NURSING CARE PREPARATION - Yuliya Whidden e-portfolio



NURSING CARE PREPARATIONStudent Name: Yuliya Whidden Date of Care: 02/27/2014Unit/Room Number: 337 01Age: 89Gender: FErikson’s Developmental Level: Integrity vs. despairDate of Admission: 02/21/14Ethnic/Cultural Preferences: noAllergies: Sulfonamide antibioticsCode Status: DNRPrimary Diagnosis: Status post hip fractureCo-morbidities:Congestive heart failure with ejection fraction per 20%hypertension hyperlypidemialeft bundle branch blockcoronary artery diseaseparoxysmal atrial fibrillationanxietyrecent right hip surgeryDischarge Plan (add day of clinical): discharge to a nursing home for skilled carePreliminary Integrated Pathophysiology primary diagnosis (what is going on with your client at the cellular level for the health condition). Explain how your clients’ primary diagnosis, co-morbidities, medications and labs interrelate. 1-3 page APA formatted. Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any assessment/elaboration should be made on the assessment sheet):Diet (Type): mechanical soft, routineIV (Fluid type, rate, access type): peripheral IV, right forearm 18G, saline lockI&O (MD order/Nursing Order/Frequency): Nursing order, every shiftCBG (Yes/No, frequency): noFall Risk/Safety Precautions (Yes/No): Yes, high risk for fallsActivity (What is the patient activity level): nonambulatory, needs assistance for ADLWound Care (Yes/No): Aquacel in place (right hip)Oxygen (Yes/No, Delivery method, how much): noDrains (Yes/No, Type): noLast BM: 02/26/2014Other Tubes: noASSESSMENTS(Include Subjective & Objective Data)Integumentary:Skin color on covered area is slightly jaundiced, warm, and dry. Good skin turgor below clavicle. On the left arm a nevus black color 0.7 x 0.7 cm with regular borders, at the middle of the back whitish raised plaque 1.7 x 1.7 cm. Right arm, elbow, and hand bruised, IV site on the right forearm, dressing clear, dry, intact. Nails on upper and lower extremities thick and yellow no clubbing. At the right hip stapled scar 15 cm long, erythematous at the edges, no swelling. Blanchable erythema at the lower back about 5 cm.Head and Neck:The skull is normocephalic/ atraumatic. Hair with average texture. Trachea midline. Neck supple, thyroid not palpable. Lymph nodes not palpable, not tender. Full ROM of neckEyes/Ear/Nose/Throat:Sclera white, conjunctive light yellow. Has difficulty hearing, no drainage in ears. Nasal mucosa pink, septum midline; no sinus tenderness. Oral mucosa pink, tongue and lips dry, no observable lesions. Missing teeth, some teeth need repair.Thorax/Lungs:RR 18 bpm, shallow. Thorax expansion symmetrical with moderate kyphosis. No tenderness, masses, or lesions. Lungs clear to auscultation at all lung fields.Cardiac:The JVP not elevated. Heart rhythm regular, sounds S1 and S2, no murmurs or extra sounds at left and right bases, left lateral and apex areas. Pulses over left radial +2, dorsalis pedis +1, symmetrical, regular. No edema.Musculoskeletal:Normal spinal curvature. Joints and muscles symmetrical. Right arm spastic, ROM less than 30%. ROM right hip less than 50%, knees and foot – right dorsal flexion less than in left side. Full ROM in neck and torso. Muscle strength +3. For ambulating needs two assistants.Genitourinary:Incontinent in brief, voiding not painful. Urine yellow, without odor.Gastrointestinal:Abdominal is rounded, nontender to light palpation, no guarding. Bowel sounds every 5 sec on all four quadrants. Tympany on percussion. Neurological/Psychosocial Awake, alert. Impossible to evaluate orientation, does not verbally communicate, speech slurred. Cooperative, with good eye contact, smiling when satisfied, grimaced when needs help.Other (Include vital signs, weight): height 65 inches, weight 50 kg, BMI 18.34BP 149/71, pulse 62, RR18, T97.7, SpO2 97% at room airPain (chronic or acute): in operated site at the right hipPain management: replacement, ice, Norco 5/325 q4hCURRENT MEDICATIONSList ALL regularly scheduled and prn medications scheduled on your client.(Due morning of clinical)Generic & Trade NameClassifi-cationDose/Route/Rate if IVOnset/PeakIntended Action/Therapeutic use. Why is this client taking med?Adverse reactions (1 major side effect)Nursing Implications for this client. (No more than one)Fentanyl patchnarcotic analgetic12 mcg/hr 1 patch TD q72hO: 12-24 hPain of postsurgical sitedepressed respirationsPlace on nonirritated flat surface, rotate sites, assess for skin reaction (redness, swelling)Aspirin enteric coatedantiplatelet81 mg 1 tab daily POP: 15 min – 2hCerebrovascular DiseaseProlonged bleeding time Enteric-coated tablets should not be crushed or chewed. Observe for bleeding (blleding gums, bloody stools, cloudy or bloody urine, petechiae, ecchymoses)Polyethylene glycol 3350 powdlaxative17 gm=1 pack PO dailyO: 2-4 daysConstipationcramps, diarrheaMix in 8 oz liquid and drink dailySenna/ docusate 8.6/50laxative2 tab PO bidO: 6-10 hConstipationabdominal crampingContinued use may lead to dependence, monitor for BM, check last BMLorazepam inj (Atavan)antianxiety0.5 mg=0.25 ml IV Q8H PRN agitation for 7 daysO: 1-5 minAnxietysedationMonitor for anxiety relief. Supervise ambulation to prevent falling and injuryHydrocodone/APAP 5/325narcotic analgetic1 tab PO Q4H PRN painO: 10-20 minpainRespiratory depressionGive with food or milk to prevent GI irritation. max amount of APAP not more than 3g/ day.DIAGNOSTIC TESTINGInclude pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays, CT, MRI, U/S, etc.]NOTE: Adult values indicated. If client is newborn or elder, normal value range may be different.DateLab Test Normal ValuesPatient Values/Date of careInterpretation as related to Pathophysiology –cite reference & pg #02/26Sodium 135 – 145 mEq/L 139norma02/26Potassium 3.5 – 5.0 mEq/L4.2norma02/26Chloride 97-107 mEq/L107norma02/26Co2 23-29 mEq/L28norma02/26Glucose 75 – 110 mg/dL86norma02/26BUN 8-21 mg/dL19norma02/26Creatinine 0.5 – 1.2 mg/dL0.62norma02/26Calcium 8.2-10.2 mg/dL8.2 LMalnutrition, decreased absorbtion sp?of calcium in gastric in elderly clients (Corbett. J.V. &Banks A. D., 2013, p. 166)Phosphorus 2.5-4.5 mg/dLN/AN/A02/26Total Bilirubin 0.3-1.2 mg/dL1.3 HAny physical or physiological stress Malnutrition (Corbett. J.V. &Banks A. D., 2013, p. 261)02/26Total Protein 6.0-8.0 gm/dL5.6 LMalnutrition (Corbett. J.V. &Banks A. D., 2013, p. 233)02/26Albumin 3.4-4.8gm/dL2.7 LMalnutrition (Corbett. J.V. &Banks A. D., 2013, p. 233)02/26Globulin 2.1-3.2 gm/dl2.9normaCholesterol <200-240 mg/dLN/AN/A02/26Alk Phos 25-142 IU/L93norma02/26SGOT or AST 10 – 48 IU/L42normaLDH 70-185 IU/LN/AN/ACPK 38-174 IU/LN/AN/A02/26WBC 4.5 – 11.09.6norma02/26RBC male: 4.7-5.14 x 10 female: 4.2-4.87 x 103.72 LAnemia, associated with malnutrition or surgical blood loss (Corbett. J.V. &Banks A. D., 2013, p. 27)02/26HGB male: 12.6-17.4 g/dLfemale: 11.7-16.1 g/dL11.3 LAnemia, associated with malnutrition or surgical blood loss (Corbett. J.V. &Banks A. D., 2013, p. 32)02/26HCT male: 43-49% female: 38-44%33.4 LAnemia, associated with malnutrition or surgical blood loss (Corbett. J.V. &Banks A. D., 2013, p. 28)02/26MCV 85-95 fL90norma02/26MCH 28 – 32 Pg 30.3norma02/26MCHC 33-35 g/dL33.7norma02/26RDW 11.6-14.8%14.8norma02/26Platelet 150-450244normaOther:DIAGNOSTIC TESTINGDateUANormal RangeResultsInterpretation as related to Pathophysiology –cite reference & pg #02/21Color/Appearanceyellowyellownorma02/21pH5-98.0norma02/21Spec Gravity1.001-1.0351.005norma02/21Proteinnegnegnorma02/21Glucosenegnegnorma02/21Ketonesnegnegnorma02/21BloodnegnegnormaDateOther(PT, PTT, INR, ABG’s, Cultures, etc)Normal RangeResultsInterpretation as related to Pathophysiology –cite reference & pg #DateRadiologyResultsInterpretation as related to Pathophysiology –cite reference & pg #02/24X-Rays HipRight hip prosthesis with satisfactory alignment. No fracture identified. Mild atherosclerotic arterial calcification.Atherosclerosis02/25X-Rays AbdomenNo acute process identifiednorma02/26X-ray Femur rightRecent right hip surgery. Atherosclerotic diseaseAtherosclerosisTelemetryOther DAR NURSING PROGRESS NOTEInclude the same note that was written in the client record for the priority nursing diagnostic statement. Include the date/time/signature.Date/TimeAssessmentNursing note01/27/20141030Integumentary systemD: Patient restless, moaning, pointed at her brief.A: Patient was assessed, light blanchable erythema at the lower back about 5 cm. Patient was incontinent in her brief. Brief was changed, bed bath given, body lotion applied at the perineal area. Assisted with mouth care.1050R: Patient nonverbally expresses satisfaction of being helped (smiling and nodding). Patient left in bed in low Fowler position on the left site with pillow supporting the right hip, bed alarm on, eyes closed, call-light in reach, side rails up.-----------------------------------------------------------------------------------------------------------Yuliya Whidden, SN----------------------------------------------------------------------------------------------------------------01/27/2014 1050PATIENT CARE PLANPatient Information: Patient is an elderly 89 years old frail woman with dementia and post a bipolar hemiarthroplasty due to a right subcapital hip fracture done on February 17, 2014. Patient cannot communicate in any manner, but sometimes pointed at her hip and moaning. Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by (AEB).Problem #1 pain: right hip r/t tissue trauma and reflex muscle spasms associated with surgical trauma AEB patient communicate non-verbally about pain intensityDesired Outcome: display decreased or tolerable pain AEB relaxed behavior, not moaning in 30 minutes after oral pain medication and during the shiftNursing InterventionsClient Response to Intervention1. Assess pain by non-verbal presentations, changing vital signs and emotions every 2 hours1. Patient did not communicate verbally, but pointed at her right hip and grimaced, moaned, and cried. Vital signs did not changed.2. Administer analgesics according to order to alleviate pain before care activities.2. Norco administered q4h, in 30 min after administration patient slept soundly, breath not compromised. Awaken denied pain. 3. Provide emotional support and therapeutic touch to refocus attention and enhance coping abilities3. Patient responded at emotional support and therapeutic tough by smiling and being calm and satisfied.Evaluation (evaluate goal & interventions, what worked/what didn’t, what would you adapt if needed): Interventions were effective as patient could express her pain, even so non-verbally. Analgesic therapy was effective AEB patient denied pain after administering Norco. Also emotional support and therapeutic touch were helpful AEB patient smiled and nodded, responding at the question about her feelings.Problem #2 Impaired skin integrity r/t disruption of tissue associated with surgical procedure AEB presence of surgical incision at the right hip redness on lumbar area noted with pericareDesired Outcome: will demonstrate skin integrity free of surrounding skin erythema, incision sited approximated, no further breakdownNursing InterventionsClient Response to Intervention1. Assess operated site for color changes, redness, swelling, warm, pain (signs of infection) once during the shift1. Incision 15 cm long, stapled, has erythema at the edges, no swelling.2. Do not reposition client on the site of skin impairment while reposition client every 2 hours during the shift2. Patient was repositioned from the back to her left site at least every 2 hours during the shift and she set in the chair for 1 hour during the shift3. Protect wound from urinary and fecal contamination during the shift3. Patient was wearing brief that was changed every 3 hours during the shift. Surgical site kept intact.Evaluation: Interventions were effective AEB no swelling and no surrounding skin erythema. Repositioning the patient from the surgical site and keeping it from contamination prevented further breakdown of the wound.Problem #3 Chronic confusion r/t neurological changes secondary to dementia AEB decrease attention span and inappropriate or lack of responsesDesired Outcome: will respond to visual and auditory cues during the shiftNursing InterventionsClient Response to Intervention1. Provide calm environment, eliminate extraneous noise/ stimuli during the shift1. Patient was able to have an uninterrupted rest twice during the shift2. Prepare for interaction with eye contact and touch, as better understanding will decrease confusion 2. Patient was able to interact with eye contact and emotions, positively reacted at touch.3. Provide opportunity for physical activity at least once during the shift3. With emotional support and assistance was able to sit in a chair, do some exercises that allowed her to stay active and communicate more clearly about her needs.Evaluation: Interactions were effective AEB patient was able to be periodically active and periodically have a rest. Emotional support and touch gave her opportunity to clearly express her needs and respond to some activities.Hip fractureYuliya WhiddenSouthwestern Oregon Community College My Patient (introduce your patient or your disease) Patient is an alderly 89 years old frail woman with dementia and post a bipolar hemiarthroplasty due to a right subcapital hip fracture done on February 17, 2014. Patient cannot communicate in any manner, but sometimes pointed at her hip and moaning.Diagnosis at a Cellular LevelHip fracture is the most common injury in older adults and one of the most frequently seen injures in any health care setting or community. It has a high mortality rate as a result of multiple complications related to surgery, depression, and prolonged immobility (Ignatavicius &Workman, 2013). Co-morbidities, Medications and Lab (and how they reflect/interact on the disease)Patient has decreased level of serum calcium that may be related to a lack of calcium intake that existed in many years (Corbett. J.V. &Banks A. D., 2013). Also malnutrition that includes a lack of vitamin D and protein (the patient has hypoproteinemia and hypoalbuminemia) eventually causes a lowered serum calcium. Osteoporosis is the biggest risk factors for hip fractures. This disease weakens the upper femur, breaks, and then causes the person to fall (Ignatavicius &Workman, 2013). Decreased hemoglobin, hematocrite, and RBC could cause weakness and fatigue, predispose the person to infection and decreased wound healing (Corbett. J.V. &Banks A. D., 2013). TreatmentsThe treatment of choice is surgical repair, when possible, to reduce pain and allow the older patient to be out of bed and ambulatory. After a hip repair, older adults frequently experience acute confusion, or delirium. These patients should be monitored frequently to prevent falls. The patients should begins ambulating with assistance the day after surgery to prevent complications associated with immobility (pressure ulcers, atelectasis, venous thromboembolism). Early movement and ambulation also decrease the chance of infection and increase surgical site healing. Special considerations for the patients having a hip repair also include careful inspection of skin including area of pressure, especially the heels. Also it is important to prevent venous thromboembolism by using sequential compression devices and/or antiembolism stockings (Ignatavicius &Workman, 2013). ConclusionThe expected outcomes for patient after surgical hip arthroplasty are that she will achieve pain control to acceptable for the patient level and will move independently or with assistive device. However, older adults sometimes cannot provide adequate response to a pain; therefore the nurse should advocate for the patient and watch for non-verbal descriptors like grimacing, furrowed brow, moaning, guarded or stiffened posture or yelling out to validate the presence of pain (Ignatavicius &Workman, 2013). Physiologic signs that may indicate pain, such as elevated blood pressure or rapid pulse, may be present as well. However the absence of behavioral or physiologic cues does not mean that pain is absent. When in doubt, the best course is to administer pain medication and evaluate the patient's response. Fink and Gates (2001) offer recommendations regarding the assessment and treatment of pain in nonverbal patients.Ascertain if the patient has a condition that might cause pain.Determine whether the patient has been treated for pain before, and if so, which treatment regimen was most effective.Attempt to obtain nonverbal feedback from the patient to signal the presence of pain (such as head nodding or eye movements).Ascertain the behaviors the patient usually exhibits when in pain. (This information may need to be obtained from family, friends, or other health care providers.)If there are signs of acute pain or reasons to suspect its presence, treat with analgesics, nonpharmacologic interventions, or both.Continue any pharmacologic and nonpharmacologic interventions that appear to result in pain relief.If a behavioral cue persists or intensifies, rule out other causes (such as delirium, adverse effects of treatment, or accumulation of drug metabolites) and focus treatment on the known or suspected cause.Assess family members' and primary caregivers' interpretations of the patient's behavior. If they believe the patient is still in pain, ask why.References Ignatavicius, D.D., & Workman, M.L. (2013). Medical - surgical nursing: Patient-centered collaborative care (7th ed.). MO: Saunders Elsevier.Corbett J.V., Banks A.D. (2013). Laboratory tests and diagnostic procedures: with nursing diagnoses (8th ed.). Pearson Education, New Jersey. Fink R, Gates R. (2001) Pain assessment. In: Ferrell B, Coyle N, editors.?Textbook of palliative nursing.?Oxford: Oxford University Press. ................
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