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Nursing 101

Fundamentals of Nursing

Client Comprehensive Data Base


and
Plan of Care

STUDENT NAME: ____________________________________________

DATE: _______________________________________________________

Prioritized Problem List

1. Risk for impaired skin integrity r/t potential for alterations in epidermis aeb foley catheter in place
causing swelling, and irritation.
2. Risk for infection r/t increased risk for invasion of pathogens aeb foley catheter in place, and recurring
urinary tract infection.
3. Risk for falls r/t increased susceptibility to falling aeb diminished mental status, history of falls, use of
wheelchair, use of diuretics, anemia, decreased lower extremity strength, and hearing difficulties.
4. Risk for unstable blood glucose level r/t variations in blood sugar levels from the normal range aeb accu
checks daily, physical activity level, and knowledge of condition.
5. Constipation r/t difficult passage of stool aeb use of laxatives, and client stating I have problems having
bowel movements.
6. Activity intolerance r/t imbalance between oxygen supply and demand aeb SOB while moving.
7. Impaired physical mobility r/t activity intolerance aeb inability to perform ADLs, inability to stand
without assistance, and inability to walk.
8. Ineffective health maintenance r/t ineffective individual coping aeb denial of medical condition,
deficient knowledge regarding health, and cognitive impairment.
9. Impaired memory r/t impaired ability to recall bits of information aeb inability to recall day events,
inability to recall factual information, and inability to recall if a behavior was performed.

Note: All observations that indicate a deviation from normal in any area need a thorough assessment.

CLIENT BIOGRAPHICAL DATA

Code status/Advanced Directive:


Client date of birth:
Place of birth:

DNR, IV therapy, Facility based evaluation and care.

10/04/1927 Age: 87

At home

Gender:

Male

Race or ethnic background: Caucasian

Primary and secondary languages (spoken and read): English


Cultural preferences (r/t care, diet, etc.): None
Spiritual assessment / religious preference & practices (r/t care, diet, etc.):
Educational level: High School Occupation:
Type of Insurance:

Baptist

Plumber

Medicare A,B,D, Medicaid

Marital status:

Single/never married
VITAL SIGNS
ASSESSMENT [COLDSPA]
Temperat 97.7F
Charact
ure
er
orally
Pulse
64
Onset
(rate, rhythm,
regular
amplitude)
and
strong
Respirati 12
Locatio
ons
n
Regular
(rate, rhythm,
depth)
rate and
rhythm
Blood
102/62
Duratio
Pressure
n
(L) sitting
(arm, position)
Severit
y

Associa
ted
Factors

PAIN

Dull
0800 Today

Bowels

All day
2
Nothing much helps, moving makes it worse.

REASON FOR SEEKING HEALTHCARE


Admitting diagnoses:

Diabetes, Chronic airway obstruction.

Secondary diagnoses: Chronic Kidney disease, Osteoarthritis, Dementia, Retention of


urine, Restless leg syndrome, Peripheral vascular disease, Hemolytic anemia, Esophageal
reflux, Neoplasm of prostate, Lymphoid leukemia, and Gout.
Clients understanding of admission/need for healthcare: States I cannot walk anymore
thats why Im here.

Feelings/fears/concerns regarding health status:

States I have no fears or concerns,

at my age there is no point worrying about things.


PAST HEALTH HISTORY
Past medical history - physical, emotional, mental (date in parenthesis)
Medical History Diagnosis (age
Surgical History Type (age- year)
diagnosed - year)

(See diagnoses on previous page)

Cholecystectomy (6-7years ago)


Splenectomy (2006)
Orchiectomy bilateral (per physician note)

Accidents/Injuries resulting disabilities: He cannot remember if any accidents or


injuries occurred.
Allergies: NKA / If YES, describe type and reaction:

Doxycycline unknown reaction;

Simvastatin-unknown reaction.
TYPE

Immunizations Status
Check if current - (date
If not current describe follow-up protocol
received)

Childhood
Tetanus
Influenza
Pneumonia

Chickenpox at 17 years old


UTO
Last received (11/07/2013)
UTO

FAMILY HEALTH HISTORY


Mother
Father

Siblings

Living (age)
Deceased (age/year)

Died 1971 at
age 72

Died 1982 at
age 82

Presence of any
heredity diseases:
(Diabetes, HTN, Heart
disease, Cancer/type)

Diabetes and
cancer

Not known

Brother died 1999 at age


67. Sister died 2002 at age
78. Sister died at age 76.
Brother-brain cancer. SisterBrain cancer. SisterAlzheimers.

REVIEW OF SYSTEMS
Skin, Hair, Nails
Minimum History Components
Ask questions regarding:
* in pigmentation / moles *Hx of pruritus, rash,
lesions, easy bruising *Hair loss * in nail color or
condition

Minimum Physical Assessment


Components
Skin: *Color & pigmentation pattern *Bruising
*Lesions *Temperature *Moisture *Turgor
*Wound/Ulcer (specify location)
Hair: *Color, distribution, lesions, infestations
Nails: *Condition of nails

SUBJECTIVE:

OBJECTIVE:

Denies any changes in pigmentation or

Skin pink color evenly distributed but pale.

moles. Denies any history of itching, rash

No lesions. Several moles distributed over

or lesions. Does report easy bruising.

body. Has a few well healed scars on

States My hair is good for my age I think,

abdomen. Skin warm and dry, turgor shows

just a little less in the front. Denies any

instant recoil. Hair gray/white, thin, coarse.

changes in nail condition or color. States

Fingernail beds pink and smooth, well

The girls take care of my nails well here.

groomed.

Head and Neck


Minimum History Components
Ask questions regarding:
*Headache *Pain or Stiffness (COLDSPA)
*Recent history of head injury/concussion
*Dizziness or fainting *Enlarged lymph nodes

SUBJECTIVE:
Denies any headaches, pain or stiffness. No
hx of recent head injury/concussion. Denies
hx of dizziness or fainting. Denies any
problems with lymph nodes. Client states
If I sleep the wrong way I get a stiff neck.

Minimum Physical Assessment


Components
Head: *Symmetry *Facial symmetry (CN VII)
Neck: * Symmetry *ROM (CN XI) *Trachea
*Lymphadenopathy

OBJECTIVE:
Head, and facial structures symmetric.
Neck symmetric, no masses noted.
Performs full ROM with ease. Trachea
midline. No lymphadenopathy.

Eyes
Minimum History Components

Minimum Physical Assessment


Components

Ask questions regarding:


*Hx of glaucoma or cataracts *Use of corrective
lens &/or contacts * Date/year of last eye exam
*Eye pain (COLDSPA) *Infections *Impaired
vision/visual disturbances-(double vision,
blurring, light sensitivity, halos, blind spots)

*Visual acuity (CN II) (near & far vision) *EOMs


*Ptosis *Redness *Discharge
*Symmetry *Conjunctiva *Sclera *PERRLA (CN
(CN III, IV, VI)
II, III)

SUBJECTIVE:
Reports hx of cataracts, denies hx of

OBJECTIVE:
Able to read words on newspaper if up

glaucoma. Does use corrective lenses.

really close. EOMs intact and tracks equally

Unsure of last eye exam. States I get my

in both eyes. Eyes symmetric, ptosis

eyes looked at every six months or so.


Denies any eye pain, infections changes or
problems with vision or visual disturbances.
States My eyes water all the time though.

present, no redness, or discharge.


Conjunctiva pink and moist. Sclera white
and moist. Pupils equal, round, reactive to
light and accommodation (PERRLA).

Ears
Minimum History Components
Ask questions regarding:
*Pain (COLDSPA) *Ringing *Drainage *Difficulty
hearing *Date/year of last ear exam *Exposure
to loud noises *Vertigo

SUBJECTIVE:
Denies any ear pain, discomfort, ringing, or
drainage. Does report difficult hearing
sometimes. Does not recall date of last
hearing exam. No hx of exposure to loud
noises or vertigo.

Minimum Physical Assessment


Components
*Symmetry *Discharge *Lesions *Hearing
*Use of hearing aids (CN VIII)

OBJECTIVE:
Ears symmetric. No discharge or lesions.
Able to hear loud conversational voice. No
use of hearing aids.

Nose and Sinuses, Mouth, Throat


Minimum History Components
Ask questions regarding:
Nose & sinuses: * Nasal obstruction
*Sneezing *Coughing *Snoring *Epistaxis
*Sense of smell *Nasal or sinus pain (COLDSPA)
Mouth / Throat: *Pain (COLDSPA) *Sore throat
*Hoarseness *Difficulty chewing or swallowing
*Halitosis *Lesions
*Chewing tobacco *Date/year of last dental/oral
exam

Minimum Physical Assessment


Components
Nose & Sinuses: *Symmetry *Nares
*Septum *Lesions *Sinus discomfort *Ability
to smell (CN I)
Mouth:

*Lips- Color, moisture, lesions *Buccal mucosaColor, Lesions *Gums- Color, Moisture, Lesions
*Teeth/dentures ability to chew food (CN V)
*Tongue- Location, Lesions *Uvula-Position (CN
IX, X) *Swallowing (CN IX)

SUBJECTIVE:

OBJECTIVE:

Denies any nasal obstruction, pain,

Nose symmetric, and nares intact. No

sneezing, coughing, snoring, epistaxis, or

lesions, or sinus discomfort upon palpation.

problems with smell. Denies any mouth

CN 1 intact. Lips pink, dry, no lesions.

pain, sore throat, hoarseness or difficulty

Buccal mucosa pink, moist, no lesions.

swallowing. Reports certain foods are

Gums pink, moist, no lesions. No teeth

difficult to chew due to having no teeth.

present. Can chew most foods. Tongue

Denies any lesions, or halitosis. No hx of

midline, pink, no lesions. Uvula midline

using chewing tobacco. States I do not see with elevation of soft palate. Able to
the dentist, I have no teeth.

swallow without difficulties.

Respiratory System - Thorax and Lungs


Minimum History Components
Ask questions regarding:
*Chest pain with breathing (COLDSPA) *Cough
*Sputum *Dyspnea *Hemoptysis *Orthopnea
*SOB with activity (type & amt) *Exposures
*Tobacco use /Smoking (pack-years)

SUBJECTIVE:
Denies any chest pain. Minimal cough, and
no sputum. Reports dyspnea. Denies any
hemoptysis, or orthopnea. Reports SOB

Minimum Physical Assessment


Components
*Respirations: *Rate/Rhythm/Quality *Use of
accessory muscles *Oxygen saturation %
*Chest shape & symmetry *Breath Sounds
*Description of Cough / Sputum if present *Use
of Respiratory Aids

OBJECTIVE:
RR 12 regular rate and rhythm. No use of
accessory muscles. Chest rises

with activity. Denies any environmental

symmetrically with breathing, flat chest. No

exposure to pollutants; reports having

cough present. Anterior, posterior, and

smoked 30 years ago.

lateral breath sounds clear. O2 stats 96%


on 2L O2/NC.

Breast and Regional Lymphatics


Minimum History Components
Ask questions regarding:
*Pain (COLDSPA) *Lumps *Discharge from
nipples *Dimpling or changes in breast size
*Swollen and tender lymph nodes in the axilla
*SBE / Mammogram (Date/findings)

Minimum Physical Assessment


Components
*Breast symmetry *Lesions *Tenderness

SUBJECTIVE:
OBJECTIVE:
Denies pain, lumps, discharge from nipples, Breasts symmetric, no lesions, or
or changes in breast size. Denies any

tenderness on palpation.

swollen or tender lymph nodes.


Cardiovascular - Heart and Neck Vessels
Minimum History Components
Ask questions regarding:
*HTN *Dyslipidemia *Chest pain assessment
(COLDSPA) *Palpitations *Fatigue *Edema
*Cardiac diagnostics (i.e., ECG, Cath)

SUBJECTIVE:
Denies hx of HTN. Cannot recall cholesterol
levels. Denies chest pain, palpations,

Minimum Physical Assessment


Components
*B/P: measurement, position, arm
*Apical pulse: rate, rhythm
*Heart sounds *Murmurs
*Carotid pulses: Strength and equality *JVD

OBJECTIVE:
BP 102/62 (L) arm sitting; apical pulse 64
bpm, regular. Apical and Pulmonic S2>S1,

fatigue, or edema.

ERBs S1=S2, Tricuspid and Mitral S1>S2;


no murmurs noted. No JVD at 45 degrees.
(R) and (L) carotid pulse +2 regular rate
and rhythm.
Peripheral Vascular
Minimum History Components
Ask questions regarding:
*Extremity coldness, numbness, tingling, &/or

Minimum Physical Assessment


Components
Upper & Lower Extremities:

swelling *Discoloration of hands or feet


*Cramping/intermittent claudication *Hx of
blood clots

SUBJECTIVE:
Denies any upper and lower extremity
coldness, numbness, tingling &/or swelling,
or discoloration of hands and feet. Reports
some pain, and cramping when moving
legs. No hx of blood clots.

*Size and symmetry *Color *Temperature


*Edema *Lesions *Peripheral pulses: list all
pulses assessed (quality & equality) *Varicose
veins *Capillary refill

OBJECTIVE:
Upper and lower extremities equal in
length, and symmetric, pink/tan, warm, no
edema, and small lesion on (R) upper arm.
Equal hair distribution on both arms and
almost no hair on legs. Peripheral pulses
(carotid, brachial, radial, femoral, pedal,
posterior tibial). No varicose veins. Upper
and lower extremity capillary refill <3
seconds.

Gastrointestinal Abdomen
Minimum History Components
Ask questions regarding:
*Indigestion/heartburn *Nausea & vomiting
(hematemesis) *Appetite *Abdominal pain (COLDSPA)
Bowel: *Usual bowel pattern * in bowel pattern
*Use of aids (laxatives, etc.) *Incontinence
*Hemorrhoids,
*Sigmoidoscopy &/or Colonoscopy (Date & findings)

SUBJECTIVE:
Denies problems with indigestion and
heartburn, nausea, and vomiting. Reports a

Minimum Physical Assessment


Components
*Abdominal contour, symmetry *Lesions *Bowel
sounds
*Palpation- tenderness, masses *Percussion

OBJECTIVE:
Abdomen rounded, symmetric, with well
healed scars. Bowel sounds active in all

good appetite Almost always eat


everything. Denies any abdominal pain.
Usual bowel pattern is every day or every 2
days. Denies any changes in bowel pattern.

four quadrants. No pain, tenderness,


masses present, distention present on
palpation. Tympany upon percussion.

Reports using laxatives to stimulate BM.


Denies incontinence or hemorrhoids. Does
not recall last colonoscopy.
Genitourinary
Minimum History Components
Ask questions regarding:
*Usual pattern * in urinary
frequency/amount *Incontinence *Hx of UTI
*Unusual discharge *Perineal rashes *Lesions

Minimum Physical Assessment


Components
Urinary: Urine color, odor, control
Genitalia: *Perineal rashes, irritations, lesions
*Discharge (amount, color, consistency)

Female: Menstrual regularity, LMP &/or


Menopause/age of onset *Date of last Pap &
results *Protection &/or Risk for STIs
*Contraception
Male: *Self testicular exam *Prostate exam
*Protection &/or Risk for STIs

SUBJECTIVE:
Denies any changes in urinary elimination

OBJECTIVE:
Urine clear, straw color, no odor. Foley.

pattern or any problems urinating. Denies

Exam of male genitalia refused at this time.

any hx of UTI, unusual discharge, rashes or


lesions. Has a foley. States I sometimes
have a problem with swelling. Denies any
concerns with sexuality , and any concerns
with sexual health.

Endocrine
Minimum History Components

Minimum Physical Assessment


Components

Ask questions regarding:


*Thyroid trouble: *Heat & cold intolerances
*Excessive
sweating
*Diabetes: *Excessive thirst or hunger
*Polyuria

Thyroid: *Presence of goiter, exophthalmia,


tachycardia or
bradycardia
Diabetes: *Blood glucose

SUBJECTIVE:
Denies any thyroid trouble, or problems

OBJECTIVE:
No presence of goiter, exophthalmia,

with heat and cold tolerance. No excessive

tachycardia or bradycardia. Blood glucose

sweating. Denies any problems with

161.

excessive hunger or urination. Reports


being thirsty all the time.
Hematologic
Minimum History Components
Ask questions regarding:
*Hx of thrombocytopenia *Anemia *Easy
bruising

Minimum Physical Assessment


Components
*Generalized color of skin and mucous
membranes *Ecchymosis *Purpura *Petechiae

SUBJECTIVE:
Denies hx of thrombocytopenia, or anemia.

OBJECTIVE:
Generalized pink, moist skin, and mucous

Reports easy brusing.

membranes. No ecchymosis, purpura, or


petechiae.

Musculoskeletal
Minimum History Components
Ask questions regarding:
*Joint: deformity, pain (COLDSPA), swelling,
stiffness
*Muscle: pain (COLDSPA) or weakness
*Hx of bone trauma or deformity
*Musculoskeletal- related interference/limitation
with ADLs

SUBJECTIVE:
Reports problems with joints every once in

Minimum Physical Assessment


Components
Joints: *Symmetry *Swelling *Masses
*Deformity
*ROM
Muscles: *Symmetry *Swelling *Masses
*Deformity
*Strength (upper & lower extremities)

awhile, some stiffness, some swelling.

OBJECTIVE:
Joints symmetric, no swelling, masses or

Muscle pain and weakness sometimes. No

deformity. Limited ROM. Moves right leg

hx of bone trauma or deformity. States able

slightly less than left leg. Muscles

to perform ADLs with help.

symmetric, without swelling, masses, or


deformity. Hand grasps equal bilaterally.
Leg strength equal bilaterally.

Neurological
Minimum History Components
Ask questions regarding:
* in LOC *Attitude *Mood *Cognitive
disturbances- ( in ability to understand,
communicate, remember, make decisions)
*Seizures *Tremors *TIA *CVA *Dizziness
*Numbness * in sensory abilities
vision/eyesight, auditory, olfactory, gustatory

Minimum Physical Assessment


Components
MENTAL STATUS:
Cognition: *LOC (oriented to person, place, time
& events)

*Memory (short & long term)


*Thought processes (Follows
through with train of
thought)

Behavior/Affect: *Mood *Cooperativeness


*Facial expression
*Appropriateness
Language: *Speech *Word choices /
vocabulary
CRANIAL NERVES:

(Assessed throughout physical

exam)

SUBJECTIVE:
Denies any changes in LOC, attitude,
mood, memory, or cognitive abilities.
Denies any problems with speech,
numbness, or dizziness. Denies any

MOTOR AND CEREBELLAR FUNCTION:


*Muscle size, tone *Tremors *Weakness *Gait
*Posture *Balance & coordination
SENSATION: *Light, sharp, & dull sensations
(identify how assessed and location)

OBJECTIVE:
Alert and oriented x3 (person, place, time).

seizures, tremors, TIA, or CVA. Denies any

Answers questions logically and coherently.

changes in vision, smell, or taste, some

Short term memory impaired, could not

problems with hearing. Reports not able to

recall any meals or snacks of the day. Long

walk anymore.

term memory intact, able to recall


information about family. Solemn facial
expression, listened intently, minimal eye
contact throughout interview. Articulates
clearly, no slurring. No twitching, tremors,
or seizure activity. Hunched over in chair.
Able to sense touch on hand and arm.
LIFESTYLE and HEALTH PRACTICES

Assessment of Nutritional Status


BMI: 28.7

Height:

54

Weight:167lbs

frame and whether intentional or unintentional:


Diet type:

If weight gain/loss indicate time


Reports no weight gain or loss.

General diet

Use of vitamins / minerals /supplements/ herbs:

Denies any use of dietary

supplements.
Food allergies / intolerances: Denies any.
Appetite:

Reports good appetite always eat almost everything.

Typical % of food eaten: Reports eating whatever they give, but likes soups. Usually
consumes 100% of meals.
Fluid intake (daily intake types & amounts):

Reports drinking tea and water. Cannot

recall anything else.


Medication Substance Use [Refer to medication list]
Problems / concerns regarding medications &/or schedules:

Denies any problems.

Use of over the counter medications and other substances (herbal / home remedies,
caffeine, nicotine, alcohol, recreational drugs): Denies any use of over the counter
medications or other herbal/home remedies. Minimal caffeine, no alcohol, recreational
drugs, or nicotine.
If yes to above, describe daily intake:

N/A

Activities - Exercise Activity Assessment

Description of a typical day (AM to PM):

Wake up in am, breakfast, crossword puzzle,

exercise, breathing lesson, dinner, bingo, free time, get ready for bed.
Activities on a typical day: Reports participating in bingo, cards, does cross word puzzles,
naps, and builds puzzles.
Exercise habits and patterns: Reports going to exercise activity a couple times a week,
and wheels around the hall.
Sleep - Rest Assessment
Sleep and rest habits and patterns - (Usual pattern of sleep (hours per nights):
Sleeps about 6 hours a night, feels well rested.
Daytime naps:

Reports taking them once in awhile.

Aids (pharmacological &/or nonphamacological:


Night awakenings:

Denies use of any sleeping aids.

Reports waking up every 2-3 hours.

Sufficient energy to carryout ADLs: Reports no problems.


Self-concept - Self Care Responsibilities - Safety
Clients description of talents / special abilities: States Im a good farmer and I can milk
cows.
Body Image - (Perceives body / self as acceptable, accepts physical limitations /
maximizes physical potential):

States its okay. Accepts physical limitations, states

I want to walk but I give up.


Activities to keep self safe, healthy, or prevent disease:

States exercise helps.

Utilization of health resources (i.e., regular dental, medical, vision exams): States
having regular vision exams, no dental exams, and doctor visits every once in awhile.
Personal safety (seatbelts, sexual practices, throw rugs, railings):

Uses a seatbelt in

his chair, uses bed rails in when in bed.


Do you feel safe in your living environment? [YES / NO] If no, describe:

Reports

feeling safe here.


Are you in a relationship in which you have been physically hurt by another? [YES / NO]
If yes, describe:

N/A

Social Activities
Social / leisure activities for fun and relaxation: Enjoys bingo, puzzles and crosswords.
Social activities contributing to society - (clubs, organizations etc.):
Relationships

Exercise group.

Relationships with family / significant other, and pets: Reports having a niece and
nephew that visit.
Family/significant other visit and show support: Reports niece and nephew sometimes.
How is your family coping with your current health status? States Okay.
Stress Level / Coping Styles
Family/significant others or support persons (availability):
Who is the main financial supporter of your family?

States Not really.

States I dont have any money.

Financial concern r/t healthcare & treatment (i.e., adequate insurance coverage):
Reports none.
What gives you strength and hope?

Reports nothing.

Significant stressors in the last 12 months

(including treatment):

Physical:
Reports not able to walk.
Psychological:
Reports none.
Describe personal stress management:

Clients overall rating of health:

States I havent had too much.

Poor 1 2 3 4 5 6 7 8 9 10 Excellent

DEVELOPMENTAL / HEALTH DEFICIT ASSESSMENT


Assessment of Eriksons Psychosocial Development:
Accept self-physically, cognitively, and emotionally
YOUNG
Independence from parenteral home
ADULT
Express love responsibly, emotionally, and sexually
Close or intimate relationship with partner
Intimacy

vs
Isolation

MIDDLE
ADULT
Generativity
vs
Stagnation
OLDER
ADULT
Ego
Integrity
vs
Despair

Social group of friends


Physiology of living and life
Profession or a lifes work that provides a means of contribution
Problem solves independence from the parental home
Healthful life patterns
Derives satisfaction from contributing to growth and development of others
Has abiding and intimate and long-term relationship with a partner
Maintains a stable home
Finds pleasure in established work or profession
Takes pride in self and family accomplishments and contributions
Contributes to community to support its growth and development
Adjusts to changing physical self
Recognize changes present as a result of aging, in relationships, and activities
Maintains relationship with children, grandchildren, and other relatives
Continues interests outside of self and home
Completes transition from retirement from work to satisfying alternative activities
Establish relationships with others who are his or her own age
Adjust to death of relatives, spouse and friends
Maintain maximum level of physical functioning through diet, exercise and personal
care
Find meaning in past life and face inevitable mortality of self and significant others
Integrate philosophical or religious values into self-understanding to promote
comfort
Review accomplishments and recognize meaningful contributions he or she has
made to community and relatives
(Weber , Kelly, 2014)

Based on Eriksons developmental level:


1. Identify the clients age appropriate developmental stage: Older adult- Ego integrity vs. Despair.
2. Discuss the effects of illness on the clients ability to attain/maintain a positive achievement of
specific factors to developmental stage and any health deficits regarding psychological (modified
self-image), physical, financial, and discharge planning needs-education, and caregiver.

Client maintains relationship with some family members, and seems to coping well
with not having relationships with other family members. Client is unable to continue
with some interests due to his weakness with walking. Does not form many
relationships with others his age due to his general weakness. Is unable to maintain
maximum level of physical functioning due to his giving up attitude when it comes to
walking.

1ST PATHOPHYSIOLOGY
Describe the disease process, signs and symptoms, diagnostic tests, possible complications and treatment.
Remember to reference source.

Pathophysiology:
Chronic obstructive pulmonary disease is a slow progressive obstruction of bronchial
airflow. This is a chronic condition, and can take many forms accompanied with varying
symptoms. The primary cause is cigarette smoking.
Signs and Symptoms:
Symptoms can vary depending on the stage you are in of the disease. The first signs and
symptoms include: productive cough, colorless sputum, and potentially cause chest pain.
The most significant symptom/sign is shortness of breath. In the early stages it may
occur only occasionally and will eventually progress to breathlessness when doing simple
things such as walking to the bathroom or around the room. Some people can also
develop wheezing. Staging of the disease is generally based on the results of a
pulmonary function test, a certain percentage puts you in a certain stage of the disease.
Diagnosis:
COPD is diagnosed by a patients breathing history, history of tobacco use or exposure,
exposure to air pollutants, or a history of lung disease. Chest x rays, or a CT scan may be
done. Another common test is an arterial blood gas or a pulse oximeter may be used to
look at the saturation level of oxygen. A patient can also be sent to a lung specialist to
determine the results of a pulmonary function test.
Treatment:
The most important treatment is to stop smoking right away. Many other medical
treatments are available such as the use of bronchodilators, steroids, mucolytic agents,
and oxygen therapy. You can also go the surgical route and undergo various procedures:
bullectomy, lung volume reduction surgery and a lung transplant. You should quit
smoking and avoid being around smoke. You can use nicotine replacement therapy or an
oral medication such as chantix to help with the quitting process.
Source:
Davis, C., & Cunha, J. (2014). COPD (Chronic Obstructive Pulmonary Disease). Retrieved
from
http://www.medicinenet.com/copd_chronic_obstructive_pulmonary_disease/page4.htm

2ND PATHOPHYSIOLOGY

Describe the disease process, signs and symptoms, diagnostic tests, possible complications and treatment.
Remember to reference source.

Pathophysiology:
Diabetes is a disorder of metabolism characterized by high blood sugar levels. The
pancreas produces to little or no insulin, or the cells do not respond appropriately to the
insulin being produced. Thus glucose builds up in the blood and passes out of the body
via urine. As the disease progresses it can affect muscle cells and fat tissue resulting in
insulin resistance. When type 2 diabetes is diagnosed the pancreas is most likely
producing enough insulin, however the body cannot use the insulin as it should.
Signs and symptoms:
Type 1 diabetes usually develops over a short time period. Signs and symptoms include
increased thirst and urination, hunger, weight loss, blurred vision, and very fatigued.
Type 2 diabetes (which my client has) insulin production declines after several years, and
is generally present in adequate amounts when diagnosed. Signs and symptoms develop
gradually, with their onset not being as sudden as type 1 diabetes. Signs and symptoms
include elevated blood sugar levels, which leads to high amounts of glucose in ones
urine. Dehydration, weight loss, nausea, vomiting, more prone to developing infections
of skin, vaginal areas, and the bladder, fluctuations in sugar levels can also lead to
blurred vision.
Diagnosis:
Diabetes is diagnosed best by a fasting blood glucose test, a fasting glucose reading of
126 mg/dl on two or more tests on different days points towards diabetes. The oral
glucose tolerance test can also be used to determine type 2 diabetes; however it is not
routinely used anymore.
Treatment:
The main goal in treating diabetes is to control the blood glucose levels without causing
abnormally low levels. Type 1 is generally treated with insulin, exercise, and a diabetic
diet. Type 2 is first treated with weight loss, a diabetic diet, and exercise. If this is not
sufficient oral medications will be used and if this does not work it can be managed via
insulin.
Source:
Shiel, W., & Conrad, M. (2014). Diabetes (Type 1 and Type 2). Retrieved from
http://www.medicinenet.com

DEFINITONS OF OTHER DIAGNOSES


Remember to reference source.
=Chronic Kidney disease- Over time your kidneys have not been working properly, therefore they
cannot function as they should (Filtering your blood, removing waste products and extra fluid).
Wastes build up in your blood making you sick. Is caused by damage to the kidneys some
examples are uncontrolled high blood pressure and high blood sugar over many years.
=Osteoarthrosis-Inflammation in joints. It is linked with a breakdown of cartilage in joints. It can
occur in almost any joint in the body with the most common being the hips, knees and spine.
=Dementia- a syndrome that involved a significant loss of cognitive abilities such as attention,
memory, language, logical reasoning, and problem solving which is severe enough to interfere
with social and or occupational functioning.
=Retention of Urine-the inability to empty the bladder.
=Restless leg syndrome- is a disorder related to sensation and movement. People often have
unpleasant feelings or sensations in parts of their bodies when they lie down to sleep. May have
a strong urge to move which alleviates the sensations however makes it almost impossible to
sleep.
=Peripheral vascular disease-refers to any disorder of the circulatory system outside of the brain
and heart. PVD is most common disease of the arteries. The buildup of fatty material inside the
vessels, atherosclerosis is what causes it.
=hemolytic anemia-a condition where a persons red blood cells are destroyed and removed
from the blood stream before their normal lifespan is complete.
=Esophageal reflux-Stomach contents back up into the esophagus leading to irritation of the
lining of a persons esophagus.
=Neoplasm of prostate- Cancer of the prostate.
=Lymphoid leukemia- a blood disorder in which there are an increased number of white blood
cells in the lymphoid tissue.
=Gout- is a kind of arthritis. It is caused by too much uric acid in the blood. It can cause an
attack of sudden burning pain, stiffness, and swelling in a joint, usually a big toe.

DIAGNOSTIC TESTS
Date of
Test

Test

Normal
Value

Initial
Value

High or Low

3/26/15

3/06/15

1/22/15

11/25/14
10/14/1
4

Urinalysis:
Color
Leukocyte
Esterase
W.B cells
R.B cells
Bacteria

Follow-up Value if
Available

Identify: If value is High or Low


Possible Cause of Abnormal Results
Nursing Interventions Related to Abnormal
Results

Clear
Neg

Cloudy
Large

0-5
0-5
None

>100
12
Many

BMP:
Sodium
Potassium
Chloride
BUN
Creatinine
GFR

134-146
3.5-5.0
98-109
5-27
0.70-1.20
>59

130
3.9
96
18
1.10
>60

Sodium and chloride low due to diuretic

CBC:
WBC
RBC
Hemoglobin
Hematocrit

4.4-12.0
3.3-5.50
12.6-17.4
36-53

14.8
3.96
10.8
33.3

WBC can indicate an infection

4.2-5.8

5.9
122
6.7
115

HbA1c:
Hemoglobin
Glucose
Uric acid
ESR

ALLERGIES:
CLIENT #:
Generic name

2.6-7.2
0-20

Could be caused by a urinary tract infection


Was treated with antibiotics

Kidney functions despite diagnosis

Hemoglobin and hematocrit low due to


diagnosis of anemia.
HbA1c increased due to diagnosis of
diabetes.
ESR increased due to infection.

MEDICATION SUMMARY

Brand name
Classification

Normal dose

Albuterol Sulfate

2.5-5mg q 20
min for 3 doses
then 2.5-10mg q
1-4 hr prn

0.083% inhalation
every 6 hours
while awake.

Dulcolax Suppository
(Bisacodyl)

10 mg single
dose

Fleet enema
(Sodium phosphate)

118 mL Fleet
Enema

10mg insert 1
suppository
rectally for
constipation if no
results from milk
of magnesia.
118mL insert 1
application rectally
as needed for
constipation.
Given at 1900.

Glucagon
(GlucaGen)

IV,IM,Subcut 1
mg may be
repeated in 15
min if necessary.

Inject 1 vial IM as
needed for low
blood sugar.

HydrocodoneAcetaminophen
(Norco, Vicodin)

2.5-10mg q 3-6
hr as needed

Insulin
Lantus
(insulin glargine)
O:3-4hr
P: none
D: 24hr
Magnesium and
Aluminum

Action of Drug

Why ordered for


this patient

Items to check
before giving

Two sid

Used as a bronchodilator to
control and prevent reversible
airway obstruction caused by
asthma or COPD. (Binds to
beta2 adrenergic receptors in
airway smooth muscle,
leading to activation of adenyl
cyclase and increased levels
of cyclic 3 and cAMP)
Treatment of constipation.
(Stimulates peristalsis. Alters
fluid and electrolyte transport,
producing fluid accumulation
in the colon).

Chronic Airway
Obstruction

Lung sounds, pulse,


Bp

CNS: nerv
restlessne
headache
CV: chest
palpitatio
arrhythmi

Constipation

Abdominal distention,
presence of bowel
sounds, and unusual
pattern of bowel
function.

GI: abdom
cramps, n
diarrhea,
burning.

Intermittent treatment of
chronic constipation.
(Osmotically active in the
lumen of the GI tract.
Produces laxative effects by
causing water retention and
stimulation of peristalsis).
Acute management of severe
hypoglycemia when
administration of glucose is
not feasible. (Stimulates
hepatic production of glucose
from glycogen stores).

Constipation

Fever, abdominal
distention, presence
of bowel sounds,
unusual pattern of
bowel function.

CNS: dizzi
headache
GI: cramp
abdomina
abdomina

Low blood sugar

CV: hypot
GI: nause

1 tablet po every 6
hours as needed
for pain.

Used mainly in combination


with nonopioid analgestics in
the management of moderate
to severe pain. (Bind to opiate
receptors in the CNS).

Pain

Signs of
hypoglycemia
(sweating, hunger,
weakness, headache,
dizziness, tremor,
irritability,
tachycardia, anxiety).
Neurological status.
Bp, pulse, and
Respirations

0.1-0.2 units/kg
once daily in the
morning or 10
units once or
twice daily

Inject 20 units
subcutaneously 1
time a day

Diabetes

Give 30 cc by
mouth every 2
hours as needed
for gastric distress

Assess for signs and


symptoms of
hypoglycemia
(anxiety, restlessness,
mood changes,
tingling hands, feet,
lips, tongue)
Heartburn, and
indigestion as well as
location, duration,
character and
precipitating factors
of gastric pain.

Hypogluce
Allergic re

5-10mL between
meals and at
bedtime

Control of hyperglycemia in
patients with type 1 or type 2
diabetes. (Lower blood
glucose by: stimulating
glucose uptake in skeletal
muscle and fat, inhibiting
hepatic glucose production).
Useful in a variety of GI
complaints. (Neutralize gastric
acid following dissolution in
gastric contents).

30-60mL single
or divided dose
or 10-20 mL as
concentrate

1200mg/15mL
suspension oral
give 30 mL per
bowel protocol

Treatment/prevention of
hypomagnesemia. (Essential
for the activity of many
enzymes).

Constipation

Assess patient for


abdominal distention,
presence of bowel
sounds, and unusual
pattern of bowel
function.

Diarrhea,
sweating

(Maalox)
Magnesium hydroxide
(Milk of magnesia)

Pt. dose &


times to give

Gastric Distress

CNS: conf
dizziness,
EENT: blu
Resp: dep

GI: constip
diarrhea

ALLERGIES:
CLIENT INITIALS:
Generic name
Brand name
Classification

Normal dose

Polyethylene glycol
(MiraLax)

17g in 8oz of
water

Morphine

30mg q 3-4 hrs


initially

Antifungals
(Nystatin cream)

Apply once daily

Potassium chloride

20-40 mEq/day

Ropinirole
(Requip)

MEDICATION SUMMARY
Pt. dose &
times to give

Action of Drug

Why ordered for


this patient

Items to check
before giving

Two sid

Give 17g by mouth


1 time a day every
other day for
constipation.
Dissolve one
capful in 8oz fluid.
15mg. Give 1
tablet by mouth 2
times a day for
pain.

Treatment of occasional
constipation. (Polyethylene
glycol in solution acts as an
osmotic agent, drawing water
into the lumen of the GI tract).

Constipation

Abdominal distention,
presence of bowel
sounds, unusual
pattern of bowel
function.

Abdomina
cramping
nausea.

Severe pain. (Binds to opiate


receptors in the CNS).

Pain

Type, location,
intensity of pain.

CNS: conf
sedation,
EENT: blu
CV: hypot
bradycard

Apply to peri area


topically as
needed for
compromised skin
apply twice daily.
10mEq give two
capsule by mouth
2 times a day for
hypokalemia

Treatment of a variety of
cutaneous fungal infections.
(Affects the synthesis of the
fungal cell wall, allowing
leakage of cellular contents).
Treatment/prevention of
potassium depletion.
(Maintain acid-base balance,
isotonicity, and
electrophysiologic balance of
the cell).

Compromised skin.

Inspect involved areas


of skin and mucous
membranes before
and during.

Burning, i
hypersens
redness

Hypokalemia

Assess for signs and


symptoms of
hypokalemia
(weakness, fatigue,
arrhythemias,
polyuria,polydipsia)

0.25 mg once
daily initially 1-3
hours before
bedtime

0.5mg oral every 6


hours. Take one
tablet 4 times
daily

Management of restless leg


syndrome. (Stimulates
dopamine receptors in the
brain).

Restless leg syndrome

Bp, Drowsiness and


sleep attacks.

Torsemide
(Demadex)

10-20 mg once
daily

10-20mg. Give 1
tablet by mouth
one time a day for
edema. 30 mg BID

Edema. (inhibits the


reabsorption of sodium and
chloride from the loop of
Henle and distal renal tubule).

Edema

Fluid status-daily
weight, I&O
Bp and pulse

Acetaminophen
(Tylenol)

325-650mg q 4-6
hr

Mild pain, fever. (Inhibits the


synthesis of prostaglandins
that may serve as mediators
of pain and fever, primarily in
the CNS).

Pain, fever

Overall health status,


alcohol use
Assess type, location
and intensity of pain.
Temperature

Ondansetron
(Zofran)

8mg every 8
hours

325mg tablet by
mouth for pain.
Elevated
temperature may
take 2 tablets PO
every 6 hours as
needed.
4mg. Give 1 tablet
by mouth every 8
hours as needed
for nausea and
vomiting

CNS: conf
restlessne
weakness
CV: arrhyt
GI: abdom
diarrhea,
nausea, v
CNS: slee
dizziness,
fatigue
CV:edema
GI: constip
nausea, v
CNS: dizzi
headache
nervousne
EENT: hea
GI: constip
diarrhea
GI: hepati
GU:renal f
Rash

Prevention of nausea and


vomiting. (Blocks the effects
of serotonin).

Nausea and vomiting

Assess for nausea ,


vomiting, abdominal
distension and bowel
sounds.

CNS: Hea
dizziness,
fatigue
GI: constip
diarrhea,
pain

Nursing Care Plan


Nursing Diagnosis (P-E-S format):
Priority Order: ________
P:Risk for impaired skin integrity
E: r/t potential for alterations in epidermis
S: aeb foley catheter in place causing swelling, and irritation
EXPECTED OUTCOMES
Goal: The client will exhibit
and maintain skin integrity
aeb
(Expected outcomes):
Within 48 hours the client will keep

NURSING INTERVENTIONS
The nurse will:

RATIONALE FOR
INTERVENTIONS (INCLUDE
AUTHOR & PAGE #)

EVAL
C

GOAL
Monitor skin condition once a

Systematic inspection can identify

Client

the problem area clean and free from

day during second shift for

impending problems early (Ackley &

integri

excessive moisture by:

color or texture changes,

Ladwig, p.739)

1.

Proper perineal care.


Being free from rashes and

redness, localized heat,


edema, dermatological

lesions.

conditions, or lesions.
2.

3.

Administer topical medications

The use of a skin protectant can

=Area

as ordered-Nystatin cream.

significantly decrease skin

excess

Teach the client skin

breakdown (Ackley & Ladwig, p. 736)


Early assessment and intervention

=RSA
=Repo

assessment and ways to

help prevent the development of

rashes

monitor for skin breakdown

serious problems (Ackley & Ladwig,

within 48 hours. i.e., assess for

p. 740)

temperature, color, moisture,


4.

turgor, and intact skin.


Encourage the client to do

Avoid harsh cleansing agents, hot

perineal care at least two times

water, extreme friction or force, or

a day.

cleansing too frequently (Ackley &


Ladwig, p.736)