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Gerontology Process PaperErin BradleyKent State University at StarkClient ProfileDH, a 93-year-old Caucasian female, was admitted to the facility with right lower leg cellulitis. Her secondary diagnoses include atrial fibrillation, hypothyroidism, osteoporosis, and glaucoma. DH is 62 inches tall and states that she weighs 108 pounds, or 49.09 kilograms. DH was previously employed by a printing company in Canton where she worked as an accountant for over 50 years. DH states that her husband had passed away several years ago and she had been living independently until only recently. Prior to entering the facility, she was abiding with her daughter’s family who lives near the Canton area. DH states that she is Protestant. She is allergic to aspirin and Dilaudid. DH is a Do Not Resuscitate-Comfort Care Arrest patient. Past Medical & Surgical HistoryDH has a history of osteoporosis, which ultimately led to the pathologic fracture of the neck of her right femur and a total right hip arthroplasty in 2011. DH states that her fracture was the reason she began living with her daughter after she was discharged from the rehabilitation facility. DH has a history of hypothyroidism that she states is well maintained by her current regimen of thyroid hormones. She also stated that she was diagnosed with glaucoma in 2008 and is on a strict regimen of ophthalmic medication to alleviate symptoms. Lastly, DH has a history of paroxysmal atrial fibrillation that occurs randomly without any known cause. Medical DiagnosesCellulitisDefinition: “A skin infection that extends into the deeper dermis and subcutaneous tissues and causes deep, red erythema without sharp borders and that spreads widely through tissue spaces” (Black & Hawks, 2009, p. 1225).Pathophysiology: Streptococcus pyogenes is usually the cause of this infection. Older patients may be at more risk for cellulitis with the presence of wounds or ulcers, malnutrition, steroid therapy, or a history of diabetes (Black and Hawks, 2009).Signs and Symptoms: Skin may appear edematous, erythematous, nodular, and tender. Sometimes they organism that causes the skin infection can cause other manifestations, such as high fever, confusion, tachycardia, and hypotension (Black and Hawks, 2009).Diagnosis: Wound specimen for culture and sensitivity testing is performed to determine the cause of infection and proper antibiotics treatment (Black and Hawks, 2009).Treatment: IV and/or oral antibiotics that are effective against streptococci and S. aureus. Soaks can be used to reduce inflammation and edema (Black and Hawks, 2009). OsteoporosisDefinition: A systemic skeletal disorder that leads to compromised bone strength and increased risk for skeletal fracture (Black and Hawks, 2009). Pathophysiology: Fractures related to osteoporosis occur when the bone encounters weight greater than what it can sustain. Post-menopausal Caucasian women are at a higher risk for osteoporosis, but other factors such as medication us (corticosteroids, thyroid hormones, anticonvulsants, and furosemides) and underlying medical conditions, like anorexia nervosa, Cushing’s syndrome, and hyperparathyroidism, place patients at risk (Black and Hawks, 2009). Signs and Symptoms: Shortened stature, kyphosis, and bone loss in the mandible leading to loss of teeth or poorly fitting dentures (Black and Hawks, 2009). Diagnosis: Diagnosis of osteoporosis is generally made after a fracture has occurred. Bone mineral density (BMD), a value of bone density that is expected for a person’s age and gender, can be measured using full-table dual-energy x-ray absorptiometry (DXA) (Black and Hawks, 2009).Treatment: Osteoporosis is preventable. Increasing calcium and Vitamin D intake as early as age 10 for females can help prevent osteoporosis. 1200 milligrams of calcium per day is recommended for patients above the age of 70. Weight-bearing exercise is also a good way to increase bone mass. (Black and Hawks, 2009).HypertensionDefinition: “Persistent elevation of the systolic blood pressure (SBP) at a level of 140mm Hg or higher and diastolic blood pressure (DBP) at a level of 90mm Hg or higher” (Black & Hawks, 2009, p. 1290). Pathophysiology: Because the cause of primary hypertension is not well known, hypertension without a cause is labeled accordingly (Tabloski, 2010). Secondary hypertension is related to problems that affect the kidneys, interfering with “sodium excretion, renal perfusion, or the renin-angiotensin-aldosterone mechanism, leading to an elevation in blood pressure over time” (Black & Hawks, 2009, p. 1293). Signs and Symptoms: When left untreated, hypertension may cause headache, dizziness, fatigue, flushing, palpitations, visual changes, and nosebleed (Black and Hawks, 2009). Diagnosis: A diagnosis of hypertension is made by taking two blood pressure readings while the patient is seated and at least two minutes apart. This must be completed after at least five minutes of rest (Black & Hawks, 2009). These readings must have an average of 140/90 or higher in order for hypertension to be diagnosed. Specific studies to diagnose hypertension include: complete blood count (CBC), urinalysis, chest x-ray, fasting blood glucose, serum levels of potassium and sodium, serum cholesterol, blood urea nitrogen (BUN), serum creatinine, and electrocardiogram (EKG) (Black & Hawks, 2009).Treatment: Antihypertensive medications include ACE-inhibitors, diuretics, beta blockers, calcium channel blockers, vasodilators, and angiotensin receptor blockers. Lifestyle modifications such as weight reduction, sodium restrictions, dietary fat modification, exercise, alcohol restriction, caffeine restriction, relaxation techniques, smoking cessation, potassium supplementation, and pharmacologic interventions are stressed as well. (Black and Hawks, 2009). Paroxysmal Atrial FibrillationDefinition: Atrial fibrillation, or A Fib, is a supraventricular dysrhythmia that is characterized by rapid depolarization of the atria from a re-entrant pathway (Black & Hawks, 2009).Pathophysiology: Impulses of 350 to 600 beats per minute may occur at random, not allowing the atrium to fully recover from one depolarization to the next. These chaotic impulses lead to ineffective atrial contraction, which in turn lead to a decrease in cardiac output by as much as 30% (Black & Hawks, 2009).Signs and Symptoms: As cardiac output continues to decline, dyspnea, angina pectoris, heart failure, and shock may result (Black & Hawks, 2009).Diagnosis: A pulse deficit between apical and radial pulses may be palpated. An electrocardiogram is preferred diagnostic test to reveal A Fib. Examination of the test reveals unidentifiable P waves and irregular ventricular rhythm (Black & Hawks, 2009). Treatment: Anticoagulation, i.e. heparin or oral warfarin are started to reduce the risk of thromboembolism. Aspirin may be started for those patients who have a fall risk or a history of hemorrhage or gastrointestinal bleeding. Converting A Fib. Back to normal sinus rhythm can be achieved by cardioversion or medications. Diltiazem, verapamil, beta-blockers, or digoxin will control heart rate (Black & Hawks, 2009). GlaucomaDefinition: “Glaucoma comprises a group of ocular disorders characterized by increased intraocular pressure, optic nerve atrophy, and visual field loss” (Black & Hawks, 2009, p. 1699). Pathophysiology: Intraocular pressure is determined by the amount of humor production in the ciliary body and the resistance to outflow of aqueous humor from the eye. An increase in intraocular pressure can occur from an obstruction of the flow of aqueous humor or a hyperproduction of aqueous humor. As the pressure increases, blood supply to the optic nerve and retina are inhibited and tissues within the eye become ischemic (Black & Hawks, 2009).Signs and Symptoms: Severe eye pain, vision loss and blurred vision, rainbow colored halos around lights, nausea and vomiting may occur (Black & Hawks, 2009). Diagnosis: Ophthalmoscope examination may show atrophy or cupping of the optic nerve. Visual field examination is tested to discover the amount of vision loss (Black & Hawks, 2009).Treatment: Increasing the aqueous humor flow can reduce intraocular pressure. This can be achieved by constricting the pupils using epinephrine or topical miotics. Topical beta-blockers or alpha-adrenergic agents will reduce the production or humor (Black & Hawks, 2009). Concept Care MapSee Concept Care Map.Lab Values/Diagnostic Test ResultsCBC w/o Diff (1/16/12):WBC: 16.4 (H)RBC: 3.88 (L)Hgb: 11.9 (L)Hct: 36.2Platelets: 285T4 Total: 8.31TSH: 7.05 (H)1/6/12: Venous duplex of right lower leg extremity: no echogenic filling was seen in vessels evaluated; swelling, redness noted in calf. Impression: no acute osseous abnormality, Conceptual Care MapStudent Name __Erin Bradley________ Client Initials __DH_____ Date _2/7/12_Age _93____ Gender __F___ Room # __205-1___ Admit Date _1/10/12_______CODE Status _DNR-CCA__ Allergies _Aspirin & Dilaudid__ Braden Score __18/23___Diet _Regular______ Activity __Up With Assist x 1_Braden Score___13/23___MedicationsAcetaminophen OTC Tab 325 mg (2 tabs) PO q 6h PRN pain 0-5Amiodarone Tab: 200 mg PO qam-0800Cosopt (dorzolamide-timolol) Drops: 2-0.5% 1 drop: ophthalmic 1 gtt to both eyes bid 0800, 2000Lyrica (pregabalin) Schedule V, capsule: 50mg 1 cap PO q am, 0800Miralax OTC Powder-Powder for reconstitution , 17gm oral 0800Surfak (docusate sodium) OTC Capsule 240 mg oral once a day 0800Synthroid (levothyroxine) Tab 75 mcg qam 0600Vicodin (hydrocodone-acetaminophen Schedule III Tab 500mg 1 tab PO qid 0000, 0600, 1200, 1800 IV Sites/Fluids/RatesNoneIV Sites/Fluids/Rate2/7/12 @ 1600:BP 143/78, HR 68, Temp 97.5, POX 95% RA, Resp 16 Weight: 108 lbsHeight: 62 inches A & O x 4 LOC : Alert Speech: ClearPain 2/10 PERRLA MAE: Yes ROM: Decreased Hand grasps: Bilateral Weakness BLE: Bilateral Weakness Lung sounds: ClearApical Pulse: 72Cough: DeniesBS x 4, active LBM 2/5/12Skin: warm, dry. Rt arm skin tear, rt knee wound, left leg hematoma, bruise left leg and right elbow. Edema noted on anterior and lateral portion of right lower extremity. Redness and tenderness noted. Surrounding skin is WNL. Patient states that her leg got caught in between her wheelchair and the toilet when a nursing home assistant took her to the restroom several weeks ago. She was seen in the ER for this incident. Skin turgor: Good, no tenting present. Cap. Refill: < 3 seconds Radial Pulses BIL +2, Pedal Pulses BIL +1. Mucous Membranes: pink, moist. Patient needs partial assistance with ADL’s. Up with assistance x 1. Wound care was provided for her bilateral lower extremities, right lateral calf and right knee. Patient ate 75% of her dinner and stated that she did not have the energy to eat in the dining room. Patient cooperated well. Patient is well oriented to the facility and states that she participates in a number of offered activities. Admitting Diagnoses/Chief ComplaintRight lower extremity cellulitisPast Medical /Surgical HistoryMedical:OsteoporosisHypothyroidismHypertensionAtrial FibrillationGlaucomaSurgical:Pathologic fracture of the right femur neck in 2011: total right hip arthroplastyTreatmentsWet to dry dressing to right knee bid 0600 and 2200. Right lower lateral calf applied steri strips (monitor until fall off) TAO, telfa and cling.Cleanse area to bilateral lower extremities with normal saline, pat dry. Cover with moistened gauze and non-adherent pad. Secure with kerlix.Physical Assessment DataAssessment DataPatient AssessmentGeneral survey.On at 1600 on February 7, 2012, the following assessment was taken for DH. DH had a pulse of 68 beats per minute, a respiratory rate of 16 breaths per minute, a blood pressure of 143/78 mmHg, a temperature of 97.5° Fahrenheit, and an oxygen saturation rate of 95% on room air. DH reported a pain level of 2, using a numeric scale of 1-10. She stated that she had some slight discomfort in her right lower extremity, particularly her knee, but she declined any medication for it. DH stated that she did not have a history of tobacco or alcohol use. DH also stated that she felt her health, although not perfect, was under control. DH is currently recovering from right lower extremity cellulitis. She explained that she needed to use the restroom, so one of the aids wheeled her into the restroom and turned the wheelchair around to get her on to the toilet when her right lower leg and knee became pinned between the toilet and the wheelchair. She stated that it was just bruised at first, but then it became painful to bear weight on the extremity. She then noticed it began to swell and became very red and tender to the touch. She was then taken to the Emergency Room at a local hospital where they tended to admitted her for treatment. Cardiovascular assessment.DH had an unlabored work of breathing. Her respirations were even and deep at 16 breaths per minute. Her oxygen saturation was 95% on room air. Upon auscultation, DH’s lung sounds were clear bilaterally. She denied the presence of cough or sputum and shortness of breath. DH’s skin turgor was good with no tenting noted. Her nail beds were pink and her capillary refill was less than three seconds. Her radial pulses were +2 bilaterally and her pedal pulses were +1 bilaterally. DH’s skin was warm and dry to the touch. No jugular vein distention was noted in DH’s assessment. Her carotid pulse was strong bilaterally. Her apical heart rate was strong and 72 beats per minute. Abdominal assessment.DH had active bowel sounds in all four quadrants. Her abdomen was soft and non-distended. Her last bowel movement was on February 5, 2012. She was continent of bowel and bladder. She denied any pain in her abdomen or upon defecation or urination. Skin assessment.DH’s skin was warm, pink, and dry to the touch. Her skin turgor was good and no tenting was noted. DH’s oral mucosa was pink and moist. She stated that she wore dentures. Her throat was pink and moist. Some skin wounds were noted during the assessment, including a right and left arm skin tear that the patient stated were from prior procedures where adhesive bandages had been applied, a right knee wound from the accident in the nursing home, a left leg hematoma, also from the accident, and bruising on her right and left elbow that the patient stated she was not sure of where they came from. The right knee wound extended to her lower lateral and anterior leg and considerable swelling was noted. The affected skin was red and warmer to the touch than the surrounding areas. The skin surrounding the area was within normal limits. The left leg hematoma and the right knee and calf wounds were cleansed with normal saline and a moistened gauze pad was applied to affected areas and secured with Kerlix. DH had a Braden Scale score of 18/23. Neurological assessment.DH was alert and oriented to person, place, time, and situation (Alert and Oriented x 4). Her level of consciousness was alert and her speech was clear. DH scored a 15/15 on the Glasgow Coma Scale. DH communicated appropriately and was cooperative throughout each assessment. DH denied using glasses or assistive devices for hearing. DH’s pupils were equal and reactive to light and accommodation (PERRLA). She had notable bilateral weakness in her upper and lower extremities, including her hand grasps. DH is able to stand on her own for short periods of time and can walk to the bathroom with assistance. DH scored a 10 on the Geriatric Depression Scale, indicating a mild risk for depression. Diet and activity. DH was up with assistance of at least one person. DH scored a three out of six on the Katz Index of Independence in Activities of Daily Living. She needs assistance bathing, transferring to the toilet, and dressing. She is able to get from the bed to the chair without assistance, eat her meals on her own, and she is continent of bowel and bladder. She is on a regular diet. She states she generally eats about 75-100% of her meals. DH enjoys being involved in group activities offered in the facility; however, she also likes to have some privacy in her room during the day to rest and relax. Gordon’s Function AssessmentAREA OF HEALTHSUBJECTIVE DATAOBJECTIVE DATAINDIRECT DATA*Identify source of indirect dataINTERPRETATION(effective patterns or barriers/potential barriers)HEALTH/PERCEPTION HEALTH MANAGEMENTGeneral Survey, perceived health& well-being, self-managementstrategies, utilization of preventative health behaviors and/or services. D.H. stated that she is tired but she is having a good day today.Patient states pain is 2/10 on vascular scale.Vital Signs: Respirations 16 and unlabored, pulse 68, temp 97.5°F, pulse ox 95% on room air, BP 143/78.Patient demonstrates personal hygiene with grooming and is dressed in clothes from home.Patient actively participates in self-care but needs assistance x 1 when becomes tired. Patient enjoys spending time doing group activities but also enjoys private time in her room.Patient seems to be well oriented to facility and is cooperative with staff members.Patient being treated for right lower leg cellulitis (chart). Patient has orders for wound treatments every 12 hours (chart). Patient has PRN medications for pain, i.e. acetaminophen and hydrocodone (chart).Patient is up with assistance x 1(chart). Patient seems to get upset that she is not as independent as she was before she entered the facility. Although patient enjoys company, she needs her privacy at times as well.NUTRITIONAL/METABOLICPatterns of food and fluid consumption,Weight, skin turgor. (Skin, Hair, Nails; Head & Neck; Mouth, Nose, Sinus; swallowing, Ht., Wt)Patient states that she will eat between 75-100 percent of her meals, depending on what is offered.Patient states that she drinks all of the beverages offered with the meals, as well as a cup of coffee in the morning and water throughout the day.During shift pt. ate 75% of dinner.Skin turgor was less than three seconds, and no tenting present.Skin was dry and warm with good color. Oral cavity was moist and pink.DH stated that she wore dentures.DD is 62 inches tall, 108 lbs.DD is partially able to perform own self care.Patient is given polyethylene glycol once a day.Patient is given docusate sodium once a day.Regular diet (chart)Patient seems to have adequate nutritional intake for dietary needs, but may need additional protein and carbohydrates for wound healing. ELIMINATIONPatterns of excretory function &Elimination of waste; relevant labs, Medications, impacting, etc.(Abdominal - bowel and bladder)Patient states “I have no pain or urgency when I need to go to the bathroom”. Patient states, “My last bowel movement was on 2/5/12”. Abdomen soft symmetrical and non-distended.Bowel sounds present in all four quadrants. Pt. denies pain with palpitation.Patient is given 17gm of polyethylene glycol once per day.Patient is given 240 mg of docusate sodium once per day.Patient may take 500mg of hydrocodone q 6h as needed for pain.Patient may have bowel elimination problems related to opioid analgesic therapy PRN. ACTIVITY/EXERCISEPatterns of exercise & daily living,self-care activities include majorbody systems involved.(Thoracic & Lung; Cardiac; Peripheral vascular; Musculoskeletal,vital signs)DH denies any shortness of breath or presence of cough. DH states that she tries to do as much as she can on her own, but needs assistance when she becomes tired during self-care activities.DH states that she enjoys participating in activities during the day but enjoys her private time as well.Heart sounds were regular.Lung sounds were clear. Patient was breathing at 16 respirations per minute.Katz ADL score was 3 out of 6.Patient had a Braden score of 18/23.Patient had a Fall Risk score of 6.Patient is taking Cordarone 200 mg daily.Patient is taking levothyroxine 75 mcg daily.Patient is taking pregabalin 50mg once daily.Patient is ordered 700 mg of acetaminophen or 500mg of hydrocodone for pain PRN.Patient is up with assist (chart).Patient is encouraged to change position in bed q 2 hours (chart).DH had an assessment for PT ordered (chart). There were no results indicated in her chart.Patient’s Braden score indicates a risk for developing a pressure ulcer.Patient is cooperative and willing to try to perform self-care activities unless becomes too tired to do so. Due to lack of mobility, patient is at a greater risk of developing infection or DVT.SEXUALITY/ REPRODUCTIONSatisfaction with present level of Interaction with sexual partners(Breast; Testes; Abdominal- Genitourinary-reproductive)Patient stated that her husband passed away several years ago.Patient stated that she has had no significant others since the death of her husband.Patient’s current medications do not have an effect on sexuality or reproduction. Found no information regarding sexuality from chart.It was clear that speaking about her husband was a difficult subject for DHSLEEP/RESTPatterns of sleep, rest, relaxation,fatigue(Appearance, behavior)Patient stated that she sleeps about eight hours every night.Patient stated that she normally takes a nap around 1400 for about two hours. Patient was in physical therapy upon arrival and was did not nap that day.Patient was pleasant and engaging in activities with others during shift.Hydrocodone administration may lead to drowsiness (chart)DH appears obtain a good amount of rest during the day and night. DH seems to have a good amount of energy to complete daily activities.COGNITIVE/ PERCEPTUALPatterns of thinking & ways ofPerceiving environment, orientationMentation, neuron status, glasses, Hearing aids, etc.DH was able to state her name, birthdate, where she was and her situation very descriptively.DH stated that she was admitted to the facility in January after she was released from a local hospital.A and O x4 person place time situationPERRLADoes not use hearing aid.Nurse and physician notes indicate patient has regularly been alert and oriented (chart).DH did not appear to have a cognitive impairment during shift.ROLE/RELATIONSHIPPatterns of engagement with others,Ability to form & maintain meaningfulRelationships, assumed roles; Family communication, response,Visitation, occupation, communityinvolvementPatient states that she used to be an accountant for a printing company in Canton.Patient states she lived independently up until this past year.Patient states she was residing with her daughter’s family just before she was admitted into the hospital. Patient had several pictures of family members in her room.Patient’s daughter visited during shift.Nothing indicated on chart about relationships with family or within community.Although patient preferred to live independently, she seemed to have a positive relationship with her daughter and appreciated her help.SELF-PERCEPTION/ SELF-CONCEPTPatterns of viewing & valuingSelf; body image & psychologicalstatePatient states that when she is at home, she relies on her daughter to take her places.DH states that she misses her independence since being admitted into the facility.Patient states that she is not afraid to die and she has lived a good life.Patient states that her level of anxiety is a 3 on a scale of 1-10.Patient says that she usually has a positive view of self.Patient feels that his level of control in his current situation is a 5 on a scale of 1 to 10.Patient feels that his normal level of assertiveness is a 6 on a scale of 1 to 10.DH was calm and cooperative during assessment. DH asked questions about assessment findings throughout assessment.DH provided information about past employment history.Patient is a DNR-CCA (chart).DH seems to miss her independence.DH seems to have an altered self-image due to her admission into the facility.COPING/STRESS TOLERANCEStress tolerance, behaviors, patternsof coping with stressful events &level of effectiveness, depression,anxiety.Patient states that she would love to go back to living independently.Patient states that she does not often feel very stressed.Patient scored a 10 on the Geriatric Depression Scale, which is indicative of a slight risk of depression.Patient is not currently ordered any medications for anxiety (chart).Patient seems to handle stress of facility and health issues well, but it is clear that she misses her independence. VALUE/BELIEFPatterns of belief, values, Perception of meaning of life thatguide choices or decision; includesbut is not limited to religious beliefsDH states that she is Protestant and has enjoyed the services in the facility. DH keeps a bible in her room.DH has a cross in her room.Patient is of Protestant faith (chart).DH is DNR-CCA patient (chart).DH did not indicate that she would like any religious measures taken in the event of her sudden illness or passing.She seems to have a strong Christian faith and is actively involved in Christian activities in the facility. Laboratory InformationSee Table 1.Table 1TestsNormal ValuesPatient ResultsAnalysisWBC4.8-10.816.4Increased; a result of infection from right lower extremity cellulitisRBC4.0-5.53.88Decreased; may be due to medication use or indicative of hemodilution from cellulitisHgb12-1611.9Decreased; may be a result of hemodilution from cellulitisHct36-4836.2Within Normal LimitsPlatelets150-450285Within Normal LimitsT4 Total4.87-11.728.31Within Normal LimitsTSH 3-4L0.35-4.947.05Increased; Primary hypothyroidism leads to high levels of TSH (thyroid stimulating hormone) because of normal feedback mechanismsNormal Values from: Nurse’s manual of laboratory and diagnostic tests (4th ed).MedicationsSee Table 2.Table 2Medication Name(Generic/Trade)Drug Action/PurposeNormal Dose RangeMajor Side EffectsNursing ConsiderationsAcetaminophen/Tylenol 325 mg (2 tabs) PO q 6 hr PRN for pain 0-5Antipyretic, non-opioid analgesic. Inhibits synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. PO:325-650mg q 4-6hr or 1 gm 3-4 times daily or 1300 mg q 8 hr (not to exceed 4g or 2.5g/24hr in patients with hepatic/renal impairment.Hepatic failure, hepatotoxicity, renal failure, neutropenia, pancytopenia, leucopenia, rash, urticariaAssess type of pain, location, and intensity prior to and 30-60 minutes following administration. Assess fever, note presence of associated signs, i.e. malaise, tachycardia, diaphoresisEvaluate hepatic, hematologic, and renal function during prolonged therapy. May alter results of blood glucose monitoring by falsely lowering values when measured with glucose oxidase/peroxidase method.Amiodarone (Cordarone) 200 mg PO q amAntiarryhthmics (class III)Prolongs action potential and refractory period, slows the sinus rate, increases PR and QT intervals, and decreases peripheral vascular resistance (vasodilation).800-1600mg/day in 1-2 doses for 1-3 weeks, then 600-800 mg/day in 1-2 doses for 1 month, then 400 mg/day maint. DoseDizziness, fatigue, malaise, corneal microdeposits, adult resp. distress syndrome, pulmonary fibrosis, pulmonary toxicity, chf, worsening of arrhythmias, bradycardia, hypotension, anorexia, constipation, nausea, vomiting, toxic epidermal necrolysis (rare), photosensitivity, hypothyroidism, ataxia, involuntary movement, paresthesia, peripheral neuropathy, poor coordination, tremorMonitor ECG continuously during initial oral therapy. Monitor heart rate and rhythm throughout therapy. Assess for signs of pulmonary toxicity (rales/crackles, decreased breath sounds, pleuritic friction rub, fatigue, dyspnea, cough, wheezing, pleuritic pain, hypoxia, hemoptysis). Assess for neurotoxicity (tremors, tingling or numbness in fingers or toes, muscle weakness).Ophthalmic exams should be performed before and regularly during therapy. Assess for signs of thyroid dysfunction.2% dozolamide + 0.5% timolol (Cosopt Opthalmic Solution)1 drop in both eyes BIDBeta-blocker; management of chronic open-angle glaucoma and other forms of ocular hypertension; decreases the formation of aqueous humor1 drop of 0.25-0.5% solution 1-2 times per day. Conjunctivitis, visual acuity, ocular burning, rashLast up to 24 hoursPregabalin (Lyrica)50 mg Capsule PO q amAnalgesics, anticonvulsantsBinds calcium channels in CNS tissues which regulate neurotransmitter release. Does not bind to opioid receptors. 50-75mg 2-3 times daily initially, may be increased within one week based on tolerabilitySuicidal thoughts, dizziness, drowsiness, edema, dry mouth, decreased platelet countsMonitor closely for changes in behavior indicative of suicide. Assess location, intensity, and characteristics of pain before and periodically during therapy.May cause increase creatine kinase levels and decrease in platelet countsPolyethylene glycol (Miralax) OTC powderLaxatives, osmoticPolyethylene glycol in solution acts as an osmotic agent, drawing water into the lumen of the GI tract.PO 17 g (heaping tablespoon) in 8 oz of water; may be used for up to 2 weeks.Abdominal bloating, cramping, flatulence, nausea.Assess patient for abdominal distention, presence of bowel sounds, and usual pattern of bowel function.Assess color, consistency, and amount of stool produced.Docusate sodium (Surfak) OTC 240 mg capsule PO once a dayLaxatives, Stool softenersPromotes incorporation of water into stool, resulting in softer fecal mass. May also promote electrolyte and water secretion into the colon.50-400 mg in 1-4 divided doses.Throat irritation, mild cramps, diarrhea, rashes.Assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel function.Assess color, consistency, and amount of stool produced.Levothyroxine (Synthroid) 75 mcg tab q amHormones, thyroid preparationsReplacement of supplementation to endogenous thyroid hormones.50 mcg as a single dose initially, may be increased q 2-3 weeks by 25/mcg/day. Usually maintenance dose is 75-125 mcg/dayInsomnia, irritability, angina pectoris, arrhythmias, tachycardia, abdominal cramps, diarrhea, vomiting, sweating, hyperthyroidism, menstrual irregularities, heat intolerance, weight lossAssess apical pulse and blood pressure prior to and periodically during therapy.Assess for tachycardia and chest pain. Monitor thyroid function studies before and during therapy.Overdose is manifested as hyperthyroidism (tachycardia, chest pain, nervousness, tremors, weight loss)Hydrocodone-acetaminophen (Vicodin) 500 mg PO QID Antitussive, opioid analgesics/nonopioid analgesic combinationsBind to opiate receptors in the CNS. Alter the perception and response to painful stimuli while producing generalized CNS depression.2.5-10 mg q 3-6 hr; acetaminophen dosage should not exceed 4g/day and should not exceed 5 tablets per day of ibuprofen-containing products.Confusion, dizziness, sedation, hypotension, constipation, dyspepsia, nausea, respiratory depression, urinary retention.Assess blood pressure, pulse, and respirations before and periodically during administration. If respirations are less than 10 per minute, assess level of sedation.Assess bowel function routinely.Assess type, location, and intensity of pain prior to and one hour after administration. Prolonged use may lead to physical and psychological dependence. Medication references used:Davis’ Drug Guide (12th ed).AnalysisNursing Diagnosis #1The primary nursing diagnosis that I chose for DH was Impaired Skin Integrity related to right lower extremity cellulitis as evidenced by edema, erythema, increased white blood cells (16.4), and pain rating of two out of ten (Carpenito-Moyet, 2010). The patient was admitted to the facility in January of 2012 after she was treated for the cellulitis and discharged from the local hospital. According to Carpenito-Moyet (201), impaired skin integrity is a state in which the patient’s epidermis and/or dermis is at risk for or is compromised. In DH’s case, the lower extremity cellulitis has spread throughout her epidermis and deeper dermis into her subcutaneous tissue and caused and promoted infection. Therefore; DH’s skin and underlying tissue has been damaged and inevitably altered. Adequate nutrition and proper wound care is essential for achieving timely wound healing. Eaton-Bancroft (2005) states that increased intake of carbohydrates, fats, protein, zinc, selenium, Vitamin K, A, and C are critical to establish tissue maintenance and repair. Additionally, the author also emphasizes the need for apposite interventions and documentation during the duration of care at any facility to ensure the progression of wound healing. Using the appropriate anatomical terms and precise measurement of the wound will aid in the evaluation and charting standards for wound care (Eaton-Bancroft, 2005). Nursing Diagnosis #2The secondary nursing diagnosis I chose for DH was Risk for Infection related to right lower extremity cellulitis as evidenced by edema, erythema, and increased white blood cell count (16.4) (Carpenito-Moyet, 2010). Carpenito-Moyet (2010) describes a Risk for Infection as “the state in which an individual is at risk to be invaded by an opportunistic or pathogenic agent (virus, fungus, bacterium, protozoan, or other parasite) from endogenous or exogenous sources”. The author goes on to state that Risk for Infection explains that the patient’s defenses are compromised, making them more susceptible to environmental pathogens. The older adult is at increased vulnerability to infection not only because of their health conditions, but also because they have a decreased immune response and their decline in mobility status (Carpenito-Moyet, 2010). DH’s wound healing has been a slow progression and the continuation of the cellulitis prolongs her risk for active infection. Nursing interventions for DH should focus on increasing resistance to infection by improving her nutritional status and minimizing the introduction of organisms through aseptic techniques and proper wound care (Carpenito-Moyet, 2010). Nursing Diagnosis #3My final nursing diagnosis that I chose for DH is Impaired Physical Mobility related to right lower extremity cellulitis, as evidenced by muscle weakness, pain of two out of ten in right lower extremity, altered sensory perception due to opioid analgesics, and infection (Carpenito-Moyet, 2010). Risk for Infection is defined as a state in which an individual experiences restrictions of physical movement, but is not totally immobile. DH currently has limited use of her right lower leg and weakness in all extremities due to infection and medication use. Nursing interventions should focus on improving strength, preventing further deterioration and restoring function (Carpenito-Moyet, 2010). Nursing Diagnoses, Plans, Interventions, and EvaluationSee Tables 3, 4, and 5.Table 3Primary Nursing Diagnosis: Impaired Skin Integrity related to right lower extremity cellulitis as evidenced by edema, erythema, WBC (16.4), and pain of two out of ten(Carpenito-Moyet, 2010). Patient Goal: Patient will exhibit wound healing within 30 days.Interventions: 1. Maintain strict skin hygiene, using mild, non detergent soap, drying gently and thoroughly, and lubricating with lotion or emollient (Doenges, Moorhouse, & Murr, 2010). Rationale: A daily bath may create dry skin problems. Use of lubricants keep skin soft and pliable, and help to keep susceptible skin from breaking down (Doenges et al., 2010).2. Assess nutritional status and initiate corrective measures by providing a balanced diet with adequate protein, vitamins, and minerals (Doenges et al., 2010).Rationale: A positive nitrogen balance and improved nutritional state can help prevent skin breakdown and promote healing (Doenges et al., 2010).3. Assist with topical applications, such as hydrogel dressings, skin barrier dressing, collagenase therapy, absorbable gelatin sponges, and aerosol sprays (Doenges et al., 2010). Rationale: Although there are differing opinions about the use of these agents, individual or combination use may enhance healing (Doenges et al., 2010).Evaluation: Unable to assess patient goal because of limited time at facility. In order to promote wound healing, I would discuss the importance of proper diet with the patient, enforce proper hygiene and continue the application of wound treatments throughout my shift. Table 4Secondary Nursing Diagnosis: Risk for Infection related to right lower extremity cellulitis as evidenced by WBC (16.4), edema, erythema, pain of two out of ten, and altered immune function related to normal aging process (Carpenito-Moyet, 2010).Patient Goal: Patient will report risk factors associated with infection and precautions that can be taken to prevent infection by the end of shift.Interventions: 1. Explain the importance of adequate nutrition. Encourage DH to develop intake goals for snacks and meals (Doenges et al., 2010). Rationale: Helps to improve general resistance to disease and reduces risk of infection from static secretions (Doenges et al., 2010).2. Provide meticulous, clean, or aseptic care; maintain good hand washing techniques (Doenges et al., 2010). Rationale: Helps eliminate and defend against health care facility acquired infection (Doenges et al., 2010).3. Observe for clinical manifestations of infection including fever, cloudy urine, confusion, and drainage (Carpenito-Moyet, 2010).Rationale: The usual signs of infection may not always be present in geriatric patients. Patient must also be educated to observe for changes (Carpenito-Moyet, 2010).Evaluation: Short term goal met. DH verbalized her understanding of risk factors for infection. She also verbalized her understanding of proper diet and increased protein, vitamins, and minerals. DH also demonstrated proper hygiene during shift. Table 5Tertiary Nursing Diagnosis: Impaired Physical Mobility related to right lower extremity cellulitis as evidenced by muscle weakness, pain of two out of ten in right lower extremity, altered sensory perception due to opioid analgesics, and infection (Carpenito-Moyet, 2010). Patient Goal: The patient will report an increase in strength and endurance in limbs within 30 days. Interventions: 1. Determine DH’s functional ability using a scale of 0 to 4 and reasons for impairment (Doenges et al., 2010). Rationale: Identifies need for and degree of intervention required (Doenges et al., 2010).2. Plan activities and visits with adequate rest periods as necessary. (Doenges et al., 2010). Rationale: Can limit or prevent fatigue; conserve energy for continued participation (Doenges et al., 2010).3. Encourage participation in self-care, occupational, and recreational activities (Doenges et al., 2010). Rationale: Promotes independence and self-esteem; may enhance willingness to participate (Doenges et al., 2010).4. Assist with transfers and ambulation; show DH ways to move safely (Doenges et al., 2010). Rationale: Prevents accidental falls and injury (Doenges et al., 2010).Evaluation: Unable to measure goal because of limited time at facility. Assisted with transfers and ambulation and planned activities together to provide adequate rest periods during shift. DH actively participated in self-care activities during shift and verbalized her functional abilities and limits. ConclusionAt the end of the shift, I felt that DH had done well throughout the day in which I cared for her. Her physical status remained constant throughout the shift. DH was pleasant and cooperative during the course of the day and willing to be actively involved in the care that I provided for her. DH was receptive to education and suggestions that I had for her and verbalized and demonstrated skills that were discussed. DH was open to discussing her past physical, emotional and social history with me as we built up our rapport together. At the end of my shift, DH verbalized her willingness and desire to improve her health condition by continuing with physical therapy and active participation in self-care activities, as well as monitoring her infection and maintaining good hygiene to promote wound healing. ReferencesBlack, J. M. & Hawks, J. H. (2009). Medical surgical nursing: clinical management for positive outcomes (8th ed.). Saint Louis, Missouri: Saunders Elsevier.Cavanaugh, B. (2009). Nurse’s manual of laboratory and diagnostic tests (4th ed.). Philadelphia, Pennsylvania: F. A. Davis Co.Carpenito-Moyet, L. J. (2010). Handbook of nursing diagnosis (13th ed.). Philadelphia, Pennsylvania: Lippincott, Williams, & Wilkins.Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing care plans: guidelines for individualizing client care across the life span (8th ed.). Philadelphia, Pennsylvania: F. A. Davis Co.Eaton-Bancroft, I. (2005). Teaming up for wound care. Nursing2005, 35(4), p32hn1-32hn3.Hopfer, J., Vallerand, A., & Sanoski, V. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia, Pennsylvania: F. A. Davis Co. ................
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