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Hi,Please, follow the instruction and the grading rubric attached in the files below. Please use the APA format,Thank you so much. pt_with_liver_disease_student_copy.doc pt_with_liver_disease_rubric.docx Unformatted Attachment Preview Adult Health II Clinical Assignment #1 Liver Failure This clinical assignment is to provide the student the opportunity to develop a patient care plan. Material should be referenced using APA (6th ed). The student will submit the assignment in Brightspace. Instructions: 1. Review the patient data on the Clinical Decision-Making Worksheet 2. Under each system assessment on “Health Assessments/Interventions” section, include the interventions a nurse should implement based on the assessment data for that system. 3. In the “Pertinent Diagnostic Data” section, explain the the significance of the abnormal lab/diagnostic values. 4. Complete the medication table for each medication this patient has been prescribed. 5. Write up the patho of liver disease in this patient. Describe liver disease, but also describe the patho of all the signs/symptoms the patient is experiencing, i.e. hepatic encephalopathy, ascites, hepatorenal syndrome, jaundice, and anemia. 6. Create three priority nursing diagnoses for this patient. 7. For each nursing diagnosis, list the assessment data to support the diagnosis, interventions, and a rationale for each intervention. PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET Patient Demographics, Health History and Admission History Patient Sex Age Mrs. J. F 71 Room Admitting 200-1 Date 24 hours ago Reason for admission: Altered mental status Present diagnosis: ER Management: Altered mental status • Hepatic Encephalopathy u/a, C &S of urine, LFTs, CBC, coag profile, CMP, • ascites CT scan • Hepatorenal syndrome Started on IV antibiotics • Jaundice IV-saline lock • DM II • Anemia Allergies: Code Status: Isolation Status: NKA Full Universal Admission Height: Admission Weight: Arm Band Status: 5 ft 4 in 66.18 kg High Fall Risk, Allergy Communication needs: The patient does not require any communication assistance. The patient speaks English. Past Medical History: • Alcohol Abuse; Alcohol hepatitis; Anemia; Ascites; Coagulopathy; Depression; Diabetes Mellitus II, Generalized Weakness; HTN; Hypothyroidism; Leukocytosis; Liver Cirrhosis; Portal HTN; Splenomegaly; OA; Macular Holes 1 Other: Patient has a history of alcohol abuse and depression. She has been treated in rehabilitation centers for alcohol abuse per medical record. Significant events during this hospitalization: • CT-Abdominal Pelvis • X-Ray- Abdomen • Ultrasound-Abdomen • Vascular Ultrasound • Electrocardiogram Tests, treatments and interventions impacting clinical day’s care: • Patient participated in physical therapy • Ultrasound of the abdomen at the bedside • CBC sent to the lab at 0900 Advance Directives/Ethical considerations: (DPOA, Hospice, DNR, Living Will, etc..) The patient is a full code. No DNR or living will available. This was not discussed with the patient during the clinical shift. 2 Health Assessments/Interventions (1 pt for each intervention; 11 pts total) Vital Signs: (2 sets per day) Pain Assessments and Interventions: Assessment: The patient was alert and orientated X 3/ X 2 and reported Time 0730 xx left hand pain at the IV site as a 5 on a scale from 0-10 at T 98 Oral 0900 d/t potassium infusion; heat pack was placed at the P 75 site and IV rate was lowered, reassessment at 0930 was a R 16 0. The patient demonstrated facial grimacing during B/P 108/60 Left arm lying movement and appeared to be discomfort through out Pulse Ox 97\% clinical shift. She stated pain level as 0 at 0730 and 1430 Pain 0 FLACC when vitals were recorded. Score Time 1430 T 97.5 Oral P 79 R 18 B/P 107/52 Left arm, lying Pulse Ox 99\% Monitor Pain O FLACC Score Respiratory Assessment and Intervention: Assessment: Patient on room air. Frequent, nonproductive, dry cough noted after an increase in activity. Patient appears to be in no distress. Barrel chest. Normal lung sounds auscultated in all lung fields. HOB is elevated to 30 degrees. No use of axillary muscles. No signs of pallor or air hunger. Interventions: Neurosensory Assessments and Interventions: Assessment: Patient is alert and orientated X3, sometimes X2. Easily arousal. PEERLA present. No use of corrective lenses/glasses. Patient has slowed, comprehendible speech. Verbal and able to follow two-step commands. Purposeful responses and purposeful movements. Generalized muscle weakness and fatigue. Interventions: Interventions: Cardiovascular Assessments and Interventions: Assessment: Patient’s HR 75 at 0730 and 79 at 1130. BP 108/60 at 0730 and 107/52. Patient is placed on remote telemetry. S1 and S2 sounds present. All four extremities are warm and dry. Skin turgor immediate recoil. No signs of clubbing/splitting. Dorsalis Pedi +1 weak pulses. Radial pulses +1 weak. Capillary refill less then 3 seconds. Patient’s color is WNL. No peripheral edema. Abdominal ascites present. SCD’s present. Patient has a hx of HTN, coagulopathy and anemia. Musculoskeletal Assessments and Interventions: (include activity) Assessment: Patient has limited ROM in all four extremities and needs partial assistance with ADL’s. Decreased ROM in all four extremities: RUE-mild LUE- mild, RLE- moderate, LLEmoderate. Decreased tone in all four extremities. No muscle contractures present. No peripheral edema or tenderness present. No traction or casts present. No abdominal binder. Able to transfer to bedside commode with one assist. Patient is on high fall risk and a bed alarm is set. Interventions: Interventions: 3 Gastrointestinal Assessment and Intervention: (include ordered diet) Assessment: Patient is on a general diet. Patient did not eat her breakfast; she ate 25\% of lunch and 25\% of her dinner. Patient’s abdomen was distended and ascites was present. Hypoactive bowel sounds present in all 4 quadrants. Patient given protonix for gastric mobility at 0900. Patient had loose brown/yellow bowel movements 4 X in the commode. Patient was on lactulose, which was discontinued in the AM. Endocrine Assessment and Intervention: Assessment: Patient has a hx of DM II. Accuchecks every 6 hours and on a sliding scale. Patient’s glucose was 170 at 1200 and was given Insulin aspart 3 units at 1200. Patient has a history hypothyroidism; synthroid 50 mcg was given on an empty stomach at 0900. Patient does not exhibit diaphoresis, nervousness, or change in skin color. No signs of heat or cold intolerances. Interventions: Interventions: Reproductive Assessment and Intervention: Assessment: Patient had two children 36 and 40 years ago. Interventions: Safety Assessment and Intervention: Assessment: Patient is at a high risk for falls. Three-side rails are up and the bed is in the lowest position. Bed alarm is on. Call light is with in reach. Turn patient every two hours to prevent skin break down. Ensure HOB is 30-45 degrees. Vascular Access Assessment and intervention: Assessment: Patient has an IV in her left hand and another IV in her right brachial. Dressing dry and intact. No continuous IV fluids running at this time. No signs of infiltration, redness or phlebitis at either IV site. Patient stated burning at left hand IV site during potassium chloride infusion, infusion lowered and heat pack given. Interventions: Post-operative/Post-procedural Assessment and Intervention: N/A Interventions: Psychosocial Assessment and Interventions: Assessment: The patient lives in a house in Chicago with her son Tommy. She has two grandchildren that came to visit her at the bedside. She was a former smoker and alcoholic. She stated that she currently drinks one mixed drink of vodka each day. Her husband passed away 15 years ago and that’s when her drinking got bad. She stated, “I’m not as bad of a drinker as my father was.” She stated that she enjoys cooking because it makes her feel happy, however has not been able to cook as much because of her limited mobility and pain. Interventions: 4 Pertinent Diagnostic Data (10 points) (complete only applicable sections) Diagnostic Data Results WBC RBC HGB HCT Platelets 11.4 2.68 9.1 28.1 243 Normal Lab Values 4,500-11,000 4.2-5.4 12-16 37-47\% 150,000-400,000 PT INR PTT 29.1 25-35 seconds Glucose BUN Creatinine Sodium Potassium Chloride Calcium 286 55 2.1 141 3.0 109 7.2 70-99mg/dL 8-21 mg/dL 0.5-1.2 mg/dL 135-146mmol/L 3.5-5.0mmol/L 98-106mmol/L 9.0-10.5/dL T Protein Albumin SGOT SGPT Alk Phos 5.9 3.0 56 9 152 6.4-8.2 3.5-5.2 <39 4-36units/L 30-120 Units Magnesium Amylase Lipase eGFR 1.8 1.3-2.1 48 >60 Diagnostic Data Results Normal Lab Values Urinalysis Color Character Spec. Grav. pH Protein Glucose Blood Nitrites RBC Yellow clear 1.015 7.0 +2 Negative Trace Negative 0-5 Yellow Clear 1.010-1.030 5.0-8.0 Negative Negative Negative Negative <2 Significance related to this patient if value is abnormal Cholesterol WDL Significance within this patient if value is abnormal 5 WBC Culture CT Scan Bilirubin Ammonia negative No growth -Lack of homogeneity of architecture of liver tissue -Ascites fluid in peritoneal cavity -Small varices -Spleen calcifications 3.70 52 Negative 0.3-1.0 0 6 Medication List Lactulose Pantoprazole Spironolactone Heparin Levothyroxine Thiamine (vit B) folic acid Insulin-Correction Factor Lispro insulin Lantus insulin Citalopram 25\% Albumin 30 ml 40 mg 25 mg 5000 u 50 mcg 5 mg 0.5 mg 140-189 = 3 units 181-220 = 6 units 221-260 = 9 units 260-300 = 12 units Greater than 301= 12 units 10 unit 20 units 20 mg 50 g PO PO PO SQ PO PO PO SQ 3 times a day Every day Twice a day Every 12 hours Every day Every day Every day Before meals and HS SQ SQ PO IV Before meals HS Every day Once a day for 2 days Pharmacological Intervention (24 points; 2 points per drug) Medication Classification Mechanism of Action Purpose for this Patient Significant Side Effects / Adverse Reactions Nursing Implications 7 Pathophysiological Discussion (10 points) ▪ Discuss the pathophysiology of liver disease in this patient. Connect the patho to the assessment data (including physical assessment, labs results, and imaging) ▪ Include appropriate references and use APA format (may use current required textbook, Up to Date, etc). You should use in-text citations and include references. 8 Nursing Diagnoses (6 points; 2 per points for each diagnosis) List the top 3 nursing diagnoses for this patient Use NANDA format (nursing diagnosis, related to, as evidenced by) Nursing Diagnosis Related to As Evidenced By 9 Nursing Diagnosis (11 points for each diagnosis; 33 points total): For each of your three nursing diagnoses, state: • the assessment data from the care plan to support the diagnosis • interventions the nurse would implement, based on the diagnosis and assessment data • the rationale for each intervention Nursing Diagnosis #1 (restate here): Assessment or data collection relative to the nursing diagnosis (2 points) Interventions (5 points) Rationale for interventions (4 points) 10 Nursing Diagnosis #2 (restate here): Assessment or data collection relative to the nursing diagnosis (2 points) Interventions (5 points) Rationale for interventions (4 points) 11 Nursing Diagnosis #3 (restate here): Assessment or data collection relative to the nursing diagnosis (2 points) Interventions (5 points) Rationale for interventions (4 points) 12 13 References (6 points) 13 1 Care Plan Grading Rubric Student Name: __________________________________________________ Grading Criterion Interventions for Health Assessments: • Complete interventions for each section of health assessment (ex. pain); interventions highlighted in green Pertinent Diagnostic Data • Identify abnormal diagnostics • State significance for this patient Pharmacology: • Complete and accurate description of current meds, including classification, MOA, purpose for this patient, side effects, and nursing implications. Pathophysiology: • Discuss the pathophysiology of liver disease in this patient (3 pts). • Connect the patho to the assessment data: • physical assessment (3 pts) • labs results (3 pts) • imaging (1pt) Nursing Diagnosis: (2 points for each diagnosis) • Reflects the primary diagnosis • Appropriate for patient scenario Rev. 9/1/19 Points 11 (1 point for each assessment) 10 24 (2 point for each drug) 10 6 Earned Comments Points 2 Grading Criterion • Points Earned Comments Points In in acceptable NANDA format, i.e. diagnosis, R/T, AEB Assessment: (2 points for each diagnosis) • Assessment data from health assessment, diagnostics Interventions: (5 points for each diagnosis) • Includes interventions (both medical and nursing) that directly relate specific diagnosis • Specific in action, frequency • # of interventions appropriate to meet the needs of the patient/family Rationale: (4 points for each diagnosis) • Evidence based information to support the intervention. References: • Correct formatting of in text citations (2 points) • Correct formatting of reference page (2 points) • Spelling, grammar, clarity (2 points) Total 6 15 12 6 100 Deductions for late work are at the discretion of the instructor. There may be no more than 10\% for every day past the indicated due date. Rev. 9/1/19 ... Purchase answer to see full attachment