Student: Leah Will Date Submitted: Jan.

31st, 2019

Patient assignment: Briefly state your patients’ diagnoses:

78M
Dx: Bradycardia (on admission to ER), AKI, hypertension, diabetes mellitus.

By answering the questions below, please discuss how you utilized critical thinking and
analysis of the information collected to provide care to your patient. Depending on area of
practice, not all indices presented below will apply (i.e. your practice area may not involve
IV pumps etc.).

Clearly indicate which ONE of your patients from above you will be discussing (provide
age, gender and diagnosis):

a) What is their admission diagnosis – briefly describe what brought patient to

hospital and demonstrate your understanding of the diagnosis. (Application of
pathophysiology)

The patient arrived in the emergency department with a diagnosis of bradycardia. The
emergency admission records indicated a HR of 20 bpm. Bradycardia is a condition where the
heartrate is extremely low. A normal heart rate is between 60 and 100 beats per minute. Risk
with bradycardia can include fainting, heart failure, cardiac arrest or sudden death. If the heart is
beating this slowly, it will not have the ability to pump oxygenated blood throughout the body.
The cause of bradycardia was unknown, but I suspect it was likely due to an intrinsic factor such
as peripheral artery disease or any other degenerative process occurring within this patient.

b) What is current medical condition - if different than admission?

The patient was no longer bradycardic during my shift of 1400-2200. He had a pulse of
98 and his radial pulses were equal bilaterally. Pedal pulses were palpable via Doppler. The
patient had no SOB, and air entry was equal bilaterally with diminished air entry to the bases.
His vitals were: T: 36.4, P: 98, RR: 14, O2: 98% (on 2.5L), BP: 169/67.
The patient was well received in bed, and was A & O x3 around 1400. He was pleasant and
cooperative. With his severe glaucoma, he had difficulties seeing, as one eye was sewn shut. He
was excited and receptive to have nursing students working with him for the day. He has a foley
catheter draining clear and yellow urine. I saw that it was quite full, and the patient kept saying
that it was good, demonstrating an understanding of the fluid he was retaining and the process of
excreting it. The patient was mentioning how cold he was very often, indicating poor circulation
and temperature regulation.
 c) Co-morbidities/past medical history – indicate knowledge of significant ones listed.

The patient had a list of co-morbidities/past medical history. This included, diabetes
mellitus, chronic kidney disease, hypertension, peripheral artery disease, benign prostate
hypertrophy, coronary artery disease w/ coronary artery bypass graft, peripheral neuropathy,
glaucoma. The most significant co-morbidities this patient has is diabetes and chronic kidney
disease.
Diabetes is a disease that prevents the body from effectively using the energy we get
from the food we eat. This patient had type 2 diabetes, in which the pancreas is capable of
making insulin, but it either doesn’t produce enough of it, or the insulin doesn’t work effectively.
This type of diabetes is usually adult onset and can often be controlled with a combination of
diet, weight management and exercise, or with antihyperglycemic medications.
Chronic kidney disease is one of the leading causes of AKI, due to the fact that there is
already kidney damage done. Other risk factors include diabetes and hypertension. This increases
the severity and risk of experiencing an AKI. AKI occurs when there is a rapid decrease in renal
function, which can happen in just days or weeks. This causes a buildup of toxic products in the
blood (azotemia). Symptoms can include a reduced urine output, edema present in legs, ankles or
feet, fatigue, shortness of breath, confusion or chest pressure/pain. Diagnosis is based on, but not
limited to lab tests of renal function, which include serum creatinine and blood urea nitrogen
(BUN). Fluid, electrolyte and acid-base disorders can also develop very quickly. One of the most
serious is hyperkalemia and edema. Patients with AKI will often have peripheral edema and
sometimes pulmonary edema will develop. Treatment of AKI usually involves restriction of
fluids, sodium, phosphate and potassium intake, administration of diuretics and any other
treatments for causes of AKI, such as an antihypertensive.

d) Social history – where does patient come from (home, nursing home etc), and who is
their support system?

The patient came from home, in Peterborough. His wife, Gloria, visited on the morning
of January 24th according to report from the nursing student who was on shift in the morning.
During my time with the patient during evening shift, I asked him about his wife and he
explained how his wife is his support system and he is thankful that they live close by so she can
come and visit him regularly.

e) Priority nursing assessments- indicate your priority systems assessed –indicate

findings and provide rationale for whether abnormal or normal.
(you should have at least 3 priority systems related to specific medical issues and
provide rationale why chosen PLUS pain if required) (Health Assessment)

When asked, the patient reported no pain and no pain medication was indicated in his chart.

My first priority assessment with my patient was cardiovascular. Even though I knew he
no longer has bradycardia, this is what originally got him admitted to hospital so I wanted to
make this a priority. The patients pulse was 98, normal. He was on telemetry. No calf tenderness
noted. +1 edema in left foot up to ankle. +2 edema in right foot up to ankle. Pedal pulses
palpable by Doppler; weak but present. +1 edema on hip bilaterally. The edema presented in his
feet, ankles and hips was most likely a result from his condition of AKI and history of chronic
kidney disease, causing fluid retention. I also kept in mind his diagnosis of hypertension, as his
BP of 169/67.
My second focused assessment was his renal system due to his diagnosis of AKI and
history of chronic kidney disease. The patient was on strict fluid monitoring, so I had to empty
his foley catheter bag and record the output. At 1430 his recorded output was 2950ml, indicating
that he was getting rid of a lot of excess fluid. The patient was taking Lasix, a loop diuretic used
to increase urine production to excrete the extra fluid he was carrying. While I didn’t actually
give the Lasix, I observed and discussed with the primary nurse about the medication. Diuretics
are also used to treat hypertension, so we would take a blood pressure before administering the
medication and continue to monitor.
My third focused nursing assessment was his respiratory system, as it works very closely
with the cardiovascular system. The patient denied any shortness of breath, only slightly at night
when he is lying down, but does not have issues with coughing. While auscultating his breath
sounds, I listened anteriorly and posteriorly, noting diminished air entry to the bases. This could
be due to the patient not being able to get a full breath of air into his lungs. Possible causes for
this could be the development of pulmonary edema as a result of the fluid retention from his
AKI. I knew that there was still excess fluid in his body, due to the amount of edema present in
his feet, ankles and hips bilaterally, as well as the large urine output.

f) Interventions required – glucometers, IV, dressings, feeds, ostomy, trach care,

education/supportive counseling etc.
Due to this patients’ diabetes, he did require glucometer monitoring, however this is
outside of my scope of practice. I understand that normal range for blood glucose level is 4-
6mmol/L. I am unsure of what his glucose level was during the shift I was on.
He had a tagaderm absorbent on his left outer lower leg, covering a diabetic ulcer present
on his leg. This dressing did not need to be changed during my shift.
The only other intervention this patient needed was a 1 person assist when walking to a
chair or getting up from bed, as well as being instructed to what was on his table in front of him
due to his poor eyesight.

g) Lab Values –relate significant lab values to current diagnosis/medical condition and
provide rationale as well as any significant concerns.
Urea – 42.0 mmol/L. The normal range for blood urea nitrogen (BUN) is 2.5 – 6.4
mmol/L. A BUN test will measure the amount of nitrogen that is present in the blood. This
comes from the waste product, urea. When proteins are broken down in the body, urea is
released and is normally excreted in the urine. This test determines kidney function. An elevated
level of urea indicates kidney damage, and in this patient, his level is quite high at 42.0 mmol/L.
This is related to the patient’s condition of acute kidney injury, as well connected to his history
of chronic kidney disease.
Phosphate – 2.93 mmol/L. The normal range for phosphate is 0.81 – 1.58 mmol/L.
Phosphate is normally absorbed in the intestines, filtered and removed from the kidneys. This
test is significant for my patient, as he has acute kidney injury, as well as chronic kidney disease.
His phosphate level is high at 2.93 mmol/L, suggesting that there is extensive kidney damage
because the phosphate is not able to get filtered and excreted through the urine.
 h) Diagnostics – incorporate knowledge of significant diagnostic findings to current
diagnosis/medical condition. Ex: Pneumonia – chest x-ray indicates pneumonia.
I did not recall seeing any diagnostic tests done on his chart, however I could have
missed a chest x-ray from this emergency department admission. I presume this would have been
done, considering he came into the department with bradycardia.
i)
List all scheduled medications for this patient and relate to patient’s current condition or to
a past medical history condition. (Pharmacology)

Pantoprazole – proton pump inhibitor. This

Tamsusolin – alpha 1 antagonist. This drug is used to treat BPH by relaxing the muscles in the
prostate and bladder.

Nitroglycerin patch – antianginal. This drug prevents angina associated with CAD.

Amlodapine – calcium channel blocker. This drug lowers blood pressure and helps with CAD by
causing vasodilation.

Exetimbe – lowers cholesterol by reducing the absorption.

Allopurinol – treats kidney stones by reducing uric acid.

Furosemide – loop diuretic to increase urine production and excretion to reduce excess fluid.

Sitaglipten – antihyperglycemic. To lower blood sugar in diabetic patients.

Communication:
a) Indicate any unique or special communication techniques for this patient.
After getting report from the nursing student who was on the morning shift, we discussed
special communication techniques for the patient as he had severe glaucoma. His right eye was
sewn shut and he had very poor vison out of his left eye. From the brief outline of the patient’s
condition prior to the shift, I was aware of the glaucoma, but I was unaware of the severity.
Patients who have severe glaucoma may no longer be able to do activities of daily living
independently, causing them to have to rely on nurses or family to do things for them. The
patient needed to have his table in front of him, and I reassured him where his water was, the
tissues and the call bell. I brought his hand over to each of these essential items for him so he
knew exactly where they were.
b) Describe patient teaching performed and patient/family response.
During the shift, there was a lot of opportunity for patient teaching, as he was very alert
and oriented and wanted to be involved in his care. The nurse I was working with that shift sat
down with the patient and I and we discussed his head to toe assessment. She would stop at each
system and ask “why” I was hearing/not hearing certain sounds, and I would explain the
underlying reason why. The patient would occasionally contribute to the conversation, saying
things like “I didn’t know that!” or, “that’s interesting!” It was amazing he was so receptive to
information about his own condition. We also made sure that if we were speaking more generally
about a certain condition or illness that became relevant in this conversation, that we were
informing the patient that it was general information, and not about him so that he would not be
concerned.
c) Indicate any collaborated communication with health care team (daily rounds,
physician etc.)
During this afternoon shift, I was not present for daily rounds. The only collaborated
communication was with the other nursing student who gave me report on the patient from her
morning shift.

d) Describe your therapeutic relationship with this patient/family.

I felt as if I developed a good student nurse – patient therapeutic relationship with this
patient. He was pleasant to talk to, and was very helpful as I was learning to do assessments and
he was encouraging me as I went.

e) What are the barriers to discharge and what is your role to ensure discharge
process is completed?
A barrier to discharge is making sure the patient is stable enough to be off of telemetry
monitoring. This could include ensuring the medication prescribed to him in regards to his heart
is working as is effective. Another barrier to discharge is making sure that the patient has family
to take him home and that the appropriate supportive care is available to him once he returns
home with his wife. At home he also needs to make sure he is adherent to his medication, and
that he understands why he is taking certain medication.

Ethical/Legal Issues: Provide an example of how you advocated on behalf of patient.

There were no ethical or legal issues regarding this patient or the care he was receiving.

Did you observe any ethical/legal concerns regarding this patient?

I did not observe any ethical or legal concerns regarding this patient. From my
perspective, his care was well managed and the patient.

What did you do well?

I communicated well with the patient during the entire shift and made sure to take my
time and make sure he was comfortable as I was learning assessments. I also communicated well
with my assigned nurse for the day and made sure she understood what I wanted to learn, my
goals for the day and what I wanted to work on. I gained a lot of confidence in my practice
during this shift because the nurse was excellent in forcing me to understand why I’m doing
certain assessments. I also feel as I have very good time management skills and never feel rushed
or behind in anything I am doing (so far).

What is an area for improvement and how will you implement strategies for this?
An area for improvement would be to find more things to keep me busy, and offer help to
more nurses who may be short staffed or need an extra hand. I also want to confidently establish
a routine for the course of the shift by potentially adding patients to my list.