NURS 111 Major Client Data Packet
Major Client Data Packet
NURS 110
Data Sheet / Projected plan of care / Pathophysiology
Student Name Sam Sanderson Date(s) of Care 10/5/2009
Instructor Name Brenda Anderson Agency Skilled Nursing Room # 503
| |Reason Client is at Long-Term Care facility: S/P ORIF left hip 2 weeks ago. Needs |
|Client initials KD Age 79 Gender: Female |rehabilitation for mobility and a dietary consult. The plan is that she will return home |
| |with her son or other living arrangements will be explored. When the patient is strong |
|Allergies NKDA |enough to be independent she will be discharged. |
| | |
|CODE STATUS Full Code |Pathophysiology of Medical Diagnosis : etiology, pathogenesis, clinical manifestations / |
| |signs and symptoms |
|Ht 5’4” Admit wt 48 kg Current wt 47.5 kg |Use Lewis Medical-Surgical Nursing Text |
| |Add additional pages if necessary |
|Mobility Needs: |Choose a different condition each week |
|Ability to Ambulate/Transfer: 1-person assist | |
| |Definition: Osteoporosis is a chronic and progressive disease that causes bones to become |
|Assistive devices: walker |fragile. |
| |Etiology: Risk factors are old age, being female, early menopause or oophorectomy, family |
|Sensory Needs: |history, white or Asian race, small stature, sedentary lifestyle, history of anorexia, |
|Glasses or Hearing Aids: None |excessive use of caffeine, or dietary calcium deficiency. My patient is malnourished and |
| |calcium deficient. She also lives a sedentary lifestyle. |
|Nutritional Needs: Regular, Soft |Pathogenesis: Normally bone mass is completed by the age of 20. Bone loss is a normal part |
|Diet/Supplements: Calcium and iron supplements |of aging but the rate of loss is different for everyone depending on their risk factors. |
| |Normally bone is kept strong by equal deposition ( osteoblasts) and resorption |
|Swallowing difficulty (yes/no) No |(osteoclasts). In osteoporosis there is an imbalance where the resorption exceeds the |
| |deposition. The bone becomes increasingly porous and weakened making the patient more prone|
|Needs assist with feeding (yes/no) No |to fractures from the slightest trauma. |
| |Clinical Manifestations: Osteoporosis is many times asymptomatic and may be called “the |
|Self Care Needs: |silent disease” (Lewis, 2007, p. 1688). Fractures may result from a jolt, bump, or fall and|
|Ability to toilet self: Assist to bathroom |may be the first symptom of osteoporosis. Patient may have back pain or decreased height |
| |from loss of vertebral structure. Patients may also have kyphosis. My patient fell while |
|Incontinent (yes/no) No |getting out of the shower. It is unclear as to whether she fell and broke her hip or |
| |whether her hip broke spontaneously and caused the fall. |
|Bowel/bladder management: No |Source & Page #Lewis (7th ed.) p. 1686-1688 |
| | |
|Ability to bath/dress/groom self : Needs assistance | |
|r/t pain and decreased mobility | |
|PRIORITY FOCUSED ASSESSMENT |PROJECTED PRIORITY NURSING DIAGNOSIS |PROJECTED NURSING INTERVENTIONS |
|(INCLUDE RATIONALE) |(INCLUDE RATIONALE) |(minimum 3) |
| | |(only 1 r/t assessment or monitoring |
|Musculoskeletal |ND: Impaired Physical Mobility |-Assess pain, gait, muscle strength, and fatigue during |
|Muscle strength/equality | |ambulation (1-person assist and walker) |
|Capillary refill/pulses |Related to: musculoskeletal impairment (secondary to | |
|edema |recent fracture of left hip) |-Encourage patient to make decisions about her daily |
|Pain | |schedule as much as possible, i.e. ADLs, activities to |
|Gait |Defining characteristics: decreased movement, range of |participate in, times for ambulation. |
| |motion, and strength of left lower extremity. | |
| | |-Increase distance of ambulation daily per PT |
| | |recommendations; pre-medicate for pain as needed (currently |
| | |ambulating 200 ft. / PT visit) |
Medications - Scheduled
(Highlight any medications that were discontinued prior to giving)
|Generic & Trade Name |Dose |Route |Time |Classification |Nursing Implications |Evaluation of Medication Effects |
| | | | |Client’s reason for taking drug |What do you need to know or do to give this medication safely? |What would you assess to know it was |
| | | | |Therapeutic class |(nursing assessments and, implementation) |working? |
| | | | |Pharmacologic class | |What was your finding? |
|calcium salts |2 tabs |po |bid |●“I have brittle bones” |Assessment: |Assess serum calcium levels |
|calcium citrate | | | |Osteoporosis |Assess for hypocalcemia: parasthesias, muscle twitching, |Results: (Fill out during clinical) |
|Citrical | | | |●Therapeutic – |Trousseau’s or Chvostek’s sign, colic, laryngospasm, cardiac | |
| | | | |mineral/electrolyte |dysryhthmias. | |
| | | | |replacement/supplement |Assess for hypercalcemia: n/v, anorexia, thirst, paralytic ileus, | |
| | | | |● none |severe constipation, & bradycardia. | |
| | | | | |Implementation: | |
| | | | | |Do not take within 2 hours of other medications or high-fiber | |
| | | | | |foods (VCE – med room). | |
| | | | | |Take on an empty stomach with a full glass of H20. | |
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| | | | | |Assessment: |Assess RBCs/Hgb, serum iron levels, |
| | | | | |Assess for n/v/d, fever, stomach pain, constipation. |energy level, pallor |
|iron supplement |325 mg. |po |TID |● “It helps me with my |May make stools dark green or black and cause constipation. |Results: |
|ferrous sulfate | | | |weakness” |Implementation: | |
|SlowFe | | | |Anemia |Give one hour before or 2 hours after meals w/ a full glass of H20| |
| | | | |●Antianemic |or juice. Absorbed better in an acidic environment – better if | |
| | | | |●Iron Supplement |given with orange juice. | |
| | | | | |May cause a false decrease in calcium. | |
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| | | | | |Assessment: | |
| | | | | |Assess abdomen for distention, pain, bowel tones. Assess bowel | |
| | | | | |pattern. |Assess bowel pattern |
| | | | | |Implementation: |Results: |
| | | | | |Give with a full glass of H20 or juice. For more rapid results | |
|docusate sodium |100 mg. |po |Daily |● “Prevent constipation” |give on an empty stomach. | |
|Colace | | | |●Laxative |Should not be given within 2 hours of other laxatives d/t | |
| | | | |●Stool softener |increased absorption. | |
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Medications - Scheduled
(Highlight any medications that were discontinued prior to giving)
|Generic & Trade Name |Dose |Route |Time |Classification |Nursing Implications |Evaluation of Medication Effects |
| | | | |Client’s reason for taking drug |What do you need to know or do to give this medication safely? |What would you assess to know it was |
| | | | |Therapeutic class |(nursing assessments and, implementation) |working? |
| | | | |Pharmacologic class | |What was your finding? |
|ibuprofen |600 mg. |po |tid |● “Pain” |Assessment: |Assess pain and surgical incision |
|Motrin/Advil | | | |●Pain & inflammation |Assess pain & fever. Monitor for GI bleeding (black tarry stools, |condition |
| | | | |●Antipyretic, |abdominal pain). |Results: |
| | | | |antirheumatic, nonopioid |Implementation: | |
| | | | |analgesic, NSAID |Give with meals or milk to decrease GI upset. | |
| | | | |●Non-opioid analgesic |Administering with opioid analgesics may increase analgesic | |
| | | | | |effects and decrease need for opioids doses. | |
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| | | | | |Assessment: | |
|oxycodone w/ acetaminophen|2.5mg/325mg |po |Every 4-6 |“Pain” |Assess for pain, LOC, & respiratory status. |Assess pain before and after |
|Percocet |1-2 tabs | |hours |Opioid analgesics |Implementation: |medication. |
| | | | |Opioid agonist/nonopioid |Check other ordered medications for contents including |Results: |
| | | | |Analgesic combination |acetaminophen. Avoid overdosing w/ acetaminophen. | |
| | | | | |Give with milk or food to decrease GI upset. | |
| | | | | |May cause drowsiness, dizziness, and may affect judgment. | |
| | | | | |Patient should change positions slowly. | |
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Medications – PRN
(List only those given in the last 24 hours)
|Generic & Trade Name |Dose |Route |Time |Classification |Nursing Implications |Evaluation of Medication Effects |
| | | | |Client’s reason for taking drug |What do you need to know or do to give this medication safely? |What would you assess to know it was |
| | | | |Therapeutic class |(nursing assessments and, implementation) |working? |
| | | | |Pharmacologic class | |What was your finding? |
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Physical Assessment
(HIGHLIGHT ABNORMAL DATA or defining characteristics for problems)
| | |
|Date 10/5/2009 |Date _____________________________ |
|General Survey | |
|Lying on back in bed. Abductor splint in place. Eyes open. No safety hazards |General Survey |
|noted. | |
| | |
|Psychological | |
|Awake, alert, oriented x4. Flat affect; seems emotionless and disinterested. |Psychological |
|c/o feeling tired and states she is unable to get up. Able to make needs known| |
|and is cooperative with care. | |
| |Changes From Day 1 |
| | |
|Vital Signs Time 10/5/2009 Time_0755 |Vital Signs Time _________ Time _________ |
|B/P 113/79 HR 106 RR 20 T- 102 O2 Sat 94% | |
| |Pain: Rating Description |
|Pain: Rating 2/10 Description “sharp” |Pain: Rating Description |
|Pain: Rating Description | |
| |Pulse Oximetry Oxygen |
|Pulse Oximetry 94% Oxygen None | |
|EEN/ Mouth |EEN/ Mouth |
|Eyes clear; sclera white; no drainage | |
|Ear and nasal skin intact; no drainage | |
|Oral membranes intact, pink, and dry. c/o discomfort and difficulty with | |
|chewing r/t poor fitting dentures. | |
|Cardiovascular |Cardiovascular |
|Heart tones regular S1 and S2. HR tachycardic. | |
|Respiratory |Respiratory |
|Respirations regular, unlabored, w/ symmetrical chest wall movement. Lung | |
|sounds clear on left; crackles in middle and lower lobes on right. No cough | |
|observed. Denies SOB at rest and with activity. | |
|Gastrointestinal/GU |Gastrointestinal/GU |
|Abdomen flat, soft, non-distended; bowel tones present x4 quadrants. Denies | |
|pain with light palpation. States last BM was at 0600; stool was brown, soft, | |
|and formed. | |
|Voiding small amounts of clear, dark amber urine; c/o stress incontinence. | |
|Upper/Lower Extremities |Upper/Lower Extremities |
|Left hip incision well approximated at 8cm, clean, dry and intact without | |
|redness, heat, or swelling. | |
|Capillary refill 3 seconds all extremities; radial and pedal pulses +2 equal. |Neuro-Muscular |
|No edema or calf pain. Grips strong and equal. | |
| | |
|Neuro-Muscular | |
|Slow, slightly unsteady gait with walker. Decreased movement, strength, and | |
|range of motion in left leg. Abductor splint in place Easily fatigued with | |
|activity. | |
|Skin Skin warm, dry, pale and intact. No redness over pressure points. |Skin |
|Diminished skin turgor. | |
| | |
Functional Health Patterns (Gordon’s)
(HIGHLIGHT ABNORMAL DATA or /defining characteristics for problems)
|Health Perception-Health Maintenance Pattern |Cognitive – Perceptual Pattern |
|Patient rarely experience illness such as colds and flu. Patient feels that |Alert and oriented x4. Processes information well; appropriate in |
|her health was good until she fell. Now she states that her health is |conversation. Processes written material and reads with understanding. Good |
|“pathetic”. She feels that she can’t take care of herself. This worries her |short and long-term memory. |
|and she is unsure as to whether or not her son will be able to give her the | |
|care she needs. She maintains her health by having regular doctor visits and | |
|trying to eat healthy, but states "my appetite just isn't what it used to | |
|be." | |
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|Activity – Exercise Pattern |Coping – Stress Tolerance |
|Does not exercise; watches TV. She has little social interaction because her |Demonstrates stress over her helplessness and loss of her past roles as a |
|son does not let her drive so she is at home unless her son or girlfriend |mother, wife, and independent adult. Fearful that her son will put her in a |
|takes her out. Tires easily. |nursing home permanently. Coping mechanism – regression and/or dissociation. |
| | |
|Nutrition– Metabolic Pattern |Self Perception – Self Concept Pattern |
| |Respect may be important to this patient – wants to be called “Mrs. ______”. |
|% of diet eaten: _____________ |Son makes all decisions for the patient. She feels like she is a helpless, |
| |old woman. Feels like she is a burden; does not feel needed. |
|Fluid intake ______________ml | |
| | |
|Has lost 5# in the last 4 months and a total of 15# since husband’s death. | |
|Poor appetite that is worse since her fall. Meals at home are irregular. Is | |
|not allowed to cook and son/girlfriend does all the shopping for food. Does | |
|not feel like she gets enough food. Poor fitting dentures make it painful to | |
|chew. Prefers soft foods. | |
|Elimination Pattern |Role – Relationship Pattern |
|Normally has a BM daily or every other day. Stool is usually brown, soft, and|No longer independent in many areas of her life. |
|formed. Does have some problems with constipation and occasionally takes |No siblings; Widow – husband died 2 years ago. Mother of one son. |
|Biscodyl. |Sold home to live with her son and his girlfriend and her teenage son. Is not|
|Urinates several times a day. Patient states urine is yellow. No dysuria, |happy living there. |
|hematuria, frequency, or nocturia. Does have some stress incontinence; wears |Has to depend on son for supplying medications and most everything else. |
|a pantiliner. |Feels like she does not have a role anymore. |
|Sleep – Rest Pattern |Value – Belief Pattern |
|Normally gets 8-10 hours of good quality sleep and naps during in the |Religion – Non-denominational. Does not attend any specific church. Practices|
|afternoon. Usually watches the evening news before bed. |Christian values. |
|Not sleeping well since surgery; naps off and on all day. | |
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Keep in mind that you will be collecting data as you care for the patient and some information may be gathered from the chart or family. To obtain this data you do not sit and interview the patient. You can use the interview process to fill in gaps. What is the patient’s baseline and what is their functioning level now?
Nursing Documentation
Narrative Head to Toe Assessment
Date/Hour
| | |
|10/5/2009 |Lying flat in bed; abductor splint in place. Awake, alert, oriented x4. Flat affect; seems emotionless |
| | |
| |& disinterested. c/o feeling tired and states she is unable to get up. Eyes, ears, & nasal |
| | |
| |intact; no drainage. Oral membranes intact, pink, & dry. c/o difficulty and discomfort |
| | |
| |while chewing due to poor fitting dentures. Skin warm, dry, pale, and intact. No redness over |
| | |
| |pressure points. Skin turgor diminished. Heart tones regular S1 & S2; tachycardic. |
| | |
| |Respirations regular, unlabored, with symmetrical chest wall movement. Left lung sounds |
| | |
| |clear; crackles in middle & lower lobes on right. No cough. Abdomen flat, soft, & non- |
| | |
| |distended; bowel tones x4 quadrants. Denies pain with light palpation. States last BM was |
| | |
| |at 0600 this am; stool brown, soft & formed. Voiding small amounts of clear, dark amber |
| | |
| |urine; c/o stress incontinence. Left hip incision dry & intact without redness or swelling. |
| | |
| |capillary refill 3 seconds; radial and pedal pulses +2 & equal. No edema or calf pain. Grips |
| | |
| |strong and equal. Slow, slight unsteady gait with walker. Decreased movement, strength, & |
| | |
| |range of motion in left leg. Easily fatigued with activity. -----------------------S. Sanderson, SN |
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|Instructor Feedback |
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Nursing Plan of Care
Points Achieved __________________
|Nursing Diagnosis/Expected Outcome |Nursing Interventions ( 1.5 points) |Rationale (1.5 points) |
| |3 required |Provide one for each intervention |
|Nursing Diagnosis | | |
|(Highlight one of the following diagnosis from the client’s chart) | | |
| |-Assess pain, gait, muscle strength, and fatigue during ambulation |Helps the nurse and the patient understand the baseline of the |
|Altered Nutrition Risk for Infection |(1-person assist and walker) |patient’s mobility and set realistic goals that will encourage and |
|Altered Elimination, urinary Activity Intolerance | |increase mobility. |
|Constipation or diarrhea Impaired Mobility | | |
|Self Care Deficit Chronic Pain | | |
|Risk for Injury Social Isolation | | |
|Other: Impaired Physical Mobility |-Encourage patient to make decisions about her daily schedule as much |Increases patient’s feelings of competency and independence. Increases |
| |as possible, i.e. ADLs, activities to participate in, times for |patient’s self-worth. Encourages a nurse-patient helping relationship |
|Etiology “Related to” ((1 point): |ambulation. |and partnership. |
|Musculoskeletal impairment (secondary to left hip fracture) | | |
| | | |
|Defining Characteristics related to Nursing Diagnosis: (2 points) | | |
|(as HIGHLIGHTED from client data sheet, physical or functional | | |
|assessment sheets) | |Gradual increase in activities prevents fatigue and discouragement; |
|Decreased range of motion, movement, and strength of left lower |-Increase distance of ambulation daily per PT recommendations; |ambulation may be decreased if patient in pain. |
|extremity. |pre-medicate for pain as needed (currently ambulating 200 ft. / PT | |
| |visit) | |
| | | |
|Expected Outcome (1 point) : | | |
|Measureable with timeframe | | |
|Patient will ambulate to the dining room for all 3 meals during my care| | |
|on 10/5. | | |
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|Evaluation of Expected Outcome (1 point) : | | |
|Was the goal met? Any changes needed? | | |
|Goal was not met. Patient refused to ambulate to dining room this | | |
|shift; continue with pain control & emotional encouragement; discuss | | |
|with PT. | | |
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