) (Adapted from Braden & Norton Scales) Mental Condition Activity Level Mobility Level Incontinence 4 Bedfast 4 Immobile 4 Constantly Moist (usually wet) 4 Inadequate Limited Response 3 Chair fast 3 Limited Mobility 3 Frequently Moist 3 Impaired Response 2 Occasionally Walks 2 Slightly Limited 2 Occasionally Moist Alert 1 Walks Frequently 1 No Limitations 1 Rarely Moist 2 3 RAPS Score Nutrition Level Unresponsive 1 1 Point 4 5 Probably Inadequate 3 6 2 Adequate (Eats > 50% meals ŝ/ĉ TF) 2 7 1 Excellent (Eats most meals) 1 >8 1 (Never eats 100% & No Tube Feedings) (Rarely eats 100% ĉ/ŝ TF < 100% calculated needs) 2 9 3 NEUROLOGIC/MUSCULOSKELETAL/MOBILITY Mental Status (highlight applicable choices) Denies Problems Recent Memory Intact Remote Memory Intact Headaches Seizures Dizziness/Vertigo TremorsParkinson’s Numbness/Tingling Head Injury/CVA/TIA Weakness Poor Coordination Cerebral Palsy Para/Hemi-plegia Difficulty Swallowing Difficulty Speaking Other ____________________________ Environmental/Occupational Hazards _Patient denies any known hazards________________________________________________ Orientation: (highlight applicable choices) Oriented to: Person Place Time Not Oriented Oriented X ___3____ Speech: Clear/Coherent Incoherent Slurred Hoarse Other__________________________________________________________________________________________________________________________ LOC: Alert __X___ Drowsy_____ Pupil Size & Reaction: (highlight applicable choices) PERRLA: Yes No Left: ___4__ mm Brisk Yes No Right: ___4__ mm Brisk Lethargic _____ Obtunded _____ Stuporous _____ Sluggish Sluggish Irregular Irregular Non-reactive Non-reactive Comatose _____ Glascow Coma Score (highlight applicable choices) 3 = Speech R E S P O N S E S 2 = Pain 1 = No Response 5 = Localizes Pain 4 = Flexion Withdrawal 3 = Decorticate Posturing 2 = Decerebrate 4 = Conversation- 3 = Inappropriate 2 = Incomprehensible 1 = No Response CATEGORY Best Eye Open Response Best Motor Response 4 = Opens Spontaneously 6 = Obeys Verbal Best Verbal Response 5 = Oriented X 3 Commands Confused Speech Sounds Posturing Numeric Sum of Eye, Motor, & Verbal Responses = GLASGOW SCORE / 15 1 = No Response 15/15 Peripheral Nervous System Symptoms: Motor & Reflex Symptoms: Patients reflexes are brisk and intact. All movements are voluntary and patient is quick to response. Comments: Deficits/Complaints/New Findings: no deficits, complaints, or new findings; unable to test reflex of right foot due to amputation MusculoSkeletal (highlight applicable choices) Joints: Pain _Patient Denies____ Stiffness Patient Denies Swelling None seen Heat / Redness Not present Bones: Pain Deformity Contracture and right foot amputation Muscles: Pain Patient denies Weakness (% from baseline?) Flaccid / Spastic Strength 5+ = able to move against full resistance 3+= able to move against gravity 1+= flicker of muscle movement Trauma/Fracture/Sprain Affected: Affected: left foot 4th and 5th toe amputations Unequal Upper/ Lower____________________ Rigid Asymmetric Affected: Affected: 4+= able to move against gravity 2+= weak movement, unable to overcome gravity 0+= no movement Range of Motion & Power (Compared to Baseline): patient is able to move from bed to chair and move from chair to restroom with assistance on rising; ROM is affected (diminished) due to amputation of right foot Functional Assessment: ADL & Self Care Deficits: unstable general movements, able to ambulate slowly but has pain with motion, able to perform some ADLs (brushing teeth, changes clothes) (patient states that he is not able to give self-shower) Comments: Patient complains of decreased muscle mass but improved strength from time of admission 4 ACTIVITY/MOBILITY Denies Problems ____ Ambulatory ____ Intolerance __X__ Bedrest _____ ADL’s performed: Self _____ Distance ambulated _____ feet Unstable Gait ____ Arthritis ____ Contractures _____ Prosthesis _____ With assistance __X___ Cane/Walker _X__ Crutches_______ Fatigue/Activity ___ Other Comments: __patent is able to ambulate with walker under supervision; patient occasionally becomes uncomfortable (has pain) with ambulation_____ Pulmonary Respiratory Unexpected landmarks, shape, asymmetry, resonance or fremitus/crepitus: symmetric chest rise and shape, no barrel chest, no crepitus, no pain to palpation Denies Problems ___ SOB _X__ Cough ____ Resp Pain _denies__ Retractions____ Hx Sleep Apnea _denies___ ↑ HOB _denies___ ° to sleep Needs > 1 pillow _ Respirations: Rate __18___ Rhythm ___regular__ Position of comfort __sitting up in chair____ Irregular ____ ↑Effort _without effort__ Unlabored __X_ ↑Accessory Muscle Use _without accessory muscle use__ Tachypnea _____ Nasal Flaring _none present___ Breath Sounds: RUL RLL LUL LLL Clear _____ Clear _____ Clear _____ Clear _____ 10/13/2016 Wheezes _X__ Wheezes _X___ Wheezes __X__ Wheezes __X___ Rales _____ Rales _____ Rales _____ Rales _____ Ronchi _____ Ronchi ____ Ronchi _____ Ronchi _____ Diminished _____ Diminished _____ Diminished _____ Diminished _____ Absent _____ Absent _____ Absent _____ Absent _____ RUL RLL LUL LLL 10/14/2016 Clear __X__ Clear __X_ Clear __X_ Clear __X_ Wheezes __ Wheezes ___ Wheezes ___ Wheezes ___ Rales _____ Rales _____ Rales _____ Rales _____ Ronchi _____ Ronchi ____ Ronchi _____ Ronchi _____ Diminished _____ Diminished _____ Diminished _____ Diminished _____ Absent _ Absent _____ Absent _____ Absent _____ Oxygen Room Air _X_ O2 via __________ @ _____ L/min CPAP /BIPAP _____ Home O2 Use ____ Nebulizer TX _____________ Cough Absent _X___ Frequency_______ Dry/+Productive _____ Color _______ TB Exposure _____________ Consistency _______ Night sweats (Does patient have to change bedding?) __Patient denies any night sweats_ Comments: Normal respirations at 18 bpm. Oxygen saturation at 96% room air. Wheezes in all lung fields on 10/13/2016. Clear breath sounds in all lung fields when check on 10/14/2016. Symmetric chest expansion. 5 COMFORT/PAIN Pain Assessment Non-Verbal Discomfort Rating (if applicable) 8 on Faces scale V-A-S Pain Rating 9/10 @ 8:30 (10/14/2016); 9/10 @ 16:00 (10/13/2016) PRN Pain medication given: Morphine 5 mg Response/Efficacy: ____Patient tolerated pain medication well. After each dose, patient became more comfortable and less rigid looking with posture. Patient verbalized relief after 30 minutes with each PRN dose given._____ Comments: Patient did become sluggish and nauseated after dose of pain medication was given. Pain Scale – Visual Analog Scale (VAS) Adult NO PAIN WORST PAIN Intensity Rating: (0 – 10) I 0 I 1 I 2 I 3 I 4 I 5 I 6 I 7 I 8 I 9 I 10 Heart & Neck Vessels CardioVascular Unexpected landmarks or asymmetry: __NONE__________ Denies Problems: X PMI = heard on auscultation S1 -S2 heard on auscultation__ S3 _not heard__ S4 __not heard_ Murmur __none_ Angina none__ Pacemaker __N/A_ Other Rhythm_____ Telemetry # __N/A____ EKG findings: __N/A__ JVD __absent_____ Internal / External Jugular findings: ____no distension______________ Carotid findings: ____no bruits present___________ Dyspnea on Exertion: _moderate dyspnea on exertion _____ Orthopnea: __not present_ Fatigue: __pt states he is slightly fatigued__ Nocturia: _patient denies____ Cyanosis/Pallor: __none__ Edema: __present bilateral lower extremities_(2+ bilaterally LE)_ HX Cardiac Surgery / Procedures: none to present List: Procedures: 6 Peripheral Vascular Pulse Quality: 3+ Bounding 2+ Strong Site 1+ Weak/Thread D (0) = Ǿ None 1+ 2+ Generalized _X____ Periorbital ______________ Edema: Location: PULSE QUALITY L Radial R Radial RUE 2+ LUE 2+ R Pedal L Pedal RLE (N/A) LLE 1+ Palpable/Doppler (highlight one) 3+ 4+ Dependent _______________ Sacral _______________ Pretibial __________ Other____________ Leg Pain on Ambulation Patient c/o leg pain to RLE on ambulation (right foot amputation area)_____________________ Capillary Refill (seconds): BUE _____ L__<2 seconds___ R__< 2 seconds___ BLE _____ L > 2 seconds_____ R_N/A____ Central Temperature vs. Distal Describe variance: no variance Nail Color /Description: Pink __X__ Pale_____ Cyanotic ___ Clubbing __none___ Orthostatic BP Measures (Only If Applicable): Supine Blood Pressure: __________ Sitting Blood Pressure: ______130/76 left arm (10/14)____ Standing Blood Pressure: __________ Comments: _unable to perform orthostatic blood pressure as patient is uncomfortable with standing for periods of time; Patient has 2+ pulses to bilateral UE and 1+ pulse to left pedal, unable to get right pedal pulse due to amputation of foot___________________ DIET & GASTRO-INTESTINAL Nutrition Formula Body Mass Index = 703 x wt. In lbs divided by height in inches squared Body Mass Index = Weight in Kg divided by height in meters squared Appearance: Healthy/Well Nourished _____ Thin/ Wasted __________ Obese ___X____ BMI Explanation __BMI has fluctuated due to slight muscle wasting_________ Usual/stated wt _____ Recent Changes ___X__ Use of diuretics __X_ BMI Ranges < 18.99 Underweight 18.99 – 24.99 Normal 25 – 30 Overweight > 30 Obese Appetite Changes __Patient states that he is slowly regaining his appetite__ Prescribed Diet: __Carbohydrate Consistent____ Last meal __________________ Usual # Daily Meals _____3_________ % Eaten (10/13/16)_____25%_____Breakfast ___50%____Lunch __50%__ Dinner % Eaten (10/14/16) _____50%_____Breakfast ___50%____Lunch __0_%__ Dinner ____0 %___ Snack am/pm ____0 %___ Snack am/pm Blood Glucose AC/HS/Other: (10/13) __207___ Breakfast __182__ Lunch __176_____ Dinner _______ Snack HS Blood Glucose AC/HS/Other: (10/14) __230___ Breakfast __170__ Lunch _not present for reading___ Dinner ______ Snack HS Gastrointestinal Shape / Appearance & Unexpected landmarks, scars or asymmetry: round, soft, symmetric, obese, no unexpected landmarks Last BM ___10/13/2016____ Stool Color/Character _loose/black___ Usual Stool Pattern __brown, loose________ Recent Changes __black color___ Denies Problems ____ Heartburn _____ Flatulence_______ Nausea/Vomiting __X ___ Diarrhea / Constipation _____ Bloody Stool/Rectal Bleeding __denies___ Hemorrhoids __X_____ Hematemesis _____Routine Laxative Use _____ Fecal Incontinence _not presently but did have on admission____ Ostomy No_X__ Yes _____ Location _____________________ Type______________________________________________ Abdomen Soft __X___ Firm _____ Distended _____ Rigid _____ Flat/Round/Obese _____ Ascites _____ Bowel Sounds Active + Hypoactive -- Hyperactive ++ Absent Ǿ BOWEL SOUNDS + RLQ + RUQ Comments: Last BM was 10/13/2016. Black, liquid quality. Denies blood in stool. Denies any or diarrhea. Denies any abdominal discomfort. + LLQ + LUQ Abdominal Girth: __could not measure__ constipation 7 GENITO-URINARY / FLUID & ELECTROLYTES / TUBES, LINES & DRAINS Genitourinary Unexpected landmarks, scars asymmetry, vulva/penis meatus, scrotum. Describe discharge, odor, including inguinal area & nodes: _______Penis and scrotum appear normal, no redness, no enlargement, no discharge, no scars_____________________________________________________________________________ Urine Color __dark yellow___ Hesitancy vs. Urgency Voids Character __clear____ Frequency Dysuria (pain/burning) none Straining none Nocturia none Bathroom _X___ Bedside commode Dialysis N/A Foley _N/A____ Urostomy/Nephrostomy _N/A____ Bladder Pressure _None____ Urinal __X__ Incontinent Suprapubic __N/A___ Distended/Nondistended _____ Male Meatus Appearance ___WNL ______________ Last Prostate Exam _unknown____ Prostate Enlargement _denies____ Female Meatus Appearance _____N/A_________ Last Gynecologic Exam __N/A___ Last Menstrual Period __N/A___ Comments: patient states he had incontinence on admission but no longer has issues with this. FLUID STATUS Parenteral Fluids: Continuous IV Infusion & TPN/PPN: Solution: _____no continuous infusion__________ Rate: ___________ 1. Type of IV Access: _____Port-a-cath_______ Size Location/ __20 gauge left upper chest_____________ Site Condition: Dressing Clean, Dry, Intact vs. Swelling Redness Warmth Drainage: Dry, Intact, IV intact, patent, saline locked, no swelling, warmth or redness, dressing is clean and dry, place 10/9________________ 2. Type of IV Access: ___Midline_________ Size Location/ __18 gauge right upper arm__________ Site Condition: Dressing Clean, Dry, Intact vs. Swelling Redness Warmth Drainage______________________ Blood Products/Units: _NONE_______ Rate _______________ Reason: ________________________ Tubes & Drains Feedings: (PEG/JEG/NGT/Dobhoff/Other) Location _NONE Prescribed Tube Feeding __N/A___ Type ________________________ Rate/Frequency _________________________________ Drains _____NGT _____JP _____Hemovac Wound Therapy)__ _____Penrose _____Chest Tube Other/Description: __WOUND VAC__(Negative Pressure Drainage Description Volume/Color/Etc. 50mL drainage (10/13/2016) Brown liquid drainage_________ (10/13/2016) Intake (Previous 23 hours) _oral: 600 IV:100__________ Output (Previous 23 hours) __urine 825 (BM x1)______ 24° Balance -125 ___ (10/14/2016) Intake (Previous 23 hours) _oral:480_____ Output (Previous 23 hours) __urine: 990______ 24° Balance -580_______________ Comments: Wound Assessment (2 Points) Type _______Surgical _____Abscess _____Cellulitis Other: Diabetic Foot Ulcer Pressure Ulcer _ Stage _____ Location: Mark diagram with all wounds, Incisions, PU’s, lines & drains) Size (cm) L x W ____ Undermining _____ Tunneling (cm) ____ Depth (cm) ______ Granulation % ____ (If > 1 mark on back) **Unable to evaluate size and undermining due to wound vac Exudate NONE SEEN Odor: None Type: None Amount: None Slight Bloody Scant Moderate Serosanguenous Small Wound Bed: Natural/Pink Beefy red Surrounding Skin Color: Pink Foul Purulent Moderate Large Granulation Slough Black (eschar) Red White/pale Dark purple Black/brown 8 PATIENT EDUCATION & DISCHARGE PLANNING Discharge Planning Anticipated Discharge Date __unknown discharge date_____________________ Probable Destination Home __X_ Alternate care facility ______________________ Discharge Transportation Private Car _____ Other_________________ Ambulance _____ Taxi/bus _____ Unknown __X_______ Assistance needed with supplies, equipment, medications or treatments No _____ Yes _X____ _______________________________________________________________________________________________________________ Ongoing health care/disease process/wound care education needed No _____ Yes ___X_______ Currently Lives: Alone _____ With Spouse _____ Specify Other: ________ Able to care for self after discharge? Yes _____ With Assistance (Family/Other) Specify: __________________ Outside services anticipated? No _____ Which agency/ies? Comments: Patient is anticipating discharge home in 4-5 days. Patient still needs consultation with physical therapy and occupational therapy for anticipation of needed equipment to remain dependent at home. 9 LABORATORY RESULTS Admission 09//26/2016 Most Recent Interpretation of Abnormal Values amber No recent No recent collection Clarity clear No recent WNL pH 5.0 No recent No recent collection Specific Gravity 1.015 No recent No recent collection Protein 100 No recent No recent collection Glucose 150 No recent No recent collection Ketones negative No recent No recent collection Nitrite negative No recent No no recent collection Leukocyte esterase negative No recent No recent collection RBC NO COLLECTION No Collection Done WBC NO COLLECTION No Collection Done Epithelial cells NO COLLECTION No Collection Done Casts NO COLLECTION No Collection Done Bacteria NO COLLECTION No Collection Done Yeast NO COLLECTION No Collection Done Crystals NO COLLECTION No Collection Done ANTIBIOTIC(S) Color AMINOGLYCOCIDE: Peak NO COLLECTION NO COLLECTION Trough NO COLLECTION NO COLLECTION CULTURES URINALYSIS Include lab value normal range in area below Blood Other Source NO COLLECTION DONE Wound (Site) NO COLLECTION DONE Reference 10 LABORATORY RESULTS BASIC / COMPLETE METABOLIC PANEL (BMP/CMP) CBC Reference Range OT HE RS (09/26/2016) Most Recent (10/13/2016) Admission Interpretation of Abnormal Values THINK PATHOPHYSIOLOGY WBC 4.8 – 10.80 16,78 6.04 Within normal limits RBC 4.500-5.900 3.700 3.650 Anemia associated with disease of sepsis 10.40 9.8 Decreased level of erythropoietin associated with renal disease decreases the number of RBC decreased HgB 29.50 28.9 Decreased level of erythropoietin associated with renal disease decreases the number of RBC decreased ct <4.2 108.0 Thrombocytopenia: Bacterial infection can cause thrombocytopenia, especially when patients is immunocompromised 158 178 Uncontrolled Diabetes Mellitus 133 129 Diuretics work by inhibiting sodium reabsorption, decreasing sodium levels 3.5 3.0 Glucose and potassium are driven out of the cell with use of insulin, potassium levels drop 70 26.4 Reduced blood volume, renal blood flow diminished and renal excretion of BUN is decreased and BUN levels rise Hgb 13.50-17.50 Hct 41.00-53.00 Platelet 150.0-400.0 Glucose 70-100 Sodium 136-144 Potassium 3.6-5.1 BUN 7-21 Creatinine 0.6-1.3 3.1 2.2 CHF impair renal function and creatinine rises Chloride 103-114 99 91 Kidney dysfunction Calcium 8.9-10.4 7.4 7.5 Renal failure Total Protein 6.4-8.1 5.4 6.6 Withn normal limits 1.9 2.2 Albumin 3.5-4.9 Disease associated with inflammation cause an increase in acute phase reactant proteins, globulin increase, albumin decreases Total Bilirubin 0.2-1.2 2.3 1.0 Withn normal limits AST 12-35 23 27 Withn normal limits ALT 8-45 27 30 Withn normal limits Alk Phos (ALP) 36-115 116 184 Found in liver, normally excreted in bile, dysfunction will cause elevations Lipase 23-300 no collection No collection Amylase 25-125 No collection No collection Done NO COLLECTION DONE Digoxin Dylanton No Depakote Collection PT/INR (coumadin) PTT (heparin) Paganda, K. D. & Pagana, T.J. (2014). Mosby’s manual of diagnostic and laboratory tests. (5th ed.). Missouri: Elsevier. Reference 11 NURSING PLAN OF CARE ASSESSMENT / ANALYSIS – PLANNING – IMPLEMENTATION – EVALUATION Each Nursing Diagnosis listed must be derived from Objective & Subjective data Objective & Subjective data must be listed beneath the listed Nursing Diagnosis Number Problems (Nursing Diagnoses) according to priority using Maslow’s Hierarchy of Needs. Number of Problems (Nursing Diagnoses) will depend on the status of your patient, but there must be a minimum of 3 Nursing Diagnoses (1) Physiological; (1) Psychosocial; (1) Nutritional / Health Promotion / Safety / Etc. The Nursing Diagnoses with priority of 1, 2, and 3 must be completed through evaluation on the following pages prior to submission Clinical Preparation: The Plan of Care must be completed through Nursing Interventions for at least one (1) nursing diagnosis prior to providing patient care Students may use the Nursing Care Plan color-coded sheets OR the concept map sheet to develop the Plan of Care 12 Medical Diagnosis: Chronic Kidney Disease Subjective Assessment Data: Patient states “I cannot stand moving like this anymore.” Objective Assessment Data: Grimacing with moving, slow and stunted movements, increased coughing and grunting after movement Intervention (1) Assess the patient during activity, and ask patient to rate perceived exertion (RPE). This assessment evaluates the degree of activity intolerance. Optimally RPE should be at 3 or less on a scale of 0-10. RN-RN (2) Notify the health care provider of increased weakness, fatigue, dyspnea, chest pain, or further decreases in hematocrit. This action enables rapid treatment of anemia related to CKD. RN-MD (3) Nursing Diagnosis: Activity Intolerance related to generalized weakness occurring with ambulation AEB use of profanity and anger with activity, bed rest, patient stating “I can’t stand moving anymore,” and pain level of 9/10 in lower extremities after ambulation. IO: Patient will demonstrate tolerance of activity by verbalizing pain level less than 4/10 with each activity performed on 10/13/16. Evaluation of Intervention (1) @11:50 (10/14/16) patient described the rate of perceived exertion at a 6 while walking to the restroom with walker. Patient verbalized pain level of 4/10 following activity. @ 13:20 (10/14.16) Patient evaluated RPE at 8 while repositioning for urinal at bedside. Patient verbalized pain level of 5/10 after activity. Effective for evaluating patient’s perception of activity tolerance-continue (2) @11:45 (10/14/16) Patient denies any increased weakness or fatigue than usual after activity of moving from bed to chair, patient denies any chest pain. Hematocrit value has not has not decreased. Patients pain level is 3/10 after move. Effective for learning of patients symptoms after activitycontinue (3) @14:40 (10/14/16) Patient evaluated at bedside at which activities increase fatigue. Patient has not been able to do much activity since admission, unable to evaluate effectively. Assist with identifying activities that increase fatigue and adjusting those activities accordingly. It is important to minimize fatigue while attempting to promote tolerance to activity. RN-RN IO: met or unmet? Partially met, due to patient’s pain level exceeding 4/10 with one of the activities. The third intervention was not fully effective as the patient has not done much activity since hospitalization . Swearingen, P. L. (2016.). All-in-one nursing care planning resource: medical-surgical, pediatric, maternity, and psychiatric-mental health. (4th ed.). Missouri. Elsevier 13 Medical Diagnosis: Diabetes Mellitus Stage 2 Subjective Assessment Data: Objective Assessment Data: Right foot amputation, left 4th and 5th toe amputations, left foot deep diabetic ulcer, blood glucose reading above 180 mg/dl Nursing Diagnosis: Unstable blood glucose level related to inadequate blood glucose monitoring and poor medication management AEB patient stating, “Im used to high blood sugar levels, I don’t need a doctor to tell me that.” high blood sugar readings (180 mg/dl at 0600), right foot amputation secondary to diabetic foot ulcer. IO: Optimally, the patient will have a blood glucose level of less than 180 mg/dl at all times until the end of shift on 10/14/16. Intervention (1) Assess blood glucose before meals. This monitors the effectiveness of blood glucose control at time’s when the patient’s glucose is not increased by food being digested. RN-RN; RNCNA (2) Administer correct dose of Insulin 5 units per doctors order. Adherence to therapeutic regimen is essential for promoting optimal tissue perfusion. Progression of vascular disease and neuropathy, including blindness, kidney failure, gastroparesis, heart attack, and stroke, is the root cause of all complications of DM. (3) Assess sensation, capillary refill, temperature, peripheral pulses and color. This assessment monitors the patients peripheral perfusion to detect macroangiopathy or PVD. Evaluation of Intervention (1) @ 0730 Patients blood glucose level was measured at 230 mg/dl @12:00 Patients blood glucose level was measured at 170 mg/dl Effective- allows to see that the patients’ blood glucose level is slightly above the outcome level (2) @0800 Insulin administered @1200 Insulin administered Patient became compliant to administration and less frustrated Effective- ease of administration for patient to realize compliance is important (3) @0800 Patients capillary refill to upper extremities < 2 seconds and to LLE > 3 seconds; patient states constant numbness and tingling in hands; patients upper and lower extremities are warm to touch and even in pigmentation Effective: These findings can change with constant high blood glucose that the patient exhibits IO: met or unmet? Partially met, the patient had one blood sugar reading >180 and another was below. Patient became more compliant during the day with administration of insulin. Swearingen, P. L. (2016.). All-in-one nursing care planning resource: medical-surgical, pediatric, maternity, and psychiatric-mental health. (4th ed.). Missouri. Elsevier 14 Medical Diagnosis: Sepsis, Colon cancer Subjective Assessment Data: Patient states that, “my mouth tastes sour.: Nursing Diagnosis: Imbalanced nutrition related to nausea occurring with disease and taste changes due to medication AEB no interest in meals, patient stating “my mouth is tasting sour,” and decreased muscle mass. Objective Assessment Data: Decreased muscle mass, patient sends back meals IO: Patient will eat at least 50 % of each meal offered by end of shift on 10/14/16. Intervention (1) Weigh the patient daily. Nausea, vomiting, anorexia, and taste changes all may contribute to weight loss. RN-RN (2) Assess food like and dislikes, as well as cultural and religious preferences related to food choices. Providing foods on the patients “like” list as often as feasible and avoiding foods on “dislike” list optimally will promote sufficient intake. However, foods previously enjoyed may become undesirable, whereas previously disliked foods may appeal. RNNutrition Services (3) Encourage good mouth care; assess mucous membranes for thrush, lesions or mucositis. Thrush infections can cause taste alterations yet are easily treated. A coated tongue may interfere with ability to taste. RN-RN; RN-CNA Evaluation of Intervention (1) 10/14/2016: Patient weight taken at 113 kg, this was compared to week of daily weights from chart and there has been only a 2 lb fluctuation. Effective only for longer time period to determine if patient is taking in adequate nutrition. (2) @0900 : Patient asked why he did not eat breakfast, if there was something not offered. Patient able to describe what he tried to order and was not given. Correct breakfast item ordered for patient. Patient able to eat breakfast that was to his liking. @1300 Patient ate 50% of meal and explained what he liked and disliked. Effective- Allows nurse to inform nutritionist to maintain adequate nutrition for the patient. (3) @0840 – Patients oral cavity was evaluated. Patient not compliant with oral care. Patient has poor dentition and whitish covering over tongue. @0900 Patient educated on oral care. Patient states, “I am set in my ways of oral care.” Ineffective- noncompliance. IO: met or unmet? Met, though some interventions were not met, patient continued to eat 50% of all meals up until end of shift on 10/14/16. Swearingen, P. L. (2016.). All-in-one nursing care planning resource: medical-surgical, pediatric, maternity, and psychiatric-mental health. (4th ed.). Missouri. Elsevier 15 Generic Name: Metronidazole Trade Name: Flagyl Classification: Amebicide; Antibiotic, Miscellaneous; Antiprotozoal, Nitroimidazole Pregnancy Category: B Dosage/Route: 500 mg PO Q8H Action: After diffusing into the organism, interacts with DNA to cause a loss of helical DNA structure and strand breakage resulting in inhibition of protein synthesis and cell death in susceptible organisms Indications: Bacterial infection Contraindications/Precautions: Hypersensitivity to metronidazole, nitroimidazole derivatives, or any component of the formulation; pregnant patients (first trimester) with trichomoniasis; use of disulfiram within the past 2 weeks; use of alcohol or propylene glycol-containing products during therapy or within 3 days of therapy discontinuation Adverse Reactions/Side Effects: Central nervous system: Headache, Gastrointestinal: Nausea Central nervous system: Metallic taste, dizziness, Dermatologic: Genital pruritus, Gastrointestinal: Abdominal pain , diarrhea xerostomia Genitourinary: Dysmenorrhea, urine abnormality urinary tract infection Infection: Bacterial infection, candidiasis Respiratory: Flulike symptoms, upper respiratory tract infection, pharyngitis, sinusitis Cardiovascular: Flattened T-wave on ECG, flushing, syncopy. Dermatologic: Erythematous rash, pruritus, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticarial. Endrocrine & metabolic: Decreased libido Gastrointestinal: Abdominal cramps, abdominal distress, anorexia, constipation, dyspareunia, epigastric distress, glossitis, hairy tongue, hiccups, pancreatitis (rare), proctitis, stomatitis, vomiting Genitourinary: Cystitis, dark urine (rare), dysuria, urinary incontinence, vaginal dryness, vulvovaginal candidiasis. Hematologic & oncologic: Leukopenia (reversible), thrombocytopenia (reversible, rare) Immunologic: Serum sickness-like reaction (joint pains) Local: Inflammation at injection site (IV) Neuromuscular & skeletal: Arthralgia, weakness Ophthalmic: Optic neuropathy Renal: Polyuria Respiratory: Nasal congestion, rhinitis Nursing Implications: Assessment & Drug Effects Discontinue therapy immediately if symptoms of CNS toxicity (see Appendix F) develop. Monitor especially for seizures and peripheral neuropathy (e.g., numbness and paresthesia of extremities). Lab tests: Obtain total and differential WBC counts before, during, and after therapy, especially if a second course is necessary. Monitor for S&S of sodium retention, especially in patients on corticosteroid therapy or with a history of CHF. Monitor patients on lithium for elevated lithium levels. Report appearance of candidiasis or its becoming more prominent with therapy to physician promptly. Repeat feces examinations, usually up to 3 mo, to ensure that amebae have been eliminated. Pt’s Age Diagnosis Dose/Route Purpose of drug for this client & compare dose to Initials Frequency recommended dose (show calculations) J.Y. 57 Sepsis, Diabetic 500 mg every 8 Anti-infective for sepsis due to gangrene Foot Ulcer, DM, hours Does ordered is within r4ecommended range Thrombocytopenia Reference: Skidmore, Linda (2015). Mosby’s Drug Guide for Nursing Students. (11th ed.). Missouri: Elsevier. 16 Date @0900: 57-year-old male admitted to hospital with sepsis two weeks prior. Vital signs: temperature 97.9, pulse rate 68 bpm, respirations 18 bpm, blood pressure 147/82, O2 saturation is 96% and patient has a pain level of 8/10 explaining that his pain is mostly in his lower extremities. Midline in right upper arm is clean, dry, and intact. Port-a-cath to left upper chest is clean dry and intact. Patient is sitting upright and chair, appearing tired with face down in hands. Patient has wheezing on auscultation. Heart sounds are normal on auscultation, no murmurs. PERLLA, sclera white, no signs of discharge. Patient is verbal and alert. Nose is pink and moist with no discharge. Ears have no discharge, no cracking of skin. Mucous membranes are moist, patient is missing teeth, white overlay on tongue. No oral lesions. Pulses are 2+ bilateral upper extremities. Pedal pulse 1+ to LLE. Right foot amputation. 4th and 5th toe amputation to left foot. Old stitches to left outer ankle. Skin is warm and dry to touch, no signs of tenting. Lower extremities are worm to touch, 2+ pitting edema bilaterally. Abdomen is soft, round, obese, no pain on palpation. Bowel sounds active in all quadrants. No crepitus to chest, chest is symmetric in size and movement. Full ROM of bilateral upper extremities. Limited ROM due to pain to bilateral LE. Bed placed in lowest position, side rails up x2, call light within reach. Nurse notified of patients status. Patient told to notify nurse by calling if any problems arise or if needed. Your name, SN 09:30 Metolazone 5 mg oral administered. Pantoprazole 40 mg oral administered, patient tolerated well, bed in lowest position, call light within reach, side rails up x2, and denies any pain. Your name, SN. 11:00 Patient sitting comfortably in chair. Patient reports no significant pain, patient reports feeling tired. Patient tolerated well, bed in lowest position, call light within reach, side rails up x2, and denies any pain. Your name, SN 12:00 Insulin Lisro 8 units administered to right upper arm. Piperacillin 3/Tazobactum 0.375/Isotonic IV piggy back started in RU arm midline over 30 minutes. Patient tolerated well, bed in lowest position, call light within reach, side rails up x2, and denies any pain. Your name, SN 13:45 Bumetanide 2 mg oral tab administered; Metronidazole 500 mg oral tab administered Patient complained to pain 8/10. Patient appears exhausted. Wheezing present in lungs on auscultation. Breathing treatment order. Reparations at 24 bpm. Pulse 72 bpm. Patient tolerated well, bed in lowest position, call light within reach, side rails up x2, and denies any pain. Your name, SN 1420 lungs clear to auscultation, patient states “I can breath a lot better now.” bed in lowest position, call light within reach, side rails up x2, and denies any pain. Your name, SN
