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NURSING CARE PREPARATION

Student Name:

Jason Villavicencio

Unit/Room Number: 62-1


Age:92
Gender: Male
Eriksons Developmental Level: Ego Integrity vs.
Despair

Date of Care:

11/05/13

Date of Admission: 10/18/13


Ethnic/Cultural Preferences: White
Allergies: Lyrica, Quinine, NKFA
Code Status: DNR

Primary Diagnosis:
Acute on Chronic Systolic Heart Failure
Co-morbidities:
Difficulty in walking
Muscle weakness (generalized)
Atrial Fibrillation
Unspecified disorder of kidney and ureter
Unspecified essential hypertension
Coronary atherosclerosis unspecified type vessel native/graft

Discharge Plan (add day of clinical):


Home with wife

Preliminary Integrated Pathophysiology primary diagnosis (what is going on with your client at the cellular
level for the health condition, due before clinical shift; (typed 1-3 pages with APA formatting). Explain how
your clients primary diagnosis, co-morbidities, medications and labs interrelate.

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 diet/Regular texture
IV (Fluid type, rate, access type): No
I&O (MD order/Nursing Order/Frequency): No
CBG (Yes/No, frequency): No
Fall Risk/Safety Precautions (Yes/No): Yes/Bedrails
Activity (Patients activity level ): 1PerAssist with
ADLs
Wound Care (Yes/No): Yes
Oxygen (Yes/No, Delivery method, how much): No
Drains (Yes/No, Type): No
Last BM: 11/5/13
Other Tubes: No

ASSESSMENTS
(Include Subjective & Objective Data)
Integumentary:
Skin: LE bilateral edema +3, smooth, no hair, uniform
color normal for age; pedal cyanosis, nails thick, dark
green; wound dressing bilateral unable to assess.
LUE ecchymosis, wound dressing X3 unable to assess,
X1 scabbing quarter size on L forearm, X2 scabbing
wound pea size forearm. UE bilateral cold cyanotic,
nails thick/brittle with longitudinal ridges, clubbing,
capillary refill unable to assess due to integrity.
Thorax color appropriate for race, no hair, scare on
sternum 8in. in length. Abdominal ecchymosis LUQ
10inX4in. Hair on scalp evenly distributed color
appropriate for age, mobile, non-tender. Open wound
on coccyx 4cmX3cm.
Eyes/Ear/Nose/Throat:
Wears classes reading and distance, color vision intact
Diminished visual field, eyes parallel, light reflex
symmetrical, Extraocular motion intact OU, no
wandering, + corneal reflex, PERRLA, pupil 3-5mm
Ears presbicusis hearing aids bilaterally, positive
Romberg, external ear non-tender, no lesions
Nose symmetrical moist, pink septum intact hair
appropriate for age.

Head and Neck:


Head: Normocephalic, erect, midline
Facial expression appropriate
Hair distribution appropriate for clients age, sex, and
ethnicity.
No lesions or abnormal movement
No periorbital edema
Sinuses no pain or swelling
Lips dry no visible lesions
Dentures top and bottom gingiva pink moist
Neck midline AROM + swallow and gag reflex, skin
intact
Larynx and trachea rise with swallowing
Bruit
Thyroid no swelling non-tender, smooth
Thorax/Lungs:
Respirations labored with increase in rate symmetrical.
No barrel chest or spinal deformities
Skin scar previous trauma
Chest non-tender, no masses
E to A consolidation
Increased fremitus, Crackles/rales, wheezing

Cardiac:
Carotid pulsation large, bounding, visible in neck
Elevated JVP, Giant A wave
Bruit, Diminished S1,

Musculoskeletal:
UE bilaterally ROM Full strength +3
Neck AROM full
Assist with ambulation and transfers
Positive Romberg
Muscle weakness in LE bilaterally unable to perform
ROM
Fingers and thumb swollen tender, no deformities
Propulsive Gait

Genitourinary:

Gastrointestinal:
Pain in ULQ dull Pt states from fall 2 on 1-10 pain
scale
BT auscultated in all 4 quadrants, gastric sounds <15
sec

Neurological / Psychosocial
A/O x3

Other (Include vital signs, weight):


T: 35.7C P: 70 R: 26 BP: 110/78 O2: 99% Wt:
195.4lbs
Pain (chronic or acute): No pain communicated by Pt
Pain management: None needed

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

Classification

Dose/Route/
Rate if IV

Onset/
Peak

Intended
Action/Therapeutic
use. Why is this
client taking med?
Fever reduction

Adverse
reactions (1
major side
effect)
Elevation of
ALT/AST

Nursing Implications for this client.


(No more than one)

Acetaminoph
en
(Tylenol)

Nonnarcotic
analgesic

325mg 2
tabs Q4H
PRN if temp
over 100.4

IpratropiumAlbuterol

Bronchodilator
s

Lorazepam
(Ativan)

SedativeHypnotic

Nitroglycerin

Antianginal/
nitrate
vasodilator

Doxycycline
Hyclate

Antibiotic

Potassium
Chloride

Electrolytic
replacement

0.5/2.5
(3)mg/3ml
neb PO PRN
SOB 3ml
q4hrs
0.5mg
Tablet
Once daily
Bedtime PO
PRN
0.4mg 1
sublingual
first sign
attack,
repeat Q5
min (no
more than 3
within 15
mins) PRN
100mg
Tablet PO
BID
20 mEq
Extended

O:
within
1H
P:0.52H
O:515min
P:0.52h

Relieves bronchial
constriction.

Elevation of HR;
cough

Monitor VS, breathing, and possible


tachycardia.

P: 2h

Insomnia

Hypertension or
Hypotension

Monitor VS, especially respirations.

O: 2
min

Prophylaxis or
treatment of
angina

Early MI,
increased ICP
(sustained
release formcontraindication
is glaucoma)

Sit/lay down 15-20 min after onset, be


aware that if symptoms don't go away
after 3 tabs in 15 mins- likely an MI,
keep record of attacks, report blurry
vision & dry mouth

P: 1.54h

Cellulitis

N/V, diarrhea

Monitor VS, hydration, fluid intake


and BM, and infection.

Hypokalemia

Cardiac
depression,

Monitor VS for irregular heartbeat.

Monitor for signs/symptoms of


hepatotoxicity

solution

Prednisone

Furosemide

Adrenal
corticosteroid

Release 1
Tablet PO
BID with or
after meals
20mg Tablet
PO daily

Electrolytic
and water
balance agent

80mg Tablet
1 PO BID
with food

Hydralazine
HCL

Vasodilator

Losartan
Potassium
(Cozaar)

Angiotensin II
Receptor

Metoprolol
Tartrate

bradycardia, or
arrest.

P:1-2h

P: 6070min
O: 3060min
25mg Tablet P: 2hrs
1 PO QID
O: 20with food
30min

25mg
P: 6hrs
Tablets 2 PO
once a day
(Do Not
Give if HR
above 50
and or Sys.
BP below
90)
Cardioselective 50mg Tablet
P:
; Bata2 PO BID
1.5hrs
Adrenergic
O:
Antagonist;
15min
Antihypertensi
ve; Anianginal

Vasculitis

CHF, N/V,
insomnia,
Hypokalemia
Hypokalemia,
dehydration

Monitor VS, wt, and I/O to determine


wt gain and water retention.

Promotes
vasodilation which
increases blood
flow to the
extremities.
Hypertension

Hypotension,
tachycardia,
heart
palpitations

Monitor VS, especially HR and BP,


extremities for adequate blood flow.

Upper
respiratory
infection

Monitor VS.

Reduce edema
from CHF,
Arrythmias

Severe
bradycardia or
hypotension

Monitor VS and potassium levels.

Edema associated
with CHF

Monitor VS, wt, and I/O

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.
Date
Lab Test
Patient Values/
Interpretation as related to Pathophysiology
Normal Values
Date of care
cite reference & pg #
Sodium
Did not find Labs
135 145 mEq/L
Potassium
3.5 5.0 mEq/L
Chloride
97-107 mEq/L
Co2
23-29 mEq/L
Glucose
75 110 mg/dL
BUN
8-21 mg/dL
Creatinine
0.5 1.2 mg/dL
Uric Acid Plasma
4.4-7.6 mg/dL
Calcium
8.2-10.2 mg/dL
Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
0.3-1.2 mg/dL
Total Protein
6.0-8.0 gm/dL
Albumin
3.4-4.8gm/dL
Cholesterol
<200-240 mg/dL
Alk Phos
25-142 IU/L
SGOT or AST
10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
WBC
4.5 11.0
RBC
male: 4.7-5.14 x 10
female: 4.2-4.87 x 10

HGB
male: 12.6-17.4 g/dL
female: 11.7-16.1 g/dL

HCT
male: 43-49%
female: 38-44%
MCV
85-95 fL
MCH
28 32 Pg
RDW
11.6-14.8%
Platelet
150-450

DIAGNOSTIC TESTING
Date

UA

Normal
Range

Results

Color/Appearance
pH
Spec Gravity
Protein
Glucose
Ketones
Blood
Date

Other
(PT, aPTT, PTT,
INR, ABGs,
Cultures, etc)

Normal
Range

Results

Date
Radiology
X-Rays: 1 Chest
View
Scans: CT
Head/Brain
EKG-12 lead
Telemetry
Other

Results

Interpretation as related to
Pathophysiology cite reference &
pg #
Did not find in chart

Interpretation as related to
Pathophysiology cite reference &
pg #

Interpretation as related to
Pathophysiology cite reference &
pg #

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.
11/05/13 Open Wound
1030: Assisted pt with ambulation off of toilet. Pulled pts brief up observed open sore on coccyx.
1300: Notified attending nurse, nurse stated that I havent heard of any sore recently.
Attending nurse thanked me and stated she would follow up.--------------------------------J.VillavicencioSN

PATIENT CARE PLAN


Patient Information: 92 year old white male, room 62

Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by (AEB).

Problem #1: Impaired Skin integrity r/t trauma AEB open wounds
Desired Outcome: Sustain current skin integrety
Nursing Interventions
Client Response to Intervention
1. Monitor wound area for color change, redness, swelling,
1. Was unable to assess wound, dressings
warmth and pain.
changed before I was able to get on floor.
2. Educate pt in the need for assistance with transfers and
ambulation.

2. Pt stated that he would use call light for


assistance.

3. Change dressings and administer wound care as


prescribed by MD

3. Was unable to assess wound, dressings


changed before I was able to get on floor.

Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):
I was unable to assess wound because of treatment timing. I would communicate with attending nurse for
wound care to assess wound. The pt did use call light for assistance with transfers and ambulation.

Problem #2: Ineffective tissue perfusion r/t CHF AEB peripheral edema
Desired Outcome: Decrease level of peripheral edema by end of AM shift
Nursing Interventions
Client Response to Intervention
1. Elevate lower extremities to promote perfusion
1. Kept lower extremities elevated while pt
rested.
2. Monitor VS and peripheral pulse for changes
2. VS showed no abnormal changes, peripheral
pulse demonstrated no change
3. Educate pt about importance of elevating legs and
3. Pt verbalized the importance by stating, yes, I
watching for skin break down.
understand what you are saying
Evaluation: Peripheral edema was not reduced by end of shift. My time from was unrealistic for the outcome.

Problem #3: Fatigue r/t difficulty sleeping AEB pt stating, I cant sleep most nights, so Im usually pretty tire
during the day.
Desired Outcome: Pt demonstrating increased energy by end of AM shift.
Nursing Interventions
Client Response to Intervention
1. Monitor pt VS between activities
1. No unexpected changes
2. Encourage pt to get rest between actives (OT, meals,
2. Pt rested in recliner in between physical
toileting)
activity
3. Assist pt with ADLs as necessary, encouraging
3. Pt verbalized appreciation by stating, Thank
independence without causing exhaustion.
you for the help
Evaluation: Pt showed an increased interest in physical activity with his participation in PT.

Running header: PATHOPHYSIOLOGY AT A CELLULAR LEVEL

Pathophysiology at a Cellular Level


Systolic Heart Failure
Jason Villavicencio
Southwestern Oregon Community College

Running header: PATHOPHYSIOLOGY AT A CELLULAR LEVEL

Diagnosis at a Cellular Level


Systolic heart failure (SHF) is the hearts inability to create a strong enough left
ventricular contraction resulting in a diminished cardiac output which limits blood circulation
throughout the body (Huether & McCance, 2012). This is also commonly referred to as
congestive heart failure (CHF). SHF is caused by the reduced efficiency of the myocardium
through damage or overload. There are many conditions that can cause this; the more wellknown causes are myocardial infarction and hypertension.
With myocardial infarction the heart muscle is starved of oxygen causing the cells to die
weakening the muscle. By weakening the muscle contractility reducing the stroke volume
causing dilation of the heart thus increasing preload. This becomes a vicious cycle that ends
with complete heart failure (Huether & McCance, 2012).
Hypertension increases peripheral vascular resistance (PVR) usually resulting in
increased afterload. This puts additional pressure on the ventricle creating a greater workload
causing thickening of the myocardium. Thickening of the myocardium leads to hypertensive
hypertrophic cardiomyopathy which then increases PVR further increasing afterload and preload
(Huether & McCance, 2012).
The patient demonstrated signs of fatigue but a willingness to participate in physical
therapy. The resulting effects of his CHF are being treated with a regimented medication plan.
He is anxious to return home to his wife but first his skin integrity must improve and his stability
must increase.

Running header: PATHOPHYSIOLOGY AT A CELLULAR LEVEL


References
Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology. St. Louis,
MO: Mosby Elsevier.

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