UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Ashley Fern |

|Patient Assessment Tool . |Assignment Date: 10/20/15 |

| ( 1 PATIENT INFORMATION |Agency: MPM |

|Patient Initials: DF |Age: 62 |Admission Date: 10/11/15 |

|Gender: female |Marital Status: single |Primary Medical Diagnosis with ICD-10 code: |

| | |Other pulmonary embolism without acute cor pulmonale (126.99) |

|Primary Language: English | |

|Level of Education: 2 years of college |Other Medical Diagnoses: (new on this admission) |

| |Deep venous thrombosis (DVT) |

|Occupation (if retired, what from?): retired from banking | |

|Number/ages children/siblings: no children | |

|2 older sisters ages 68 and 70 | |

| | |

|Served/Veteran: no |Code Status: full |

|Living Arrangements: Patient lives alone with 2 cats to keep her company. She lives in a one|Advanced Directives: yes, patient states she has filled them out and |

|story house with no stairs or rugs that impair her ability to get around. She has no problem |has a living will |

|taking her medications or completing her activities of daily living. She does use a walker to| |

|assist her with walking. Patient’s significant other passed away in 1999. | |

| |Surgery Date: N/A Procedure: none specified |

|Culture/ Ethnicity /Nationality: Caucasian/ White/ American | |

|Religion: Methodist |Type of Insurance: Medicare, Medicaid- share of cost |

|( 1 CHIEF COMPLAINT: |

|“I was extremely short of breath for 2 days and finally I called my friend, and when she came to see me she called 911 |

|because at that point I could barely breathe anymore and I was very scared. The ambulance brought me here and I guess |

|they thought that I could have been having a mild heart attack, but the CT scan showed blood clots in my lungs instead |

| |

|( 3 HISTORY OF PRESENT ILLNESS: |

|Patient was admitted on 10/11/15 with complaints of shortness of breath and severe anxiety. Her admitting diagnosis was |

|hypoxia until further tests were done. Patient showed slightly elevated levels of troponin however the ECG showed |

|normal sinus rhythm although heart rate was elevated from patient’s baseline, and NSTEMI was ruled out. CT scan of the |

|chest revealed bilateral pulmonary embolism and further venous ultrasound also showed right peroneal DVT. Patient was |

|moved to the cardiac floor and placed on telemetry to monitor for issues of myocardial ischemia related to the hypoxia |

|and was placed on supplemental oxygen and given 5000 units IV heparin bolus followed by 1300 units/hr continuous IV. |

|Patient was also started on warfarin 7.5mg PO 1x daily and heparin was discontinued on 10/17/15 when INR levels came |

|into a therapeutic range. |

|CC-OLDCARTS |

|O- patient reported feelings of shortness of breath on 10/9, two days prior to admission |

|L- location was in the chest, extreme shortness of breath |

|D- patient stated it was a constant shortness of breath that didn’t start feeling better until after a few hours on oxygen |

|C- described as a “tightening of the chest- I kept inhaling but just couldn’t catch my breath” (Patient denies any chest pain) |

|A- patient states that trying to talk made it worse |

|R- patient reports that the only relieving factor was the oxygen they gave her in the ER |

|T- patient says that she didn’t try any treatments at home but that the supplemental oxygen in the hospital made her feel a lot better |

|S- severity of the shortness of breath was rated a 10 “Oh my god! I would give it a 10+ if I could. I have never been more scared in my life!” (patient denies any |

|chest pain throughout the experience) |

| |

( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY

|Date |Operation or Illness |

|1975 |HTN: Tekturna 150mg PO 1x daily, Lasix 40mg PO 1x daily, hydrochlorothiazide 25mg PO 1x daily |

|Mid 1990s |Asthma: Advair HFA 230/21 1 puff daily, Singulair 10mg PO 1x daily |

|Early 2000s |Morbid Obesity- not currently being managed |

|2002 |Anxiety: Effexor XR 150mg PO 1x daily |

|2003 |Hyperlipidemia: Lipitor 80mg PO 1x daily |

|2011 |Chronic Venous Stasis/Insufficiency: aspirin 81mg PO 1x daily, Trental 400mg PO 1x daily |

|2011 |Bilateral lower extremity cellulitis and nonhealing ulcers (Pyoderma Gangrenosum): routine dressing changes, Dapsone 100mg PO 1x daily |

| |(taken while in hospital) |

|2013 |Obstructive Sleep Apnea: use of CPAP machine at night |

| | |

|1963 |Surgery for lengthening of Achilles tendon |

|1993 |Hammertoe Surgery |

|2000 |Left rotator cuff surgery |

|2002 |Right rotator cuff surgery |

|2010 |C-spine decompressive surgery |

|( 2|Age (in years) |

|FAM| |

|ILY| |

|MED| |

|ICA| |

|L | |

|HIS| |

|TOR| |

|Y | |

| | |

| |Father was diagnosed with HTN at a young age and then around age 40 was diagnosed with arteriosclerosis |

| |Mother had asthma from a young age but later in life (around age 60) was diagnosed with emphysema brought on by smoking |

| |Sister (age 70) has had Type 2 Diabetes since age 36 and has had a-fib since age 54 |

| |Sister (age 68) has no other health problems other than Rheumatoid Arthritis since she was around 40 |

| | |

| | |

| | |

| | |

|( 1 immunization History |

|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |

|Routine childhood vaccinations | | |

|Routine adult vaccinations for military or federal service | | |

|Adult Diphtheria (Date) | | |

|Adult Tetanus (Date) 2007 | | |

|Influenza (flu) (Date) 10/17/15 | | |

|Pneumococcal (pneumonia) (Date) November 2014 | | |

|Have you had any other vaccines given for international travel or occupational purposes? Please List | | |

|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |

|REACTIONS |Causative Agent | |

|Medications |Cipro |Hives all over body |

| |Vancomycin |Rash- mild hives |

| |Zosyn |Rash- mild hives |

| |Zyvox |Rash- mild hives |

| | | |

| | | |

|Other (food, tape, latex, dye, |Latex |Rash |

|etc.) | | |

| |Pine trees, Oak trees, Sable |Sneezing, itchy watery eyes |

| |palms | |

| |Dogs |Sneezing, itchy watery eyes |

| |No known food, tape, or dye | |

| |allergies | |

|( 5 PATHOPHYSIOLOGY: |

|A pulmonary embolism is a condition that results from the “occlusion of the pulmonary vascular bed by an embolus” |

|(Huether & McCance, 2012, p. 698). It is most often caused by a blood clot that has detached from a deep venous |

|thrombosis and traveled up to the lungs, although other causes can include tissue fragments, lipids, a foreign body, or an |

|air bubble. Risk factors for pulmonary emboli “include conditions and disorders that promote blood clotting as a result of |

|venous stasis, hypercoagulability, and injuries to endothelial cells that line the vessels” (Huether & McCance, 2012, |

|p. 698). The impact of the embolus depends on how much the pulmonary blood flow is obstructed. If there is major |

|obstruction, then infarction can occur in which tissue damage and death results in the affected portion of the lung. However, “if the embolus does not cause |

|infarction, the clot is dissolved by the fibrinolytic system and pulmonary |

|function returns to normal” (Huether & McCance, 2012, p.698). Common clinical manifestations of a pulmonary |

|embolism include pleuritic chest pain, dyspnea, tachypnea, tachycardia, and severe anxiety. The diagnosis of pulmonary |

|embolism is usually made by looking for the occlusion in a CT scan as well as testing for elevated D-dimer levels. |

|Treatment for this condition is mainly anticoagulant therapy, initially starting with heparin. “If a massive, life-threatening |

|embolism occurs, a fibrinolytic agent, such as streptokinase, is sometimes used, and some individuals will require surgical |

|thrombectomy (Huether & McCance, 2012, p.699). Once the patient is stabilized, they are started on either warfarin or |

|low-molecular-weight heparins to continue to prevent new clots from forming. |

( 5 Medications:

|Name: heparin (Hep-Lock) |Concentration (mg/ml): 1000 units/mL |Dosage Amount (mg): 1300 units |

|Route: IV continuous infusion |Frequency: 1300 units/hour |

|Pharmaceutical class: antithrombotic |Home Hospital or Both |

|Indication: treatment of pulmonary embolism, prevention of extension of existing thrombi or thrombus formation |

|Side effects/Nursing considerations: bleeding, heparin induced thrombocytopenia, anemia, fever, hypersensitivity, hepatitis, rashes, urticarial/ Teach patient to |

|report any signs of unusual bleeding or bruising to a nurse immediately. Instruct patient not to take any aspirin or NSAIDs while on heparin therapy. Instruct the |

|patient to use a soft toothbrush and electric razors while on this medication to avoid excess bleeding. Remind the patient to tell any health care professional of |

|heparin therapy before any procedures and to carry an identification card with their anticoagulation information on it. Remind patient that they will need routine |

|lab work done while they are on heparin therapy. |

| |

|Name: carvedilol (Coreg) |Concentration: |Dosage Amount: 6.25mg |

|Route: PO |Frequency: 2x daily |

|Pharmaceutical class: beta blocker |Home Hospital or Both |

|Indication: management of hypertension |

|Side effects/Nursing considerations: dizziness, fatigue, weakness, blurred vision, bradycardia, heart failure, pulmonary edema, diarrhea, constipation, nausea, |

|orthostatic hypotension, Stevens-Johnson syndrome, toxic epidermal necrolysis, itching, rashes, hyperglycemia, muscle cramps, anaphylaxis, angioedema/ Instruct |

|patient to not discontinue this medication abruptly as life-threatening arrhythmias, hypertension, or myocardial ischemia could occur. Teach the patient how to |

|take their pulse and blood pressure and to contact the health care professional if there is a sudden drop in blood pressure or the pulse drops to below 50 bpm. |

|Teach patients to stand up and change positions slowly to avoid orthostatic hypotension. |

| |

|Name: atorvastatin (Lipitor) |Concentration: |Dosage Amount: 80mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: hmg coa reductase inhibitor (lipid lowering agent)|Home Hospital or Both |

|Indication: management of hyperlipidemia |

|Side effects/Nursing considerations: dizziness, HA, weakness, abdominal cramps, constipation, diarrhea, flatus, heartburn, altered taste, rashes, hyperglycemia, |

|rhabdomyolysis/ Notify provider of unexplained muscle weakness, pain, tenderness, or pain. Teach patient to wear sunscreen to avoid photosensitivity. Instruct |

|patient to take this medication at night. Teach patient not to drink grapefruit juice with this medication. |

|Name: Dapsone (Aczone) |Concentration: |Dosage Amount: 100mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: anti-infective |Home Hospital or Both |

|Indication: treatment of Pyoderma Gangrenosum (lower extremity cellulitis and nonhealing ulceration) |

|Side effects/Nursing considerations: HA, insomnia, blurred vision, tinnitus, hepatotoxicity, abdominal pain, n/v, Stevens-Johnson Syndrome, agranulocytosis, |

|hemolytic anemia, peripheral neuropathy/ Instruct patient to finish the full course of treatment even if they are feeling better. Ask patient to inform health care|

|provider of any herbal medications or OTC they may be taking. Teach patient to notify health care professional immediately if rash, sore throat, fever, chills, |

|persistent fatigue, yellow skin/eyes, bruising, or bleeding occur. Advise patient to avoid pregnancy or breastfeeding while on this medication. |

| |

|Name: aspirin (Ecotrin) |Concentration: |Dosage Amount: 81mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: salicylate |Home Hospital or Both |

|Indication: prophylaxis of transient ischemic attacks and MI related to chronic venous stasis |

|Side effects/Nursing considerations: tinnitus, GI bleeding, dyspepsia, epigastric distress, n/v, abdominal pain, hepatotoxicity, anemia, rash, anaphylaxis, |

|laryngeal edema/ Teach patient to take medication with food and a full glass of water to avoid GI upset. Instruct patient to report any unusual bleeding of gums, |

|bruising, or black and tarry stools. Warn patient to avoid alcohol and other NSAIDs while taking this medication as it could increase the risk for GI bleeding. |

|Instruct patients that tablets with a vinegar like odor should be thrown away. Teach patients to inform their health care provider of aspirin therapy before any |

|treatment or surgery as it may need to be discontinued for a week prior. |

| |

|Name: lisinopril (Prinivil) |Concentration: |Dosage Amount: 5mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: ACE inhibitor |Home Hospital or Both |

|Indication: management of hypertension |

|Side effects/Nursing considerations: dizziness, fatigue, HA, cough, hypotension, abdominal pain, n/v, diarrhea, impaired renal function, rashes, hyperkalemia, |

|angioedema/ Teach patient to avoid salt substitutes containing potassium or foods high in potassium which could increase the risk for hyperkalemia. Instruct the |

|patient to stand and change positions slowly to avoid orthostatic hypotension. Instruct patient to notify the health care professional immediately of any swelling |

|of the face, eyes, lips, or tongue, or if having difficulty swallowing or breathing. Warn patient that a persistent and dry cough may occur, and that if it becomes|

|too bothersome to notify a health care professional about being switched to an alternative medication. Teach patient how to check their blood pressure and to |

|report any significant changes to health care professional. |

| |

|Name: aliskiren (Tekturna) |Concentration: |Dosage Amount: 150mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: renin inhibitor |Home Hospital or Both |

|Indication: management of hypertension |

|Side effects/Nursing considerations: cough, hypotension, abdominal pain, diarrhea, dyspepsia, reflux, angioedema/ Instruct patient to stand up and change positions|

|slowly to avoid orthostatic hypotension. Teach patient to report swelling of the face, eyes, lips, tongue, difficulty breathing or swallowing to a healthcare |

|professional immediately. Warn patient to avoid pregnancy or breastfeeding while on this medication. |

| |

|Name: furosemide (Lasix) |Concentration: |Dosage Amount: 40mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: loop diuretic |Home Hospital or Both |

|Indication: management of hypertension |

|Side effects/Nursing considerations: dizziness, HA, tinnitus, hypotension, N/V, excessive urination, Stevens-Johnson Syndrome, hyperglycemia, hyperuricemia, |

|dehydration, hypokalemia, muscle cramps, aplastic anemia, agranulocytosis/ Instruct patient to take medication in the morning to avoid urination during the night. |

|Advise patient to eat a diet high in potassium. Teach patient to wear sunscreen to prevent photosensitivity. Teach patient to monitor blood glucose for increases |

|due to medication. Instruct patient to notify healthcare professional of weight gain of more than 3 pounds in 1 day. Teach patient to stand up and change positions|

|slowly to avoid orthostatic hypotension. |

| |

|Name: hydrochlorothiazide (Microzide) |Concentration: |Dosage Amount: 25mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: thiazide diuretic |Home Hospital or Both |

|Indication: management of hypertension |

|Side effects/Nursing considerations: dizziness, drowsiness, hypotension, anorexia, cramping, hepatitis, n/v, Stevens-Johnson Syndrome, photosensitivity rash, |

|hyperglycemia, hypokalemia, dehydration, hyponatremia, hyperuricemia, muscle cramps, pancreatitis/ Instruct patient to take this medication at night to avoid |

|nocturia. Instruct patient to stand up and change positions slowly to avoid orthostatic hypotension. Teach patient to wear sunscreen and protective clothing to |

|avoid photosensitivity. Teach patient that they may need additional potassium in their diet. Teach patient how to take their blood pressure and to report any |

|significant changes to a healthcare professional. |

| |

|Name: pentoxifylline (Trental) |Concentration: |Dosage Amount: 400mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: blood viscosity reducing agent |Home Hospital or Both |

|Indication: management of chronic venous stasis |

|Side effects/Nursing considerations: dizziness, drowsiness, HA, insomnia, blurred vision, dyspnea, angina, arrhythmias, edema, hypotension, abdominal discomfort, |

|n/v, tremor, anaphylaxis/ This medication may take several weeks to show effects of therapy, so it should be taken as directed and not stopped without consulting a|

|doctor. Teach patient that this medication could cause dizziness and blurred vision, so they should not drive until they know how it affects them. Advise patient |

|not to smoke since nicotine constricts the blood vessels. Instruct patient to tell health care professional if n/v, GI upset, drowsiness, dizziness, or HA |

|persists. |

| |

|Name: fluticasone (as part of Advair HFA 230/21) |Concentration: |Dosage Amount: 230mcg |

|Route: INH |Frequency: 2 puffs, 2x daily |

|Pharmaceutical class: corticosteroid |Home Hospital or Both |

|Indication: management and prophylactic treatment of asthma |

|Side effects/Nursing considerations: HA, dizziness, rhinorrhea, sinusitis, dysphonia, bronchospasm, cough, diarrhea, adrenal suppression, Cushing’s syndrome, |

|muscle pain, anaphylaxis, laryngeal edema/ Teach patient not to discontinue this medication suddenly, as it needs to be tapered off. Instruct patient that when |

|taking this with a bronchodilator, to take the bronchodilator first, wait 5 minutes, and then take the corticosteroid. Remind patient that this drug is not used to|

|treat acute asthma attacks, and that for that they should use a rescue inhaler. Instruct patient to tell health care provider if sore throat or mouth occurs. |

|Name: salmeterol (as part of Advair HFA 230/21) |Concentration: |Dosage Amount: 21mcg |

|Route: INH |Frequency: 2 puffs, 2x daily |

|Pharmaceutical class: adrenergic (bronchodilator) |Home Hospital or Both |

|Indication: management and prophylactic treatment of asthma |

|Side effects/Nursing considerations: HA, palpitations, nervousness, tachycardia, abdominal pain, nausea, diarrhea, muscle cramps, paradoxical bronchospasm, cough/ |

|Remind patient that this medication is not used to treat acute asthma attacks, and that for that they should use a rescue inhaler. Instruct patient to notify |

|health care professional immediately if difficulty in breathing continues or worsens after using this medication. Remind the patient to have regular follow-up |

|exams to evaluate the effectiveness of the treatment. |

|Name: warfarin (Coumadin) |Concentration: |Dosage Amount: 7.5mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: anticoagulant |Home Hospital or Both |

|Indication: Treatment and prophylaxis of pulmonary embolism and venous thrombosis |

|Side effects/Nursing considerations: cramps, nausea, dermal necrosis, bleeding, fever/ Teach patient to limit foods that are high in Vitamin K as it may decrease |

|the effectiveness of this medication. Teach patient to avoid any activities that could lead to injury and to use a soft toothbrush and electric razor to avoid the |

|increased risk of bleeding. Instruct patient to notify a health care provider of any unusual signs of bleeding or bruising. Teach patient to avoid alcohol, |

|aspirin, and other NSAIDs while taking this medication as it puts them at increased risk for bleeding. Remind patient to tell any health care professional about |

|warfarin therapy as they may want to discontinue it a week before procedures. |

|Name: montelukast (Singulair) |Concentration: |Dosage Amount: 10mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: leukotriene antagonist |Home Hospital or Both |

|Indication: Chronic treatment and management of asthma |

|Side effects/Nursing considerations: suicidal thoughts, agitation, anxiety, depression, HA, nosebleed, cough, rhinorrhea, abdominal pain, tremor, Stevens-Johnson |

|Syndrome, toxic epidermal necrolysis, Churg-Strauss Syndrome, fever/ Instruct patient that this medication is to be taken in the evening or at least 2 hours before|

|exercise. Remind patient not to stop taking this medication without talking to their doctor. Remind patient that this medication is not used to treat acute asthma |

|attacks, and that for that they should use a rescue inhaler. Teach patient and family to notify health care professional of any rashes that develop or of worsening|

|depression or thoughts of suicide. |

|Name: venlafaxine (Effexor XR) |Concentration: |Dosage Amount: 150mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: SSNRI |Home Hospital or Both |

|Indication: management of generalized anxiety disorder |

|Side effects/Nursing considerations: neuroleptic malignant syndrome, seizures, suicidal thoughts, anxiety, dizziness, HA, insomnia, nervousness, weakness, |

|rhinitis, visual disturbances, tinnitus, chest pain, hypertension, palpitations, tachycardia, abdominal pain, anorexia, constipation, dry mouth, n/v, sexual |

|dysfunction, urinary frequency, ecchymosis, itching, rash, paresthesia, serotonin syndrome, chills/ Instruct patient to not discontinue this medication suddenly, |

|it should be tapered off for more than 6 weeks before discontinuation. Teach patient and family to report signs of worsening depression or suicidal thoughts to a |

|healthcare professional. Teach patient that this medication could cause drowsiness or dizziness and that they should not drive until they know how it affects them.|

|Instruct patient to notify a healthcare professional if rash or hives occur while taking this medication. |

*Medication references from (Unbound Medicine, Inc., 2015)

|( 5 NUTRITION: |

|Diet ordered in hospital? Cardiac |Considering the patient’s age, height, weight, and minimal physical activity |

| |level, MyPlate recommends that she should consume, on average, 1600 calories a |

| |day in order to lose weight. According to Supertracker analysis of her 24 hour |

| |diet recall, the patient consumes, on average, more than 3300 calories a day. The|

| |patient exceeds by far the daily recommended calorie intake, and yet is still |

| |deficient in certain nutrients. |

|Diet pt follows at home? Regular |According to the food tracker made off of the patient’s average 24 hour home |

| |diet, she fails to meet the daily requirements of fruit and dairy, but exceeds |

| |the daily recommendations of grains, vegetables, and protein. |

|24 HR average home diet: | |

|Breakfast: 1 cup regular grits cooked with cheese and margarine, 1 large poached |According to MyPlate, the daily grain recommended intake for the patient is 5 oz.|

|egg, 2 slices of white toast, 2 tablespoons of salted butter, 1 mug (8 fl. oz.) |grains daily. The patient far exceeds this recommendation by more than half by |

|black coffee |consuming approximately 12 oz. of grains per day. This excess amount of |

| |carbohydrates is most likely a major contributing factor to the patient’s |

| |obesity. It would be helpful to recommend that the patient substitute some of her|

| |daily grains for some of the other food groups that she is lacking in, such as |

| |fruit. Perhaps rather than having toast for breakfast or a sandwich for lunch, |

| |she could substitute those for a fruit salad or a fruit smoothie. |

| | |

|Lunch: 1 McDonald’s salad with grilled chicken, lettuce, cheese, and tomato, 1 |According to MyPlate, the daily vegetable recommended intake for the patient is 2|

|packet of Ranch dressing, 1 peanut butter and jelly sandwich, 1 snack size |cups of vegetables daily. The patient exceeds this by a small margin and |

|container (4 oz.) chocolate pudding |consumes, on average, 2 ½ cups of vegetables per day. The patient does well at |

| |meeting this recommendation however it seems that most of her vegetable intake |

| |only comes from salads. MyPlate recommends choosing a variety of vegetables each |

| |day of all types of colors, including starchy vegetables and beans. It might be |

| |helpful to remind her that there are many forms of vegetables: raw, cooked, |

| |frozen, and canned. It should be recommended that she try new options of |

| |vegetables and try to have them with every meal of the day. |

| | |

|Dinner: 1 cup cooked pasta, 3 tablespoons Alfredo sauce, 1 tilapia fish fillet, 1|According to MyPlate, the daily fruit recommended intake for the patient is 1 ½ |

|cup salad with lettuce, cheese, tomato, and carrots, 1 packet ranch dressing |cups of fruit daily. The patient completely fails to meet this recommendation and|

| |consumes, on average, 0 cups of fruit per day. This could possibly be a |

| |detrimental deficiency to the patient’s health as she is most likely not |

| |consuming the adequate amount of fruit which contains necessary vitamins and |

| |nutrients. MyPlate suggests selecting various types of fruit such as: fresh, |

| |frozen, canned, and dried. It could be recommended that the patient substitute |

| |some of her snacks for some fresh fruit or yogurt fruit parfaits. |

| | |

|Snacks: 1 bag buttered microwave popcorn, 1 cup bite sized Chips Ahoy cookies |According to MyPlate, the daily dairy recommended intake for the patient is 3 |

| |cups of dairy daily. The patient fails to meet this recommendation and only |

| |consumes, on average, 2 ¼ cups of dairy per day. Seeing as though the patient is |

| |a postmenopausal woman, it is important that she receive adequate calcium in her |

| |diet, which is found in dairy products. MyPlate recommends to include fat-free |

| |and low-fat dairy products into meals every day in order to get the proper amount|

| |of calcium without the added calories. It could be recommended that the patient |

| |have some fat-free yogurt with breakfast or maybe even some low-fat frozen yogurt|

| |as a sweet snack instead of cookies and buttery popcorn. |

| | |

|Liquids (include alcohol): at least 8 cups (64oz.) of water a day. Patient states|According to MyPlate, the daily protein recommended intake for the patient is 5 |

|“other than a cup of coffee at breakfast, I usually only drink water throughout |oz. of protein daily. The patient exceeds this amount and consumes, on average, 9|

|the day.” |oz. of protein daily. This is not necessarily a bad thing, but by consuming so |

| |much protein, she could be neglecting some of the other nutrients. MyPlate |

| |recommends to choose variety when it comes to protein. There are many different |

| |options such as fish, poultry, beef, beans, and nuts. It might be helpful for the|

| |patient to select different types of proteins throughout the week and also to |

| |choose lean cuts of meat to avoid consuming too many calories. |

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|[pic] | |

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| |See below both the daily food tracker for patient’s average daily intake as well |

| |as well as daily food plan with recommended amounts of daily intake for the |

| |patient’s 1600 calorie diet. |

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|(1 COPING ASSESSMENT/SUPPORT SYSTEM: |

|Who helps you when you are ill? |

|“Usually nobody since I live by myself. If I’m ill, like I have been, I go to my cousin’s house.” |

|How do you generally cope with stress? or What do you do when you are upset? |

|“I take my Effexor to help me deal with stress and anxiety. Without that I’m not a happy camper. But I guess there are |

|other things I do, like reading or calling my sisters, or even talking to my cats.” |

| |

| |

|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |

|“I guess the most recent was on Sunday night after the doctor came to talk to me about my condition and told me that I |

|need to shape up and lose weight if I want to get to healthy. I cried for a long time after that, not because of what he said, |

|but because I was scared. What did I do to myself? How could I have let things get this bad?” |

| |

| |

|+2 DOMESTIC VIOLENCE ASSESSMENT |

| |

|Have you ever felt unsafe in a close relationship? “In the early 1980s, but I ended the relationship quickly” |

| |

|Have you ever been talked down to? “yes” Have you ever been hit punched or slapped? “he slapped me once, and I ended the relationship” |

| |

|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?  “no” If yes, have you sought help for |

|this?  _____________________ |

|Are you currently in a safe relationship? “Yes, with my sisters and my group of friends” |

| |

| |

|( 4 DEVELOPMENTAL CONSIDERATIONS: |

|Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. |

|Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair |

|Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your patient’s age group: |

|Generativity vs. Stagnation is the seventh out of eight stages of Erikson’s psychosocial development. “The goal of this |

|stage is to be creative and productive. […] The person who fails to achieve generativity (the desire and motivation to |

|guide the next generation) may manifest stagnation in the form of superficial relationships and self-absorption” (Treas & |

|Wilkinson, 2014, p.164). |

|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |

|The patient is currently in Erikson’s seventh stage of psychosocial development entitled “Generativity vs. Self-absorption/ |

|Stagnation” with “Self-absorption/Stagnation” being the option most applicable to her life. The patient seems somewhat |

|distressed about having lived to 62 years of age and not having much to show for it. She lived with her significant other |

|for 12 years before he passed away, but she has never been married and she has no children. And after he died, she |

|adapted poor coping skills that mainly consisted of over-eating to deal with her grief. She retired from her job in banking |

|and became severely overweight. The patient feels that she is at a very “stand-still” point in life and is struggling with |

|how to move forward and make a change. |

| |

| |

|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |

|The patient is convinced that her hospitalization will have a big impact on her life. She feels like she has been given a |

|second chance and she is ready to make big changes in her life in relation to her health. She wants to get healthy again so |

|that she can get her life back and “start living again.” |

| |

|+3 CULTURAL ASSESSMENT: |

|“What do you think is the cause of your illness?” |

|“I thought the shortness of breath was because I hadn’t been able to pick up my Effexor prescription and hadn’t taken it in |

|3 days, so I was trying to get myself in a happy place. But it turns out it was a lot more serious than just my anxiety.” |

| |

|What does your illness mean to you? |

|“It scared me a lot and its put me on the right track that I know I need to get healthier. I don’t want this to happen again |

|because the next time could be the last time and I might not make it through something like this again.” |

| |

|+3 SEXUALITY ASSESSMENT: |

| |

| |

|Have you ever been sexually active? “yes” |

|Do you prefer women, men or both genders? “men” |

|Are you aware of ever having a sexually transmitted infection?  “yes” |

|Have you or a partner ever had an abnormal pap smear? “no” |

|Have you or your partner received the Gardasil (HPV) vaccination? “no” |

| |

|Are you currently sexually active?   “no” When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an |

|unintended pregnancy? “I never really used any when I was sexually active” |

| |

|How long have you been with your current partner? “I was with my significant other for 12 years before he passed away” |

| |

|Have any medical or surgical conditions changed your ability to have sexual activity?  “I guess if I was sexually active, my leg wounds would probably change my |

|ability and even want to have sex” |

|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? |

|“no” |

±1 SPIRITUALITY ASSESSMENT:

What importance does religion or spirituality have in your life?

“It doesn’t really have any importance in my life. I’m not really a practicing Methodist. I pray occasionally but that’s it really.”

Do your religious beliefs influence your current condition?

“Yeah I guess they do. I’ve questioned a few times since I have been here as to why God let this happen to me.”

|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |

|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No |

| If so, what? N/A |How much?(specify daily amount) |For how many years? X years |

| | N/A |(age thru ) N/A |

| | | |

|Pack Years: | |If applicable, when did the patient quit? |

| | |N/A |

| | | |

|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? |Has the patient ever tried to quit? N/A |

|Mother smoked. Patient was exposed for first 18 years of life when she lived at home| |

|with her mother. | |

| |

| |

|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |

| What? |How much? (give specific volume) |For how many years? |

|“Usually scotch on the rocks is the only drink I like" |Very infrequently. “I had a scotch on the rocks 5 |(age 19 thru 62 ) |

| |weeks ago at a party, and then the last time I drank | |

| |was a glass of wine at a Christmas Eve party last | |

| |year. | |

| | | |

| If applicable, when did the patient quit? N/A | | |

| |

| |

|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |

| If so, what? |

| |How much? |For how many years? |

| | |(age thru ) |

| | | |

| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |

| | | |

| | | |

|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |

|“no” |

| |

| |

| |

| |

| |

| |

| |

| |

( 10 Review of Systems

|General Constitution |Gastrointestinal |Immunologic |

| Recent weight loss or gain | Nausea, vomiting, or diarrhea | Chills with severe shaking |

|Integumentary | Constipation Irritable Bowel | Night sweats |

| Changes in appearance of skin (unhealing ulcers on | GERD Cholecystitis | Fever |

|lower legs) | | |

| Problems with nails | Indigestion Gastritis / Ulcers | HIV or AIDS |

| Dandruff | Hemorrhoids Blood in the stool | Lupus |

| Psoriasis | Yellow jaundice Hepatitis | Rheumatoid Arthritis |

| Hives or rashes | Pancreatitis | Sarcoidosis |

| Skin infections | Colitis | Tumor |

| Use of sunscreen no SPF: | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: showers every other day |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

| | Last colonoscopy? 2008 | |

|HEENT |Other: |Hematologic/Oncologic |

| Difficulty seeing nearsighted |Genitourinary | Anemia |

| Cataracts or Glaucoma | nocturia patient reports it is normal for her | Bleeds easily |

| |because she drinks a lot of water | |

| Difficulty hearing deaf in left ear | dysuria | Bruises easily |

| Ear infections | hematuria | Cancer |

| Sinus pain or infections | polyuria | Blood Transfusions |

|Nose bleeds when on oxygen | kidney stones |Blood type if known: unknown to patient |

| Post-nasal drip |Normal frequency of urination: 9 x/day |Other: |

| Oral/pharyngeal infection | Bladder or kidney infections | |

| Dental problems | |Metabolic/Endocrine |

| Routine brushing of teeth 3 x/day | | Diabetes Type: |

| Routine dentist visits 2 x/year | | Hypothyroid /Hyperthyroid |

|Vision screening | | Intolerance to hot or cold |

|Other: | | Osteoporosis |

| | |Other: |

|Pulmonary | | |

| Difficulty Breathing | |Central Nervous System |

| Cough - dry or productive |Women Only | CVA |

| Asthma | Infection of the female genitalia | Dizziness |

| Bronchitis | Monthly self breast exam | Severe Headaches |

| Emphysema | Frequency of pap/pelvic exam | Migraines last major one was one year ago |

| Pneumonia | Date of last gyn exam? April 2015 | Seizures |

| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |

| Environmental allergies pine trees, oak trees, sable | menarche age? 11 | Encephalitis |

|palm, dogs | | |

|last CXR? 10/12/15 | menopause age? 45 | Meningitis |

|Other: |Date of last Mammogram &Result: 2013, normal results |Other: |

| |Date of DEXA Bone Density & Result: 2010, normal | |

| |results | |

|Cardiovascular |Men Only |Mental Illness |

|Hypertension | Infection of male genitalia/prostate? | Depression |

| Hyperlipidemia | Frequency of prostate exam? | Schizophrenia |

| Chest pain / Angina | Date of last prostate exam? | Anxiety |

|Myocardial Infarction | BPH | Bipolar |

| CAD/PVD |Urinary Retention |Other: |

|CHF |Musculoskeletal | |

|Murmur | Injuries or Fractures |Childhood Diseases |

| Thrombus | Weakness | Measles |

|Rheumatic Fever | Pain | Mumps |

| Myocarditis | Gout | Polio |

| Arrhythmias | Osteomyelitis | Scarlet Fever age 5 |

| Last EKG screening, when? 10/11/15 |Arthritis | Chicken Pox age 23 |

|Other: |Other: |Other: |

| | | |

|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |

|“no” |

| |

| |

| |

| |

| |

| |

|Any other questions or comments that your patient would like you to know? |

|“no, I think you about covered everything” |

| |

| |

| |

| |

|±10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes) |

|General Survey: Patient is a very |Height: 60 inches |Weight: 267 lb. BMI: 52.1 |Pain: (include rating & location) |

|talkative and pleasant 62 year old woman | | |0/10, patient denies any pain |

|who is alert and oriented x3. Patient is | | | |

|obese but looks her stated age. She is | | | |

|dressed in street clothes in preparation | | | |

|for discharge and is in no sign of | | | |

|obvious distress. | | | |

| |Pulse: 81 |Blood | |

| | |Pressure: | |

| | |(include location) | |

| | | | |

| | |148/77 (right upper arm) | |

|Temperature: (route taken?) |Respirations: 19 | | |

|98.1 (oral) | | | |

| |SpO2 96 |Is the patient on Room Air or O2: 3L Nasal Cannula |

|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |

| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |

| |

| |

|Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] |

| awake, calm, relaxed, interacts well with others, judgment intact |

| |

|Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] |

| clear, crisp diction |

| |

|Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat |

| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |

|Other: |

|Integumentary | |

| Skin is warm, dry, and intact (patient has unhealed ulcers on both ankles) | |

| Skin turgor elastic | |

| No rashes, lesions, or deformities | |

| Nails without clubbing | |

| Capillary refill < 3 seconds | |

| Hair evenly distributed, clean, without vermin | |

|The only visible skin markings were the unhealed ulcers on both ankles, when | |

|asked if she had any other scars, patient reported the one on the back of her | |

|neck and upper back from C spine decompressive surgery. | |

| | |

| | |

| | |

| Peripheral IV site Type: 22 gauge Location: left AC Date inserted: 10/11/15 |

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? |

| Peripheral IV site Type: Location: Date inserted: |

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? |

| Central access device Type: Location: Date inserted: |

|Fluids infusing? no yes - what? |

| |

|HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline |

| Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge |

| Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |

| PERRLA pupil size equal bilaterally Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |

| Ears symmetric without lesions or discharge Whisper test heard: right ear-24 inches & left ear- 0 inches (patient is deaf in left ear) |

| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |

|Dentition: |

|Comments: |

| |

|Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric |

| | | Lungs clear to auscultation in all fields without adventitious sounds |

| |CL – Clear |Percussion resonant throughout all lung fields, dull towards posterior bases |

| |WH – Wheezes |Sputum production: thick thin Amount: scant small moderate large |

| |CR - Crackles | Color: white pale yellow yellow dark yellow green gray light tan brown red |

| |RH – Rhonchi | |

| |D – Diminished | |

| |S – Stridor | |

| |Ab - Absent | |

| | | |

| | | |

|Cardiovascular: No lifts, heaves, or thrills PMI felt at: 5th IC space, mid-clavicular line |

|Heart sounds: S1 S2 Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD |

|Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze) |

|Patient was being prepared for discharge and was already taken off of telemetry monitoring. Patient’s chart had also been emptied in preparation for discharge and a |

|copy of the EKG was not able to be made. I did look at the image on the computer chart though and analyzed that it showed normal sinus rhythm. |

| |

| |

| |

| |

| |

| |

| Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding] |

|Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 2 PT: 2 |

|No temporal or carotid bruits Edema: 0 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ] |

|Location of edema: pitting non-pitting |

|Extremities warm with capillary refill less than 3 seconds |

| |

| |

| |

| |

| |

|GI/GU: Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly |

|Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation |

|Urine output: Clear Cloudy Color: pale yellow Previous 24 hour output: 1,000 mLs |

|Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance |

|CVA punch without rebound tenderness |

|Last BM: (date 10 / 20 / 15 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |

|Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red |

|Hemoccult positive / negative (leave blank if not done) |

|Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |

| Other – Describe: |

| |

| |

|Musculoskeletal: ( Full ROM intact in all extremities without crepitus |

|Strength bilaterally equal at ___5____ RUE ___5____ LUE ___5____ RLE & ___5____ in LLE |

|[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance] |

|vertebral column without kyphosis or scoliosis |

|Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias |

| |

| |

| |

|Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |

|CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative |

|Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride |

|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |

|Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: |

|positive negative (not performed) |

|*Patient’s gait was not smooth and regular with symmetric length of stride. She is unsteady on her feet and uses a walker. |

|*DTR was not assessed due to unavailable equipment |

| |

| |

|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS |

| |

| |

|Lab |

|Dates |

|Trend |

|Analysis |

| |

|INR: |

| |

|1.0 |

| |

|1.0 |

| |

|1.1 |

| |

|1.4 |

| |

|2.2 |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|Normal: 2-3 for patients receiving anticoagulant therapy |

| |

| |

|(10/11/15) 18:30 |

| |

|(10/12/15) 06:48 |

| |

|(10/13/15) 06:12 |

| |

|(10/14/15) 06:13 |

| |

|(10/17/15) 06:28 |

| |

| |

|The patient’s INR levels slowly trended upward through the days she was in the hospital, which was to be expected since she was started on warfarin, and it was |

|anticipated that her INR levels would rise to therapeutic levels of between 2 and 3. |

|Since the patient experienced a pulmonary embolus and a DVT, it was necessary to put her on anticoagulant therapy in order to thin her blood and slow her clotting |

|time to prevent other clots from forming. Warfarin (which is measured by INR levels) was started at the same time as the heparin, but since it takes a few days to |

|become therapeutic, the patient remained on heparin until the INR reached a therapeutic level of 2.2 at which point the heparin was discontinued and the patient will|

|be going home on continued warfarin therapy. |

| |

|PT: |

| |

|11.0 seconds |

| |

|11.4 seconds |

| |

|12.3 seconds |

| |

|15.9 seconds H |

| |

|24.8 seconds H |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|Normal: 10-13 seconds |

| |

| |

|(10/11/15) 18:30 |

| |

|(10/12/15) 06:48 |

| |

|(10/13/15) 06:12 |

| |

|(10/14/15) 06:13 |

| |

|(10/17/15) 06:28 |

| |

|The patient’s prothrombin time results slowly increased over the days which she was in the hospital. This was to be expected since she was on both heparin and |

|warfarin treatments at this time. |

|Since the patient was on extensive anticoagulant treatment to manage her pulmonary embolism and to prevent new clots from forming, it is expected that her PT |

|intervals would be trended upward, meaning that it took the blood longer than normal to clot when it was tested. For someone on anticoagulant therapy, this is a |

|desired result as it will prevent new clots from forming as easily. However, since the heparin was discontinued after the last lab result was drawn, it would be |

|anticipated that the PT interval would trend down slightly since the patient is now only on warfarin. |

| |

|Troponin – I: |

| |

|1.140 ng/mL H |

| |

|1.130 ng/mL H |

| |

|1.000 ng/mL H |

| |

| |

| |

| |

| |

| |

| |

|Normal: less than 0.5 ng/mL |

| |

| |

|(10/11/15) 18:30 |

| |

|(10/12/15) 06:48 |

| |

|(10/13/15) 06:12 |

| |

| |

|The patient’s troponin levels are on a downward trend which is a good sign. It was originally thought on admission that the patient could be having an MI, however |

|that was ruled out by the physician. It is still important though to keep an eye on the troponin levels and make sure that they continue to decline. |

|In the physician’s notes, he stated that the elevated troponin levels were most likely due to the pulmonary embolism. It is not unusual for a large pulmonary |

|embolism like the patient had to cause myocardial ischemia because of severe hypoxia. The elevated troponin levels showed that this damage occurred to the heart |

|muscle following the lack of oxygen. |

| |

|WBC: |

| |

|10,600/mm3 |

| |

|10,600/mm3 |

| |

|11,600/mm3 H |

| |

|7,600/mm3 |

| |

|8,000/mm3 |

| |

| |

| |

| |

| |

|Normal: 5,000-11,000/mm3 |

| |

| |

|(10/11/15) 18:30 |

| |

|(10/12/15) 06:48 |

| |

|(10/13/15) 06:12 |

| |

|(10/14/15) 06:13 |

| |

|(10/17/15) 06:28 |

| |

|The patient’s white blood cell count remain in a fairly constant state within the normal range, except for one day when they were slightly elevated. However that |

|could be attributed to a testing error or could have just been an anomaly for the day. |

|It is expected that the patient’s white blood cell count stay within the normal range. An elevated WBC count could mean the presence of infection. And especially |

|since the patient has the unhealing ulcers on her ankles and lower legs related to the Pyoderma Gangrenosum, it puts her at increased risk for infection. So it is |

|important to keep an eye on her white blood cell levels and make sure they don’t get too high. |

| |

|HGB: |

| |

|12.5 g/dL |

| |

|12.8 g/dL |

| |

|11.6 g/dL L |

| |

|12.1 g/dL |

| |

|12.2 g/dL |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|Normal: 12-16 g/dL |

| |

| |

|(10/11/15) 18:30 |

| |

|(10/12/15) 06:48 |

| |

|(10/13/15) 06:12 |

| |

|(10/14/15) 06:13 |

| |

|(10/17/15) 06:28 |

| |

|The patient’s hemoglobin levels remained in a fairly constant state within the normal range, except for one day when they were slightly lower than normal. However, |

|that could be attributed to a testing error or could have just been an anomaly for the day. |

|Since the patient is on anticoagulant therapy, it is important to make sure that her hemoglobin levels are remaining normal and stable. Since the patient has been on|

|heparin and warfarin while in the hospital, it puts her at increased risk for bleeding. And if she experiences too much bleeding than she could become anemic and |

|this would be displayed in the hemoglobin levels with the red blood cells not receiving enough oxygen. Therefore it is important to keep an eye on the hemoglobin |

|levels and make sure that they stay within the normal range. |

| |

|Potassium: |

| |

|5.0 mg/dL |

| |

|4.6 mg/dL |

| |

|4.5 mg/dL |

| |

|4.5 mg/dL |

| |

|4.8 mg/dL |

| |

| |

| |

| |

| |

|Normal: 3.5-5.3 mg/dL |

| |

| |

|(10/11/15) 18:30 |

| |

|(10/12/15) 06:48 |

| |

|(10/13/15) 06:12 |

| |

|(10/14/15) 06:13 |

| |

|(10/17/15) 06:28 |

| |

|The trend for potassium levels remains fairly constant throughout the time the patient is in the hospital. This trend would be expected to continue without change. |

|Since the patient is on a loop diuretic to help control her hypertension, it is important that her potassium levels be monitored. Loop diuretics are the most |

|powerful diuretics and are also potassium wasting which puts the patient at risk for hypokalemia. If the potassium levels were seen to be decreasing, this could be |

|cause for concern and possibly adding extra potassium to the patient’s diet. |

| |

|Glucose: |

| |

|122 mg/dL H |

| |

|153 mg/dL H |

| |

|113 mg/dL H |

|102 mg/dL H |

| |

|107 mg/dL H |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|Normal: 60-100 mg/dL |

| |

| |

|(10/11/15) 18:30 |

| |

|(10/12/15) 06:48 |

| |

|(10/13/15) 06:12 |

| |

|(10/14/15) 06:13 |

| |

|(10/17/15) 06:28 |

| |

|The patient shows a fairly steady trend of slightly elevated blood glucose levels. This is unexpected as the patient is not a diabetic and has never been treated for|

|diabetes before. |

|These slightly elevated levels of blood glucose could be emerging evidence of the patient being in the pre-diabetes stage and approaching an actual diagnosis of |

|diabetes. It would make sense since she does have diabetes in her family history. She also exhibits all of the symptoms of metabolic syndrome including: high blood |

|pressure, excess body fat around the waist, and high cholesterol, all of which put her at risk for diabetes. If she is not able to manage these things with lifestyle|

|changes, she will most likely soon have to start treatment for diabetes as well. |

| |

|BUN: |

| |

|29 mg/dL H |

| |

|29 mg/dL H |

| |

|43 mg/dL H |

| |

|36 mg/dL H |

| |

|29 mg/dL H |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|Normal: 10-20 mg/dL |

| |

| |

|(10/11/15) 18:30 |

| |

|(10/12/15) 06:48 |

| |

|(10/13/15) 06:12 |

| |

|(10/14/15) 06:13 |

| |

|(10/17/15) 06:28 |

| |

|The patient’s blood urea nitrogen levels show a marked elevated trend throughout her time in the hospital. This is also another unexpected finding seeing as though |

|her Creatinine levels were all in normal levels, with not one elevated levels reported. |

|My best analysis of the patient’s elevated BUN levels but normal Creatinine levels would be explained by what we recently learned in class. BUN levels are affected |

|by hydration levels and protein intake, whereas Creatinine is dependent completely on kidney function. This is why Creatinine is a more constant and reliable test of|

|kidney function. Seeing as though the patient consumes excess protein than is necessary in her 24 hour diet recall, her BUN could be elevated because of all the |

|excess protein in her body. |

| |

| |

|*All normal lab values were referenced from (Unbound Medicine, Inc., 2015) |

| |

|Diagnostic Procedures: |

|A diagnostic 12 lead ECG was performed on admission on 10/11/15. An ECG or electrocardiogram is a |

|noninvasive study that “measures the electrical currents or impulses that the heart generates during a cardiac |

|cycle” (Unbound Medicine, Inc., 2015). This diagnostic test was performed because it was suspected that the |

|patient was experiencing an NSTEMI. However, the results showed a normal sinus rhythm with an elevated rate |

|from baseline, most likely related to the hypoxia and anxiety the patient was experiencing. |

|A chest x ray was also done on admission on 10/11/15 to look at both the heart and the lungs and make sure the |

|patient was not having an MI, but also to see what was causing the hypoxia. A chest x-ray is one of the most |

|common radiological diagnostic tests where the lungs and heart are “easily penetrated by x-rays and appear on |

|chest images” (Unbound Medicine, Inc., 2015). The results of the CXR are as follows: The heart is enlarged but |

|there is no focal infiltrate present; no effusion or pneumothorax is seen in the lungs. At this point the physician |

|was fairly confident that an MI was not occurring, but he still was not sure what was wrong with her lungs. |

|An angio chest CT scan was then performed to look specifically at the lungs. “Computed tomography |

|angiography is a noninvasive procedure that enhances certain anatomic views of vascular structures” (Unbound |

|Medicine, Inc., 2015). It allows the blood vessels to be studied in great detail to assess for aneurysm, embolism, |

|or stenosis. The results of that test are as follows: presence of intraluminal filling defect consistent with acute |

|thrombus involving the right main pulmonary artery, right upper lobe, right lower lobe branches; on the left there |

|is thrombus in the lingual, secondary branches of the right lower lobe as well as upper lobe branches. The final |

|impression was “bilateral pulmonary embolism.” |

|A venous doppler ultrasound was then performed on the veins in both lower extremities to look for a |

| possible cause of the embolism in the lungs. Ultrasound procedures use high frequency sound waves that bounce |

|off of internal structures to create an image. They are used to “obtain information about the patency of the venous |

|vasculature in the upper and lower extremities to identify narrowing or occlusions of the veins or arteries” |

|(Unbound Medicine, Inc., 2015). In this case the US showed that the right peroneal calf veins were not visible |

|and that there was a right peroneal deep vein thrombosis. Clots from this location most likely broke off and |

|traveled to the lungs where they caused the pulmonary embolism. |

| |

| |

|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: |

|Patient is scheduled to turn, cough, and deep breathe every hour to open the airway, provide oxygen to the lungs and body, and prevent pneumonia while lying in the |

|hospital bed |

|Dressing change ordered: for both lower legs and ankles- cleanse with saline, pat dry, apply Acticoat Flex 3 (lightly moistened with water) followed by dry dressing-|

|change every 3 days. This is to keep the unhealing ulcers dry and free of infection. |

|SCDs ordered to prevent further deep vein thrombosis while lying in the hospital bed |

|I&Os ordered q8hrs to make sure urinary stasis does not occur due to immobility |

|Vital signs ordered q8hrs to check for any discrepancies from baseline vitals and also to make sure that antihypertensives are appropriate to give |

|Daily weight is ordered to make sure that the patient does not gain or lose significant amounts of weight in a short amount of time which could be indicative of a |

|more serious health issue |

|Patient is ordered a cardiac diet due to history of hypertension and obesity |

|Obtain and order a 12 lead ECG as needed for chest pain. This is a precautionary measure since the patient was initially thought to be having a NSTEMI |

|Physical Therapy is ordered daily. The patient has had minimal physical activity for a long time which is likely the cause of her PE and DVT. Suggestion of PT is |

|useful to get her moving again and to help prevent further clots |

|Metered dose inhaler treatment, routine 2x daily for the patient’s asthma and also to help with the hypoxemia she suffered from the pulmonary embolism |

|CPAP ordered nightly to manage the patient’s sleep apnea |

| |

|( 8 NURSING DIAGNOSES |

|1. Impaired gas exchange related to altered blood flow to the alveoli secondary to lodged embolus, as evidenced by the patient’s shortness of breath and need for |

|supplemental oxygen (Ackley & Ladwig, 2014a). |

| |

| |

|2. Imbalanced nutrition: more than body requirements related to excessive intake in relation to metabolic needs and sedentary lifestyle, as evidenced by the |

|patient’s severe obesity and BMI of 52.1 (Ackley & Ladwig, 2014b). |

| |

| |

|3. Fear related to the threat of death, as evidenced by the patient stating “Oh my God, I have never been so scared in all my life! I thought I was going to die!” |

|(Ackley & Ladwig, 2014c). |

| |

| |

|4. Ineffective peripheral tissue perfusion related to deep vein thrombus formation as evidenced by weakened lower extremity peripheral pulses (Ackley & Ladwig, |

|2014d). |

| |

| |

|5. Activity intolerance related to patient’s severe obesity, as evidenced by the patient’s current sedentary lifestyle and the need to use a walker in order to |

|ambulate (Ackley & Ladwig, 2014e). |

| |

| |

± 15 CARE PLAN

Nursing Diagnosis: Impaired gas exchange related to altered blood flow to the alveoli secondary to lodged embolus, as evidenced by the patient’s shortness of breath and need for supplemental oxygen (Ackley & Ladwig, 2014a).

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day care is Provided |

| | |Provide References | |

|Short Term: Patient will exhibit an adequate gas |*Monitor the patient’s respiratory rate, depth, and |-It is important to monitor the patient on a regular |The goal was met. By the end of the shift the patient|

|exchange and respiratory function by maintaining a |ease of breathing. Also check to see if the patient |basis to see if she is having difficulty breathing. |had a respiratory rate of 19 and was breathing |

|respiratory rate of 12-20 breaths per minute and |needs to use accessory muscles to breathe. |An increase in respiration could be a sign that she |comfortably on 3L nasal cannula. |

|reporting the ability to breathe comfortably on | |is not getting enough oxygen. “Normal respiratory | |

|supplemental oxygen by the end of shift. | |rate is 10-20 breaths/min in the adult” (Jarvis, | |

| | |2012, as cited in Ackley & Ladwig, 2014a). | |

| | | | |

| | |-“Changes in behavior and mental status can be early | |

| | |signs of impaired gas exchange” (Schultz, 2011, as | |

| |*Monitor the patient’s behavior and mental status for|cited in Ackley & Ladwig, 2014a). It is necessary to | |

| |signs of restlessness, agitation or confusion. |know if the patient’s mental status has changed from | |

| | |their baseline because it could be the first clue | |

| | |pointing to them not getting an adequate amount of | |

| | |oxygen to their lungs and surrounding tissues, | |

| | |including the brain. | |

| | | | |

| | |-By having the patient in a sitting position, it | |

| | |helps to expand the lungs making it easier to breathe| |

| | |and providing more effective gas exchange. Also, it | |

| | |has been shown that patients have a decreased | |

| | |incidence of hospital acquired pneumonia if they are | |

| |*Place the patient in a semi-fowler’s position with |placed “in a 30-45 degree semirecumbent position as | |

| |the head of the bed having at least 30 degrees |opposed to a supine position” (Siela, 2010, as cited | |

| |elevation. Encourage her to sit up as much as |in Ackley & Ladwig, 2014a). | |

| |possible rather than lying down in bed. | | |

| | |*Using the tripod position helps also to expand the | |

| | |lungs and airway to improve the quality of breathing | |

| | |and help more oxygen get into the lungs. Also, | |

| | |“leaninf forward can help decrease dyspnea, possibly | |

| | |because gastric pressure allows better contraction of| |

| | |the diaphragm” (Langer et al, 2009, as cited in | |

| | |Ackley & Ladwig, 2014). | |

| |*If the patient is displaying acute dyspnea, have | | |

| |them lean forward on the bedside table in the tripod |-“The hypoxic client has limited reserves; | |

| |position. |inappropriate activity can increase hypoxia” (Ackley | |

| | |& Ladwig, 2014a). While it is important to get the | |

| | |patient up and moving again to increase activity | |

| | |tolerance, it needs to be done at a slow and gradual | |

| | |interval. The patient has been under a lot of | |

| | |physical and emotional stress and needs time to rest | |

| | |and recover from that. She doesn’t want to push | |

| | |herself too fast. | |

| |*Schedule the patient’s care to provide rest and | | |

| |minimize fatigue. Gradually increase amounts of | | |

| |physical therapy as the patient can tolerate them. | | |

|Long Term: Patient will be able to breathe |*Discuss with the patient what strategies help her |-Because the patient has had a pulmonary embolism and|Goal was not met by the end of shift. |

|comfortably while performing daily activities of |most during times of dyspnea. Educate the patient on |a DVT, her current weight and sedentary lifestyle put|Suggest reevaluating the patient in 3 months to see |

|living and maintain an O2 saturation of 95% or higher|how to self-manage the symptoms of dyspnea and when |her at risk for another. She needs to be aware of the|if she can function in her activities of daily living|

|without supplemental oxygen within 3 months of |she should call a health care professional. |signs and symptoms so that if it happens again, she |without supplemental oxygen while maintaining an O2 |

|discharge. | |can get help much faster than before. However, if she|saturation of 95% or higher. |

| | |is just experiencing dyspnea from weakness and trying| |

| | |to wean off of the supplemental oxygen, there are | |

| | |many self-managing techniques that could help. “A | |

| | |study found that use of oxygen, self-use of | |

| | |medication, and getting some fresh air were most | |

| | |helpful in dealing with dyspnea” (Thomas, 2009, as | |

| | |cited in Ackley & Ladwig, 2014a). | |

| | | | |

| | |“Clients with decreased oxygenation have decreased | |

| | |energy to carry out personal and role-related | |

| | |activities” (Ackley & Ladwig, 2014a). Since the | |

| |*Refer the client to home health services as needed |patient lives alone, she may need some help, at | |

| |for assistance with activities of daily living. |first, with her daily ADLs until she regains her | |

| | |strength and is able to continue her daily activities| |

| | |without shortness of breath. | |

| | | | |

| | |-Since the patient is going home on supplemental | |

| | |oxygen and has only used it before in the hospital, | |

| | |it is likely that she will have some questions and | |

| | |room for knowledge in how to use the oxygen she is | |

| | |being discharge with. “Client education improves | |

| |*Educate the patient about home oxygen therapy, |compliance with prescribed use of oxygen” (Ackley & | |

| |including the delivery system, liter flow, safety |Ladwig, 2014a). | |

| |precautions, and number of tanks needed. | | |

| | |-Physical therapy can be beneficial to the patient by| |

| | |helping her to increase her activity level and | |

| | |tolerance first with the supplemental oxygen, and | |

| | |then without it. It would be important to have a | |

| | |physical therapist help with this tolerance building | |

| | |because he would be able to formulate a plan based on| |

| |*Refer the patient to physical therapy, both while |the patient’s ability and needs and would be able to | |

| |she is in the hospital and when she returns to her |help should respiratory distress and dyspnea occur | |

| |home. |during the therapy (Ackley & Ladwig, 2014a). | |

|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |

|Consider the following needs: |

|□SS Consult * -consult to SS to help set up home health to help with oxygen and physical therapy |

|□Dietary Consult * -have dietary come discuss healthier food options to lose weight |

|□PT/ OT * -consult PT to continue working with patient at home to help her with activity tolerance without the use of supplemental oxygen |

|□Pastoral Care |

|□Durable Medical Needs |

|□F/U appts * -help patient set up follow up appointments and have her arrange for someone to drive her if she is not able to |

|□Med Instruction/Prescription * -teach patient about new medications that she has been put on, especially Coumadin and the risk for bleeding as well as the importance of not eating too much Vitamin K |

|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |

|□Rehab/ HH |

|□Palliative Care |

± 15 CARE PLAN

Nursing Diagnosis: Imbalanced nutrition: more than body requirements related to excessive intake in relation to metabolic needs and sedentary lifestyle, as evidenced by the patient’s severe obesity and BMI of 52.1 (Ackley & Ladwig, 2014b).

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |

| | |Provide References | |

|Short Term: Patient will design a plan of dietary and|*Educate the patient on how to keep a food diary to |-By keeping a record of all that she eats in a day, |Goal was not met by the end of shift. |

|lifestyle modifications to meet her individual |keep track of everything she eats. If applicable, |it helps to bring reality to the patient of how much |Patient had expressed a desire to change her |

|long-term goal of weight loss by the time of |help the patient set up an app on her smart phone |she is actually eating, and therefore can help |lifestyle but had not yet formulated a plan as to |

|discharge. |that can make this task easy for her. |decrease the amount she chooses to eat. An app on a |how. Suggest that the nurse go over these |

| | |smart phone may be even more helpful since “a study |interventions with her prior to discharge and help to|

| | |found that use of a personal digital assistant for |get a plan set up. |

| | |self-monitoring of food intake was more effect than | |

| | |use of a paper record, yet both groups had a similar | |

| | |weight loss” (Acharya et al, 2011, as cited in Ackley| |

| | |& Ladwig, 2014b). | |

| | | | |

| | |-“Measuring food alerts the client to normal portion | |

| | |sizes. Estimating amounts can be extremely | |

| | |inaccurate” (Ackley & Ladwig, 2014b). Most patients | |

| |*Teach the patient how to measure food and give her |are unaware what appropriate portion sizes actually | |

| |information on appropriate portion sizes for each |are and just fill their plates with however much they| |

| |meal. |think they can eat. This causes them to over-eat a | |

| | |majority of the time. | |

| | | | |

| | |-By getting the patient more involved with the | |

| | |planning, it gives her a better sense of control over| |

| | |the situation. By using the Supertracker to plan her | |

| | |meals and get an analysis on everything she is | |

| | |eating, it can help her to make healthier choices. | |

| |*Show the patient how to use the Supertracker at |“To lose weight, the client must eat fewer calories, | |

| | to plan her diet, determine the |or expend more calories, or preferably do both” | |

| |number of calories she should be eating each day, and|(Academy of Nutrition and Dietetics, 2012, as cited | |

| |gain more information on how to eat healthily. |in Ackley & Ladwig, 2014b). | |

| | | | |

| | |-Most patients, and people for that matter, don’t | |

| | |bother to read food labels. And for that reason they | |

| | |eat much more than they should. They eat the whole | |

| | |container which actually may contain 3 serving sizes,| |

| | |and therefore they need to take into consideration | |

| | |that the amount of fats and carbs they thought they | |

| |*Teach the patient how to read food labels and to |just ate should actually be multiplied by 3. | |

| |concentrate specifically on serving size, total fats,|“Saturated fats and sugars contribute the least to a | |

| |and simple carbohydrates. |healthful diet and the most to excessive calorie | |

| | |intake” (Lutz & Przytuulski, 2011, as cited in Ackley| |

| | |& Ladwig, 2014b). | |

| | | | |

| | |-“A meta-analysis found that diet plus exercise | |

| | |resulted in significantly greater weight loss than a | |

| | |diet-only intervention for weight loss” (Wu, Gao, & | |

| | |Chan, 2009, as cited in Ackley & Ladwig, 2014b). This| |

| | |makes sense, and is important to stress to the | |

| | |patient. You can lose weight by restricting calories,| |

| | |but you can lose even more weight by burning off | |

| | |stored calories and fat that is already in the body. | |

| | | | |

| | | | |

| | | | |

| |*Inform the patient about the disadvantages and | | |

| |difficulties of trying to lose weight by dieting | | |

| |alone, and encourage her to include exercise in the | | |

| |weight loss plan. | | |

|Long Term: Patient will lose weight in a reasonable |*Recommend that the patient try to lose weight |“Slower weight loss is generally more likely to be |Goal was not met by the end of shift. |

|period of 1-2 pounds per week through diet and |slowly, at a about a rate of 1-2 pounds per week, |lasting weight loss. It is important that increased |Suggest doing a follow up with the patient in a year,|

|exercise within the next year. |using both a healthy diet and exercise. |activity be included to help burn more calories and |and assessing her lifestyle modifications and how |

| | |to give the client all the benefits of exercise” |they correlate to any changes in her weight and BMI. |

| | |(Ackley & Ladwig, 2014b). Also, it needs to be taken | |

| | |into consideration that the patient has just spent a | |

| | |considerable amount of time in the hospital for a | |

| | |life threatening condition. If she tries to do too | |

| | |much, too fast, she could seriously hurt herself and | |

| | |end up back in the hospital. | |

| | | | |

| | |“A study demonstrated that people who skipped | |

| | |breakfast were 450 times more likely to be obese” (Ma| |

| | |et al, 2003, as cited in Ackley & Ladwig, 2014b). By | |

| | |eating a healthy and nutritious breakfast, the body | |

| |*Remind the patient of the importance of eating a |is getting the adequate calories it needs after | |

| |healthy breakfast every morning. |fasting the night before, and it will sustain hunger | |

| | |until lunch so the patient is not absent mindedly | |

| | |snacking on junk food throughout the day. | |

| | | | |

| | |-Fast food is cheap and fast for a reason, because it| |

| | |is unhealthy and not beneficial to someone who is | |

| | |trying to lose weight. It has been shown that “people| |

| | |who often eat fast foods gain an average of 10 pounds| |

| | |more than those who eat fast food less often, and | |

| | |were two times more likely to develop insulin | |

| | |resistance, which can lead to diabetes (Pereira, | |

| |*Advise the patient to avoid eating in fast food |Kartashov, & Ebbeling, 2005, as cited in Ackley & | |

| |restaurants. |Ladwig, 2014b). | |

| | | | |

| | |-Although the patient currently uses a walker to | |

| | |assist her with moving around, it is likely that with| |

| | |a decrease in weight this will no longer be necessary| |

| | |and the patient will be able to walk for longer and | |

| | |further. “A study demonstrated that in middle-aged | |

| | |women, those who walked more had lower BMIs, and that| |

| | |women who walked 10,000 or more steps per day were in| |

| | |the normal range for BMI (Thompson et al, 2004, as | |

| | |cited in Ackley & Ladwig, 2014b). | |

| | | | |

| | |-In her 24 hour dietary recall, fruits and vegetables| |

| |*Recommend that the patient continue to work with |were a big part of the diet that the patient was | |

| |physical therapy at home and to begin walking more, |lacking in. These are food groups that she cannot | |

| |using a pedometer to help track the number of steps |afford to omit. “Vegetables are low in calories: 10 | |

| |she takes. |to 50 calories per serving, yet packed with vitamins,| |

| | |minerals, and phytochemicals, which can protect from | |

| | |disease” (Liebman & Hurley, 2009, as cited in Ackley | |

| | |& Ladwig, 2014b). | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| |*Encourage the patient to increase intake of | | |

| |vegetables and fruits to at least 5 servings per day.| | |

|± DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |

| |

|Consider the following needs: |

|□SS Consult * -consult to SS to help set up home health to help with oxygen and physical therapy |

|□Dietary Consult * -have dietary come discuss healthier food options to lose weight |

|□PT/ OT * -consult PT to continue working with patient at home to help her with activity tolerance without the use of supplemental oxygen |

|□Pastoral Care |

|□Durable Medical Needs |

|□F/U appts * -help patient set up follow up appointments and have her arrange for someone to drive her if she is not able to |

|□Med Instruction/Prescription * -teach patient about new medications that she has been put on, especially Coumadin and the risk for bleeding as well as the importance of not eating too much Vitamin K |

|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |

|□Rehab/ HH |

|□Palliative Care |

References

Ackley, Betty J. & Ladwig, Gail B. (2014a). Impaired gas exchange. In Nursing diagnosis handbook: an

evidence-based guide to planning care (pp. 374-378). St. Louis, MO: Mosby Elsevier.

Ackley, Betty J. & Ladwig, Gail B. (2014b). Imbalanced nutrition: more than body requirements. In Nursing

diagnosis handbook: an evidence-based guide to planning care (pp. 564-570). St. Louis, MO: Mosby

Elsevier.

Ackley, Betty J. & Ladwig, Gail B. (2014c). Fear. In Nursing diagnosis handbook: an evidence-based guide to

planning care (pp. 353-357). St. Louis, MO: Mosby Elsevier.

Ackley, Betty J. & Ladwig, Gail B. (2014d). Ineffective peripheral tissue perfusion. In Nursing diagnosis

handbook: an evidence-based guide to planning care (pp. 810-815). St. Louis, MO: Mosby Elsevier.

Ackley, Betty J. & Ladwig, Gail B. (2014e). Activity intolerance. In Nursing diagnosis handbook: an

evidence-based guide to planning care (pp. 120-125). St. Louis, MO: Mosby Elsevier.

. (2015). Adult BMI calculator. Retrieved 05 November 2015, from

ml

. (2015). Daily food plans. Retrieved 06 November 2015, from



Huether, Sue E. & McCance, Kathryn L. (2012). Chapter 26: Alterations of pulmonary function.

In Understanding pathophysiology (pp.698-699). St. Louis, MO: Elsevier Mosby.

Supertracker.. (2015). SuperTracker: My Foods. My Fitness. My Health.. Retrieved 06 November

2015, from

Treas, L., & Wilkinson, J. (2014). Development: infancy through middle age. In Basic nursing: concepts,

skills, & reasoning (pp. 164). Philadelphia, PA: F.A. Davis Company.

Unbound Medicine, Inc. (2015). Nursing Central (1.25.) [Mobile application software]. Retrieved from



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