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ASSESSMENT Latest Update .//
Patient is a 89-year-old female residing at Sentara Williamsburg med-surgery unit. Patient was admitted with gallstone pancreatitis and underwent a cholecystectomy a week ago. PAST MEDICAL HISTORY Patient has a history of GERD, hypertension, type 2 diabetes, hypothyroidism, COPD, CHF, right sided breast cancer biopsy that did not require surgery, brother was diagnosed with coronary artery disease at 87 years old. CURRENT ORDERS DIET: Diabetic, low sodium ACTIVITY: Daily physical therapy, patient needs extensive assistance with ADL’s. TREATMENTS: Incentive spirometer, patient will continue to receive everyday medications at appropriate times. Patient will continue to receive extensive care while performing ADL’s. DEVELOPMENTAL ASSESSMENT ERIKSON’S STAGE: Ego integrity vs. Despair (Lillis, Taylor, Lemone & Lynn, 2011). EVIDENCE: Patient recalls being a independent prior to her hospital admission and states that everything keeps going downhill and it was obvious by her facial expressions that she was sad.
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PHYSICAL ASSESSMENT
(Complete head to toe assessment. WNL is not accepted. Please be specific.) Neurologic: LOC, pain assessment, GCS score Alert & Oriented to person, time, place, answers questions appropriately, verbal communication appropriate. Patient reports no discomfort. ROM passive in patient’s upper extremities. Legs are weak and give out without assistance. GCS 14 Respiratory: Rate and O2 saturation Lung sounds clear bilaterally to all lung fields. Symmetrical chest expansion. Respirations: 18, not labored, regular rhythm. Mucous membranes are moist and pink. No cough. O2 level 99. Cardiovascular: HR, BP, JVD, peripheral pulses, capillary refill BP: 112/89 Peripheral Pulse: 89 Temp: 98.2. Radial pulse rate: 84 rhythms normal. Cap refill <3 sec, brisk. Apical pulse: no audible murmur, no JVD Gastrointestinal: Last BM and description Abdomen round, soft. No discomfort on abdomen during palpation and no pain. Normal bowel sounds x 4 quadrants. Last BM 11MAR13, stool large, soft, brown, with heavy odor.
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Musculoskeletal: Hand grips weak bilaterally. Right leg and left leg push/pull weak patients legs are weak and give out after short time standing, she needs to assistants at all times when transferring. Integumentary: Scalp no visible lesions hair is gray. No pitting edema present around ankles. Hands warm to touch. Patients back and buttocks are light pink. No bruises, or open areas present. Patients skin intact but dry. There was a scare tissue from a previous wound on her buttocks area and she did have skin tears on her hand from turning herself in bed. Psychosocial: Patient was pleasant and cooperative. Easily distracted. Liked talking about her family visiting. No past history of smoking or drinking. Nutritional: Include % of each meal consumed Diet diabetic. Patient consumed 100% of breakfast and lunch. Patient enjoys her cranberry juice. MEDICATIONS Please include trade & generic name, dosage, action, reason your patient is receiving this medication, major side effects, and nursing implications. Include your source citation for each med. Trade Name: Flagyl Generic Drug Action: Disrupts DNA and protein synthesis Is Dose Appropriate? Yes Adverse Reactions: Seizures, Nursing Implications: Assess for
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Name: metroniadazo le Dose: 500mg/100ml Route: IV in susceptible organisms. Bactericidal, trichomonacid al, or amebicidal action. Most notable for activity against PTs Weight 67 kg dizziness, h eadache,asept ic meningitis encephalopathy optic neuropathy, tearing abdominal pain, anorexia, nause a, diarrhea, dry mouth, furry tongue, infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy.
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Trade Name: Ramipril Generic Name: Alltace Dose: 10mg Route: PO Time: Daily in am INDICATION: ace inhibitor for Drug Action: ACE inhibitors block the conversion of angiotensin I to the vasoconstricto r angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandins . Lowering of BP in hypertensive patients. Is Dose Appropriate? Yes PTs Weight: 67 kg Adverse Reactions: Dizziness, drowsiness, fatigue, headache, insomnia, vertigo, weakness. cough, dyspnea, hypotension, chest pain, edema, tachycardia, hyperuricemia, taste disturbances, abdominal pain, anorexia, constipation, diarrhea, Nursing Implications: Monitor BP and pulse frequently during initial dose adjustment and periodically during therapy. Notify health care professional of significant changes. Monitor frequency of prescription refills to determine adherence. Assess patient for signs of angioedema
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hypertension Citation: (Vallerand, Sanoski & Deglin, 2011) nausea, vomiting, erectile dysfunction, proteinuria, renal dysfunction, renal failure, flushing, pruritis, rashes. (dyspnea, facial swelling). Trade Name: Glucagon Generic Name: Glucagen Dose: 0.5mg Route: IM Time: Daily INDICATION: For hypoglycemic Citation: (Vallerand, Sanoski & Deglin, 2011) Drug Action: Glucagon binds to the glucagon receptor, a G protein-coupled receptor, located in the plasma membrane. The conformation change in the receptor activates G proteins, a heterotrimeric protein with α, β, and γ subunits. When the G protein interacts with the receptor, it undergoes a conformational change that results in the replacement of the GDP molecule that was bound to the α subunit Is Dose Appropriate? Yes PTs Weight: 67 kg Adverse Reactions: Hypotension, nausea, vomiting. Nursing Implications: Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and notify health care professional immediately if these symptoms occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction.
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hyperglycemia Citation: (Vallerand, Sanoski & Deglin, 2011) drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait) LAB DATA & DIAGNOSTIC EVALUATION Include date CITE SOURCE FOR EACH VALUE AND INDICATION LAB Ordered: HCT 3// . Client Values: HCT 44. Normal Values 35.1-48% (Corbett & Banks, 2012). Indication for Diseases / Illness Hematocrit (he-MAT-uh-krit) is the proportion of your total blood volume that is composed of red blood cells. A hematocrit (Hct) test indicates whether you have too few or too many red blood cells (Corbett & Banks, 2012).
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LAB Ordered: INR 3/5/ Client Values: INR 2. Normal Values: 2.0-3.0 (Corbett & Banks, 2012). Indication for Diseases / Illness The INR is a test of blood clotting, which is primarily used to monitor warfarin therapy, where the aim is to maintain an elevated INR in a certain range (Corbett & Banks, 2012).
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fat, liver, and muscle cells do not respond correctly to insulin. This is called insulin resistance. As a result, blood sugar does not get into these cells to be stored for energy (Taylor, Lillis, Lomone,& Lynn,2011) Hypothyroidism Hypothyroidism (underactive thyroid) is a condition in which your thyroid gland doesn't produce enough of certain important hormones. Hypothyroidism upsets the normal balance of chemical The patient showed signs of fatigue, muscle weakness and dry skin which are all signs of hypothyroidism.
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reactions in your body. (Taylor, Lillis, Lomone,& Lynn,2011) COPD Chronic obstructive pulmonary disease (COPD) refers to a group of lung diseases that block airflow and make breathing difficult. (Taylor, Lillis, Lomone,& Lynn,2011) The patient showed no signs or symptoms of having COPD. CHF Heart failure, also known as congestive heart failure (CHF), is when the heart can't pump enough blood to meet the body's needs. Over time, conditions such as narrowed arteries in your heart (coronary artery disease) or high blood pressure gradually leave your heart too weak or stiff to fill and pump efficiently. (Taylor, Lillis, Lomone,& Lynn,2011) The patient is on a strict diabetic and low sodium diet although she is not very active the low sodium diet is helping with CHF PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS List all nursing diagnosis relevant to patient condition & based on assessment
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1 Sara^ Bernard 3/11/
MED SURG Care Plan 2 CLINICAL PHYSICAL ASSESSMENT
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Student Name: Sara Bernard Date: 3/11/13 Class: Med-surg Patient Initials: J.S A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest priority first. Be sure to include “related to”, “as evidenced by”, or “risk factors” (if at risk diagnosis) for each medical/psych diagnosis. Write one short term and one long term “expected outcome” (measurable goal) per nursing diagnosis stated in terms of client achievement - “the client will…”). List 3 specific nursing actions (interventions) for your short term and your long term nursing diagnosis and give the scientific rationale for selecting the action you will use to work toward that goal. NURSING DIAGNOSIS EXPECTED OUTCOME NURSING INTERVENTIONS
RATIONALE EVALUATION
(NANDA APPROVED) (Measurable Goal) (What do you plan to do?) (Why are you doing this?) Cite Source for Each Rationale (Include your measure in your evaluation) NURSING CARE PLAN
1 Sara^ Bernard 3/11/
MED SURG Care Plan 2 CLINICAL PHYSICAL ASSESSMENT
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Maintain a heart healthy diet by avoiding high fat high sodium foods. Promotes health and wellness (Gulanick, Myers, 2011).
MED SURG Care Plan 2 CLINICAL PHYSICAL ASSESSMENT
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NURSING DIAGNOSIS EXPECTED OUTCOME NURSING
INTERVENTIONS
RATIONALE EVALUATION
Short Term Goal: 3 short term interventions: 3 Rationales: Short term evaluation: Impaired mobility related to patients weakness as evidenced by patients unsteady gate. Patient will perform active range of motion exercises by the end of this shift. Be present for all and assist safety transfers. Encourage rest between activities that are tiring. Supervising transfers will eliminate the risk for fall (Ackley & Ladwig, 2011). Rest periods are needed to conserve energy. Patient must respect limitations of restrictions (Ackley & Ladwig, 2011). Goal ongoing Have patient participate in therapy as ordered Physical and occupational therapy will assist the patient to reach successful recovery and independent mobility (Ackley & Ladwig, 2011). Long Term Goal: Within one week patient will display strength, ROM, and improved function as evidenced by 3 Long Term Interventions: Medicate as needed and before therapy activities so that client is able to 3 Rationales: Adequate analgesia is a priority to decrease pain, reduce muscle tension to facilitate Long term evaluation: Goal ongoing
