NURS 201-3 Medical/Surgical Nursing Practice Theory: Case ...



NURS 201-3 Medical/Surgical Nursing Practice Theory: Case Study and Care PlanTrina SkinnerStenberg CollegeNURS 201-3K. Bagshaw April 28th, 2013NURS 201-3 Medical/Surgical Nursing Practice Theory: Case Study and Care PlanIDENTIFYING DATA AND GENERAL DESCRIPTIONName: A.K.D. Sex: F Race: Caucasian Culture: Canadian Relationship Status: MarriedAppearance and referral source: Admitted from home (resides with husband). Prior to admission for CVA able to perform ADL’s independently, able to mobilize independently (walk/transfer). Slightly underweight/ malnourished, well-adjusted, as per patient chart records. *CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESSReason for admission: L side Cerebral Vascular Accident (CVA/stroke), occult hip fracture (ruled out)Significant signs & symptoms: Loss of sensation entire R side of body, patient verbalized she was experiencing moderate pain in leg affected by stroke (Right leg). Unable to mobilize leg on stroke affected side, maintained use of R arm (minimal strength upon assessment), lack of coordination, patient reports difficulty swallowing, states she must “eat slowly” (AK.D., 2013).. Stresses & precipitating factors: Cardiovascular health compromised; History of Hypertension, Atrial Fibrillation, TIA’s.History of medication compliance & treatment program: Willingly took all prescribed medications, A.K.D. explained that during the week she would mobilize under supervision/care of physiotherapist. Patient was optimistic regarding discharge plan, although reluctant to mobilize with nursing staff (or myself); A.K.D. felt comfortable mobilizing exclusively with physiotherapist. I was able to convince patient to transfer from bed to Broda chair @ meal times.Medications:MedicationDoseRouteTime*Metoprolol (Lopressor/Betaloc)50 mg Lopressor25 mg. BetalocPO- BID09001700Levothyroxine (Synthoid)50 mcg/0.05 mgPO0900Atrovastatin (Lipitor)40 mgPO0900Felodipine ER (Plendil)10 mgPO0900Tramacet325 mg Acetaminophen/ 37.5 TramadolPO- TID090017002100Citalopram10 mgPO0900Baclofen100mgPO1700Ferrous fumerate (Palafer)300 mgPO2100*Warfarin (Coumadin)Pharmacist Managed1 Dose QDPO1600Pantoprazole Magnesium (Tecta)40 mgPO- BID unit stock09002100Risodronate (Actonel)35 mgPOQThursErgocalciferol (Ostoforte)50 000 Int. UnitPOQThursPAST MEDICAL HISTORYA.K.D. has a fairly extensive medical history, affecting all body systems. Past and current medical conditions include: Atrial fibrillation, Transient Ischemic Attack’s (TIA’s), Hypothyroidism, Glaucoma, Heart Disease- Class I Corotid artery disease, Osteoporosis, Hypertension, Cerebral Vascular Accident- CVA (Right side)SURGICAL HISTORYA.K.D.’s surgical history includes a bowel resection, partial hysterectomy CABG (Coronary Artery Bypass Graft surgery).ALLERGIESA.K.D. has been identified as having allergic reactions to both Codeine, and Sulpha drugs; specific reaction (not available). DISEASE PROCESS TEXTBOOK DESCRIPTION OF DISEASE PROCESS CLIENTS PRESENTATION OF DISEASE PROCESS Diagnosis: Cerebral Vascular Accident (CVA)Physician confirmed CVA had occurred Right side of brain (left side of body affected) post CT scanEtiology/Pathophysiology: CVA, or stroke (apoplexy) “is the sudden onset of weakness, numbness, paralysis, slurred speech, aphasia, problems with vision and other manifestations of a sudden interruption of blood flow to a particular area of the brain. The ischemic area involved determines the type of focal deficit that is seen in the patient” (ISC, 2012). A.K.D. was admitted following a fall at her home on the premise of a possible occult hip fracture and CVA. Following an X-ray, the possible hip fracture was ruled out. A CT scan revealed evidence that a stroke had occurred“Computerized tomography (CT) scan. Brain imaging plays a key role in determining if you're having a stroke and what type of stroke you may be experiencing. A CT scan uses a series of X-rays to create a detailed image of your brain. A CT scan can show a brain hemorrhage, tumors, strokes and other conditions” (MayoClinic, 2012).Clinical Signs and Symptoms: Trouble with walking. You may stumble or experience sudden dizziness, loss of balance or loss of coordination.Trouble with speaking and understanding. You may experience confusion. You may slur your words or have difficulty understanding speech.Paralysis or numbness of the face, arm or leg. You may develop sudden numbness, weakness or paralysis in your face, arm or leg, especially on one side of your body. Try to raise both your arms over your head at the same time. If one arm begins to fall, you may be having a stroke. Similarly, one side of your mouth may droop when you try to smile.Trouble with seeing in one or both eyes. You may suddenly have blurred or blackened vision in one or both eyes, or you may see double.Headache. A sudden, severe headache, which may be accompanied by vomiting, dizziness or altered consciousness, may indicate you're having a stroke.The patient exhibited signs and symptoms such that included numbness and tingling on left side of body. It was yet to be determined if permanent hemi paralysis would ensue. The upper left quadrant of A.K.D.’s body (including arm and face) were unaffected by visual assessment. The patient stated that she could not mobilize her leg and was experiencing loss of sensation as well as occasional sharp pains, particularly on movement/when repositioned. This patient was experiencing dysphagia (difficulty swallowing), which she was aware of and explained to me that she would require my assistance with feeding, although she had use of both upper extremities, A.K.D. explained that she was experiencing systemic weakness. I assisted with feeding, and did so at a very slow pace, as this patient was at high risk for choking/aspiration. Patient was able to squeeze my hands with minimal strength and lift her arms slightly for only a few seconds. Patient denied any visual disturbance/effect and complained frequently of headaches and dizziness(Mayoclinic, 2010)LAB RESULTSThe following is a panel of laboratory results that outlines abnormal values in comparison to levels that are of ‘normal range’. All lab tests were performed by laboratory technicians on site @ Nanaimo Regional General Hospital. The following information is extracted from VIHA’s online charting system, on operating system Cerner (VIHA Intranet).*International Normalized RatioLab TestPatient’s Value Normal RangeNeutrophils6.59-High2.00-6.00Lymphocytes0.87-Low120-150Monocytes0.81-Low0.35-0.45*INR5.8-High0.9-1.1Chloride96 -Low96-106 Sodium132-Low135-145Urea Level11.5-High3.0-7.5NURSING PHYSICAL ASSESSMENT Upon introducing myself to A.K.D., I assessed her level of orientation, she is oriented x 3 (to person, place, and time). Upon visual assessment I noted that this patient was extremely thin with a distinct lack of muscle tone. Her pallor was pale, her affect was congruent with her mood and she was very pleasant to interact with. I noted her pupils were equal in diameter and reactive and her lips were dry and chapped, which indicated that she may be dehydrated. I then assessed A.K.D’s vitals, the first set I recorded @ 0800 hrs are as follows: BP 149/87, HR 81, Oxygen sats. 98%, Temp. 37.0.Upon auscultation of heart and lungs, I noted a distinct irregular heart beat. Her lungs were clear, no adventitious sounds in all lobes. A.K.D. presented as somewhat nervous in regards to certain aspects of her care. For instance she was concerned that Tecta be administered 30 minutes ac breakfast to reduce symptoms of GERD. Capillary refill was good, skin was think and fragile. Bowel sounds present in all four quadrants and A.K.D.’s abdomen was soft upon palpitation. IV site was absent of redness, swelling, & pain. Patient stated that on a pain scale of 1-10 (1 being no pain, and 10 being the worst pain she had experienced in her life) A.K.D. stated her pain level was a 4. The pain she described was sharp and intermittent occurring on her entire left side. She explained that she was thirsty and her mouth was dry, but she had difficulty swallowing and required my assistance. Skin was dry and intact, my only concern was a reddened area on her right heel which she said was painful when pressure applied to the area. A.K.D. also presented with slight pedal edema bilaterally. A.K.D. was able to grip my hands with hers with a moderate level of strength. While assessing this patient’s ROM (range of motion) it was clear that attempting to mobilize the patient (without use of the overhead lift) would not be safe as she was unable to raise her legs or resist the pressure of my hands against her feet. Pedal pulse was palpable bilateral. This patient was underweight and undernourished as per clinical manifestations noted throughout assessment phase. Patient was clean, comfortable, dry, & safe when released from my care. well doneTREATMENT PLANThe current treatment plan on the unit is to promote comfort, and pain management for this patient. One goal is to decrease incidence of heartburn/nausea in order to increase adequate nutrition, promote client ability to feed herself. The main focus/goal in this case is to have A.K.D. mobilize and restore patient to equal or greater level of functioning prior to admission to hospital. Patient is transferred from bed to chair pc breakfast- pc lunch. Encourage patient to mobilize and perform ROM’s as much as possible, promote increased input to increase strength to the point A.K.D. can return home safely. Medication education is necessary, as this patient is on a number of medications, several *high alert cardiac meds that require compliance and comprehension of what these medications are for. AAT (Activities as tolerated), presently movement of muscles and joints and encouragement to gradually restore ability to perform own personal care as much as possible. A.K.D. must be educated on the importance of mobilization as the primary factor in her recovery. A.K.D. will also receive education upon discharge in terms of outpatient treatment to obtain highest quality level of health and wellness. Patient will continue to receive treatment from resident physiotherapist. Patient’s emotional state is pleasant and she maintains an optimistic attitude regarding her current state of health and continued recovery. The client is interested in which medications she is prescribed and the function of each prior to administration. In terms of receptiveness with plan of care, patient is reluctant in terms of proceeding forward with efforts to mobilize, she voices some concern about the rate at which she is being encouraged to mobilize. Patient also expresses some fear of further injury if she attempts to mobilize; patient’s concerns are validated and patient education regarding the necessity of obtaining adequate nutrition and mobilizing daily in order to be discharged was implemented. TEACHING AND DISCHARGE PLANIn regards to necessary patient teaching upon discharge, A.K.D. must have her medication regime explained in a way that we are able to verify understanding. Perhaps meds can be prepared in blister packs labeled and if the patient finds the medication regime overwhelming; A.K.D. must also be encouraged to seek clarification and address any concerns she may have prior to or regarding discharge. The plan is for A.K.D. to be discharged and return home with the assistance of her husband following the ability to mobilize safely and achieve a safe level of intake food & fluids. The patient will be discharged as per physician’s order. Whatever follow up treatment and medication will be presented and explained with assurance that patient or next of kin understand in order to enhance the likelihood of compliance. Outpatient treatment and community resources will be provided upon discharge, and follow-up with GP or specialists as per physician’s orders. STUDENT REFLECTION UPON WRITING CASE STUDYOver the course of the few days I worked with A.K.D. I enjoyed the interaction I shared with her. She was consistently pleasant and maintained a very positive attitude. Upon further studying of her past medical history, I became very humbled and touched by her sunny disposition in spite of all the major health concerns she is faced with. Her smile is radiant, and the time that we spent communicating throughout provision of care and whenever I had a few free minutes, I felt very grateful for my health and all the loving support and opportunity I have in my life. Working with A.K.D. helped remind me how crucial it is to live in the present. I noticed I had quite an emotional response to caring for this client, as it was reminiscent of my former work as an HCA and the patients I had developed therapeutic relationships with. After working with more patients who have been affected by CVA than I can recall, I felt a familiar anxiety and slight fear arise in me, as after caring for a large population of older adults who have suffered strokes, I developed a fear of one day suffering a stroke myself. I am extremely empathetic for patients who experience TIA’s or strokes as the thought of losing my ability to communicate and persistent numbness/tingling, let alone full on hemi paralysis. I certainly feel grateful that I made drastic lifestyle changes prior to the start of the RDPN program, giving up smoking, drinking alcohol, healthy/clean eating, and regular exercise and meditation/yoga practice. I would like to work to reduce the risks of developing cardiovascular problems as much as possible. Following this experience, I am more committed to maintain my current, as well as broaden my healthy lifestyle choices in the future. excellent reflection.ReferencesJaap H. Buurke, Anand V. Nene, Gert Kwakkel, Victorien Erren-Wolters, Maarten J. IJzerman & Hermie J. Hermens (2008) Recovery of Gait After Stroke: What Changes? Neurorehabil Neural Repair. 22: 676 DOI: 10.1177/1545968308317972Kim, T. Y., Lang, N. M., Berg, K., Weaver, C., Murphy, J., & Ela, S. (2007). Clinician adoption patterns and patient outcome results in use of evidence-based nursing plans of care. AMIA 2007 Symposium Proceedings, 423-427.Lewis, S.L., Heitkemper, M.M.Dirksen, S.R., Bucher, L., and O’Brien, P.G. (2010).? Medical-Surgical Nursing in Canada (Canadian 2nd Ed.). Toronto, ON: Elsevier (2012). Stroke symptoms. Retrieved from , A. E., Doran, D. M., McGillis Hall, L., O’Brien Pallas, L., Pringle, D., Cranley, L. A., & Tu, J. V. (2006). Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing,57(1), 32-44.10.1111/j.1365-2648.2006.04084.xWilliams, L. (2007). The fluid and electrolyte balancing act. Nursing Homes: Long Term Care Management, 56(12), 31-33. Retrieved from DiagnosisDesired OutcomesInterventions (I)-Independent(C) - CollaborativeRationale & APA ReferenceEvaluation of InterventionsNDX: (Problem)Impaired skin integrityR/T: (etiology/factor):Related to inability to mobilize or reposition selfAEB: (s/sx; defining characteristics)1. Inability to turn from back onto either side without assistance2. Reddened area on left heel as a result of pressure (bed rest)3. Inability to mobilize transfer from bed*If ‘risk for’ would exhibit:Decubitus ulcers, reddened/ open/blistered areas of skin over bony prominences, maceration of skinNDX: ProblemDeficient fluid volume, risk forR/T: (etiology/factor):Related to Insufficient fluid intake, compromised cardiac healthAEB: (s/sx; defining characteristics)1. Abnormal levels of sodium, chloride as evidenced in lab values2. Presence of pedal edema, bilateral3. Decreased intake/output related to difficulty swallowing*If ‘risk for’ would exhibit:Poor skin turgorElectrolyte imbalancesPoor muscle toneNDX: ProblemMobility, impaired physicalR/T: (etiology/factor):Related to Immobility as result of CVAAEB: (s/sx; defining characteristics)1. Patient is incapable of reposition/transferindependently2. Patient’s lack of confidence/initiative to attempt to mobilize3. Pain and discomfort verbalized upon reposition/transferGoal (Reversal of Problem)Patient’s skin integrity is no longer compromised by when *Client will (list measurable outcomes; reverse signs and symptoms)1. No presence of redness over bony prominences2. No evidence of maceration of skin prone to moisture (perineal area)3. Increased mobility to improve circulation/systemic blood flow maintaining skin integrity by means of adequate tissue perfusion (integumentary system is nourished)Evaluation of Outcomes (address each outcome)1. Patient’s skin is intact2.Healthy pallor3. No evidence of signs related to skin breakdownGoal (Reversal of Problem)Patient will achieve sufficient fluid volume by dischargeClient will (list measurable outcomes; reverse signs and symptoms)1. Lab values RE: electrolyte balance will return to within normal range2. Exhibit no edema3. Establish consistent intake/output fluid volumeEvaluation of Outcomes (address each outcome)1. Resolution of dysphagia2. Increased muscle tone3. Patient records indicate adequate intake/outputGoal (Reversal of Problem)Patient is rehabilitated and able to mobilize independently (mobility aides prn, i.e. walker) following dischargeClient will (list measurable outcomes; reverse signs and symptoms)1. Patient will continue to work with PT upon discharge RE: mobility2. Patient will perform ROM’s & AAT upon discharge3. Patient will be made aware of and establish contact with community resources RE: heart & strokeEvaluation of Outcomes (address each outcome)1. Patient practices healthy lifestyle habits in relation to her co-morbid diagnoses2. Patient maintains appropriate diet in relation to health status upon dischargeN-1 Assess skin daily for signs of irritation so that early treatment can provided (C) N-1 Wash and dry skin thoroughly, paying special attention to areas @ higher risk for breakdown (i.e. groins/abdominal skin folds) where bacteria can accumulate(C)N-2 Promote independence in terms of encouraging patient to wash and dry herself thoroughly as per instruction (I)N-3 Implement patient education regarding significance of properly drying and moisturizing skin (C)N-4 Encourage patient to perform ROM exercise/AAT in order to retain ability to reposition/mobilize self (I)N6- Turn Q2h as preventative measure (decubitus ulcers)N7- protect bony prominences with pillows/padding & elevate heels off the bed (no direct pressure applied)N-1 Request swallowing assessment to be performed by OT (C)N-2 If patient is unable to swallow to obtain adequate fluid/electrolyte balance; IV fluids will be ordered (physician) and administered by nursing staff (C)N-3 Monitor intake/output as accurately as possible each shiftN-4 Elevate feet (above heart)N-5 Patient on cardiac diet N-6 Assess vitals QID, with special attention to HR, BPN1- Establish schedule with PT to assist patient with rehabilitation (C)N2- Encourage patient to mobilize as tolerable to restore patient to highest level of health possible (C) N3- Teach client significance of ROM’s/ perform ROM’s daily (C)N4- Address and validate patient’s concerns/anxiety RE: rehabilitation, regaining mobility (C)N5- Promote independence as every opportunity, encourage patient to do as much for herself as possible in preparation for dischargeN6- Administer all patient medications as per physician’s ordersEducate patient on risks associated with skin breakdown in order to increase likelihood patient will participate in own care RE: maintenance of skin integrityExplain process of development of decubitus ulcers Encourage patient to regain independence or perform as much personal care as possible; to increase likelihood of patient continuing to care for skin upon discharge; ability to perform own personal care will expedite scheduled dischargeReposition patient frequently (Q2h) to avoid extended periods of pressure on any area of the body- which decreases circulation of vital nutrients to support/maintain healthy skinPillows or other protective aids will promote prevention of skin breakdownROM’s will help to promote healthy circulation to ensure skin is nourished(Tourangeau, 2006)R1- If patient is unable to swallow, initiative must be taken to ensure sufficient fluid volumeR2- If patient is unable to obtain fluid PO, hydration via IV may be necessaryR3- An accurate account of patient’s fluid volume intake and output will demonstrate evidence of adequate hydration/fluid-electrolyte balancesR4- Elevating feet/lower legs above heart level will function to prevent/reduce edemaR5- As the patient has significant cardiac issues, a diet that takes these comorbid disorders into account will function to increase likelihood of maintaining adequate nutrition/fluid balance(Williams, 2007)(Lewis, et al., 2010)R1- Patient feels comfortable working with PT, PT specialize in rehabilitation of physical health impairmentR2- Promote restoration of mobility to highest level possible (post-CVA)R3- ROM’s are extremely important in maintaining health in the elderly and bed ridden patient, in order to promote/maintain mobility & circulation. All body systems require movement/exercise of some sort to function adequatelyR4- Patient must regain ability to provide care for herself or arrange provision of care upon discharge from hospitalR(5)- Patient’s compliance with medication regime and established enables proper management of co-morbid conditions(Jaap, 2008)(Lewis, et al., 2010)Patient is washing and drying herself safely & effectivelyPatient makes effort to reposition herself as per her ability; or requests assistance from nurse to reposition if in same side-lying or supine position for extended period of timePatient understands the relationship between mobility and impaired skin integrity & therefore makes effort to mobilize as much as possible in order to avoid constant pressure on skin and to promote circulationPatient summarizes knowledge obtained regarding the necessity of proper skin care in order to allow nurse to check for understandingE1- Patient’s ability to swallow is regained or alternate means of nutrition is undertaken (IV, nasogastric tube, parenteral feeding) if necessaryE2- Patient will monitor fluid intake/output; notify healthcare provider if inadequate amounts/patient will identify signs of fluid deficiency as per nursing education/teachingE-3 Patient will continue to elevate feet/lower legs at rest. Consider need for TED stockings with physicianE-4 Patient will adhere to ‘heart healthy’ diet and follow guidelines of patient teaching prior to discharge RE: nutritionE1- Patient is able to mobilize independently upon dischargeE2- Mobility aides are provided and implemented with proper patient teaching if necessaryE3- Patient performs ROM’s daily and understands significance of doing suchE4- Patient maintains healthy diet that takes cardiac issues into considerationE5- Patient is educated on signs/symptoms of CVA and is informed on when to contact health care providerE6- Patient refrains from any risk factors associated with CVA and cardiovascular systemE7- Patient is made aware of and establishes/maintains communication with community resources i.e. heart and stroke foundationPSY 201-3 Med/Surg TheoryCase Study and Care Plan (20%)Mark AssignedMark EarnedCommentsAPA Format (5%)11Structure and Scholarly Presentation (15%)Well structured paper, logically & coherently developed content11Reference list reflecting depth and breadth of reading11Spelling, punctuation and grammar11Content and Care Plans (80%)Accuracy and depth of head to toe assessment, treatment and teaching plan and other pertinent information66Demonstrated critical thinking & reflection both throughout paper and in student reflection section22Sound rationale for ideas and conclusions22Thoughts & opinions substantiated with relevant & current sources12Care plans concise, patient focused with clear diagnoses, interventions, rationales and evaluation54.5See comments.Total2019.5Well done. ................
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