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Melanie Carlson 4/5/04 PERSON Name: Melanie Carlson’s patient (rm 304) Current Medical/Surgical Diagnoses: Cerebral Palsy w/ mental retardation and chronic seizure disorder; type 1 diabetes mellitus w/ gastroparesis; osteomyelitis of the left heel; chronic heel ulcers; benign prostatic hyperplasia Age: 54 Code Status: Full LEO Admit Date: 3/23/2004 Transfer Date to LTAC: 4/2/2004 Date of Care: 4/1/2004 P NEED: This patient is a 54-year-old, 208-pound, 6’4”, single, white male who is well known to the facility. He has cerebral palsy with mental retardation and seizures. He was admitted on March 23rd, 2004, after an episode in his doctor’s office of altered mental status. He apparently had a 15-minute episode of decreased alertness with unresponsiveness. He recalls being at his doctor’s office, but does not remember anything else until the emergency room. The patient was recently in the hospital (discharged on 3/12/04) for DKA and Dilantin toxicity. His anticonvulsive regimen was rearranged by discontinuing Dilantin and adding Keppra and Depakote. Upon admission on 3/23/04, his Depakote level was a bit low and required adjustment while hospitalized. The patient has not had a recent history of any seizures. On 4/1/04, the patient’s level of consciousness was diminished somewhat from the previous day, and the doctor ordered a repeat blood level of valproic acid (Depakote). The patient is a resident of Southwood Care Center, but has been evaluated by Cornerstone Hospital and approved for LTAC on 3/31/04. His physician is currently waiting for approval from his sisters for the transfer, and for a bed to become available at Cornerstone. He is a nonsmoker and nondrinker. He is insured by Medicaid and Medicare Part A and B. He has sisters who are supportive and help to look after him. One sister has told the hospital staff that he often pretends to understand more than he really does. He was oriented times three upon admission. He has remained lucid of his location and knows what day it is because he reads the newspaper each morning. He is able to voice his wants/needs, make simple decisions, and follow simple verbal commands. His memory is impaired, supported by his lack of name recall of staff (he asked my name 7 times on 4/1/04), lack of ADL recall (he often doesn’t remember getting up to sit in the chair or being assisted to the bathroom), and his lack of recall of simple activities (how to order a newspaper to his room was explained each morning). Because of this impairment, it was difficult to obtain a thorough Review of Systems or Past Medical History from him. He is not anxious or upset, and told the attending physician upon admission that he felt like he was in his usual state of health. Diagnostics: Upon admission, a CT brain scan was performed and revealed atrophy, but no evidence of acute abnormality. Meds: Keppra 1500 mg po b.i.d.; Depakote 1500 mg po b.i.d. Labs: Depakote WNL (50-100) during hospital stay, except elevated on 3/24/04 to 113.4; Depakote level for 4/1/0/4 pending. E NEED: Patient has a past medical history of benign prostatic hyperplasia. This can lead to urinary retention and acute pain, but the patient complains of neither symptom. He is eliminating without difficulty on a regular basis. He has not had N/V, fever or chills. Upon admission, the patient complained of chronic constipation. While hospitalized, his medications have improved this infirmity and caused soft, loose stools. He has a large bowel movement every day; on 4/1/04, it was very soft, orange and odorous. He is often incontinent of urine even though a urinal is at his 1 bedside. He doesn’t remember to use it. Because of erythema and scaling on his scrotum, the patient is lying on an absorbent pad, but does not wear adult diapers for the incontinency. Protective ointment is being applied to his scrotal area to prevent further skin breakdown. Meds: Demadex 40 mg po q.am.; Flomax 0.8 mg po q.d.; Colace 100 mg po b.i.d.; Reglan 10 mg po a.c./h.s.; Os-Cal 500 mg po b.i.d. Labs: On 3/31/04, BUN 24.0 H; creatinine 0.9. Diagnostics: On 3/29/04, a urinalysis was performed. Sp gr 1.005; pH 5.0; 1+ leuk esterase; negative for nitrite, protein, glucose, ketone, bilirubin or WBC; urobilinogen .2; blood 1+; and yeast “rare”. R NEED: The patient does not complain of any pain, and is unable to use a 1-10 pain scale. He has not requested any pain medication during his hospital stay. Past medical history includes microvascular type 1 diabetes mellitus with gastroparesis and peripheral vascular disease. Upon admission, his blood sugar was slightly elevated, but no evidence of DKA or acidosis in spite of acetone being present. He is to continue his Lantus and be covered with sliding scale insulin (Humalog). Accucheck a.c./h.s. The patient has a past medical history of hypothyroidism and takes Levothroid to maintain it. Meds: Actos 15 mg po q.d.; Lovenox 40 mg SQ q.d.; Humalog a.c./h.s. (sliding scale) SQ; Levothroid 0.1 mg po q.d. Labs: Blood glucose is very sporadic, ranging from 78 to the high 200s. On 4/1/04, morning Accucheck was 78 (no Humalog admin.); noon was 283 (10 units of Humalog admin.). S NEED: ALLERGIES: NKDA CODE STATUS: Full LEO The patient has glasses and dentures and needs assistance with ambulation from caregiver and a walker. When attempting to stand, the patient’s arms shake and he has difficulty holding his weight on the walker. While standing, patient has a tendency to lean forward with head down as if tipping over. Upon verbal reminders, he is able to lift his head and straighten his body. Patient has no IV, with only a heplock at his left wrist that was started on 3/23/04; CDI. Patient has cerebral palsy with a chronic seizure disorder and muscle spasticity. Skin examination reveals numerous sites of skin breakdown. He has Elastogels on both elbows to prevent pressure ulcers at that site. He has a duoderm on his coccyx, where skin breakdown has already occurred with signs of erythema and epidermal skin peeling off. It would classify as a Stage I on the verge of becoming a Stage II pressure ulcer. He has Kerlex dressings to bilateral heels of his feet, along with cushioned boots to prevent further pressure points. He has a Stage IV pressure ulcer with resolving osteomyelitis in the left heel. According to wound care physician, granulation buds continue to increase and there is a small amount of serous yellow drainage. In the right heel, there is a Stage III pressure ulcer with black hard eschar, green drainage, pitting edema, and surrounding erythema. A podiatrist was being consulted because the wound care doctor was unable to debride the wound because of the hard eschar. The right heel is worrisome for infection, and Ceftin is being administered. The right leg has erythema surrounding the ulcer and coming up the anterior aspect to below the knee. The admitting physician reported that the patient had what seems like a ruptured bullous lesion on the posterior aspect of the right calf. Osteomyelitis of the right heel was ruled out on 4/1/04. Labs: 3/31/04 – WBC 7.2; RBC 3.23 L; Hgb 10.1 L; Hct 29.7 L; platelets 269. These values have remained as such during his hospital stay, with WBC & platelets WNL, and RBC, Hgb & Hct values remaining low secondary to infection. Diagnosics: An MRI of the right foot was performed on 3/31/04 to rule out osteomyelitis (bone involvement). It came back negative for bone involvement. Meds: Ceftin 500 mg po q.12h. O NEED: 2 The patient’s vital signs were stable during his entire hospital stay, with no signs of acute respiratory distress or fever. The patient does have bilateral edema of his lower extremities, 3+ on the right and 2+ on the left. A Doppler was done in January to rule out DVTs. However, admitting physician feels his edema is much worse and has reordered it to be sure he has not developed a clot. (See S NEED for description of skin.) Bilateral pedal pulses are +1; radial pulses are +3. Heart sounds are regular, with no murmur or gallop. He has mild rhinitis, with clear drainage from his nose. This could be secondary to Flomax or Keppra medications. Blood pressure upon admission was 163/94. During my time with this patient, his blood pressure was not highly abnormal, ranging in the 150-160s for systolic and 80-90s for diastolic. I did not find evidence in his chart of a past medical history of hypertension, but he was taking Demadex, a loop diuretic and antihypertensive agent. Labs: 3/31/04 – CO2 34.0 H; MCV 92; MCH 31.2 H; MCHC 33.9. His MCH has been elevated throughout his hospital stay. Meds: Aspirin E.C. 81 mg po q.d.; Demadex 40 mg q.am.; Allegra 180 mg po q.d.; folic acid 1 mg po q.d.; Flonase 2 puffs q.d.; Trental 400 mg po t.i.d. w/ meals Diagnostics: Doppler of lower extremities – pending. N NEED: No recent weight loss; patient is 6’4”, 208 pounds. Appetite is normal. Patient has upper and lower dentures. Current diet is CHO diabetic diet of 1500 calories. The patient’s fine motor skills are impaired and he needs assistance cutting his food and opening containers. He is able to feed himself with only minor difficulties, and has no trouble swallowing. Current diagnoses include mild hyponatremia and hypomagnesemia. Meds: Zinc Sulfate 220 mg po q.d.; Vitamin C 500 mg po b.i.d. 3 MEDICATIONS Name: Actos (pioglitazone hydrochloride) Dosage: 15 mg po q.d. (1 tab) Classification: antidiabetic; thiazolidinedione Action: increases insulin sensitivity by affecting insulin receptors; decreases hepatic glucose output and increases insulin-dependent muscle glucose uptake in skeletal muscle and adipose tissue Indication: This patient has type-1 DM, with blood glucose levels that vary sporadically. Side Effects: upper respiratory tract infection; edema & fluid retention; hypoglycemia; mild anemia Nursing Considerations: This medication states it is contraindicated in type 1 diabetes or treatment of DKA, which I thought was interesting. It also has a “cautious use” for patients with hypertension or edema. Therefore, it is important to closely monitor the patient’s blood glucose levels, any changes in his lower extremity edema, and response to medication (peak is at 2 hours). Name: Aspirin E.C. (acetylsalicylic acid) Dosage: 81 mg po q.d. (1 tab) Classification: Action: Indication: The anti-inflammatory actions of aspirin should help prevent spreading of his lower bilateral edema. He also has a risk for DVT in his lower extremitities due to his impaired mobility (aspirin inhibits platelet aggregation and reduces ability of blood to clot). Side Effects: N/V; heartburn; stomach pains; hemolytic anemia; bronchospasm, anaphylactic shock Nursing Considerations: Review diagnostic test interferences that occur with aspirin administration. Give with food or fluid to minimize gastric irritation. Monitor for loss of tolerance to aspirin. Observe patient for signs of bleeding or other adverse effects. Name: Demadex (torsemide) Dosage: 40 mg po q.am. (2 – 20 mg tabs) Classification: loop diuretic Action: Inhibits reabsorption of Na and Cl primarily in the Loop of Henle and also in the proximal and distal renal tubules. Has lower potassium-wasting effects than furosemide, and a longer half-life. Indication: My patient’s blood pressure is borderline hypertensive. I could not find confirmation in the chart of a past medical history of hypertension, nor do I know the exact reason for this medication. Side Effects: hypokalemia, hyponatremia, orthostatic hypotension, headache Nursing Considerations: This medication states a “cautious use” warning for diabetes patients. Monitor blood pressure often and assess for orthostatic hypotension. Monitor serum electrolytes, uric acid, blood glucose, BUN and creatitine during course of therapy. Name: Flomax (tamsulosin hydrochloride) Dosage: 0.8 mg po q.d. (2 capsules) Classification: alpha-adrenergic antagonist; autonomic nervous system agent Action: Blockage of alpha-adrenergic receptors can cause smooth muscles in the bladder outlet and prostate gland to relax, resulting in improvement in urinary blood flow and reduction in symptoms of BPH. Indication: My patient has benign prostatic hyperplasia. This medication improves his ability to void by decreasing bladder outlet obstruction. Side Effects: headache, dizziness;, orthostatic hypotension (w/ first dose), rhinitis, abnormal ejaculation Nursing Considerations: Monitor for signs of orthostatic hypotension. 4 Name: Levothroid (levothyroxine sodium) Dosage: 0.1 mg po q.d. (100 mcg tablet) Classification: thyroid agent; hormone & synthetic substitute Action: Synthetically prepared monosodium salt and levo-isomer of thyroxine. T3 and T4 serum levels increase, and improves diuresis, weight loss and puffiness. Indication: This patient has hypothyroidism and requires replacement therapy for diminished thyroid function. Side Effects: insomnia; weight loss; palpitations; irritability Nursing Considerations: This patient has likely been on this medication for an extended period of time with the dosage already adjusted to the most effective level. Most adverse effects occur during early adjustment or with first doses. Baseline and periodic tests of thyroid function are necessary. Name: Allegra (fexofenadine) Dosage: 180 mg po q.d. Classification: H1-receptor antagonist; non-sedating antihistamine Action: Antagonizes histamine at the H1-receptor site to inhibit antigen-induced bronchospasm and histamine release from mast cells. Indication: The patient has rhinitis with drainage. Side Effects: headache, nausea, fatigue, dyspepsia Nursing Considerations: Monitor effectiveness; assist patient with proper usage. Name: Colace (docusate calcium) Dosage: 100 mg po b.i.d. Classification: stool softener Action: anionic surface-active agent w/ emulsifying and wetting properties Indication: The patient complained of constipation upon admission, but of loose stools by 4/1/04. Miralax was discontinued on that day, but this medication was not. Side Effects: diarrhea Nursing Considerations: Assess patient’s stools for improvement in symptoms of constipation. This medication states a “cautious use” for patients with edema or diabetes mellitus, so edematous sites and blood glucose levels need to be closely monitored. Name: Os-Cal (calcium carbonate) Dosage: 500+ D tabs (1 tab po b.i.d.) Classification: antacid Action: Rapid-acting antacid with high neutralizing capacity and relatively prolonged duration of action. Decreases gastric acidity, thereby inhibiting proteolytic action of pepsin on gastric mucosa. Also increases lower esophageal sphincter tone. Indication: This patient has gastroparesis (failure of the stomach to empty) likely caused by diabetic autonomic neuropathy. Side Effects: Constipation, flatulence, hypomagnesemia, polyuria Nursing Considerations: This could be causing his hypomagnesemia. Monitor lab values closely and replete magnesium as ordered. Name: Folic Acid Dosage: 1 mg po q.d. Classification: vitamin B9 Action: Vitamin B complex essential for nucleoprotein synthesis and maintenance of normal erythropoiesis. Indication: Side Effects: Nursing Considerations: 5 Name: Lovenox (enoxaparin) Dosage: 40 mg SQ q.d. Classification: low molecular weight heparin Action: Antithrombitic properties with effect on TT and aPTT values. Indication: Due to severe impaired mobility secondary to ataxia and pressure ulcers, this patient is a high risk for DVT. Side Effects: hemorrhage, angioedema arthralgia, dyspnea, allergic reactions, pain & inflammation at injection site Nursing Considerations: Report signs of unexplained bleeding immediately. Monitor platelets, hct, and hgb closely. Name: Zinc sulfate Dosage: 220 mg po q.d. Classification: nutrional supplement, mineral Action: Antithrombitic properties with effect on TT and aPTT values. Indication: Diabetes mellitus with gastroparesis increases the body’s need for folic acid. Skin disorders (in this case – pressure ulcers) also increase the need for folic acid. Side Effects: very few adverse effects unless taking large doses or overdosed Nursing Considerations: Space doses of folic acid 2 hours apart from fiber-containing foods, phosphoruscontaining foods and whole-grain breads & cereals to get full benefit of supplement. Name: Flonase (fluticasone) Dosage: 2 puffs per nares q.d. Classification: adrenal corticosteroid; anti-inflammatory Action: Antithrombitic properties with effect on TT and aPTT values. Indication: Due to severe impaired mobility secondary to ataxia and pressure ulcers, this patient is a high risk for DVT. Side Effects: transient nasal irritation, burning, sneezing Nursing Considerations: Usually prescribed for a maximum of four days. Monitor nasal tissue for irritation. Name: Keppra (levetiracetam) Dosage: 1500 mg po b.i.d. Classification: anticonvulsant; CNS agent Action: Precise mechanism is unknown. It is a broad spectrum antiepileptic which does not involve GABA inhibition. Indication: The patient has a history of chronic seizure disorder associated with his cerebral palsy. Side Effects: Asthenia, headache, infection, somnolence, ataxia, amnesia, rhinitis, cough Nursing Considerations: Name: Vitamin C (ascorbic acid) Dosage: 500 mg po b.i.d. Classification: low molecular weight heparin Action: Increases protection mechanism of the immune system, thus supporting wound healing. Necessary for wound healing and resistance to infection. Must be consumed daily. Indication: Pressure ulcers, skin breakdown, and risk for infection in the bilateral heel ulcers strongly indicates a need for vitamin C. Side Effects: headache, N/V (most adverse effects don’t occur until administering high dosage) Nursing Considerations: Be aware of diagnostic test interferences that may occur when taking vitamin C, including false-negative tests for occult blood in stools. 6 Name: Reglan (metoclopramide hydrochloride) Dosage: 10 mg AC/HS po Classification: GI agent; prokinetic agent; ANS agent; direct-acting cholinergic (parasympathomimetic); antiemetic Action: Exact mechanism of action not clear but appears to sensitize GI smooth muscle to effects of acetylcholine by direct action. Increases resting tone of esophageal sphincter, and tone and amplitude of upper GI contractions. As a result, gastric emptying and intestinal transit are accelerated with little effect, if any, on gastric, biliary, or pancreatic secretions. Indication: The patient has a past history of gastroparesis associated with his diabetes mellitus. Side Effects: mild sedation, fatigue, restlessness, diarrhea, hypertensive crisis (rare) Nursing Considerations: Report immediately the onset of restlessness, involuntary movements, facial grimacing, rigidity, or tremors. Monitor serum electrolytes. Name: Trental (pentoxiphylline) Dosage: 400 mg po t.i.d. w/ meals Classification: hemorrheologic agent; antiplatelet agent Action: Useful in restoration of blood flow through nutritive capillary microcirculation that has been compromised by structural and flow dynamic changes in cerebral and peripheral vascular disorders. Action mechanism unclear, but drug action interrupts the vicious cycle of tissue hypoxia, sludging and stasis of capillary blood flow, microthrombotic activity, reduced oxygen delivery to ischemic cells. Indication: The patient has been diagnosed with microvascular diabetes mellitus with peripheral vascular disease. He has edema of his lower extremities, and improved blood flow to the feet would greatly improve healing of the ulcers. Also, due to impaired physical mobility, patient is at risk for DVT. Side Effects: dizziness, dyspepsia, N/V, angina Nursing Considerations: Monitor therapeutic effectiveness. Monitor BP because patient also on antihypertensive treatment. Drug may slightly decrease an already stabilized BP, necessitating a reduced dose of the hypotensive drug. Name: Humalog (insulin lispro) Dosage: sliding scale – Accucheck done before meals and h.s. Classification: antidiabetic agent; hormone & synthetic substitute Action: Human insulin that is a rapid-acting, glucose-lowering agent that works by increasing peripheral glucose uptake (esp. skeletal muscle and fat tissue) and by inhibiting liver from changing glycogen to glucose. Indication: This patient has type-1 diabetes mellitus. Often, before lunch and bedtime, his blood glucose level is in the 200s. Side Effects: nausea, tremulousness, palpitation, confusion, ataxia, profuse sweating, and coma Nursing Considerations: Monitor patient for hypoglycemia from 1-3 hours after injection. Be aware that insulin injections can cause interference in thyroid and liver function tests, and may decrease serum potassium and calcium. Name: Depakote (valproic acid) Dosage: 1500 mg po b.i.d. Classification: anticonvulsant; GABA inhibitor Action: May be related to increased bioavailability of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) to brain neurons. Depresses–abnormal neuron discharges in the CNS, thus decreasing seizure activity. Indication: The patient has cerebral palsy with chronic seizure disorder. Side Effects: N/V, drowsiness, sedation, deep coma & death, liver failure, pancreatitis, bone marrow depression, prolonged bleeding time, Nursing Considerations: Be aware that Depakote can cause interference in many serum and diagnostic tests. Because this patient is on multiple drugs for seizure control, there is an increased risk of hyperammonemia, 7 marked by lethargy, anorexia, asterixis, increased seizure frequency, and vomiting. Report such symptoms promptly to physician. Name: Ceftin (insulin lispro) Dosage: 500 mg po q.12h. Classification: antibiotic; 2nd-generation cephalosporin Action: Preferentially binds to one or more of the penicillin-binding proteins (PBP) located on cell walls of susceptible organisms. This inhibits third and final stage of bacterial cell wall synthesis, thus killing the bacterium. Effectively treats bone and joint infections, and skin & soft-tissue infections. Indication: Due to osteomyelititis in the left heel, and risk for infection in other present pressure ulcers, this medication is a good choice. Side Effects: diarrhea, antibiotic-associated colitis Nursing Considerations: Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of drug allergies before therapy is initiated. Perform culture and sensitivity tests before initiation of therapy and periodically during therapy if indicated. Monitor and report onset of loose stools and/or diarrhea. ------------------------------------------------------------------------------------------------------------------------------------- LIST OF APPLICABLE NURSING DIAGNOSES 1. Self care deficit: toileting, bathing, hygiene, instrumental related to general debilitation and perceptual/cognitive impairment 2. Thought processes, disturbed related to loss of cells/brain atrophy and cerebral palsy 3. Skin integrity, impaired related to inadequate tissue perfusion, prolonged pressure to skin & SQ tissue, and diminished sensation in lower extremities secondary to peripheral polyneuropathy 4. Urinary elimination, impaired related to impaired ability to recognize bladder cues secondary to cerebral palsy and diabetic neuropathy 5. Physical mobility, impaired related to ataxia, muscle rigidity and weakness secondary to cerebral palsy, ulcers on bilateral heels 6. Injury, risk for: Falls related to sensory loss and weakness of lower extremities secondary to pressure ulcers; ataxia and chronic seizure disorder secondary to cerebral palsy, and lack of awareness of environmental hazards 7. Infection, risk for related to osteomyelitis of left heel, cellulitis of right lower extremity, and incontinence 8 CEREBRAL PALSY Mosby’s Dictionary p. 324 Online sources: http://gait.aidi.udel.edu/res695/homepage/pd_ortho/clinics/c_palsy/cpweb.htm http://www.neurocarecenter.com/conditions/cp.html http://www.about-cerebral-palsy.org Cerebral palsy is a motor function disorder caused by a permanent, nonprogressive brain defect or lesion present at birth or shortly thereafter. The neurologic deficit may result in spastic hemiplegia, monoplegia, diplegia, or quadriplegia; athetosis or ataxia; seizures; paresthesia; varying degrees of mental retardation; and impaired speech, vision and hearing. The disorder is usually associated with premature or abnormal birth and intrapartum asphyxia, causing damage to the nervous system. Risk Factors: highest risk is premature, very small baby who does not cry in the first five minutes after delivery, who needs to be on a ventilator for over four weeks, and who has bleeding in his brain babies wtih congenital malformations in systems such as the heart, kidneys, or spine are also more likely to develop CP, probably because they also have malformations in the brain Seizures in a newborn also increase the risk of CP Clinical Manifestations: Symptoms of the condition vary from mild to severe. Mild symptoms might include speech impairment, fine motor coordination problems, or mildly awkward movement. More severe symptoms include inability to walk, speak, or control their own movements. Depending on the type and location of damage to the brain, a child may have additional problems such as mental retardation, seizures, or language, learning, vision, and hearing problems. Cerebral Palsy does not get better or worse with time. For most patients, whatever their challenges are as a child will remain with them throughout their adult life. Diagnostic Studies: When an infant or child has brain damage, a variety of symptoms can lead doctors and parents to suspect that something is wrong, including lethargy, poor feeding abilities, abnormal posture and seizures. During the first six months of life, other signs of brain injury may also appear in an infant’s muscle tone and posture. Once a baby with brain damage reaches six months of age, it usually becomes quite apparent that he or she is picking up movement skills slower than normal. Infants with cerebral palsy are more often slow to reach certain developmental milestones, such as rolling over, sitting up, crawling, walking and talking. Parents are more likely to notice these developmental delays and abnormal behaviors, especially if this is not their first child. Sometimes when they express their concerns to their physicians, their child is immediately diagnosed as having cerebral palsy. More often, however, medical professionals hesitate to use the term "cerebral palsy"at first. When diagnosing cerebral palsy, doctors must rule out other disorders that can cause abnormal movements. Magnetic resonance imaging (MRI) and Computed Tomography (CT) scans are often ordered and may provide evidence of hydrocephalus (an abnormal accumulation of fluid in the cerebral ventricles), or they may be used to exclude other causes of motor problems. A diagnosis of cerebral palsy cannot be made on the basis of an x-ray or blood test, though the physician may order such tests to exclude other neurologic diseases. In conclusion, to make a diagnosis of cerebral palsy, the most meaningful aspect of the examination is the physical evidence of abnormal motor function, and most children display a defininite and permanent abnormality by 18 months of age. 9 Nursing Dx & Support Data Skin integrity, impaired related to inadequate tissue perfusion, prolonged pressure to skin & SQ tissue, and diminished sensation in lower extremities secondary to peripheral polyneuropathy Support Data Bilateral pressure ulcers in heels Skin breakdown (stage 1) at coccyx Mild erythema at elbows; elastogels applied as protection Cellulitis & erythema of right leg Impaired physical mobility Need to turn patient q.2h. or get out of bed to chair Diabetes mellitus with peripheral vascular disease Goal/Outcome & Outcome Attainment 1) The patient will demonstrate progressive healing of tissue. Outcome Attainment As I was only present for one day, I was unable to determine improvement in the healing of tissue. However, interventions were in place to prevent further breakdown and promote healing. Nursing Interventions 1a) Cover open pressure ulcers with sterile dressings or protective barrier. 1b) Consult with specialist for treatment of stage IV pressure ulcers. 1c) Implement measures to prevent further breakdown. 1d) Perform actions to prevent infection in wound. 1e) Encourage client to wear immobilization device. Scientific Rationale 1a) May reduce bacterial contamination and promote healing. 1b) MRI may be necessary to determine bone, muscle or supporting structure involvement. Wound care specialist has knowledge of how to promote healing of stage IV pressure ulcer. 1c) Friction, maceration, shearing and skin surface abrasion can cause pressure ulcers. Pressure-reducing/relieving measures can prevent these. 1d) Infection will delay healing and increase involvement of underlying tissues, bone, muscle and supportive structures. 1e) Reduces risk for trauma to pressure points. 10 Evaluation 1a) Patient has sterile dressings to bilateral heel ulcers that are changed and inspected daily by Wound Care. 1b) Wound care physician comes every day to inspect the wounds, debride, and apply new duoderm to coccyx, elastogel to elbows, and dressings to feet. 1c) The patient’s linens were changed and his perineal area washed thoroughly each time he was incontinent of urine or feces. He was assisted to a bedside chair, or turned q.2h. Feet cushioned on pillows at all times. Protective ointment applied to the scrotal area. 1d) Patient was instructed to avoid touching dressing or open wounds. Sterile technique used during dressing changes and wound care. Ceftin 500 mg q.12h. given to fight infection. 1e) The patient wore bilateral boots in bed and when in chair. Boots only removed for dressing changes, wound care and shower. Nursing Dx & Support Data Injury, risk for (Falls) related to sensory loss and weakness of lower extremities secondary to pressure ulcers and edema of lower extremities; ataxia and chronic seizure disorder secondary to cerebral palsy, and lack of awareness of environmental hazards Support Data cerebral palsy with chronic seizure disorder ataxia, mucle weakness & rigidity spastic arm muscles while trying to use walker and get into standing position pressure ulcers on feet and associated decrease in sensation of lower extremities edema of lower extremities mental retardation Goal/Outcome & Outcome Attainment 1) Patient will be free of injury during hospitalization. Outcome Attainment The goal was successfully attained during the patient’s hospital stay, before his transfer to Cornerstone Hospital. Nursing Interventions Scientific Rationale Evaluation 1a) Change position slowly to prevent orthostatic hypotension. 1a) Each time patient was helped into chair or to bedside commode, his feet were dangled at bedside and he was asked if dizzy. 1b) Explain importance of using call light to ask for assistance before getting up; keep bedside rails up. 1a) Orthostatic hypotension may occur as result of venous pooling, or as a side effect of medication admin. 1b) Bed side rails help remind patient to call for help, and prevent accidental falls from the bed. 1c) Administer seizure medication as prescribed. 1c) Prevention of seizure activity minimizes risk for injury. 1d) Assess functional ability and extent of impairment. 1d) Identifies potential risks in the environment and heightens awareness of risks so caregivers are more alert to dangers. 1e) Assist/instruct patient with use of mobility aids. 1e) If patient is knowledgeable and confident in the usage of a mobility aid, there will be less risk for fall. 1f) If patient begins to fall, caregiver is able to move behind, slip hands under arms, and assist patient to a chair or slowly slide patient to floor. 1f) Stand slightly behind patient with hands on patient’s arms when patient is ambulating. 11 1b) Patient had no difficulty using his call button, and understood the importance of asking for assistance to get out of bed. However, he very seldom asked for assistance to go to the bathroom and was often incontinent. 1c) Depakote and Keppra are prescribed for the patient’s seizures. They are effective on this patient, but it was necessary to assess his degree of alertness due to their side effects of somnolence, dizziness, ataxia and fatigue. 1d) Before each task, I usually asked a staff member or the patient concerning his ability or extent of impairment. For example, I asked him if he needed help cutting his food. I asked the nurses if he needed help getting into the upright position because he was 208 pounds (and I could not lift him alone). 1e) The patient used a walker to transfer from the bed to the commode or chair. Due to his memory impairment, he did not recall how to use it properly and was instructed each time. 1f) Because of the patient’s size, I got help each time before ambulating the patient. On one occasion, when patient was trying to stand up from bedside commode to return to bed, he began to fall. As I was behind him and another nursing student was in front of him, we were able to catch him and return him to the commode until he felt more stable.