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MIAMI DADE COLLEGE -SCHOOL OF NURSING FUNDAMENTAL OF NURSING PLAN OF PATIENT CARE

Student's Name: Llubica Barkovic Client's Initials: HS DOB: 9/24/23

Date: 10/15/2013 Sex: F Age: 90

Time: 0830 h Admission Date: 9/1/2013 Race: W

Admitting Medical Diagnosis (s): Client is unable to care for herself. Client needs total care. Surgical Procedure (s) (include date): Hip joint replacement July 2013. Appendectomy age 7, Hysterectomy age 21 What brought you to the Institution (Hospital, Home?) Client was initially admitted to MJH for rehabilitation after sustaining fracture to right hip and the physician Dr. Blanco recommended that she remain at MJH for long-term care starting 9/1/13 History of present illness: Client sustained fracture to right hip in July 2013. Client also suffers from Hypertension, Type Two Diabetes, Anemia, Constipation. Currently client suffers from impaired physical mobility, but is receiving care at Miami Jewish Hospital. Client's understanding of illness: Client is oriented to person. Client understands that she has an ulcer on her right heel that causes acute pain, but has deficient knowledge about her type two Diabetes Mellitus, Neuropathy Diabetes, Anemia, right hip fraction, incontinence, Constipation and Peripheral Vascular Disease. Past medical history: Type two Diabetes Mellitus, Diabetic Neuropathy , Hypertension, Peripheral Vascular disease, Coronary Atherosclerosis, Anemia , Esophageal Reflux, Constipation, full incontinence of feces, urinary incontinence, generalized pain, right hip fracture, COPD

What medications are you currently taking? See Pages attached.

Medications (Topical, PO, IM, SQ, and IV): Name/Dose/Route Frequency

High Alert Medication Lidodem 5% Patch (Lidocaine) 2/ Patch topically/to right foot/daily

Safe Rang e
Up to 3 patches may be applied once up to 12 hr. in 24 period 9002400 mg a day

Mechanism of Action
Control of ventricular arrhythmias. Local anesthesia.

Indications
Pain due to postherpetic neuralgia

Side Effects
Seizures Confusion Drowsiness Cardiac Arrest

Nursing Considerations
May cause drowsiness and dizziness, advice patient to call for assistance during ambulation or transfer.

Gabapentin/ 200mg Capsules/PO 3x a day

Decreased incidence of seizures, decreased post herpetic pain, decreased leg restlessness Maintenance of blood glucose. Decreases hepatic glucose production. Decreases intestinal glucose absorption. Increases sensitivity to insulin.

Neuropathic pain diabetic peripheral, anxiety, bipolar disorder, leg restlessness Management of type 2 diabetes mellitus; may be used with diet, insulin, or sulfonylurea oral hypoglycemic.

Suicidal thoughts Confusion Depression Drowsiness Ataxia Facial edema Hypertension Abdominal bloating Diarrhea Vomiting Nausea Hypoglycemia

Monitor Closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior. Take with meals Observe for hypoglycemic reactions

Metformin HCL ER/500 mg tablets/PO Once daily with dinner

500mg2000m g

High Alert Medication Metoprolol Tartrate/ 25 mg Tab/ by mouth/ once daily

25-450 mg

Decreased BP and heart rate.

Hypertension. Angina

Decreased frequency of attacks of angina pectoris. Decreased rate of cardiovascular mortality and hospitalization in patients with heart failure.

pectoris. Prevention of MI and decreased mortality in patients with recent MI.

Fatigue Weakness Constipation Diarrhea Anxiety Dizziness Pulmonary Edema Bradycardia

Take Apical Pulse before administering. If <50 bpm or if arrhythmias occurs, withhold medication and notify health care professional. Administer with meals or directly after eating. Monitor BP

High Alert Medication Regular Insulin Humulin/ see sliding scale/ Subq/ 4x daily before meals and at bedtime dose Enulose ( lactulose) Solution/ give 30 mL (20 mg)/ by mouth/ once daily PRN for constipation

See Sliding Scale facility Up to 40 mg daily

Lowers blood glucose uptake in skeletal muscle fat, inhibits hepatic glucose production Relief of constipation. Increases water content and softens the stool.

Control of hyperglycemia

Hypoglycemia Erythema Swelling pruritus Belching Cramps distention flatulence diarrhea

Monitor blood glucose levels + body weight and symptoms of hypoglycemia. Rotate injection site.

Treatment of chronic constipation.

Assess patient for abdominal distention, presence of bowel sounds, and normal pattern of bowel function

Acetaminophen(MAPAP) Tablet/ 650 mg PO/ Q4r PRN for Pain

Do not exceed 4 mg in 24hrs

Analgesia

Treatment of: Mild pain, Fever.

failure (high doses/chronic use) rash, urticarial

Assess amount, frequency, and type of drugs taken in patients self-medicating, especially with OTC drugs

Alprazolam (Xanax)/ 0.25 mg/ tablet PO / every 6 hours as needed

3-6 mg daily

Relief of anxiety.

Generalized anxiety disorder (GAD). Panic disorder. Anxiety associated with depression. Treatment & prevention iron deficiency anemia.

dizziness, drowsiness lethargy confusion, hangover headache mental depression

Assess Mental Status

Ferrous Sulfate/ 325 mg tablet/ PO daily

6001000 mg daily

Resolution or prevention of iron deficiency anemia. Increase in blood glucose. Relaxation of GI musculature, facilitating radiographic examination.

Glucagon (GlucaGen)/

Acute management of severe hypoglycemia when administration of glucose is not feasible Treatment and prevention of vitamin deficiencies.

dizziness, headache, syncope nausea constipation, dark stools pain GI bleeding vomiting nausea, vomiting Hypoglycemia

Assess nutritional status and dietary history to determine possible cause of anemia and need for patient teaching. Assess for signs of hypoglycemia (sweating, hunger, weakness, headache, dizziness, tremor, irritability, tachycardia, anxiety) prior to and periodically during therapy.

Vitamin C/ 500 mg tab/ by mouth 2x daily

50-500 mg

Replacement of vitamins in patients who are deficient or at risk for deficiency.

Fatigue Drowsiness headache

Assess for signs of Vitamin C deficiency.

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Chemistry Normal Value Client's Value Date CBC Normal Value Client's Value Date

Sodium Potassium Chloride CO2 Calcium Phosphorus Cholesterol Albumin T. Protein Bun Creatinine Magnesium Uric Acid Bilirubin Lipid Profile Amylase Lipase LDH HDL LDL Urinalysis Color Turbidity SG pH Glucose Ketone Blood Protein Bilirubin Urobilinogen Nitrate Leukocyte

136-145 mmol/L 3.5-5.5 mmol/L 98-110 mmol/L 21-31-mmol/L 8.5-10.8mg/dL <200 3.5-5.7g/dL 6-8.3 7-25mg/dL 0.6-1.3 mg/dL

138 mmol/L 4.4 mmol/L 104 mmol/L 24 mmol/L 9.87mg/dL 166 3.53g/dL 5.5 24mg/dL 0.86 mg/dL

9/17 9/17 9/17 9/17 9/17 9/17 9/17 9/17 9/17 9/17

0.3-1

0.4

9/17

23-92 75-92 Bleeding Time yellow clear 1.005-1.030 5.8 negative Negative Negative Negative negative 0.2-1 negative negative

32 117 Yellow Cloudy 1.021 7 negative Negative Negative Negative Negative 1 Negative Trace

9/14 9/14 9/17 9/17 9/17 9/17 9/17 9/17 9/17 9/17 9/17 9/17 9/17 9/17

RBC HGB HTC MCH MCV MCHC WBC Neutrophils Bands Segments Eosinophils Basophils Lymphocytes Monocytes Platelets Coagulation Test (Norms) Platelets Count PTT PT Bleeding Time INR Miscellaneous Tests Test (Norms)

3.9-6.4 12-17g/dL 36-53 26-32 80-97 32-37 4-11 40-74%

3.93 12.2g d/L 36.5 31 93.1 33.3 9.75 65.5%

9/17 9/17 9/17 9/17 9/17 9/17 9/17 9/17

0-7 0-0.2 1-4.8 2-11 130-400 Normal Value

0.8 0.7 2.4 8.7 478 (high) Client's Value

9/17 9/17 9/17 9/17 9/17 Date

Normal Value

Client's Value

Date

Abnormal

Patients platelet count is elevated which may indicate a condition called thrombocytosis which can cause an increase in clotting

Cast RBC Crystals WBC Epithelial Cells

0.2

0-2

9/17

Brief Textbook Picture Textbook

Pathophysiology: According to Brunner & Suddarths (pg. 183) Pressures ulcers are localized areas of necrotic tissue that occur when pressure applied to the skin over time is greater than normal capillary closure pressure, which is about 32 mm Hg. Etiology: According to Brunner & Suddarths (pg. 185) the major causes of pressure ulcers are Immobility, Impaired Sensory Perception or Cognition, Decreased Tissue Perfusion, Decreased Nutritional Status, Friction and Shear, Increased Moisture. Sign and Symptoms According to Brunner & Suddarths (pg. 186) the initial sign of pressure is erythema (redness of the skin) caused by reactive hyperemia. Unrelieved pressure results in tissue ischemia or anoxia. The cutaneous tissues become broken or destroyed, leading to progressive destruction and necrosis of underlying soft tissue, and the resulting pressure ulcer is painful and slow to heal. Pressure ulcers will have different signs and symptoms depending on their developmental stage. There are four stages. Stage I is mainly erythema that does not blanch with pressure. In Stage II skin will break, ulcer drains, partial-thickness wound. Stage III Ulcer will extend to the subcutaneous tissue, and it is a full-thickness wound Stage IV ulcer extends to underlying muscle and bone, deep pockets of infection develop. Medical Treatment: According to Brunner & Suddarths (pg. 187) frequent changes of position are needed to relieve and redistribute the pressure on the patients skin and to promote blood flow to the skin and subcutaneous tissue. Regardless of the stage of the pressure ulcer, the pressure on the area must be eliminated because the ulcer will not heal until the pressure is removed. Turning schedules are important and must be included in the plan of care. Additionally Protein deficiency must be corrected to promote healing of the pressure ulcer. Carbohydrates are necessary to spare the protein and to provide energy source. Vitamin C and trace elements, especially zinc, are necessary for collagen formation and wound healing. Prognosis: According to Brunner & Suddarths (pg. 188) all stages of pressure

Client
Patient has a heeling unstageable pressure ulcer on her right heel for over 2 years. Factors complicating would healing: diabetes, and history of diabetes. Patient is not ambulatory, is of advanced age and suffers from full bowel incontinence and urinary incontinence.

The Client reports no pain. No exudate. 100 % thick adherent black necrotic tissue (eschar). Wound progress; stable. Wound size: 1.5 cm x 2.5 cm X Not measurable (as evidence by the chart). Unsteageble pressure ulcer.

Patient is getting a dressing change once daily, using float heels in bed, repositioning every two hours, using pressure relieving air mattress, is getting high protein diet with zinc. Client is also taking Vitamin C necessary for collagen formation, and wound healing.

Patient is getting care for the pressure ulcer, and is progressing with the healing of the

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ulcers could be eliminated with good care of skin, repositioning, and teaching of the causes and prevention of pressure ulcers. wound. Patients has a positive outlook, and with the proper dressing changes and reposition will be able to have intact skin.

Nursing Diagnosis
Nursing Diagnosis Activity Intolerance Definitions Insufficient physiological or psychological energy to endure or complete required or desired activities Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool/ and or passage of excessively hard, dry stool change in normal bowel habits characterized by involuntary passage of stool Inability of usually continent person to reach toilet in time to avoid unintentional loss of urine Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. Altered epidermis and/or dermis Insufficient or excessive quantity or ineffective quality of social exchange At risk for variations of blood glucose/sugar levels from the normal range that may compromise health at risk for being invaded by pathogenic organisms Decrease in blood circulation to the periphery that may compromise health Limitation in independent, purposely physical movement of the body or one or more extremities At risk for experiencing for experiencing decreased intravascular, intracellular, and or intestinal fluid. Damage to mucous membrane or to corneal, integumentary, or subcutaneous tissue Limitation of independent movement from one bed position to another Increasing susceptibility to falling may cause physical harm

Constipation

Bowel Incontinence Functional Urinary Incontinence

Acute Pain Impaired Skin Integrity Impaired Social Interaction Risk for unstable blood glucose level Risk for Infection Risk for ineffective peripheral tissue perfusion Impaired Physical Mobility Risk for deficient fluid volume Impaired Tissue Integrity Impaired Bed Mobility Risk for falls

Bathing Self-Care deficit

Impaired ability to perform or complete bathing/hygiene activities for oneself

Miami Dade College School of Nursing Fundamentals of Nursing Physical Assessment Patient Initial: Pulse 78 85 HS Student: Llubica Barkovic SPO2 97% 98% Ht. 53 53 Date: 10/11/13 Wt. 96lb 97lb

Respiration Temperature B/P 19 98.9 111/54 18 98.6 149/87

Head to Toe Assessment General Appearance: Patient is a Caucasian women. Patient appears to be her stated age. Patient is awake, alert and oriented x3. Patient appears well groomed. Patient is relaxed and comfortable. Patient seems underweight. Head & Hair: Head Normocephalic. Hairs is gray, shoulder length. Patient has thinning of hair. Patient has dandruff. No lice present. Absence of lumps or lesions. Face: Face is oval, and symmetrical. Skin tone is even, no cyanosis or pallor present. Skin is intact no lesions. Facial features symmetric with movement. Appears happy, and is cooperative. No involuntary movements. Eyes: Patient does not wear glasses. Extraocular movements smooth and symmetric with no nystagmus. No redness, discharge, or crusting noted on lid margins. Conjunctiva and sclera appear moist and smooth. Sclera white with no lesions or redness. Pupils are equal in size and reactive to light and accommodation. Ears: Ears are equal in size bilaterally. Auricles are aligned with the corner of each eye. Smooth, no lumps, lesions, nodules. No discharge. Nontender on palpation. Small amount of moist yellow cerumen in external canal. Whisper test: patient repeats 2 syllable word. Nose: Nose smooth and symmetric. Able to sniff through each nostril. No purulent drainage noted. Frontal and maxillary sinuses are nontender to palpation. Lips/Mouth/Throat: Lips pink, smooth, and moist without lesions. Patient wears dentures. Buccal mucosa pink, moist, and without exudates. Protrudes tongue in midline with no tremors. Tonsillar pillars pink and symmetric. Uvula rises with phonation. Neck: Symmetric, no masses. Thyroid not tender. No carotid bruits or jugular venous distention (as evidence by the chart). Chest/Breast: Lungs: 19 bpm. Respirations regular, no crackles or wheezing noted (as evidence by the

chart). Respiration Genitalia (Internal Exam Deferred): Rectum (Internal Exam Deferred): Extremities: Inspection: Extremities have pink-tan color without redness, cyanosis. No edema. Unstageable pressure ulcer right lower heel. Extremity size is symmetric without swelling. Palpation: Temperature is warm and = bilaterally. All pulses present, 2+ and = bilaterally. No clubbing. Patient is not ambulatory. Back: No tenderness over spines. R.O.M.: Limited ROM in lower extremities
Document findings on next page

Unsteageble pressure ulcer.

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Miami Dade College -Medical Center Campus - Department of Nursing Generic Nursing Program
Nursing Diagnosis: Impaired Bed Mobility related to weakness as evidence by Supportive Data: Subjective: Patient Stated It hurts to move out of bed It is not as easy as you think. Patient also stated It is hard just to move myself up, or center myself. Objective: Patient having trouble repositioning or scooting body. Requires help from another person to reposition herself in bed. Patient had a hip replacement 2013 that affected her mobility. Nursing Student performed the Functional Mobility Assessment on 10/ 18/2013. (See attached). Patient scored a <10. Results indicate the patient is completely dependent with basic ADLs like transferring, toileting, and dressing. Goals: Long Term: Patient will demonstrate ability to use equipment or devices to assist with moving about in bed safely by 11/1/2013 Short Term: Maintain or improve muscle strength and joint range motion (ROM) by 10/25/2013 Evaluation of Short Term Goal: Date Nursing Actions

Scientific Principle and/or Rationale

Evaluation

Modification of Plan of Care

10.25.2013

10.25.13

Nursing student will perform ROM exercises to affected joints, unless contraindicated, at least once per shift. Progress from passive to active.

According to Lindermann, U., Richard (pg. 247) to prevent join contractures and muscle atrophy.

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10.25.13

Nursing student will consult with Physical therapist to continue improvement in bed mobility. Occupational therapist to continue to maximize self-care skills every Friday.

According to Lindermann, U., Richard (pg247) it will help the patient to help ensure continuity of care and reinforce learned skills.

10.25.13

Nursing Student will assess and record daily evidence of complications related to impaired bed mobility.

10.25.13

Nursing student will reposition patient every Friday, and every two hours, to prevent breakdown of the skin.

11.1.13

Nursing Student will teach the patient techniques of passive ROM to improve bed mobility and ways to prevent complications.

According to Lindermann, U., Richard (pg247) recording findings can help maintain the integrity of the skin. According to Perry and Potter page 407 prolonged times in the same position can alter circulation and impaired skin integrity. According to Lindermann, U., Richard (pg. 247) teaching a patient is an important and valuable step. Teaching a patient instead of just performing, helps the patient be involve in self-care.