Fluent Essays

PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET Student Name: Week: 5 Dates of Care: 09/26/2021 Patient Initials Sex F Age 74 Room 813 Admitting Date 09/24/21 Admitting Chief Complaint: What symptoms cause the patient to come to the hospital? Sinus problem, upper respiratory infection Attending physician/Treatment team: Consults: Infectious Disease Consultation Present Diagnosis: (Why patient is currently in the hospital) Cough weakness/ Failure output Treatment/ Immunocomprised ER Management: (if applicable) Allergies: Sulfa antiobiotics, Clindamycin, Hydromorphine, Statins, Tramadol Code Status: Full Code Isolation: (type and reason) N/A Admission Height: 5’9” Admission Weight: 60.3kg Arm Band Location (colors & reasons) Communication needs: (verbal, nonverbal, barriers, languages) Past Medical History: (pertinent & how managed) History DVT, Seizure in the past, Bilateral ovarian removal, Osteoporosis, Fibromyalgia, Hysterectomy, Appendectomy, Ehlers-Danlos Syndrome, Right foot cellulitis, Asthma Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome) Tests/Treatments/Interventions impacting clinical day’s care (include current orders) Assessments and interventions: (Include all pertinent data) Vital signs: (2 sets per day) Time T P R B/P Time T P R B/P GI: Diet: Swallow precautions: Tube feedings: NG / G tube: Blood Glucose: (time & date) Last bowel movement: (time & date) Pertinent Labs/Test: Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting) Respiratory: 02 modalities: 02 Saturation: Suction: Resp Rx’s: Trach: Chest Tubes: Pertinent Labs/Test: Assessments/Interventions: (Lung sounds, cough, sputum, SOB) Neurosensory: Neuro checks: Alert & Orientated: Follows commands: Speech Comprehensible: Pertinent Labs/Test: Assessments/Interventions: (LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness) Cardiovascular: Telemetry: Pacemaker/IAD: DVT Prevention: Daily Weights: Pertinent Labs/Test: Assessments/Interventions: (peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations) Musculoskeletal: Activity: Traction: Casts/Slings: Pertinent Labs/Test: Assessments/Interventions: (strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps Renal: Catheter (indwelling/external): CBI: Dialysis: A/V access: Pertinent Labs/Test: Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O) Skin: Braden Score: Pertinent Labs/Test: Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type) Pain: Pain score: Assessments/Interventions: (scale used, location, duration, intensity, character, exacerbation, relief, interventions) Vascular Access: (IV site) Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance) Gyn: Gravida/Para: LMP: Last Pap: Breast exam: Pertinent Labs/Test Assessment/Interventions: (bleeding, discharge) Post-operative /procedural: Assessments/Interventions: (immediate post procedure care) Safety: Call light: Bed Rails: Bed alarms: Fall risk: Assistive Devices: Sitter use: Restraints (type, duration & reason): Assessment/Interventions (modifications to room, environment, Patient) Advance Directives/Ethical considerations: DPOA: Hospice: Pertinent Data (Labs, X-rays, Etc.) Results Normal Lab Values Significance to your patient WBC RBC HGB HCT MCV MCH MCHC Platelets RDW MPV PT INR APTT Glucose BUN Creatinine Sodium Potassium Cloride Calcium T Protein Albumin SGOT SGPT Alk Phos Magnesium Amylase Lipase CPK LDH Cholestrol CK CK-MB Troponin I Myoglobin LDI Urinalysis Color Character Spec. Grav. pH Protein Glucose Acetone Bilirubin Blood Nitr Urobili RBC WBC Epithelium Urine Culture Chest X-ray MRI CT Scan Others test: Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics) Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions) Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient: Current overall plan of care: (A short statement that summarizes the anticipated plan of care) Discharge plans and needs: Teaching needs:(Disease process, medications, safety, style, barriers) Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. Include appropriate references and use APA format. ADH II: attach a research article pertaining to diagnosis of patient. Write a summary about the article. List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis. Priority Nursing Diagnosis Related to As Evidence By Rationale (reason for priority) 1 2 3 4 5 Medications Classification Dose Route Freq Purpose/Mechanism of Action Significant Side Effects / Adverse Reactions Nursing Implications Albuterol Levothyroxine Baclofen Azelastine Clonazepam Nursing Diagnosis: Identify the top two nursing Diagnoses and expand Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis) Patient Goal(s) Statement of purpose for the patient to achieve Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.) (Must have at least two short term outcomes and two long term outcomes) Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale. Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set) Nursing Diagnosis: Identify the top two nursing Diagnoses and expand Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis) Patient Goal(s) Statement of purpose for the patient to achieve Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.) (Must have at least two short term outcomes and two long term outcomes) Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale. Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set) PAGE 1 1 DO NOT COPY, OR TAKE THE INFORMATION AS YOUR OWN FROM THIS CARE PLAN. THIS IS SOLELY FOR EXAMPLE PURPOSES. Student Name: PROPERTY OF RESURRECTION UNIV Week: 3 Dates of Care: March 11, 2018 Patient Demographics, Health History and Admission History Patient TM Sex M Age 79 Room 2131 Admitting Date 2/5/2018 Admitting Chief Complaint: Guillain Barre Syndrome/AIDP s/p IVIG (1/31 – 2/4); Paraplegia Attending Physician/Treatment Team: Eric Brehm, MD James Daniel, RN Melissa Perez, CNA Consultants seen during this hospitalization: Neurology (Steven B. Nussbaum, MD); Cardiac (Kim Ki, MD); GU/Renal (John Michael Li, MD); Dermatology (Cosette Burian, MD); Psychiatry (Richard Clarey, MD) Present Diagnosis: Exacerbation of chronic demyelinating polyneuropathy; Paraplegia; Dementia with behavior disturbance ER Management: CBC &ESR, screening for viral markers, toxic metal, serum CPK level, thyroid profile Allergies: Shellfish Code Status: DNR Isolation Status: None Admission Height: 6’0” Admission Weight: 172lb Arm Band Status: Fall Communication needs: Pt presents easily agitated with impaired concentration r/t dementia, causing barriers to effective communication. Nursing interventions include: Learn patient needs and pay attention to nonverbal cues; Manage irritability by promoting self-soothing techniques and de-escalating as needed Past Medical History: Acute GI bleeding (Hx of tx with proton pump inhibitors); BPH (Hx of tx with alpha-blockers); GERD (Hx of tx with proton pump inhibitors, antacid); HTN (Hx of tx with ACE inhibitor, diuretic); A-Fib (Hx of tx with Xarelto and Metoprolol); Urinary retention (Hx of tx with I&O catheter); AKI (s/p IVF on 2/3); Dementia with possible acute worsening (Hx of tx with donepezil) Significant events during this hospitalization: Refusing food and increased agitation—consult with psychiatry ordered for evaluation and medication recommendation. Night Delirium, treated with PO Trazadone 50 mg scheduled and additional 25 mg Q6 hours PRN. New areas of blanching erythema on feet—orthotics to readjust shoes. Tests, treatments and interventions impacting clinical day’s care: 2 Continue to encourage timed voids, can use condom catheter during therapies if interrupting therapy. Intermittent catheterization as needed. Started on Flomax 0.4 mg QHS (2/19). Continue to monitor and encourage PO intake. Apply barrier ointment to L buttock DTI (present at admission). Utilize foam for protection on multiple abrasions to bilateral knees and elbows (present at admission). Apply Medihoney and foam daily to R foot ulcer (prior cellulitis). Monitor electrolytes and replete as needed. Maintain scheduled physical therapy to improve strength, cognition, and balance. Advance Directives/Ethical considerations: DNR. Despite acute worsening of dementia symptoms, Pt remains decisional at this time. Health Assessments Vital Signs: (2 sets per day) Time 8:00AM T 97.9 Oral P 82 Radial R 18 Observed B/P 113/70 Automatic Pulse Ox 97\% Right Index Pain Score 2 Subjective Time 12:00PM T 97.3 Oral P 79 Radial R 18 Observed B/P 125/72 Automatic Pulse Ox 98\% Right Index Pain Score 1 Subjective Pain Assessments and Interventions: Patient seen and assessed for pain. Pt was asked if he currently was experiencing any pain or discomfort. Pt confirmed that he had very mild pain. Pt asked to rate pain on a scale from 1-10, with 1 being the least and 10 being the most. Pt reports a pain rating of 2. Pt states that his pain is located at posterior neck and bilateral elbows and upper arms. Pt noted to appear without grimaces or other nonverbal cues of pain or distress. Interventions: Acetaminophen 650 mg 2-tab(s) Q4hr PRN for pain, may pre-medicate for treatment. Comfort measures maintained, Pt propped on pillows, and items that could pose hazard potential removed from Pt’s vicinity. Maintain physical therapy schedule and encourage Pt to participate. Respiratory Assessment and Intervention: Patient seen and assessed for respiratory impairment. Pt denies SOB. Pt noted to be breathing with equal bilateral chest expansion and unlabored. Respirations observed to be within normal range. During auscultation no adventitious sounds heard. Will continue to monitor signs of distress. No supplemental oxygen needed at this time. Neurosensory Assessments and Interventions: Patient seen and assessed for neurosensory impairment. Pt denies any complaints at this time. Cranial nerves noted to be without impairment/dysfunction; assessed during 5-minute assessment at bedside. Patient presents with neurogenic bladder r/t paraplegia. Pt has impaired mobility which is precipitating skin breakdown; Pt presents with stage 2 pressure ulcer at sacral area, it’s shallow and has visible loss of dermis, and it measures (L) 2cm x (W) 3cm; Pt also presents with stage 1 wound on right heel, with non-blanchable redness. Pt also has hx of dementia w/ possible acute worsening. Will intervene with intermittent catheter when bladder scan reveals 250 mL of retained urine. Will change dressings on 3 wounds and document change in size; will also encourage Pt to be shift weight more—especially while in wheel chair. Will consult with psych. Side rails raised, bed alarm on, comfort measures maintained. Cardiovascular Assessments and Interventions: Patient seen and assessed for cardiovascular impairment/dysfunction. Pt denies any SOB, LH, or pain. Pt presents with active dysrhythmia, noted as A-Fib during auscultation; Pt has hx of chronic A- Fib. Heart rate at 82 bpm, +2. BP WNL. Of note, despite current A-Fib, Pt presents with normal heart sounds—S1 and S2 auscultated at apex. Will continue to monitor Pt’s vitals. Will administer scheduled rivaroxaban (Xarelto) 20mg daily, and monitor effects. Chest x-ray performed prior to admission, unremarkable. Musculoskeletal Assessments and Interventions: Patient seen and assessed for musculoskeletal impairment/dysfunction. Pt denies any discomfort currently, however did remind this writer of slight pain felt at posterior neck and bilateral upper arms. Pt presents with (L) knee contusion, paraplegia, and edema to peripheral LE. Pt cannot ambulate, remains in bed with bed alarm on, wearing edema boots on both feet d/t peripheral swelling r/t immobility. Pt requires minimal assistance to rollover in bed, and maximum assistance to transfer—requires mechanical lift to get out of bed and transferred to and from wheelchair. No weakness noted on upper extremities, though Pt appears dysphoric and lethargic when not demanding and irritable. Pt is on fall risk precaution. Bed is kept at lowest position with rails up. Knee x-ray was negative. Comfort measures maintained. Renal Assessments and Interventions: Patient seen and assessed for renal impairment/dysfunction. Pt denies any discomfort currently; denies urgency to urinate or pain r/t to urinary retention. No distention noted. Pt has PMH of AKI. Previous urine noted to be amber color and cloudy. Hematuria noted in UA. Slightly elevated BUN. Creatinine and Chloride levels unremarkable. Pt fluid intake from previous day noted to be 3 L, and most recent output from +7 hours ago noted as 300 ml; Pt 50/50 incontinence status, with prn straight catheter, Q 8hrs. Bladder scanner revealed 250 mL of retained urine. Intermittent catheter initiated. Pt encouraged to intake 2-4 L of fluids during this shift to help maintain renal function. Comfort measures maintained. Skin and Integument Assessments and Interventions: Patient seen and assessed for integumentary impairment. Pt does not verbalize any complaints at this time. Pt presents with a stage 2 pressure ulcer at sacral area, it is shallow with visible loss of dermis, and measures 2 cm in length and 3 cm in width. Pt also presents with stage 1 wound on his right heel with noted redness (non-blanchable). Pt has severely impaired skin integrity 2/2 immobility, and a L buttock DTI present at admission. Pt also has cellulitis on R foot and multiple abrasions to bilateral knees and elbows, present at admission. DTI being treated with barrier ointment, applied daily. Cellulitis on R foot being treated with Medihoney and foam daily, appears to be improving. Bilateral abrasions being treated with foam for protection. Pressure ulcers monitored daily and dressed, and pictures taken to document progress. Orthotics consult to adjust shoes re erythema on feet. Care instructions include to protect skin from maceration and “moisture associated dermatitis” with a moisture barrier or 4 protective film. Gastrointestinal Assessment and Intervention: Patient seen and assessed for GI impairment. Pt denies any current complaints. Pt is 50/50 bowel incontinent. Pt is on a regular diet, thin with calorie count. Pt PMH of acute GI bleeding and GERD. Pt HGB at 10.0 (low), may indicate GI bleeding. Pt will use adult diapers, staff will continue to monitor for bowel movements. Pt will be administered docusate-senna Q12pm, to help with bowel movements. Endocrine Assessment and Intervention: Patient seen and assessed for endocrine impairment/dysfunction. Pt denies any current complaints. Pt glucose noted to be within normal range at 96 mg/dL. BUN at 24 mg/dL. And creatinine at 0.88 mg/dL. NO report of DM, thyroid gland dysfunction, or other endocrine system disorders noted in chart. Reproductive Assessment and Intervention: Patient seen and assessed for reproductive dysfunction. Pt denies any current complaints. Pt has PMH, treated in the past with alpha- blockers. No current reproductive system disorder noted in Pt’s chart. Will continue to monitor and maintain comfort measures. Vascular Access Assessment and intervention: Pt is nonverbal and unable to respond to questions related to vascular access assessment. Pt has 20 gauge peripheral IV located in right hand. Dressing dry and intact, skin surrounding appears to be impaired, with tears and excessive dryness noted. No signs of infection or infiltration at site. Safety Assessment and Intervention: ID band in place—Pt on Fall precaution. Bed is in lowest position, with rails up. Pt does not ambulate, and requires maximum assistance for transfers to and from bed; Pt requires minimal assistance to roll over in bed. Pt monitored and comfort/safety measures maintained. Post-operative/Post-procedural Assessment and Intervention: N/A 5 Psychosocial Assessment and Interventions: Pt is AOx4, presents easily agitated and with an irritable mood and congruent affect, however, is easily redirectable. Pt is a widowed Caucasian male, 79, with 2 children (son Ted and daughter Alyse) and an extended family—which makes up his social support system. Pt is a former proprietor of several bars in the Chicagoland area, and currently has his nephew and son overseeing the family business. Pt resides at the Brookdale assisted living facility Cultural/Spiritual Assessment and Interventions: Per Pt chart, religion noted as “non/no religion.” Pt is complete DNR. Admitted to spinal injury unit at Shirley Ryan Ability Lab (former RIC Chicago). Pt at times is irritable and angry, however has been noted to be more cooperative in afternoon and has presented at times with a bright affect and euthymic mood. Growth & Development Assessment and intervention: Regarding Pt’s growth and development, and based on his current condition and presentation—notably as angry/hostile and with a low threshold for frustration, we can say that employing Erikson’s model of development he is at the ninth stage of development, in which “introspection is replaced by the attention demanded to ones loss of capacities and disintegration” (W. W. Norton, 1998, pp. 112-113). 6 Pertinent Diagnostic Data Diagnostic Data Results Normal Lab Values Significance within your patient WBC 6.0 4.0-11.0 Within normal range RBC 3.83 4.34-5.60 Below normal range, may indicate active bleeding. HGB 10.9 13.0-17.0 Below normal range, may indicate GI bleeding. HCT 33.7\% 38.6-49.2 Below normal range, may indicate active ulcer or other bleeding issue. Platelets 199 150-450 Within normal range PT 16.4 10.1-13.1 sec Above normal range, indicates that blood is taking too long to form a clot. INR 1.5 0.9-1.1 Above normal range, indicating that the blood is clotting slower. PTT 48 25-36 sec Above normal range, may indicate bleeding problem. Cholesterol Glucose 93 70-99 Within normal range BUN 20.8 6.0-20.0 Slightly elevated, could indicate renal dysfunction. Creatinine 3.95 0.7-1.3 Above normal range, may indicate impaired kidney function or kidney disease. Sodium 148 133-144 Slightly elevated, hypernatremia, could indicate dehydration or loss of body fluids. Potassium 3.9 3.5-5.1 Within normal range Chloride 116 98-107 Elevated levels, could indicate dehydration or kidney disease. Calcium 9.0 8.6-10.3 Within normal range T Protein 6.4 6.4-8.9 Within normal range Albumin 2.2 3.5-5.7 Below normal range, may indicate inflammation or malnutrition. SGOT SGPT Alk Phos 176 40-129 Above normal range, indicative of hepatic dysfunction. Magnesium 1.9 1.6-2.6 Within normal range Amylase Lipase eGFR CK CK-MB Troponin I Myoglobin LDI 7 Diagnostic Data Results Normal Lab Values Significance within your patient Urinalysis Color Amber Yellow-Straw May indicate disease. Character Cloudy Clear May indicate excess protein or crystalline substances. Spec. Grav. 1.022 1.001-1.035 Within normal range pH 5.5 5.0-8.0 Within normal range Protein Negative Negative Within normal range Glucose Negative Negative Within normal range Blood Small Negative May indicate kidney dysfunction Nitrites Negative Negative Within normal range RBC 0-3 0-3/hpf Within normal range WBC 51-100 0-5/hpf May indicate kidney dysfunction Urine Culture n/a n/a n/a Current Plan of Care: Manage symptoms, monitor for distress, monitor wounds, complete rehabilitation regiment, including PT/OT/RT, and stabilize mood. Discharge back to ALF. Code status: DNR per patient and son—confirmed on admission. Follow up appointments and aftercare: John Michael Li, MD—2-4 weeks after rehab; Eric Brehm, MD—within 7-days of discharge. Discharge Plan: Patient to be discharged back to assisted living facility, The Brookdale, with follow-up aftercare appointments with PCP, neurology, and PT. Teaching Needs: Educate patient and family members about need to improve mobility and independence, medications, and ongoing therapy and importance of adherence to treatment s/p discharge. Educate about available counseling services, home care, outpatient rehabilitation, and necessary medical equipment. 8 Pathophysiological Discussion Pt is a 79-year-old Caucasian male, AOx4, admitted to the spinal cord injury unit d/t symptoms of Guillain Barre Syndrome (AIDP) s/p immunoglobulin intravenous therapy from 1/31 – 2/4; recurrence of neurogenic bowel r/t paraplegia, resulting in urinary retention requiring intermittent catheterization. Pt diagnosed with Guillain Barre Syndrome after spinal cord surgery following a compression fracture at the T7 and T11 level of his spinal cord. Pt’s compression fracture was precipitated by progression of osteoporosis, diagnosed 5 years earlier. Pt lives at a skilled nursing facility and has good social support. Pt presented to ED at NWM on 1/29 c/o weakness and tingling at upper peripheral extremities, and dysphagia. Pt was admitted to general medical floor and started on IVIG therapy. Intravenous immunoglobulin is used to treat autoimmune syndromes by introducing antibodies into the patient’s veins from an external plasma source, typically from donated blood (VanMeter & Hubert, 2014). Guillain Barre Syndrome is an autoimmune disorder in which the spleen produces antibodies that attack the host nerve cells, this can be precipitated by the flu, surgery, or other infections—it is not very common, and occurs in approximately 40 out of 1-million people. The Pt’s neurologic dysfunction resulting from his spinal cord injury has caused him to experience bladder malfunction. The Pt has experienced a complete spinal cord lesion, the type of injury that results in significant loss of function: “total loss of sensation and voluntary muscle control below the lesion” (Hinkle & Cheever, 2014, p. 2010). The patient has experienced a few episodes of urinary retention since his hospitalization, and it is likely that his loss of sensation has added to the challenges already faced by the lack of reflex activity of his bladder, as Hinkle & Cheever (2014) point out, “because the patient has no sensation of bladder distention, overstretching of the bladder and detrusor muscle may occur, delaying the return of bladder 9 function” (p. 2017). And because of this, the patient has standing orders for intermittent catheterization to avoid over-distention of the bladder. Another complication that has arisen as a result of Pt’s immobility d/t paraplegia is skin impairment and breakdown. Pt had reportedly been struggling with pressure ulcers prior to hospitalization but has experienced worsening skin breakdown since being hospitalized in late January. The pressure ulcer is a common co-occurring condition with impaired mobility, i.e. paraplegia, and has been known to delay rehabilitation in 20\% to 30\% of patients (VanMeter & Hubert, 2014). Impaired sensation prevents the Pt from recognizing the physical cues that an ulcer is forming, and this keeps the Pt from reflexively shifting his position to avoid the pain and preventing further skin breakdown. It is therefore a high priority to have the Pt repositioned at least every 2 hours—especially while hospitalized. This repositioning helps to prevent ulcers and can help prevent thrombosis as well. As VanMeter & Hubert (2014) explain, “turning not only assists in the prevention of pressure ulcers but also prevents pooling of blood and edema in the dependent areas” (p. 324). Pt utilizes Ted hose to prevent DVT in his lower extremities and has a daily regiment of physical therapy during hospitalization. Pt is encouraged by staff to be as mobile as possible, and to be as independent as he can. 10 Nursing Diagnoses List the nursing diagnoses for this patient. Use NANDA format (diagnosis, related to, as evidenced by) and place the diagnoses in their priority order. Briefly discuss the rationale for this priority order. Priority Nursing Diagnosis Related to As Evidence By Rationale 1 Impaired skin integrity Immobility As evidence by pressure ulcer of sacral region, stage 2 Immobility leads to pressure, shear, and friction (Gulanick & Myers, 2017). 2 Impaired Urinary Elimination Neurogenic bladder; disruption in bladder innervation Bladder distension; incontinence/overflow, retention Pt observed to have mildly distended bladder; Pt 50/50 incontinence status, with prn straight catheter orders Q 8hrs if unable to void. As Glulanic & Myers (2017) mention, “Perception of bladder fullness, bladder distention above symphysis pubis implies urinary retention” (p. 205) 3 Impaired physical mobility Compression fracture at T7 and T11 level of spinal cord Paralysis of lower extremities Pt’s limitations will be assessed continuously, with goal of improving mobility, preventing pressure sores, and providing education and encouraging treatment plan compliance—esp. PT 4 Constipation Gastrointestinal atony Bowel incontinence and difficulty passing stools. Pt’s constipation will necessitate intervention by administration of stool softeners and increase of fiber in diet. 5 Chronic pain Prolonged immobility and exacerbation of behavioral disturbances Subjective complaints of pain, and agitated presentation Encourage Pt to report pain. Utilizing cognitive behavioral therapy— reframing Pt’s dysfunctional beliefs— may help alleviate psychic injury 11 Medication Dose, Route & Frequency Classification Purpose / Mechanism of Action Significant Side Effects / Adverse Reactions Nursing Implications (Flomax) tamsulosin 0.4 mg, PO, HS Peripherally acting antiadrenergics Decreases contractions in smooth muscle of the prostatic capsule by preferentially binding to alpha1- adrenergic receptors. Therapeutic Effects: Decreased symptoms of prostatic hyperplasia (urinary urgency, hesitancy, nocturia). CNS: dizziness, headaches. EENT: rhinitis. CV: orthostatic hypotension. GU: priapism, retrograde/diminished ejaculation. Assess Pt for urinary hesitancy, feeling of incomplete bladder emptying, interruption of urinary stream, impairment of size and force of urinary stream, terminal urinary dribbling, straining to start flow, dysuria, urgency. Atorvastatin 10 mg, PO, QD Therapeutic: lipid- lowering agents Pharmacologic: HMG-CoA reductase inhibitors Pregnancy Category X Inhibits 3-hydroxy-3- methylglutaryl- coenzyme A (HMG- CoA) reductase, an enzyme which is responsible for catalyzing an early step in the synthesis of cholesterol. Therapeutic Effects: Lowering of total and LDL cholesterol and triglycerides CNS: amnesia, confusion, dizziness, headache, insomnia, memory loss. EENT: rhinitis. Resp: bronchitis. CV: chest pain, peripheral edema. GI: abdominal cramps, constipation, diarrhea, flatus, heartburn. Endo: hyperglycemia. GU: erectile dysfunction Evaluate serum cholesterol and triglyceride levels before initiating, after 2– 4 wk of therapy, and periodically thereafter. If symptoms of serious liver injury, hyperbilirubinemia, or jaundice occurs discontinue atorvastatin and do not restart 12 Thiamine 100 mg, PO, QD Therapeutic: vitamins Pharmacologic: water soluble vitamins Pregnancy Category A Required for carbohydrate metabolism. Therapeutic Effects: Replacement in deficiency states. CNS: restlessness, weakness. EENT: tightness of the throat. Resp: pulmonary edema, respiratory distress. CV: hypotension, vasodilation, vascular collapse. GI: GI bleeding, nausea. Derm: cyanosis, pruritus, sweating, tingling, urticaria, warmth. Assess for anorexia, GI distress, irritability, palpitations, tachycardia, edema, paresthesia, muscle weakness and pain, depression, memory loss, confusion, psychosis, visual disturbances, elevated serum pyruvic acid levels. Lidocaine topical (Lidoderm 5\% topical film) 1 patch(es), TD, QD, PRN Therapeutic: anesthetics (topical/local) Pregnancy Category B Produces local anesthesia by inhibiting transport of ions across neuronal membranes, thereby preventing initiation and conduction of normal nerve impulses. Local: stinging, burning, contact dermatitis, erythema Assess degree of numbness of affected part. Dealing with transdermal you should monitor for pain intensity in affected area periodically during therapy. Trazodone 50 mg, PO, HS Therapeutic: antidepressants Pregnancy Category C Alters the effects of serotonin in the CNS. Therapeutic Effects: Antidepressant action, which may develop only over several weeks. CNS: SI, confusion, hallucinations. EENT: blurred vision, tinnitus. CV: hypotension, arrhythmias, chest pain, hypertension. GI: dry mouth, constipation, diarrhea, nausea, vomiting. Monitor BP and HR before beginning. Assess for ED, sexual dysfunction. Assess for serotonin syndrome—especially of on an SSRI. Assess for depression, assess mental status. Assess for pain. Assess for 13 Derm: rash. GU: hematuria, erectile dysfunction, priapism, urinary frequency. SI, especially early on in therapy, and especially with children and adolescents. Bisacodyl 10 mg, 1 supp, PR, HS Therapeutic: laxatives Pharmacologic: stimulant laxatives Pregnancy Category C Stimulates peristalsis. Alters fluid and electrolyte transport, producing fluid accumulation in the colon. Therapeutic Effects: Evacuation of the colon. GI: abdominal cramps, nausea, diarrhea, rectal burning. MS: muscle weakness (with chronic use). Assess for hypokalemia with chronic use. Assess for abdominal distension. Assess for color, consistency, and amount of stool produced. (Seroquel) quetiapine 25 mg, PO, HS Therapeutic: antipsychotics, mood stabilizers Pregnancy Category C Acts by serving as an antagonist of dopamine and serotonin. Also antagonizes histamine H1 receptors and alpha1- adrenergic receptors. Therapeutic Effects: Decreased manifestations of psychoses, depression, or acute mania. CNS: seizures, dizziness, cognitive impairment, EPS, sedation, tardive dyskinesia, neuroleptic malignant syndrome. EENT: ear pain, rhinitis, pharyngitis. Resp: cough, dyspnea. CV: increased BP in children, palpitations, peripheral edema. GI: pancreatitis, anorexia, constipation, dry mouth, dyspepsia. Derm: sweating. Endo: weight gain, Monitor mental status. Assess for SI. Assess weight throughout therapy. Monitor for EPS. Monitor for tardive dyskinesia. Assess for rash. Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness). Advice Pt to change positions 14 hyperglycemia, hyperlipidemia. slowly so as to minimize orthostatic hypotension. Advice Pt to avoid extremes in temperature; this drug impairs body temperature regulation. 15 Nursing Management and Intervention Nursing Diagnosis: Impaired Urinary Elimination related to disruption in bladder innervation, as evidence by bladder distension; incontinence/overflow, retention Assessment or data collection relative to the nursing diagnosis Patient Outcome (objective, expected or desired outcomes, or evaluation parameters) Interventions/ Implementations Evaluation Subjective: Patient reports that he has not voided in +7 hours. States, “nothing has come out, and I’ve been drinking a lot of ice water.” Patient denies any discomfort or pain presently. Objective: Pt observed to have mildly distended bladder; Pt fluid intake from previous day noted to be 3 L, and most recent output from +7 hours ago noted as 300 ml; Pt 50/50 incontinence status, with prn straight catheter orders Q 8hrs if unable to void. Pt has hx of bladder and bowel incontinence r/t neurogenic dysfunction. • Pt will achieve urinary voiding within next hour, with < 50 mL PVR identified by bladder scan. • Pt will verbalize understanding of condition during this shift. • Pt will intake 2-4 L of fluids during this shift to help maintain renal function. • Encourage Pt to void by providing assistance and support, monitoring for distress, and educating Pt on potential for catheterization. • Educate Pt on current condition, re bladder retention, and have Pt verbalize understanding of signs and symptoms of urinary incontinence. • Provide Pt with plenty of fluids, including water and clear fluids, to meet daily intake requirements—except during fluid restriction if initiation of intermittent catheterization is needed. • Pt was unable to void during the shift—goal not achieved. And because of the bladder scan (Pt had 250 mL PVR in his bladder), intermittent catheterization started. • Pt verbalized understanding his condition, accurately identifying signs/sxs of retention and bladder distention. Goal achieved. • Pt complied with fluid intake recommendation, and by the end of the shift he had taken in the recommended volume. As such, goal was achieved. 16 Nursing Diagnosis: Impaired skin integrity related to immobility as evidence by pressure ulcer of sacral region, stage 2 Assessment or data collection relative to the nursing diagnosis Patient Outcome (objective, expected or desired outcomes, or evaluation parameters) Interventions/ Implementations Evaluation … 9/26/21, 12:42 PM Rubric Assessment - NUR4641-03:Adult Health Nursing II (2021 Fall Term 1)-14133 - Resurrection University https://oakpoint.brightspace.com/d2l/lms/competencies/rubric/rubrics_assessment_results.d2l?ou=16386&evalObjectId=30497&evalObjectType=1&us… 1/6 Care Plan Rubric Course: NUR4641-03:Adult Health Nursing II (2021 Fall Term 1)-14133 Criteria Good 4 points Fair 3 points Poor 2 points Incomplete 0 points Criterion Score Patient information and health assessment: Complete patient demographics, health assessment and interventions / 4 Pertinent Diagnostic Data: Identify abnormal diagnostics, state significance for this patient. / 4 All of the demographic section is completed, all areas of the health assessment is completed interventions are identified for the health assessment data that is identified. Approximately half to 2/3rds of the demographic section is complete. The health assessment is at least half complete and is accurately identified although minimal interventions are still noted based on the health assessment dated gathered Minimal demographic information is provided in the care plan, many areas of the health assessment section are omitted, interventions are limited. No Demographic information is noted in the care plan, health assessment and interventions are not identified correctly. Identified all of the abnormal diagnostics and stated the significance for this patient. Identified all of the abnormal diagnostics and was able to state SOME of the significance for this patient. Identified half of the abnormal diagnostics and was able to state SOME of the significance for this patient. No Diagnostics were identified for this patient. 9/26/21, 12:42 PM Rubric Assessment - NUR4641-03:Adult Health Nursing II (2021 Fall Term 1)-14133 - Resurrection University https://oakpoint.brightspace.com/d2l/lms/competencies/rubric/rubrics_assessment_results.d2l?ou=16386&evalObjectId=30497&evalObjectType=1&us… 2/6 Criteria Good 4 points Fair 3 points Poor 2 points Incomplete 0 points Criterion Score Number of Nursing Diagnoses: Provided 5 correct nursing diagnoses for the patient based on the patient health assessment, history, labs, and pathophysiolog y. / 4 Pathophysiolog y: Disease process description including “Signs and Symptoms” as well as APA references cited / 4 Identified 5 nursing diagnoses for the patient that are correct based on the patient assessment, history and data Identified 4 nursing diagnoses for the patient that are correct based on the patient assessment, history and data Identified 3 nursing diagnoses for the patient that are correct based on the patient assessment, history and data Identified 2 nursing diagnoses for the patient that are correct based on the patient assessment, history and data. Explanation of pathophysiology chosen; given with accurate details related to client’s symptoms and current illness. APA references noted No explanation of pathophysiology chosen; given with accurate details related to client’s symptoms and current illness. APA references noted No explanation of pathophysiology chosen; given with accurate details related to client’s symptoms and current illness. No APA references noted Not identified correctly or correctly identified although with many omissions noted. The pathophysiology is not integrated into the plan of care 9/26/21, 12:42 PM Rubric Assessment - NUR4641-03:Adult Health Nursing II (2021 Fall Term 1)-14133 - Resurrection University https://oakpoint.brightspace.com/d2l/lms/competencies/rubric/rubrics_assessment_results.d2l?ou=16386&evalObjectId=30497&evalObjectType=1&us… 3/6 Criteria Good 4 points Fair 3 points Poor 2 points Incomplete 0 points Criterion Score Pharmacology: Complete and accurate description of current medication list that includes description of medications, side effects as well as nursing considerations specific to the patient / 4 Nursing Diagnosis: (Includes all 5 Dx) Reflects the primary diagnosis and is appropriate for patient scenario as well as priority level. Expressed in acceptable NANDA format. Also includes all parts stem, R/T, and AEB / 4 List all MAR meds with description, side effects and nursing considerations specific to patient and why patient is receiving drug Most of the MAR meds with description, side effects and nursing considerations specific to patient and why patient is receiving drug List some MAR meds but does not include relevant side effects and nursing considerations specific to patient Only some of the current meds are written & discussed in the meds section. Info is incomplete with many omissions noted. The meds are not integrated in the plan of care Diagnosis is appropriate for patient/priority level. NANDA approved. Diagnosis also includes all parts and information Diagnosis is appropriate for patient/priority level. NANDA approved. Does not include all parts or info is listed in wrong part of diagnosis Diagnosis is not appropriate for patient and priority level. May also not be NANDA approved and may not include all parts Diagnosis selected reflects that no effort to interpret info was applied resulting in a flawed plan of care. NANDA format is not complete or used correctly 9/26/21, 12:42 PM Rubric Assessment - NUR4641-03:Adult Health Nursing II (2021 Fall Term 1)-14133 - Resurrection University https://oakpoint.brightspace.com/d2l/lms/competencies/rubric/rubrics_assessment_results.d2l?ou=16386&evalObjectId=30497&evalObjectType=1&us… 4/6 Criteria Good 4 points Fair 3 points Poor 2 points Incomplete 0 points Criterion Score Assessment: Appropriate for chosen diagnosis. Includes objective & subjective historical data that support actual or risk for nursing diagnosis / 4 Patient Outcomes Outcomes should be specific to the patient Dx., The outcome statement should also contain the following 4 criteria: measurable, attainable, realistic, and timed. All criteria should be present to be a specific patient expected outcome / 4 Includes all pertinent data related to nursing Dx., and does not include data that is not related to Dx Includes all pertinent data related to nursing Dx., but also includes data not relate to Dx Doesn’t include all pertinent related data to nursing Dx. May include data not relating to Dx Not all relevant subjective & objective data is collected. There is an absence of the use of inquiry to collect info relevant to the individuals disease & circumstances. Outcomes statement is specific to pt. Dx. and contains all 4 measurable criteria Outcomes statement is specific to pt. Dx., but also includes data not related to Dx. Doesnt include all pertinent related data to the nursing Dx. May also include data not relating to the patient Dx. It only contains two of the 4 measurable criteria. Doesnt include many of the needed measurable criteria. Outcome is not specific to the patient. 9/26/21, 12:42 PM Rubric Assessment - NUR4641-03:Adult Health Nursing II (2021 Fall Term 1)-14133 - Resurrection University https://oakpoint.brightspace.com/d2l/lms/competencies/rubric/rubrics_assessment_results.d2l?ou=16386&evalObjectId=30497&evalObjectType=1&us… 5/6 Criteria Good 4 points Fair 3 points Poor 2 points Incomplete 0 points Criterion Score Interventions: Include interventions or nursing actions that directly relate to the patients goal; are specific in action, frequency and contain rationale. The number of interventions should be appropriate to help patient/family meet their goal / 4 Intervention portion contains an adequate number of interventions to help the patient/family meet their goal. The interventions are specific in action and frequency, and are also listed with rationales. Intervention portion contains an adequate number of interventions to help the patient/family meet their goal. The interventions may not be specific in action and frequency, and may not be labeled with or listed with rationales. Intervention portion doesnt include an adequate number of interventions to help the patient/family meet their goal. May also not be specific, labeled or listed with rationales. Inappropriate interventions are included in the plan of care, interventions are not realistic & appropriate to the patients current status. 9/26/21, 12:42 PM Rubric Assessment - NUR4641-03:Adult Health Nursing II (2021 Fall Term 1)-14133 - Resurrection University https://oakpoint.brightspace.com/d2l/lms/competencies/rubric/rubrics_assessment_results.d2l?ou=16386&evalObjectId=30497&evalObjectType=1&us… 6/6 Total / 40 Overall Score Criteria Good 4 points Fair 3 points Poor 2 points Incomplete 0 points Criterion Score Evaluation: Includes all data that is listed as criteria in outcome statement. Based on this data, outcome is determined to be met, partially met, or not met. If is not met or partially met, plan of care is revised or continued and a new evaluation date / 4 Evaluation portion does contain data that is listed as criteria within the goal statement. Does describe the outcome as met, partially met, or not met, includes revision of plan of care, or new evaluation date/time. Evaluation portion does contain data that is listed as criteria within the outcome statement, but does not describe the goal as met, partially met, or not met. May not include a revision of plan of care, or new evaluation date/time. Evaluation portion does not contain data that is listed as criteria in the outcome statement. May also not describe goal as met, partially met, not met. May also not include revision or new evaluation date/time. Does not clearly evaluate if the outcome is met; evaluation is purely based on if interventions are applied to patients care. Level 4 11 points minimum Level 3 8 points minimum Level 2 5 points minimum Level 1 0 points minimum