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N355 MEDICAL-SURGICAL ROTATION Clinical Write up

Student name: ___________________________ Date: ____________

DIRECTIONS: 1. Prior to first day of clinical: Complete sections 1 -3, 6-9 and show these sections to instructor at the beginning of the first clinical day 2. During the first clinical day: Complete sections 4-5 and your clients physical assessment 3. Beginning of second clinical day: show sections 10 through 12 to instructor at the beginning of the second clinical day 4. During second clinical day, revise document as needed 5. Two Complete write-ups to be handed in during each of the clinical rotations this quarter ********************************************************************************************************************** 1. DEMOGRAPHICS and VITAL SIGNS Client Initials: xx Age and gender: xx & xxxxxx Date of hospital admit: xx/xx/xx Dates cared: for xx/xx/xx & xx/xx/xx Allergies: Codeine, Sulfites, red dye. Unable to locate allergy response in medical chart. Advanced directive: DPA is Nephew Code status: Full code Wt: bed scale 76.1kg xx/xx/xx per chart Height: * BMI: * VS Temp P R BP Pain O2 sat DAY 1 0715 99.7 Ax 106 23 117/39 0/10 resting 96% DAY 2 0720 100.2 Oral 105 26 128/41 0/10 resting 97%

Pain ssessment Scale: FLACC pain scale, Patient had 2/10 pain upon movement especially of fingers and extremities on xxxx and xxxxx. O2 sat: Ventilator Settings Day 1: PRVC, 40%O2, PEEP 10; Ventilator Settings Day 2: PRVC, 35% O2, PEEP 10 *Unable to locate patient height in medical chart and therefore unable to calculate BMI, patient does not require daily weights due to low dose PO lasix and minimal edema (per xxx, RN). 2. BRIEF medical history (Reason for admission; medical diagnoses; surgeries; summarize hospital course); use bullet points Quit smoking tobacco in xxxx Hx of recurrent falls: xx/xx fractured R ilium, R inferior and superior ramus and sacrum Admitted to xxxxxxxxxxx on xx/xx/xx for respiratory failure/ARDS/RLL pneumonia (S. pneumonia)/multilobar infiltrates Xx/xx/xx Admitted to xxxxxxxx for ventilator weaning o Medical Diagnoses: altered mental status, C. diff (xx/xx/xx treated with 2 weeks of Flagyl; last dose xx/xx), rash (improved with Nystatin), metabolic alkalosis, UE basilica vein thrombosis (L-arm, resolved xx/xx/xx), UTI (resolved), chronic bronchitis and COPD, diabetes, osteoporosis, HTN, arthritis o Xx/xx Video-assisted fiberoptic bronchoscopy with bronchoalveolar lavage o xx/xx Echocardiogram: mildly sclerotic aortic and mitral valves but with normal function and no evidence of wall motion with normal L ventricular systolic function o xx/xx U/S guided thoracentesis of R posterior chest wall o xx/xx Percutaneous tracheostomy o xx/xx L radial arterial line o xx/xx Head CT: negative for acute hemorrhage, showed microvascular changes o xx/xx liberated from ventilator to HFG @ 40% O2 and PEEP 5 o xx/xx Emesis x3 with possible aspiration, FT off until 1800 when it was resumed at 15ml/hr, patient reintubated 3. PATHOPHYSIOLOGY: Describe all major conditions that might impact this hospitalization, including reason for admission and any chronic illnesses impacted by this admission.

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Page 2 Use a bullet list 3 - 5 bullets for pathophysiology, 2-3 bullets for treatment, 1 2 bullets for expected course, 3-5 bullets for selective nursing or laboratory assessments related to condition Acute Respiratory Distress Syndrome (ARDS): sudden and progressive form of respiratory failure which results in damage to the alveolar capillary membranes and causes them to become more permeable to intravascular fluid (Lewis et al., 2007). To understand ARDS, it helps to understand how the lungs work. When you breathe, air passes through your nose and mouth into your windpipe. The air then travels to your lungs which contain small sacs called alveoli. Small blood vessels called capillaries run through the walls of the air sacs. Oxygen passes from the alveoli into the capillaries and then into the circulatory system. Blood within the circulatory system carries the oxygen to all parts of the body. In ARDS, infections, injuries, or other conditions cause the lung's capillaries to leak more fluid than normal into the alveoli. This prevents the lungs from filling with air and moving adequate amounts of oxygen into the circulatory system. When this happens, the body's organs don't get the oxygen they need. Without oxygen, the organs may not work properly or may stop working altogether. Most people who develop ARDS are hospitalized for a variety of problems associated with organ failure or insufficiency. (THIS EXPLAINATION IS GREAT!) o Treatment Administer oxygen to correct hypoxemia Mechanical ventilation provides additional respiratory support 2 Some patients improve O perfusion when turned from the supine to the prone position (Lewis et al., 2007) o Expected Course Maintain adequate oxygenation and ventilation meanwhile preventing infection. xx vomited on xx/xx with possible aspiration. Precautions have been taken to treat possible pneumonia r/t this aspiration event. o Keep HOB at 30-45 to decrease risk of further aspiration. Wean patient off ventilator as they become stronger and able to begin breathing on their own. xx was weaned off the ventilator and placed on HFG on xx/xx but required reintubation on xx/xx. o Nursing/Laboratory Assessments Assess respiratory rate, rhythm, breath sounds, pulse ox Assess ABG looking for respiratory/metabolic acidosis/alkalosis CXR to determine placement of endotracheal tube. Last PCXR was taken on xx/xx. Another PCXR should have been done after reintubation to ensure proper endotracheal tube placement (unable to locate record). COPD: airway obstruction that is worse with expiration, the presence of chronic bronchitis and emphysema characterize chronic obstructive pulmonary disease, underlying symptoms are dyspnea and wheezing, virtually impossible to differentiate asthma from COPD (Lewis et al., 2007) (THIS DOES NOT DOMONSTRATE AN UNDERSTANDING THE DISEASE) o Treatment Smoking Cessation will cause the accelerated decline in pulmonary function to slow and pulmonary function usually improves (Lewis et al., 2007). xx ceased tobacco use in xxxx after having smoked for approximately 40 yrs (per spouse). Bronchodilator drug therapy relaxes smooth muscles in the airway and improves the ventilation of the lungs. Long-term O2 therapy improves survival, exercise capacity, cognitive performance and sleep in hypoxemic patients (Lewis et al., 2007). In COPD patients, there is a loss of elasticity and decreased alveolar surface area on surrounding capillaries. This results in a decrease in air movement in the alveolar space and therefore decreased perfusion of oxygen and carbon dioxide which leads to air trapping. o Expected Course It is a preventable and treatable disease state, a disease state characterized by airflow limitation that is not fully reversible (Lewis et al., 2007, p. 768). Maintain adequate oxygenation and ventilation Wean patient off ventilator as they become stronger and able to begin breathing on their own. xx had weaned off the ventilator and was placed on HFG before having to be reintubated after possible aspiration. o Nursing/Laboratory Assessments Assess respiratory rate, rhythm, depth, pulse ox, breath sounds Assess ABG looking for respiratory/metabolic acidosis/alkalosis Assess capillary refill to determine peripheral blood perfusion S. pneumoniae: can be a community-acquired pneumonia (35%) or a hospital-acquired pneumonia; can infect the upper respiratory tract, the blood, and the nervous system; the organism is generally found in the nose and throat

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Page 3 (Lewis et al., 2007). Risk factor for aspiration pneumonia is tube feedings (xx had high residual volumes prior to emesis and poss aspiration); infecting organism is usually one of the normal oropharyngeal flora such as S. pneumonia (Lewis et al., 2007). (THIS DOES NOT DOMONSTRATE AN UNDERSTANDING THE DISEASE) o Treatment Antibiotic therapy. xxxx was immediately started on piperacillin/tazobactam (an extended spectrum penicillin) to treat potential pneumonia r/t possible aspiration. When giving antibiotics it is important to keep in mind the development of multidrug resistant organisms and a patients sensitivity to certain antibiotics. Supportive measures: oxygen therapy to treat hypoxemia, analgesics to relieve chest pain, and antipyretics for significantly elevated temperature. Important to provide nutritional intake to meet the demands of the patient since they often loose weight because of increased metabolic demands. IV administration of fluid and electrolytes is necessary in xxs case since she is strictly NPO. Monitor renal function and cardiac function and adjust fluid intake appropriately so as not to cause fluid-overload. o Expected Course Physical assessment: may find dullness to percussion, increased fremitus (vibratory tremors felt through chest wall upon palpation), bronchial breath sounds, and crackles. May manifest with headache, fatigue, sore throat, nausea, vomiting and diarrhea. In uncomplicated cases, the patient will respond to drug therapy within 48-72 hours. o Nursing/Laboratory Assessments Change in fever Sputum purulence/Resp Secretions presence of pus Leukocytosis monitor serum blood values to determine if there is an increase in leukocytes, WBC Oxygenation Chest x-ray patterns: concentrating on location and size of infiltrates Be sure to include your patients assessment findings and appropriate teaching related to their pathophysiology Day 1 - General UE +1 edema patient unable to be taught, but arms were elevated on pillows - HR ranged from 106 122 monitor patient for sinus tachycardia with possible PACs - Thick, yellow secretions unable to teach patient how to use call light and how/when to notify staff of suctioning need, provide routine respiratory assessments and PRN suctioning - No spontaneous movement - unresponsive - Patient appeared to have 2/10 pain (FLACC Pain Assessment Tool) when her fingers were straightened, most likely due to previous diagnosis of arthritis. While performing PROM, OT explained to xx the need to stretch and move her fingers. - Left FA wound (present upon admission to RH and the result of an infiltrated peripheral IV line) dressing changed on xx/xx and it was requested that dressing be removed three days later. However, this dressing was still intact on xx/xx. Xxxxx, the wound RN, was consulted and she recommended this dressing be removed. I removed dressing and irrigated wound with NS on xx/xx and placed a new duoderm dressing secured with tegaderm per Xxxxx wound instructions located in the chart. The dressing was dated, timed and initialed. - ~11:15, pressure increased to 60s on the ventilator, mucous obstruction suspected and patient was suctioned and received several high pressure ambu bag breaths. Pressures decreased to 33 which indicated the mucous plug obstruction had been removed. (Mucous plug acts as a valve allowing air into the lungs with every breath, but not allowing air to escape the lungs during exhalation which causes the increased pressures in the lungs). Day 2 - 2+ pitting edema on RUE, arms elevated on pillows. Xx startled to her name and opened her eyes when she was rotated in bed. She had no spontaneous movements. Before every procedure/medication administration etcI informed xx of what was going to happen and talked to her through the procedures especially the uncomfortable OT exercises with her hands and fingers. - @ 0920, her 0900 meds were administered which included FeSo4. Approximately 0940, xx began to vomit which significantly increased her risk for aspiration. She was immediately suctioned and her FT was stopped. She was given a bed bath and her linens were changed. She was again placed with the head of her bed at a 30 degree angle one intervention to prevent/limit aspiration. Its possible the emesis was a reaction to the to the FeSO4 and this was communicated to Dr. Xxxx during rounds. He proceeded to discontinue FeSO 4. Her FT was resumed at 1030 at 30ml/hr and at 1310 it was increased to 50ml/hr (the desired rate). xx was not

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Page 4 responsive but she was reassured throughout the cleaning process and provided necessary care. Her PEG tube dressing, PICC line dressing and trach dressing were also changed to decrease risk of infection. @ 0730, she had clear lung sounds in the LUL and RUL and crackles in RML and diminished with crackles in the RLL and LLL. @ 1230, she had clear and diminished lung sounds in the LLL but crackles in the RLL (diminished), RML, RUL, and LUL. This assessment is critical following her emesis and aspiration event from the morning. xx was unable to be taught due to her unresponsiveness. I was able to discuss appropriate hand-washing techniques with family members and visitors.

List two physiological nursing diagnoses related to this patients pathophysiology 1. Impaired gas exchange r/t alveolar-capillary membrane changes 2. Risk for infection r/t possible aspiration and exposure of pathogens to lungs 4. DEVELOPMENTAL ASSESSMENT: (refer to growth charts with infants & children); Compare and contrast your client to typical growth & development issues for someone of this age and sex? See bulleted chart below. What are expected healthcare concerns for someone of this age and sex? Are these your clients concerns? Expected Healthcare Concerns: decreased peripheral circulation (yes, this is pertinent to xx since she has hypertension and diabetes, both of which can decrease peripheral circulation), declining cardiac and renal function, decreased response to stress and sensory stimulation, skeletal decline (yes, this is pertinent to xx due to her osteoporosis and arthritis), decrease tolerance to heat and cold (this is not a major concern of xx), loss of teeth leading to changes in food intake (this is not a major concern at this time), atrophy of reproductive organs (this is not a major concern); xxs major healthcare concerns at this point in time are weaning off the ventilator while maintaining appropriate oxygenation, maintaining a healthy weight by receiving adequate nutrients and maintaining ROM in all extremities to ensure a more timely rehabilitation. Describe one example of health care promotion for this client based on their growth and development and health concerns. When teach opportunities arrive teach xx to practice good health habits, such as proper diet and hygiene, adequate rest, and regular exercise all of which can maintain the natural resistance to infecting organisms (i.e. pneumonia) and aid in the management of diabetes and hypertension. Incentive spirometry use, deep breathing and effective coughing along with adequate fluid intake will promote lung expansion and secretion mobilization which will improve O2 perfusion and decrease risk of further infection. Bullet important points of expected development Decreased peripheral circulation Declining cardiac and renal function Decreased response to stress and sensory stimulation Skeletal decline Your patients actual stage with supporting assessment findings This is a concern for xx due to her diabetes and hypertension which can decrease blood flow to the extremities. Peripheral pulses 2+/1+, cap refill < 3 sec in fingers and toes. This is a concern for xx since her body has experienced increased levels of stress related to sepsis, pneumonia and her recent aspiration. S1S2 sounds present with sinus tachycardia (106 122), and occasional PACs, urinary output (400ml between 0700-1500) patient takes 20mg lasix orally, creatinine 0.44 on xx/xx indicative of inadequate protein intake and does not indicate renal failure. Patient was unresponsive to verbal stimuli and showed signs of pain when fingers were manipulated (2/10 on FLACC Pain Assessment Scale), she opened her eyes when her position was changed to perform a full skin assessment and listen to posterior lung sounds. OT and PT conducted PROM on all extremities but she resisted manipulation of her fingers. She was unable to sit in chair due to her increased work in breathing as evidenced by her RR which was 24-26/12. This is not a major concern of xx/xx at the moment. Instead her body is recuperating from a previously diagnosed and treated sepsis, pneumonia and aspiration events. Once those conditions are managed, then sensory stimulation and ROM will be important during her

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Page 5 rehabilitation. xx has osteoporosis and arthritis both of which affect her skeletal system. She resisted PROM exercises in her fingers most likely due to arthritis. She takes tums as a calcium replacement/supplement and did not show signs of hypocalcemia and/or hypercalcemia.

5. FAMILY ASSESSMENT: (family composition, # and ages of siblings (for child), occupation/work, retirement, education, family residence and other relevant information that may influence planning and care) Lived independently at home with husband in Xxxxx They identify with the Catholic faith Husband diagnosed with early stage Alzheimers disease Patient was caregiver for husband at their residence before hospitalization Have 4 nieces and 2 nephews Nephew who is DPA is currently caring for patients husband at his residence during her hospitalization Patient used to be seamstress/sewing but is now retired Two psychosocial nursing diagnoses related to development/family/psychosocial issues are 1. Interrupted family process r/t family roles shift, shift in health status of family member, situational crises 2. Risk for spiritual distress r/t life change, social alienation and chronic illness 6. DESCRIBE TYPE AND WHY THESE INTERVENTIONS ARE ORDERED FOR YOUR PATIENT: Type and rationale and relevant nursing assessments Diet: (for children include fluid requirements, calculations of fluid and caloric needs) Feeding tube formula/strictly NPO at risk for aspiration, patient sedated; Rationale: provide adequate nutrition w/o risk of aspiration; assess for residual volume following NG feeding. xxxx receives Nutren pulmonary TF with a goal rate of administration at 45 ml/hr. On xx/xx, after patient had emesis x 3, TF was stopped @ 1230 and restarted at 1800 at 15ml/hr. Rationale: This lower rate is to reduce likelihood of aspiration, reduce volume of residual output and still stimulate the GI tract and provide nutrients to the patient. What outcomes are associated with these treatments? Patient maintaining weight @ xxxx kg. Patient weighed xx kg upon admission on xxxxxxx. Precautions taken to prevent aspiration, provide nutrients needed for skin healing, Nutritionist calculated xxxxxx caloric need and increased her tube feeding rate to 50ml/hr on xx/xx. xx had emesis and aspirated at ~0940 on xx/xx. Her FT was stopped and resumed @ 1030 at 30ml/hr. It was increased to 50ml/hr @ 1310. Patient unable to sit in chair or change position in bed. However, her O2 sat stayed consistent between 96-97% while in bed. She did experience a mucous plug on xx/xx but this was dislodged promptly by RT, no new skin breakdown xx did not assist PT/OT in PROM exercises. Contractures are in the early stages on her feet and she did not respond favorably to PROM exercises with her fingers. Her hands and fingers were placed in splints to facilitate movement and prevent contractors.

Activity:

Patient on rotating bed which turns her from side-to-side q15 minutes Rationale: prevent pressure ulcers, facilitate adequate lung expansion, discourage pooling of secretions; assess skin q shift

OT PROM bilateral upper extremities every week day; assess for contractors and muscle atrophy Rationale: redistributes synovial fluid around the joints which decrease risk of contractures and increases relaxation,

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Page 6 Treatments (such as dressing changes, OT/PT): L arm/wrist wound, dressing changed on xx/xx per wound care instructions located in chartduoderm applied and secured with tegaderm. The dressing was dated, timed and initialed. Rationale: By dressing the wound, it is protected and provides the necessary environment for the wound to heal. Necessary to assess wound for signs of infection as well as evaluate the healing process. I did not observe wound on xx/xx when dressing was first applied so I did not have a frame of reference to compare it to. xx, however, was able to assess the wound on xx/xx and assisted my in changing the dressing on xx/xx. She indicated that the wound had healed significantly during that time. There were no signs of redness or drainage. The wound was healing appropriately. Powder applied to redden skin under skin folds, armpits, breasts and on coccyx. RN described yeasty infection in peri-area to be much improved since xx/xx. Dark reddened skin was observed on coccyx with no new skin breakdown. xx had 1+ and 2+ pedal pulses on xx/xx and xx/xx respectively. Her legs were of normal room temperature and there were no reddened or hot areas found. She did not show signs of pain when her legs were manipulated with movement. Blood sugar was 191 on xx/xx and 4 units of regular insulin was administered. Blood sugar was 146 on xx/xx and 2 units of regular insulin was administered. She showed no signs of hyperglycemia on either day. xx maintained oxygenation between 96-97% on xx/xx and xx/xx. She was on PRVC ventilation with 40% O2 on xx/xx and 35% O2 on xx/xx with a PEEP of 10 on both days. She did experience a mucous plug on xx/xx and this was noticed when her ventilator alarm when off when her peak pressures increased to the 60s. This plug was immediately dislodged by the RT after thorough suctioning and firm ambu-bag breaths.

Skin cream/powder applied to yeasty areas (under breasts and armpits and under pannus) including groin treat yeast infections; assess for signs of infection including redness, edema, ecchymosis, drainage and approximation (REEDA) Sequential Compression Devices (SCD) applied daily to patients lower legs Rationale: to increase venous return and decrease risk of developing DVT in the lower extremities; assess for signs of DVT (redness, increased skin temperature, pain) Additional interventions: (chemsticks, pulse oximetry, etc.) Chemstick q6h; Ratioanle: patient is diabetic and important to detect hypoglycemic or hyperglycemic episodes; assess patient for signs of hyperglycemia or hypoglycemia

Continued pulse ox; patient on ventilator and the RN needs to know how patient is oxygenating at all times. Rationale: indicates the appropriateness of ventilation settings, assess lung sounds regularly and assess for possible suctioning need. Early prevention of complications.

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Page 7 7. MEDICATIONS: Please complete table for all regularly scheduled medications, given over the entire 24 hour day and for any prn meds given within the past 24 hours for this patient Drug/Drug Class Be sure to include HOW/WHY the drug works xxxxxxxxxxx Antiulcer Agent/ Proton Pump Inhibitor Binds to enzyme of gastric parietal cells in presence of acidic gastric pH, prevents final transport of hydrogen ions into gastric lumen xxxxxxxxxx Diuretic/ Loop diuretic Inhibits reabsorption of Na and Cl from the loop of Henle and distal renal tubule Dose, route, frequency Why ordered for this client Nursing assessments and interventions r/t medication Evaluation of Rx effect, including possible side effects, adverse reactions, etc.

40 mg oral susp. 0630

Prophylaxis for developing gastric ulcers

Monitor for epigastric or abdominal pain, and frank or occult blood in stool, emesis or gastric aspirate

Day 1: No abdominal pain upon palpation, no blood observed in stool, gastric residual or emesis. Day2: No abdominal pain upon palpation, no blood observed in stool, gastric residual or emesis.

20 mg tablet PO daily 0900

Edema due to renal insufficiency, HTN

Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, mucous membranes, BP, HR

Day 1: Due to low dose PO furosemide and minimal edema, patient does not require daily weights (per RN). Total intake: 3048ml, total output: 1700ml; no pitting edema, general 1+ edema UE; lung sounds clear in am, crackles in upper lobes in afternoon but clear after suctioning; BP 117/39, HR 106 Day 2: Intake between 0700 and 1430 ~744ml, Output between 0700 and 1430 ~ 400ml; 2+ pitting edema on right FA, no general edema; crackles in RML,RLL,LLL clear in LUL and RUL; BP 128/41; HR 105 Day 1: No signs of hypokalemia or hyperkalemia; no abdominal pain upon palpation, no diarrhea, no vomiting Day 2: No signs of hypokalemia or hyperkalemia; no abdominal pain upon palpation, no diarrhea, patient vomited and aspirated (emesis coming out through trach) @ 0940 most likely due to FeSO4 administration @ 0920.

xxxxxxxx (Potassium Bicarbonate) Mineral and electrolyte replacement/suppl ement Maintain acidbase balance, isotonicity, and electrophysiologic balance of the cell

20 meq packet FT daily 0900

Treatment/ prevention of potassium depletion

Monitor for signs/symptoms of hypokalemia (weakness, fatigue, arrhythmias, polyuria, polydipsia) and hyperkalemia (slow, irregular heartbeat, fatigue, muscle weakness, paresthesia, confusion, dyspnea, depressed ST segments, prolonged QT segments, widened QRS complexes, loss of P waves, cardiac arrhythmias)

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Page 8 SE: abd pain, diarrhea, flatulence, nausea, vomiting Assess nutritional status; assess bowel function for constipation or diarrhea; monitor Hgb and Hct lab values

xxxxx Antianemic/Iron supplement Iron enters the bloodstream and liver/spleen/bone marrow where it is separated out and becomes part of iron stores

300mg/5ml oral liquid FT daily 0900

Prevention/tr eatment of irondeficiency anemia

Day 1: +BS all quadrants, had medium sized bowel movement on xxxxxxxx, tube feeding increased to 50ml/hr due to increased caloric needs as determined by the nutritionist; Hgb and Hct lab values increased between xxxx and xxxx but decreased between xxxxx and xxxxx (aspiration event occurred on xxxxx). Day 2: +BS all quadrants, last BM on xxxxxxxx, ~20 minutes after administering medication, patient aspirated. This was communicated to Dr. xxxxx during rounds and he discontinued this medication b/c it likely irritated xxxxxx stomach and was the precipitating factor to the emesis; tube feeding turned off immediately following emesis and resumed @ 30ml/hr at 1030, tube feeding increased to 50ml/hr @ 1310 Day 1: No signs or symptoms of scurvy, patient does have decreased RBC, Hct, Hgb likely due to inadequate nutritional intake Day 2: No signs or symptoms of scurvy, patient does have decreased RBC, Hct, Hgb likely due to inadequate nutritional intake Day 1: No abdominal pain upon palpation, had medium sized bowel movement on 10/14/08 Day 2: No abdominal pain upon palpation, had bowel movement @ 0550 on 10/16/08

xxxxxxxxxxxxx Water soluble vitamins Vitamin supplement

500 mg tab PO daily 0900

Treatment and prevention of vitamin C deficiency due to NPO status

xxxxxxxxxxx Lipid-lowering agent/ HMG-CoA reductase inhibitor Inhibit enzyme which is responsible for catalyzing an early step in the synthesis of cholesterol

20 mg tablet PO HS 2100

Management of hypercholest erolemia

Monitor for vitamin C deficiency: scurvy (disease caused by inadequate intake of ascorbic acid, whose symptoms include fatigue, skin, joint and gum bleeding, impaired wound healing, dry skin, lower extremity edema), defective teeth, anorexia, anemia Assess for abdominal cramps, constipation, diarrhea, flatus, rashes

xxxxxxxx Laxative/stool

250mg/25ml oral liquid FT daily

Prevention of constipation

Assess for abdominal distension, presence of

Day 1: Abd slightly firm on palpation, + BS all quadrants,

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Page 9 softener 0900 Promotes incorporation of water into stool resulting in softer fecal mass bowel sounds, and usual pattern of bowel elimination Assess color, consistency and amount of stool produced had medium sized bowel movement on xxxx (not present to assess consistency and amount of stool produced) Day 2: Abd slightly firm on palpation, + BS all quadrants, had bowel movement at 0550 (not present to assess consistency and amount of stool produced) Day 1: Abd slightly firm on palpation, + BS all quadrants, had medium sized bowel movement on xxxxx (not present to assess consistency and amount of stool produced) Day 2: Abd slightly firm on palpation, + BS all quadrants, had bowel movement at 0550 (not present to assess consistency and amount of stool produced) Day 1: No signs of hypocalcemia, no signs of abdominal pain upon palpation, + BS all quadrants. Day 2: No signs of hypocalcemia, no signs of abdominal pain upon palpation, + BS all quadrants.

xxxxxxx Stimulant laxative Accumulation of water in large intestine and increased peristalsis

1 tablet PO HS 2100

Treatment of constipation from immobility

Assess for abdominal distension, presence of bowel sounds, usual pattern of bowel function Assess color, consistency, and amount of stool produced

xxxxxxxxxxxxxxxx xxxxxxxx Mineral and electrolye replacement/suppl ement Calcium is essential for nervous, muscular, and skeletal systems, bone formation and blood coagulation; activator in transmission of nerve impulses and contraction of cardiac, skeletal and smooth muscle xxxxxxxxx Laxative/ Osmotics Increases water content and softens the stool

500 mg tablet PO tid 0900, 1300, 1800

Adjunct in prevention of postmenopausal osteoporosis/ treatment and prevention of hypocalcemia

Monitor for symptoms of hypocalcemia (paresthesia, muscle twitching, laryngospasm, colic, cardiac arrhythmias, Chvosteks contraction of facial muscles in response to a light tap over the facial nerve in front of the ear or Trousseaus sign carpal spasms induced by inflating a BP cuff on the arm) Assess for heartburn, indigestion, and abd pain. Inspect abdomen and auscultate bowel sounds.

20 gm FT daily 0900

Treatment of constipation

Assess for abdominal distension, presence of bowel sounds, and usual pattern of bowel elimination Assess color, consistency and amount of stool produced

Day 1: Abd slightly firm on palpation, + BS all quadrants, had medium sized bowel movement on xxxxx (not present to assess consistency and amount of stool produced) Day 2: Abd slightly firm on palpation, + BS all quadrants, had bowel movement at 0550 (not present to assess consistency and amount of stool produced) Day 1: No signs of abdominal

xxxxxxxxxxx

40mg/0.6ml oral

Relief of

Monitor for abdominal

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Antiflatulent Causes coalescence of gas bubbles xxxxxxxxxxxxxx Anticoagulant/ Antithrombotic Potentiates inhibitory effect of antithrombin, prevents conversion of prothrombin to thrombin and of fibrinogen to fibrin xxxxxxxxxxxxxx Antiemetic Stimulates motility of upper GI tract and accelerates gastric emptying, prevents and relieves nausea and vomiting xxxxxxxxxxxxxxxx Antidiabetic/pancr eatic Lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production **High Alert Med**

liquid PO qid 0900, 1300, 1800, 2100 Dose: 80mg 5000 units/1ml SQ q8h 0600, 1400, 2200

painful symptoms of excess gas in the GI tract

pain, distension, BS

Page 10 pain upon palpation, abd slightly firm, + BS all quadrants Day 2: No signs of abdominal pain upon palpation, abd slightly firm, + BS all quadrants Day 1: No signs of bleeding in stool, gastric residual etcsmall bruises noted on abdomen at sites of SQ heparin administration which is a normal finding Day 2: No signs of bleeding in stool, gastric residual or emesis, small bruises noted on abdomen at sites of SQ heparin administration which is a normal finding Day 1: Abd slightly firm, + BS all quadrants Day 2: Abd slightly firm, + BS all quadrants, patient vomited and aspirated @ 0940

Prophylaxis and treatment of DVT (resolved xxxxxxx)

Assess for signs of bleeding

10 mg tablet PO q6h 0000, 0600, 1200, 1800

Prevent aspiration

Assess for abdominal distension and bowel sounds

100 units/ml SQ 1800 Dose: 10 units

Management of diabetes

xxxxxxxxxxxxxxxx Antifungal Affect synthesis of the fungal cell wall, allowing leakage of cellular contents

56.7 gm bottle BID and PRN 0900, 1800

Treatment of fungal infection

Assess for signs and symptoms of hypoglycemia (anxiety, restlessness, mood changes, tingling in hands, feet, lips, or tongue, chills, cold sweats, confusion, cool pale skin, difficulty in concentration, drowsiness, headache, irritability, nausea, nervousness, rapid pulse, shakiness) and hyperglycemia (confusion, drowsiness, flushed, dry skin, fruitlike breath odor, rapid, deep breathing, frequent urination, loss of apptit, tiredness or weakness), monitor blood glucose regularly Inspect involved areas of the skin

Day 1: BS 191 4 units of regular insuli SQ PRN per the sliding scale Day 2: BS 146, 2 units of regular insulin SQ PRN per the sliding scale; discontinued by Dr. xxxxx on xxxxxxx. Unsure why this was discontinued since patient routinely had high chemstick results. Perhaps this is because the PRN regular insulin is controlling blood sugar well.

Day 1: Reddened skin underneath skin folds, armpits, breasts and on coccyx Day 2: Reddened skin underneath skin folds, armpits, breasts and on coccyx

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xxxxxxxxxxxxxxxx xxxxxxx Antiinfective/Extended spectrum penicillin Binds to bacterial cell wall membrane, causing cell death

4.5 gm inj in 100 ml NS bag q6h 0400, 1000, 1600, 2200 *Started xxxxx following aspiration

Treat potential pneumonia r/t aspiration on xxxxxxxx and xxxxxxxx

Assess patient for infection (VS, wound, sputum, urine, stool, WBC), ascultate lung sounds

Page 11 Day 1: Temp 99.7F axillary in am, Temp 100.6F axillary in pm, no growth in blood culture after 24 hours; lower respiratory sputum culture + for gram rods; lung sounds clear in am, crackles in upper lobes in afternoon but clear after suctioning Day 2: Temp 100.2F oral in am, Temp 101.0F oral in pm, no growth in blood culture after 48 hours; RN reports flora growing in lower respiratory sputum culture does not require vanco to treat (per Dr. Clark during rounds) and therefore vanco discontinued; crackles in RML,RLL,LLL clear in LUL and RUL Day 1: Temp 99.7F axillary in am, Temp 100.6F axillary in pm, no growth in blood culture after 24 hours; lower respiratory sputum culture + for gram rods; lung sounds clear in am, crackles in upper lobes in afternoon but clear after suctioning Day 2: Temp 100.2F oral in am, Temp 101.0F oral in pm, no growth in blood culture after 48 hours; crackles in RML,RLL,LLL clear in LUL and RUL; Vanco discontinued after receiving vancomycin trough lab value which was higher (14.1) than the range (5-10) and lab culture results which showed no organisms that require treatment with vanco (per Dr. xxxxx during rounds).

Xxxxxxxxxx Anti-infective Binds to bacterial cell walls resulting in cell death

1000 mg vial in 250ml NS bag q12h Started xxxxxxxx for possible aspiration pneumonia 0200, 1400

Treat potential pneumonia r/t aspiration on xxxxxxxx and xxxxxxxx

Assess patient for infection (VS, wound, sputum, stool, WBC), ascultate lung sounds

xxxxxxxxxxxxxxxx xxxxx Antidiabetics/ Pancreatics Lower blood glucose by stimulating glucose uptake in skeletal muscle and fat and inhibiting hepatic glucose production

100units/1ml <60=Hypoglycemi c protocol 6-120 = 0 units 121-150 = 2 units 151-200 = 4 units 201-250 = 6 units 251-300 = 8 units 301-350 = 10 units 351-400 = 12 units >400 = 14 units, call MD!

Management of Diabetes Millitus

Assess for signs and symptoms of hypoglycemia (anxiety, restlessness, mood changes, tingling in hands, feet, lips, or tongue, chills, cold sweats, confusion, cool pale skin, difficulty in concentration, drowsiness, headache, irritability, nausea, nervousness, rapid pulse, shakiness) and

Day 1: BS 191 4 units of regular insuli SQ PRN per the sliding scale; no signs of hyperglycemia Day 2: BS 146, 2 units of regular insulin SQ PRN per the sliding scale; no signs of hyperglycemia

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Page 12 **High Alert** hyperglycemia (confusion, drowsiness, flushed, dry skin, fruitlike breath odor, rapid, deep breathing, frequent urination, loss of apptit, tiredness or weakness), monitor blood glucose regularly

8. LAB TESTS (blood, urine, sputum, cultures, etc): Please complete table for laboratory tests pertinent to the reason for admission and clients health history. TEST/DATE For lab tests: RANGE/FINDIN GS 5 10 / 14.1 What is the purpose of this test? Why ordered for this patient (what is the clinical significance for this patient?) Patient is on vancomycin. Want to determine if she has a therapeutic dose onboard immediately prior to receiving her next dose. Increased levels indicate leukocytosis or infection or inflammation Leukocytosis found in majority of patients with bacterial pneumonia (Lewis et al., 2007) Nursing actions that require assessment or follow up (npo, diet changes, med change)

Vancomycin Trough Xx/xx/xx

WBC Xx/xx/xx

4.00 11.0 / 19.2

Indicates the amount of vancomycin in the patients blood stream immediately prior to administering the next vanco dose. The WBC count indicates the degree of response to a pathological process

Trough value is high. This indicates that the vancomycin dose needs to be decreased. However, lab blood cultures found flora that does not require treatment with vancomycin and vanco was discontinued on xxxxxxxx. Day 1: Temp 99.7F axillary in am, Temp 100.6F axillary in pm, no growth in blood culture after 24 hours; lower respiratory sputum culture + for gram rods; lung sounds clear in am, crackles in upper lobes in afternoon but clear after suctioning, increased temperature indicates the body is fighting an infection most likely in the lungs following aspiration Day 2: Temp 100.2F oral in am, Temp 101.0F oral in pm, no growth in blood culture after 48 hours; RN reports flora growing in lower respiratory sputum culture does not require vanco to treat (per Dr. Clark during rounds) and therefore vanco discontinued; crackles in RML,RLL (common following aspiration) and LLL ,clear in LUL and RUL, increased temperature indicates the body is fighting infection most likely in the lungs following aspiration Lab values indicate E.W. has anemia due to inadequate nutritional intake. She had increased HR at 106 and 105 on xxxxx and xxxxx respectively.

RBC Xx/xx/xx

4.00 5.20 / 3.28

RBCs contain Hgb, which is responsible for transport and exchange of oxygen, so # of

Monitor for anemia (palpitations, dyspnea, diaphoresis, pallor, jaundice, pruritus, increased HR

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Page 13 circulating RBCs is important. Decrease in RBC, Hgb and Hct indicates anemia. Measures Hgb which carries oxygen to and removes carbon dioxide from RBCs Measure % of RBCs in a volume of whole blood. Decrease of RBC, Hgb and Hct indicate anemia. To evaluate renal function

Hgb Xx/xx/xx

12.0 16.0 / 9.9

Hct Xx/xx/xx

36.0 46.0 / 29.5

Monitor effects of acute bleeding from the mouth, evaluate suspected anemia, monitor fluid imbalances Monitor effects of acute bleeding from the mouth, evaluate suspected anemia

Lab values indicate E.W. has anemia due to inadequate nutritional intake. She had increased HR at 106 and 105 on xxxxx and xxxxx respectively; xxxx did not have acute bleeding Lab values indicate xxxx has anemia due to inadequate nutritional intake. She had increased HR at 106 and 105 on xxxxxx and xxxxx respectively; xx did not have acute bleeding Low value most likely indicates inadequate protein intake. The nutritionist evaluated E.W. on 10/15/08 and determined that her caloric needs were higher than the rate at which she was receiving her tube feeding formula and therefore her formula rate was increased to 50ml/hr. Monitor for signs of infection such as increased temperature (which is seen on 10/15 and 10/16), continue to ascultate the lungs listening for crackles and other signs of pneumonia (i.e. infiltrates on pCXR). Monitor wound on pts left FA for signs of infection.

Creatinine Xx/xx/xx

0.50 1.20 / 0.44

To determine if patient has kidney failure (increased values) or inadequate protein intake/decreased muscle mass (decreased values) Increased levels indicate leukocytosis or infection or inflammation Leukocytosis found in majority of patients with bacterial pneumonia (Lewis et al., 2007) Monitor for anemia (palpitations, dyspnea, diaphoresis, pallor, jaundice, pruritus, increased HR

WBC 10/13/08

4.00 11.0 / 11.9

The WBC count indicates the degree of response to a pathological process

RBC 10/13/08

4.00 5.20 / 3.54

Hgb 10/13/08

12.0 16.0 / 10.8

Hct 10/13/08

36.0 46.0 / 32.1

RBCs contain Hgb, which is responsible for transport and exchange of oxygen, so # of circulating RBCs is important. Decrease in RBC, Hgb and Hct indicates anemia. Measures Hgb which carries oxygen to and removes carbon dioxide from RBCs Measure % of RBCs in a volume of whole blood. Decrease

Lab values indicate E.W. has anemia, most likely stemming from the fact that she is lacking excellent nutrition and therefore has a decrease in RBC production.

Monitor effects of acute bleeding from the mouth, evaluate suspected anemia, monitor fluid imbalances Monitor effects of acute bleeding from the mouth, evaluate suspected anemia

Lab values indicate E.W. has anemia due to inadequate nutritional intake. She had increased HR at 106 and 105 on 10/15 and 10/16 respectively; E.W. did not have acute bleeding Lab values indicate E.W. has anemia due to inadequate nutritional intake. She had increased HR at 106 and 105 on

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Page 14 **All infor mati on Glucose 60 90 / 129 Patient is diabetic, BS > 120, 2 units of insulin obtai 10/6/08 must monitor or regular administered, monitor for ned hypoglycemia and signs of hyperglycemia; continue from hyperglycemia, may chemstick q4h Xxxx administer insulin xx et according to the al. glucose value and (xxx the sliding scale x)** Creatinine 0.50 1.20 / 0.43 To evaluate renal To determine if Low value most likely indicates No 10/6/08 function patient has kidney inadequate protein intake. The othe failure (increased nutritionist evaluated E.W. on r lab values) or 10/15/08 and determined that her resul inadequate protein caloric needs were higher than ts intake/decreased the rate at which she was were muscle mass receiving her tube feeding locat (decreased values) formula and therefore her formula ed in rate was increased to 50ml/hr. patie Albumin 3.1 5.2 / 2.3 Measure main Decreased levels Continue nutren pulmonary tube nts 10/6/08 transport protein indicative of feeding 50ml/hr per chart in the body nutritional deficiency recommendation of nutritionist; . strictly NPO; test normal considering patient does not take Crea in any nutrients/food PO and tinin indicates adequate but not e did excellent nutritional status not RBC 4.00 5.20 / 3.31 RBCs contain Monitor for anemia Lab values indicate E.W. has chan 10/6/08 Hgb, which is (palpitations, anemia due to inadequate ge responsible for dyspnea, nutritional intake. She had signi transport and diaphoresis, pallor, increased HR at 106 and 105 on fican exchange of jaundice, pruritus, 10/15 and 10/16 respectively. tly oxygen, so # of increased HR) betw circulating RBCs een is important. xx/x Decrease in x RBC, Hgb and and Hct indicates xx/x anemia. x. Hgb 12.0 16.0 / 10.2 Measures Hgb Monitor effects of Lab values indicate E.W. has Decr 10/6/08 which carries acute bleeding from anemia due to inadequate ease oxygen to and the mouth, evaluate nutritional intake. She had d removes carbon suspected anemia, increased HR at 106 and 105 on creat dioxide from monitor fluid 10/15 and 10/16 respectively; inine RBCs imbalances E.W. did not have acute bleeding valu Hct 36.0 46.0 / 29.6 Measure % of Monitor effects of Lab values indicate E.W. has es 10/6/08 RBCs in a acute bleeding from anemia due to inadequate indic volume of whole the mouth, evaluate nutritional intake. She had ative blood. Decrease suspected anemia increased HR at 106 and 105 on of of RBC, Hgb and 10/15 and 10/16 respectively; decr Hct indicate E.W. did not have acute bleeding ease anemia. d muscle mass owing to debilitating disease/increasing age or inadequate protein intake. of RBC, Hgb and Hct indicate anemia. Measure amount of glucose present in serum; important since patient is diabetic 10/15 and 10/16 respectively; E.W. did not have acute bleeding Trends: Date Xx/xx

RBC 3.31

Hgb 10.2

Hct 29.6

WBC -

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Page 15 Xx/xx Xx/xx 3.54 3.28 10.8 9.9 32.1 29.5 11.9 19.2

RBC/Hgb/Hct values increased between xx/xx and xx/xx but still remained low. This indicates that anemia is resolving, mostly likely due to increased oral iron intake. Xx aspirated on xx/xx, her tube feeding was immediately decreased and resumed at 30ml/hr later in the day. Her body was under stress which indicates why the RBC/Hgb/Hct values decreased on xx/xx. Her WBC increased dramatically between xx/xx and xx/xx which indicates infection most likely in the lungs following the aspiration event on xx/xx. On xx/xx her tube feeding rate was increased to 50ml/hr due to her increased caloric needs as determined by the nutritionist and to provide additional energy her body will need to fight off infection. 9. DIAGNOSTIC TESTS and Procedures (x-ray. ECG, EEG, ultrasound, radiography, etc.). Please complete table for diagnostic tests pertinent to the reason for admission and clients health history. All TEST/DATE What is the purpose Why ordered for this Nursing actions that require assess or othe of this test (text patient (related to follow up (npo, diet changes, med r reference) primary dx?) Plan of change) diag care implications? nost PCXR Examine pulmonary, Determine location of Assess respiratory function: Day 1 ic Xx/xx/xx cardiac and skeletal PICC line, PEG tube, PRVC, 40% O2, PEEP 10, RR 24/12, test systems and endotracheal tube; lungs clear after suctioning, thick yellow s Evaluate cardiovascular secretions; Day 2 PRVC, 35% O2, wer health and pulmonary PEEP 10, RR 26/12, crackles in LUL, e status (i.e. infiltrates r/t RUL, RML, RLL, clear sounds in LLL com pneumonia) (crackles due to aspiration event morning plet of xx/xx) ed whil WBC elevated on 10/14, look for e infiltrates on following PCXR which, if pati present, will be indicative of infection ent (pneumonia) was adm ECG Assess cardiac Compare findings to Assess cardiac function: Difficult to itted Xx/xx/xx function ECG from xx/xx and distinguish S1S2 when ascultating, HR at determine if there is any 106 and 105 = sinus tachy with possible Xxx cardiac decline PACs, BP 117/39 and 128/41 xxxx xxxxxxx. 10. INTEGRATION OF CARE:

What are the relationships between the pathophysiology, priority nursing diagnoses, outcomes, medications, labs, and treatments for this patient at this time?
xx was weaned off the ventilator and decannulated on xx/xx and subsequently responded well for 72 hours. On xx/xx she aspirated and had to be reintubated. Since that time she requires full ventilator support at a PEEP of 10. Dr. Xxxx immediately prescribed Piperacillin/Tazobactam to be started on xx/xx to treat potential pneumonia that could develop from the aspiration event. Vancomycin was added on xx/xx after receiving positive sputum culture. This was discontinued on xx/xx after learning that the organisms present in the sputum culture would not respond to vancomycin because they were gram and vancomycin targets gram + organisms. After the aspiration event on xx/xx, xx/xx WBC count increased from 11.9 to 19.2 indicative of infection. Therefore, respiratory assessment is crucial in assessing the patients ability to fight the infection and the location of infection. It will be imperative to continue PCXR to assess for infiltrates. xx will require continued O 2 monitoring as she fights infection and continues on the ventilator. In addition, her temperature must be taken regularly to assess for fever, another sign of infection. As xxs body fights infection and pneumonia, it is imperative that she is receiving proper caloric intake via her feeding tube and this was increased by the nutritionist on xx/xx. Following her aspiration event on xx/xx, FeSO4 was discontinued and aspiration precautions still need to be implemented (strictly NPO, head of bed at 30 etc). The latest two aspiration events have proved to be a setback in xxs recovery but with early detection of problems, proper interventions can be implemented to eliminate further complications.

11. NURSING PROCESS AND PLAN OF CARE

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Page 16 Identify one priority physiologic and one psychosocial nursing diagnosis for this client. The diagnoses should be stated correctly. Nursing diagnoses should be supported by the assessment data (both subjective and/or objective) you collected and documented. State the expected outcomes for each diagnosis. Remember that outcomes should be specific, realistic and observable or measurable. Include a deadline date for meeting the outcome. Review content in Craven and Hirnle on nursing diagnosis, outcomes, etc. The nursing interventions need to be individualized, specific and realistic. Each intervention should have a frequency as well (QD at 10 AM, at all times, FYI, Q4H 02, 06, 10, etc.). Be sure to include collaboration and client teaching, if appropriate. A colleague should be able to take the care plan and implement it in your absence.

Physiologic ND: NURSING DIAGNOSIS Include problem, etiology and s/s(defining characteristics or as evidenced by ) from your assessment data major characteristic(s) should be present in your client to qualify.

EXPECTED OUTCOME(S) Outcomes are measurable, realistic and time-limited to your patient in the acute care. If teaching, what outcome(s) would be necessary?

INTERVENTIONS with RATIONALE(S) Interventions should be appropriate to the stated nursing diagnosis and related to factor. They should be specific and include frequency of implementation. Be sure to include reference the source of rationale from NANDA book or other nursing text.

EVALUATION Were your expected outcomes met? If not, would you revise your EO or your interventions Why or why not, and what would you do differently? Please use a second ink color if adding or revising. Day 1: RR 24/12 which means the ventilator was set to 12 breaths/min but xx was breathing 24 breaths/min; tidal volume remained between 350-400, no use of accessory muscles, nasal flaring or abnormal breathing patterns; lung sounds clear bilaterally after suctioning; oxygen saturation 96% Day 2: RR 26/12; tidal volume remained between 350-400, no use of accessory muscles, nasal flaring or abnormal breathing patterns; crackles heard in LUL, RUL, RML, RLL (most likely due to aspiration event) and clear in the LLL; oxygen saturation 97%. My outcomes were not met due to the aspiration event on xx/xx. However, these are still appropriate

Impaired gas exchange r/t alveolar-capillary membrane changes AEB diagnosis of COPD and potential pneumonia infection resulting from aspiration events on xx/xx/xx and xx/xx/xx

Xx Will demonstrate improved ventilation and adequate oxygenation within 7 days as evidenced by O2 sat and ventilator settings. Xx will exhibit clear lung fields and remain free of signs of respiratory distress within the next 7 days.

Monitor RR, depth and effort, including use of accessory muscles, nasal flaring and abnormal breathing patterns. Rationale: Increased RR, use of accessory muscles, nasal flaring, abd breathing and a look of panic in the clients eyes may be seen with hypoxia. Ascultate breath sounds q1-2h. The presence of crackles and wheezes may alert the nurse to airway obstruction, which may lead to or exacerbate existing hypoxia. Rationale: In severe exacerbations of COPD, lung sounds may be diminished or distant with air trapping. Monitor oxygen saturation continuously by pulse oximetry. Ratioanale: In oxygen saturation of less than 90% indicates significant oxygenation problems. The goal of inpatient therapy for the client with COPD is to maintain the oxygen saturation greater than 90%.

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Page 17 outcomes for the future. It is hoped that she will be able to begin weaning off the ventilator in the next few days and hopefully her lung fields will clear as she fights the infection/pneumonia. Psychosocial ND: NURSING DIAGNOSIS Include problem, etiology and s/s(defining characteristics or as evidenced by ) from your assessment data major characteristic(s) should be present in your client to qualify.

EXPECTED OUTCOME(S) Outcomes are measurable, realistic and time-limited to your patient in the acute care. If teaching, what outcome(s) would be necessary?

INTERVENTIONS with RATIONALE(S) Interventions should be appropriate to the stated nursing diagnosis and related to factor. They should be specific and include frequency of implementation. Be sure to include reference the source of rationale from NANDA book or other nursing text.

EVALUATION Were your expected outcomes met? If not, would you revise your EO or your interventions Why or why not, and what would you do differently? Please use a second ink color if adding or revising. Xxs family members did not visit while I was working on the unit and therefore I did not get an opportunity to meet them and establish a therapeutic relationship. However, I still feel the interventions are crucial to ensuring the overall wellness of this family during a very difficult and uncertain time.

Interrupted family process r/t family roles shift, shift in health status of family member, situational crises AEB patients hospitalization and inability to care for cognitively impaired husband

Xxs nephew (and temporary caregiver to her husband) will identify ways to cope effectively and use appropriate support systems within one week.

Healthcare staff will develop rapport immediately with nephew and husband by providing accurate and timely information related to patients changing health status. Rationale: Family care can be improved by focusing on building rapport and communicating problems and concerns between families and health professionals. Involve all family members in the care, information, and client teaching session with E.W. when they are visiting. Rationale: Family-focused activities can help families cope better with the hospital experience.

Refer xx, her husband and her nephew to appropriate community resources for assistance (i.e. support groups, counseling, spiritual support, and financial assistance). Rationale: The most important predictors of family health were family structural factors. It was found that the better the family structure and relationships were, the better the family health was. *ND information obtained from Ackley and Ladwig (xxxx).

The social worker has already referred xxs nephew to resources to help in the care of her husband and in regards to financial security. My outcome was met however it was implemented by other staff on the unit. Xxs nephew has been referred to several services.

12. DISCHARGE PLANNING FOR THIS CLIENT: Include information such as resources, living situation, insurance, community support, support systems, care givers, etc.)

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Page 18 After the latest two aspiration events, xx is far from being discharged from xxxxxx. When the time comes to discharge xx there are many areas to educate her and her family on for continued future wellness. It is important that she and her family members be aware of the signs and symptoms of pneumonia in the elderly. The elderly do not exhibit classic pneumonia signs. Instead they have symptoms of lethargy, confusion, tachypnea, anorexia or abdominal pain. xx has a long road to recovery ahead of her and she is bound to experience stress and anxiety as she navigates this path. Therefore it is imperative to encourage her not to return to her previous habit of smoking to relieve that stress and to reinforce the health benefits of not smoking. If home oxygen therapy is recommended, xx. and her family members will need to be instructed on how to use the equipment. Lastly, xx. will not be 100% back to her old self upon discharge and therefore she might be worried about the future of her husband if she cannot provide the same level of care she was providing before she became ill. There are resources that provide short-term or long-term care for her and/or her husband and these options should be presented to them as well as their nephew. If necessary, it will be important for the social workers to contact these resources and set-up consultation appointments. 13. References used APA format Ackley, B.J., Ladwig, G.B. (xxxx). Nursing diagnosis handbook: An evidence-based guide to planning th care. X edition. St. Louis: Elsevier Mosby. Craven, R.F., Hirnle, C.J. (xxxx). Fundamentals of nursing: Human health and function. X edition. Philadelphia: Lippincott Williams and Wilkins. Deglin, J.H., Vallerand, A.H. (xxxx). Daviss drug guide for nurses. 10 edition. Philadelphia: F.A. Davis. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., OBrien, P.G., Bucher, L. (xxxx). Medical-surgical nursing: th Assessment and management of clinical problems. X edition. St. Louis: Mosby. Venes, D. (xxxx). Tabers cyclopedic medical dictionary. XX edition. Philadelphia: F.A. Davis Company. Van Leeuwen, A.M., Kranpitz, T.R., Smith, L. (xxxx). Daviss comprehensive handbook of laboratory and nd diagnostic tests with nursing implications. X edition. Philadelphia: F.A. Davis.
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