NURSING CARE PREPARATION #1

Student Name: Elizabeth Blair Archibald Date of Care: 2/20/2018

Unit/Room Number: Med/Surg Date of Admission: 02/16/2018

Age: 70 years’ old Ethnic/Cultural Preferences: Caucasian
Gender: Female Allergies: Levaquin, PCN, ASA, Celecoxib, Lipitor
Erikson’s Developmental Level: Ego Integrity Code Status: DNR/DNI
Versus Despair

Primary Diagnosis: Cellulitis, and a complicated UTI

Co-morbidities:
Arthritis, HTN, obesity, sleep apnea, chronic pain, iron deficient anemia, right LE ulcer.

Discharge Plan: Upon student’s arrival to the hospital, the plan was that the patient would be discharged 02/20/2018, but the nursing
home that patient was to be discharged to has decided that she is not a good fit for their facility. The social worker is looking for another
place that will accept her. Until then, patient will be in a swing bed.

Integrated Pathophysiology:

Patient was diagnosed with a UTI in November 2017. The patient was prescribed Cipro that was never filled. Her UTI continued until she
developed secondary sepsis. She arrived at the hospital 02/16/2018 with confusion and weakness. She would not allow the doctor to
perform a thorough exam in the ED. What the doctor did gather was that the patient was agitated, has a right lateral LE ulcer, and has
bilateral lower extremity edema.

Sepsis: A complication of an infection. When the body attempts to fight the infection, the immune system can become overwhelmed. In
return, the body starts a system wide inflammatory response. This can cause organ damage, and MODS. Early interventions with
appropriate antibiotics will prevent organ damage, MODS, and death. (1)

Encephalopathy: Altered mental state caused by toxins. In this situation, the altered mental status was secondary to sepsis. (2)

Assessments pertinent to diagnosis of UTI: Need for foley catheter. Signs of encephalopathy, fever, lower abdominal pain, burning
with urination, hematuria have resolved.

Assessments pertinent to diagnosis of right lower extremity ulcer: Ulcer to right lower extremity is located on the lateral aspect of
shin and was measured at 7 CM by 8 CM. This wound was surgically debrided yesterday. Today, the flesh was pink, without granulation
tissue present. There is serosanguinous discharge. There is no excoriation to periwound/periwound skin intact. There is no slough or
eschar present. There is no tunneling or undermining present. Patient expresses a great deal of pain associated with wound. See notes
on bandage change below.

Assessments not related to disease process, but significant: Patient has copious amounts of yeast under her breasts, pannus, in her
groin/vagina, and in/around her buttocks. Patient is non-compliant, and refuses care. Patient seldom allows us to clean her, and denies
application of Nystatin power. Today we convince patient to allow us to clean her, and apply Nystatin powder. Mary, RN, states that over
the last two days, patient’s skin has gotten much worse. It is excoriated, erythemic, scaly/flaking, and pruritic. Patient does not feel pain
associated with irritated skin. Evidently, patient has major neuropathy, because she did not even know that she had passed stool and was
laying on it. We cleaned her, and it was clear that skin area on patient’s buttocks has progressed to a stage 2 ulcer.

Patient’s hematology report shows that she has an elevated WBC count of 12.5 K/uL (due to UTI, and leg ulcer), elevated RDW of 15.9%
due to wide RBC distribution (3), a decreased RBC of 3.46 M/uL (due to iron deficient anemia), and a low H&H of 9.8 g/dL and 28.9% (due
to iron deficient anemia).

Patient has a low sodium value of 131 mEq/L, a low potassium value of 3.4 mEq/L, and a low albumin level of 2.8g/dL. These findings
indicate a nutritional deficiency. (4)

Patient’s urinalysis is consistent with a UTI because there is significant WBC, RBC, and bacteria present in straight catheter collection.
Culture= Escherichia coli.

Blood cultures were taken: pending results.

Lower leg radiographs show that ulcer could be due to hardware failure, and/or infection from a previous leg surgery. When asking the
patient about her surgical history, she was not willing to discuss it.

Patient continued to be frustrated and did not allow most care all day.

Data Collection
Diet: Regular IV: NS 25 ML/HR
I&O: No order present CBG: No
Fall Risk/Safety Precautions: Yes Activity: Bed rest, total assist.
Wound Care: Yes Oxygen: No
Drains: None Last BM: Today, formed/soft
Other Tubes: None
 CURRENT MEDICATIONS

Generic & Classification Dose/Ro Onset/Peak Intended Adverse Nursing

Trade ute/ Action/Therapeutic use. reactions Implications for this
Name Rate if client.
IV
Baclofen Therapeutic: 10 MG PO Onset: HR- Decreased muscle Nausea
(Liorisal) anti-spasticity tab PO WK spasticity; bowel and Assess patient for
(5) agents, TID PO Peak: bladder function may also nausea/emesis
skeletal Unknown be improved. Q8H.
muscle
relaxants

Metronidaz Therapeutic: 500 IV Onset: Rapid Most notable for activity Abdominal Assess patient for
ole anti-infective, MG/NS PO Peak: End against anaerobic bacteria Pain pain Q8H.
(Flagyl) (6) anti-protozoal, 100 ML of infusion
antiulcer @ 100
agents ML/HR
IV

Pharmacologi 50 MG PO Onset: 1 Decreases BP and HR Hypotension Take BP TID.

Atenolol c: beta PO BID HR
(Tenormin) blockers PO Peak: 2-4 H
(7)

Cephalexin Therapeutic: 250 MG PO Onset: Treatment of respiratory Diarrhea Auscultate all four
(Kelfex) (8) anti-infective PO TID Rapid infection quadrants BID for
PO Peak: 1 increased
Hour peristalsis.
DAR NURSING PROGRESS NOTE

02/20/2018 @ 1100
Data: Risk for infection R/T wound on lower extremity AEB open tissue that had to be debrided yesterday by a surgeon.
Action: Patient assisted Mary (RN) with bandage change. Old bandage was removed, wound was flushed with sterile saline, an alginate
dressing, gauze, kerlex, and coband were applied.
Response: Patient complained of pain, but she was pre-medicated with an opioid by Mary (RN). Assisted client to position of comfort post
bandage change.
Signature: Liz, student RN

PATIENT CARE PLAN

Patient Information:
UTI since November 2017

Problem #1 Ineffective health management R/T sepsis induced encephalopathy AEB patient being
diagnosed with a UTI in November, but never filling her antibiotics to have this treated.
Desired Outcome: Patient will state understanding of importance of antibiotics, and comply with
treatments.
Nursing Interventions Client Response to Intervention
1. Administer antibiotics as ordered by MD. 1. Patient took her antibiotics well today.

2. Offer patient water Q1H 2. Patient drinks plenty of water, and is on

NS 25 ML/HR
3. Educate client on signs and symptoms of UTI, and 3. Patient is unwilling to be educated.
how it is treated.

Evaluation
Patient was compliant with medications, and fluid intake, but she is non-compliant/stubborn about
certain things, including: education, cleanliness, etc. The nurses and students did the best they
could with what they were offered.

References

(1) https://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc-20351214
(2) https://www.medicinenet.com/script/main/art.asp?articlekey=101343
(3) https://emedicine.medscape.com/article/2098635-overview
(4) https://www.medicinenet.com/low_potassium_hypokalemia/article.htm#what_are_the_causes_of_low_potassium_hypokalemia
(5) https://davisplus.fadavis.com/3976/meddeck/pdf/baclofen.pdf
(6) https://davisplus.fadavis.com/3976/meddeck/pdf/metronidazole.pdf
(7) https://davisplus.fadavis.com/3976/meddeck/pdf/atenolol.pdf
(8) https://davisplus.fadavis.com/3976/meddeck/pdf/cephalexin.pdf

NURSING CARE PREPARATION #2

Student Name: Elizabeth Blair Archibald Date of Care: 2/20/2018

Unit/Room Number: Med/Surg Date of Admission: 02/16/2018

Age: 84 years’ old Ethnic/Cultural Preferences: Caucasian
Gender: Female Allergies: Levaquin
Erikson’s Developmental Level: Ego Integrity Code Status: Full Code
Versus Despair

Primary Diagnosis: Respiratory Failure

Co-morbidities:
Atrial Fibrillation, Congestive Heart Failure, GERD, hypothyroidism, dyslipidemia, chronic lower extremity edema, acute renal insufficiency,
history of CVA with left sided deficit, chronic pain.

Discharge Plan: The doctor’s plan is to have patient urinate without foley, to wean her off her oxygen, and to send patient home
tomorrow.

Integrated Pathophysiology:

Patient was being treated for a UTI with Levaquin at her home of Shore Pines assisted living. Within hours or taking medication, patient
had a sudden onset of severe dyspnea. Her SPO2 was 87% with EMS, and her lung fields auscultated with bilateral wheezes. EMS
treated her with an albuterol treatment, and applied a face mask at 5 L/M.

When doctor examined patient she still had dyspnea, and was coughing up yellow sputum. With auscultation, heart had an irregular rate
and rhythm, but no abnormal heart sounds heard. Lungs auscultated diminished breath sounds in bilateral bases, with scattered
inspiratory/expiratory wheezing with minimal rales.

Today’s assessments pertinent to patient’s disease process: Patient is dyspneic with exertion. She has cyanotic fingers, toes, and,
mucous membranes. With auscultation, she has inspiratory wheezes, and expiratory rhonchi. She gurgles and has copious amounts of
mucous to her upper airway with inspiratory and expiratory. Her SPO2 is highest at rest (90% on 2 L/M O2 via nasal cannula), and drops
to 86% (lowest) with activity. Patient’s heart rate is irregular, but no murmur heard. She does not have JVD. There is 1+ pitting edema.
All pulses are palpated 2+.

Patient’s hematology report shows an elevated WBC count of 14.9 K/uL that is consistent with inflammation occurring in lungs, and
possible infection. It also shows an elevated BUN of 31 mg/dL which can be due to impaired blood flow from the heart secondary to CHF
(1). Patient’s blood shows an elevated ALKP of 124 IU/L which is also indicative of CHF (2).

Patient’s BNP was elevated at 202 pg/mL. This is a hormone that is released with high blood pressure and indicates that the heart is
working too hard from HTN. (3)

The patient’s CPK was elevated at 290 U/L, and her CK-MB was elevated at 13.7 ng/mL. These values are traditionally elevated from a
MI, but can also be elevated from ischemia, inflammation, or hypothyroidism without an MI. (4)

Troponin was WNL at 0.02 mg/mL. If it were elevated, it would indicate damage to the heart.

Sputum cultures: Pending results.

Chest CT: Cardiomegaly. Vessel atheromatous calcification. No evidence of aneurysm, pneumothorax, or pleural effusion. There is
bibasilar atelectatic changes and/or scarring. No consolidation/mass lesion, or discrete nodule. Moderate hiatal hernia, and fatty infiltrate
of liver.
Chest Radiographs: Worsening bilateral pulmonary opacities and cardiomegaly. This could represent fluid overload or infectious
process.

Data Collection
Diet: Regular IV: Saline Lock
I&O: No order present CBG: No
Fall Risk/Safety Precautions: Yes Activity: One person assist
Wound Care: No Oxygen: Nasal cannula 2 L/M
Drains: None Last BM: Not since patient has been admitted
Other Tubes: None

CURRENT MEDICATIONS

Generic & Trade Classification Dose/Rout Onset/Peak Intended Action/Therapeutic Adverse Nursing
Name e/ use. reactions Implications for
Rate if IV this client.
Cephalexin Therapeutic: anti- 250 MG PO Onset: Rapid Treatment of respiratory Diarrhea Auscultate all
(Kelfex) (6) infective PO TID PO Peak: 1 Hour infection four quadrants
BID for
increased
peristalsis.
Gabapentin Therapeutic: 600 MG PO Onset: rapid Decrease nerve pain Ataxia Assist patient
(Neurotin) (7) analgesic PO BID PO Peak: 2-4 H when
adjuncts, ambulating
therapeutic,
anticonvulsants,
mood stabilizers

Therapeutic: anti- 300 MG PO onset: 1-2 days Prevention of attack of gouty Rash Assess skin for
Allopurinol (Alloprim) gout agents, anti- PO QD PO Peak: 1-2 WK arthritis and nephropathy. rash QD
(8) hyper-urinemic

Therapeutic: Anti- 81 MG PO PO Onset: 5-30 min Prevent clots GI Bleeding Assess stool for
Aspirin (9) platelet QD PO Peak: 1-3 H melena
aggregator

Therapeutic: 112 MCG PO Onset: Replacement in hypothyroidism Hyperthyroidism Assess for

Levothyroxine hormones PO QD Unknown to restore normal hormonal signs of
(Synthroid) (10) PO Peak: 1-3 WK balance hyperthyroidism
: anxiety, weight
loss, etc.
DAR NURSING PROGRESS NOTE

02/20/2017 @ 1000
Data: Acute pain R/T removal of foley catheter AEB burning sensation described by patient.
Action: Nurse removed foley per doctor’s order. Balloon was fully deflated prior to removal. Skin in
perineal area, and tip of catheter were both intact.
Response: Patient reported mild burning, but tolerated the procedure well.
Signature: Liz, student RN

PATIENT CARE PLAN

Patient Information:
Respiratory Failure, CHF

Problem #1 Impaired gas exchange R/T dyspnea with exertion AEB desaturation of SPO2, cyanosis,
and elevated BP with standing/walking/shifting in bed.
Desired Outcome: Patient’s SPO2 will stay greater than or equal to 90% for entire shift.
Nursing Interventions Client Response to Intervention
1. Administer oxygen via nasal cannula @ 2 L/M 1. Patient wore oxygen all day.

2. Have patient use Ocapela 10 times per hour 2. Patient was very compliant with Ocapela
use Q1H.
3. Perform deep breathing exercises with patient to 3. Patient did deep breathing exercises with
increase oxygenation, and induce relaxation. student nurse.

Evaluation
Patient’s SPO2 went down with exertion, but not as much as it did prior to interventions.

References

(1) https://labtestsonline.org/tests/blood-urea-nitrogen-bun
(2) https://labtestsonline.org/tests/alkaline-phosphatase-alp
(3) https://labtestsonline.org/conditions/congestive-heart-failure
(4) https://labtestsonline.org/tests/ck-mb
(5) https://labtestsonline.org/tests/troponin
(6) https://davisplus.fadavis.com/3976/meddeck/pdf/cephalexin.pdf
(7) https://davisplus.fadavis.com/3976/meddeck/pdf/gabapentin.pdf
(8) https://davisplus.fadavis.com/3976/meddeck/pdf/allopurinol.pdf
(9) https://davisplus.fadavis.com/3976/meddeck/pdf/aspirin.pdf
(10) https://davisplus.fadavis.com/3976/meddeck/pdf/levothyroxine.pdf