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NURSING 110 CARE PREPARATION

Student Name: Elizabeth Blair Archibald


Date of Care: October 25, 2016

Unit/Room Number:
Not listed for HIPPA purposes Date of Admission: July 2016
Age: 82 years old Ethnic/Cultural Preferences: Caucasian
Gender: Male Allergies: Adhesive
Eriksons Developmental Level: Code Status: DNR- Hospice
Despair

Primary Diagnosis: Multiple Myeloma to right femur and pelvis

Co-morbidities: Cellulitis (right and left lower leg), anxiety, depression, insomnia,
lymphangitis, heart failure, atrial fibulation, hypertension, hyerlipidemia, anemia,
diabetes mellitus, chronic pain, GERD, gout, benign prostatic hyperplasia.

Discharge Plan (add day of clinical): Patient is present for hospice and will be at GSS
for the remainder of his life. Patient is present for pallative care.

Pathophysiology (explain in 250 words or less your clients primary diagnosis)


Bone Metastases: Normal bones remodel themselves with the help of bone cells.
The bone cells are osteoclasts (bone tissue breakdown), and osteoblasts (bone tissue
building). Skeletal malignancies lead to degeneration of bone by excessive
osteoclasts. Therefore, osteolysis leads to pain, potential fractures, and possible
death.

Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any
assessment/elaboration should be made on the assessment sheet):
Diet (Type): Regular/Normal IV (Fluid type, rate, access type): None
I&O (MD order/Nursing Order/Frequency):
CBG (Yes/No, frequency): Yes, Q6H
Not measured or recorded
Fall Risk/Safety Precautions (Yes/No): Activity (What is ordered):
Yes Up in W/C or assisted with FWW.
Oxygen (Yes/No, Delivery method, how much):
Wound Care (Yes/No):
Yes, 2 LPM; nasal cannula, PRN in the
Yes, please see below ***
event that CRT is longer than 3 seconds.
Last BM: Patient has not had a BM since
Drains (Yes/No, Type): No
Sunday.
Other Tubes: Foley Catheter in place

*** Integument/Wound care orders:


-If skin is bleeding: Apply firm pressure, clean with wound spray and pat dry,
approximate edges if needed, apply skin prep, and triple antibiotic ointment. Utilize
sterile strips, and non-adhesive dressing.
-Heel blisters:
Apply dilute betadine, wound cleanser, and change non-adhesive dressing Q5D.
-Obtain wound culture is purulent exudate present.

ASSESSMENTS
(Include Subjective & Objective Data)

*** Please see DAR notes regarding


lack of assessment data***
Integumentary:
Patient has new bruises over his eye.
He fell out of bed on Sunday, and has a
large approx. 1 inch x inch bruise over
his right eyebrow, and a approx. inch x
inch bruise over palpebral fissure area,
and inferior eye. Head and Neck:

Thorax/Lungs:

Patient is demonstrating Cheyenne-Stokes


Ear/Nose/Throat:
breathing at a rate of 20 BPM.

Cardiac:

Musculoskeletal:

Gastrointestinal:

Patient has not had a BM since Sunday.

-----------

Since my patient passed, I did my abdominal


Gastrointestinal:

Patient has not had a BM since Sunday.

-----------

Since my patient passed, I did my abdominal


exam on another resident:

Subjective: Patient's last BM this AM


(normal, medium consistency, brown) and
urination was just before exam. Patient eats
a variety on fruits, vegetable, and meats.
She has prunes, and prune juice with every
meal.
Genitourinary:
Patient does not have a change in BM's or
any toileting problems. Patient does not
have any abdominal diseases, or pain. She
did have a hysterectomy, and a bowel
resection, but could not remember why or
the name of the surgery.

Patient does not have trouble swallowing,


heartburn, nausea, vomiting, diarrhea,
bloating, or gas.

Objective: Patient's stomach is normal


color: not yellow, there are no rashes
present, etc. Umbilicus is set in ("inny") and
uniform color to the rest of the patient's skin.
Auscultation to all 4 quadrants is
normoperistaltic. No bruits heard in any
arteries. Indirect percussion was tympanic
over air filled regions, dull over organs.
Patient is not having any kidney pain, and
palpation is non-tender. Light palpation (1-2
CM) does not show pain, or masses.
Spleen and liver are not palpable.
Neurological:
Unresponsive/comatose

Other (Include vital signs, weight):


arteries. Indirect percussion was tympanic
over air filled regions, dull over organs.
Patient is not having any kidney pain, and
palpation is non-tender. Light palpation (1-2
CM) does not show pain, or masses.
Spleen and liver are not palpable.
Neurological:
Unresponsive/comatose

Other (Include vital signs, weight):

CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)

Intended
Nursing
Action/ Adverse
Implications
Generic & Dose/Route/ Therapeutic reactions (1
Classification Onset/Peak for this client.
Trade Name Rate if IV use. Why is major side
(No more than
this client effect)
one)
taking med?

DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays,
CT, MRI, U/S, etc.]
NOTE: Adult values indicated. If client is newborn or elder, normal value range may be
different.
Interpretation as
Lab Test Patient Values/ related to
Date
Normal Values Date of care Pathophysiology cite
reference & pg #
Sodium
8/29/16 135 145 mEq/L
141
Potassium
8/29/16 3.5 5.0 mEq/L
5.1 H CKD
Chloride
8/29/16 97-107 mEq/L
107
Co2
8/29/16 23-29 mEq/L
25
Glucose
8/29/16 118 H DM
75 110 mg/dL
BUN
8/29/16 8-21 mg/dL
49 H CKD
Creatinine
8/29/16 0.5 1.2 mg/dL
2.96 H CKD
Uric Acid Plasma
4.4-7.6 mg/dL
Calcium
8/29/16 8.2-10.2 mg/dL
9.2
Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
8/29/16 0.4
0.3-1.2 mg/dL
Total Protein
8/29/16 6.0-8.0 gm/dL
4.7 L CKD
Albumin
8/29/16 3.4-4.8gm/dL
3.2 L CKD/CHF
Cholesterol
<200-240 mg/dL
Alk Phos
8/29/16 25-142 IU/L
91
SGOT or AST
10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
WBC
8/29/16 4.5 11.0
7.3
RBC
8/29/16 male: 4.7-5.14 x 10 3.12 L CKD
female: 4.2-4.87 x 10
HGB
8/29/16 male: 12.6-17.4 g/dL 9.5 L CKD
female: 11.7-16.1 g/dL
HCT
8/29/16 male: 43-49% 29.6
female: 38-44%
MCV
8/29/16 85-95 fL
95.0
MCH
8/29/16 30
28 32 Pg
MCHC
8/29/16 33-35 g/dL
32
RDW
8/29/16 11.6-14.8%
16.9 L CKD
Platelet
8/29/16 male: 12.6-17.4 g/dL 9.5 L CKD
female: 11.7-16.1 g/dL
HCT
8/29/16 male: 43-49% 29.6
female: 38-44%
MCV
8/29/16 85-95 fL
95.0
MCH
8/29/16 30
28 32 Pg
MCHC
8/29/16 33-35 g/dL
32
RDW
8/29/16 11.6-14.8%
16.9 L CKD
Platelet
8/29/16 150-450
87 L CKD

DIAGNOSTIC TESTING

Interpretation as
related to
Date UA Normal Range Results Pathophysiology
cite reference &
pg #
Color/
8/24/16 Straw
Appearance
8/24/16 pH 5-9 5
8/24/16 Spec Gravity 1.005-1.030 1.018
8/24/16 Protein NEG NEG
8/24/16 Glucose Normal Normal
8/24/16 Ketones NEG NEG
8/24/16 Blood NEG NEG

Interpretation as
Other
related to
(PT, PTT, INR,
Date Normal Range Results Pathophysiology
ABGs, Cultures,
cite reference &
etc)
pg #
7/21/16 PTT 11.8-13.6 16.0 H ?
7/21/16 INR 1.4 0.8-1.3 H ?

Interpretation as
related to
Date Radiology Results Pathophysiology
cite reference &
pg #
There are no
fractures or
dislocations
identified. No
radiopaque
foreign bodies
or significant
soft tissue
findings are
AP Pelvis seen.No specific
8/24/16 X-Rays
1 or 2 views or significant
Interpretation as
related to
Date Radiology Results Pathophysiology
cite reference &
pg #
There are no
fractures or
dislocations
identified. No
radiopaque
foreign bodies
or significant
soft tissue
findings are
AP Pelvis seen.No specific
8/24/16 X-Rays
1 or 2 views or significant
degenerative
abnormalities
are identified.
Intramedullary
nail in the right
femur.
No significant
osseous
abnormalities.
Scans
EKG-12 lead
Telemetry

DAR NURSING PROGRESS NOTE


Include the same note that was written in the client record for the priority nursing
diagnostic statement. Include the date/time/signature.

Data-
My patient passed today. When I arrived to clinicals, he had been demonstrating
Cheyenne-Stokes breathing. The charge nurse reported that he had been bed
ridden since yesterday. Sunday, he was mobile, but in a severe amount of pain.
Monday, patient stayed in bed and was sleeping, but responsive. Tuesday, patient
was completely unresponsive.

Action-
As a student nurse I took care measures, including: sitting with patient and talking
to him, reading to patient, applying lip balm PRN, wetting down mouth with lemon-
glycerin swabs.
Response-
While sitting with patient, his breathing changed to an agnal pattern, and he began
to vomit. I turned him on his side while a fellow student nurse ran to get a charge
nurse. At this time, patient opened his eyes briefly as I felt him pass.
This experience was very hard, but I am honored to have spent his last hours with
him.

I took this opportunity to work with the patients hospice nurse to perform post
mortem care. We cleaned him up, prepared his family, and assisted the gentleman
from the morgue in getting him to the van for transport. This was an invaluable
learning experience. I am glad that I could ease some suffering and help him in his
final moments.