Transcript: impaired skin integrity related to diabetes and immobility AEB pressure ulcers At risk for infection related to diabetes as evidenced by disrupted skin integrity and pre-existing DRE in urine. Cognition impairment related to diabetes and age AEB confusion while speaking Interventions 1. Monitor vital signs frequently* 2. Monitor I &O * 3. Limit fluid intake when necessary 4. Weigh patient periodically 5. Auscultate lung sounds periodically* Evaluation: Controlling HTN in ESRD through patient education, nursing support, and encouraging self care. 2 groups: 1.) Interention- 2 educational classes, goal BP log. sodium and fluid intake check list, and follow up call from nurse on weekly basis. 2.) Control group- Monitor BP and medication adjustment as needed Results: Patients in the intervention group showed significant reduction in systolic and diastolic BP's compared with control group. Also, increased rate of self care by decreasing sodium and fluids to meet goals. Short-term: Goal met. Patient understands the importance of proper infection prevention. Visitors utilizing isolation precautions. Nursing student provided perineal care and wound dressings. Long-term: Goal partially met. Culture was obtained and was free of previous DRE infection in urine. Patient will continue wound dressings to ensure infection-free healing of pressure ulcers. Rationale 1. Antibiotics help the immune system rid the body of infection 2. Prevents infection and promotes healing 3. Prevents further infections in urinary tract 4. indicates if infection (DRE) still present, another infection developing, or sensitivity to antibiotics. Short-term: Goal met. Patient educated on importance and reasoning behind monitoring (vital signs, I&O) and interventions were applied by nursing student and patient to prevent further edema. Long-term: Goal Partially Met. Patients medications (Lasix and Coreg) increased urine out put and decreased HTN. Patients edema improved but still evident in R foot. Revisions: MD was called for orders to remove immobilizer; patient will increase movement of RLE and continue medications as well as current interventions. Thank You! (Kauric-Klein, 2012) Integumentary System: 3 stage 2 lower extremity pressure ulcers - R lower lateral leg , right upper posterior thigh 1 stage one sacral pressure ulcer Surgical incisions on the R lateral upper thigh and hip Fluid volume excess r/t decreased glomerular filtration rate and sodium retention as evidenced by peripheral edema impaired urinary elmination r/t decreased glomerular filtration rate as evidenced by decreased urine out put in foley catheter At risk for falls related to immobilizer and health condition as evidenced by muscle weakness Acute pain related to physical injury as evidenced by patient reports of. 72 year old, African American Female Medical Diagnoses: R distal femur fracture, end stage renal disease On dialysis, immobilizer on R leg, voiding by foley catheter, receiving 4L O2 nasal cannula Hoyer lift, 3 assisst, fall risk precautions, isolation precautions Interventions 1. Stress proper hand washing technique by all care givers and patient PRN* 2. Application of aseptic technique throughout all areas of care as indicated 3. Monitor patient's visitors for signs of infection and encourage the use of isolation precautions 4. Provide proper perineal care daily and PRN* Long-term goal: Patient will manifest signs of stablilized fluid volume as evidenced by stable vital signs and no signs of edema by discharge. Long-Term goal: Patient will comply with therapy and be free of infection by discharge. Clinical Case Study (Moorhouse, 2010) References Kauric-Klein, Z. (2012). Improving Blood Pressure Control in End Stage Renal Disease Through a Supportive Educative Nursing Intervention. Nephrology Nursing Journal. May 2012; 39(3): 217-229. Moorhouse, M.F. (2010). Nursing Diagnosis manual, Planning, Individualizing, and Documenting Client Care, 3rd edition. Philadelphia, PA: F. A. Davis Company Short-term goal: Patient and nurse will identify and implement interventions to prevent infection throughout shift. Rationale 1. Establish baseline and indicates further complications 2. Evaluates fluid retention and further excess 3. Prevent further complications of pulmonary edema 4. Evaluates degree of fluid volume excess 5. Assess for crackles/congestion (Moorhouse, 2010) Rationale 1. Proper handwashing is first line of defense against infection 2. Prevents further contamination/spread of infection throughout the body 3. Prevents cross-contamination 4. Prevent spread of infection and colonization of bacteria Nursing Interventions and Outcomes Shannon Toole (Moorhouse, 2010) Rationale 1. Increases urinary output to decrease excess fluid volume 2. Strict monitoring of output -- ensures accuracy 3. assesses kidney functions 4. Stabilizes BP 5. Lessen fluid retention and overload 6. Research shows that it has increased compliance in BP maintenance and positive effects on reducing
Transcript: CT 9/23/17: 21.81 (High, normal is 4-11, indication of infection) 10/6: Atelectasis of right and left upper lobes were present at the beginning of patients stay 10/16: Patient was prescribed Metaneb Q6 with albuterol -Metaneb is a chest expansion therapy used to expand the lungs, break up secretions, prevent atelectasis and pneumonia. -Albuterol is a bronchodilator used to relax and open up the airway. Pt was also prescribe Pulmicort BID -Pulmicort is a steroid used to improve lung function and is used as a preventative for asthma. Pt was also given an IS to use at bedside when he was able to cooperate ABGs 11/13/17: HGB: 10.2 (Low) HCT: 32.0 (Low) Vent Settings Patient was admitted on 9/23/17 Intubated 9/23/17 and put on vent Trached 9/24/17 Taken off Vent 10/6/17 Put on 28% trach collar Weaned to 21% by 10/17/17 Trach capped 10/17/17 Patient was discharged 11/13/17 11/13/17: 3.52 (low) Atelectasis Hemopneumothorax Rib Fractures Jaw fracture Acquired brain injury Admitting Data, CC RBC: Patient was placed on vent 9/24/17 Patient was trached in trauma ICU Vent was removed on 10/6/17 Patient was placed on 28% trach collar Patient was placed on capping trial on 10/16/17 Patient was capped on 10/17/17 Radiology / X-Ray 9/24/17: -Patient was intubated in the ER on 9/23/17 , Size 7 ET tube, Depth: 25cm -Vent settings: FiO2: 100% Vent Mode: Assist / Control Tidal Volume: 500ml Rate: 20 PEEP: 7.5 9/28/17: Vent mode: Volume support / pressure support Tidal Volume: 610ml Rate: 29 Peak inspiratory pressure: 34.0 Mean airway pressure: 16.0 , (high, normal for patients with normal compliance is 5-10cmH2O.) Treatments and Outcomes Continued 10/9/17: Chest CT without contrast Pleural effusion, atelectasis in right lung base / upper lobe, left compressive lung atelectasis, normal heart size, no enlarged mediastinum, hillier or axillary, increased size of left pleural effusion Clinical Case Study OU Medical Center Fall Semester 1 Issues With Labs or X-Rays 9/23/17: 299,000 (Normal, normal is 150,000 to 400,000) 10/24/17: 11.98 (High) 10/24/17: HGB: 10.2 (Low) HCT: 33.7 (Low) 10/9/17: pH: 7.39(normal) CO2: 44(normal) CO3: 27(normal) Sat: 98% Within Normal Limits. Working / Admitting Diagnosis Lab Data Patient was intubated with size 7 ET tube 24 cm deep and was placed on a vent upon arriving to the hospital Patient was not given any long term care plans related to respiratory care. Patient brought IS home and was instructed to use as needed if patient was not ambulated for long periods of time. Pertinent Treatment or Outcomes Respiratory Treatments Vent Settings 9/23/17: HGB: 13.7(Normal, 13-18) HCT: 41.0 (normal, 39.0-52.0) 9/30/17: pH: 7.25(low) CO2: 56(high) CO3: 24(normal) Sat: 94% Uncompensated Respiratory Acidosis Patient was admitted with ear lac, left upper arm lac, contusion to the left jaw / neck, jaw fracture, acute hemopneumothorax with compression atelectasis, air in the left chest / lung, lower contusion below hemopneumothorax, fractured ribs 1-11, acquired brain injury result from skull fracture. 10/3/17: Vent Mode: CMV FiO2: 100% PEEP: 5 Flow by: 60 Pressure Support: 0 PIP: 26 Volume: 500 Rate: 16 MVC/Roll over 9/23/17: 4.41 (low, normal male RBC is 4.5-5.9) Lab Data 9/23/17: Radiology notes included that left-sided hemopneumothorax was still present, bilateral air opacities noted, slightly increased on the left, findings suggest a volume overload. Cardiac and Mediastinal findings are overall similar, soft tissues unchanged, multiple rib fractures noted. 10/20/17: Lung volumes are noted as slightly smaller, more prominent bronchovascular crowding at the right lung base suggestive of atelectasis given the smaller lung volumes. Opacity in the left lung region has not changed. No discrete pneumothorax or large pleural effusion is present. Left lower rib fractures are noted. Cardiac and mediastinal appear unchanged. Impression: Smaller lung volumes with probable worsening of right basilar atelectasis. Admitting Data, CC WBC: Treatment for hemopneumothorax: -1 chest tube , connected to suction , -Location: Left upper lateral chest Drainage: Bloody During admission, patient was unresponsive and unconscious. After being transferred from the ER to ICU, the patient was intubated. Patient history was not able to be obtained due to the patient being unconscious and intubated. Patient History Medical, Family, Social, Occupational Length of stay, Prognosis, Etc. 11/13/17: 5.65 (Normal) 9/24/17: pH: 7.26(low) CO2: 34(low) CO3: 15(low) Sat: 97% Partially Compensated Metabolic Acidosis LB 33 year old Male 5'8 265lbs (obese) Issues With Labs or X-Rays 10/24/17: 3.56 (low) Admitting Vital Signs 9/23/17: HR: 146 RR: 55 BP: 205/155 O2 saturation: 99 Temp: 37.9 C Patients neurological function and status were questionable and altered throughout his stay. Altered respiratory condition was also noted. Platelets Treatments and Outcomes 10/24/17: 468,000 (High, normal is 150,000 to 400,000) CT Hemoglobin / Hematocrit: Patient
Transcript: Proprioceptive/Balance Athlete complained of left shoulder pain Denied head or neck pain Also denied neurological symptoms Lacked concussive symptoms Able to skate off ice/ change before evaluation Off ice the athlete complained of "collar bone" pain and pain on top of the shoulder Pain control IFC Game ready (cryo-compression) Ibuprofen Ice bags Injury Mechanism of Injury Patient: Male, Hockey athlete MOI: Fell shoulder first into boards/Ice Initial Treatment Grade 1 AC Sprain Goals: control pain/inflammation, also increase AROM and strength Point tender over AC ligament and distal clavicle Minor soreness over Coracoid process Shoulder flex/abd pain free to 90 Pain with IR Clinical Case Study Brayden Starr Athletic Training clinical skills-I High plank -Dyna disc -Physio ball Strength Isometrics -flex/ext -abd/add -IR/ER -5 sets @ 10sec -Push as hard a possible w/o eliciting pain Dumb bell -IR, ER, side-lying abduction, prone row w/ external rotation, standing shoulder flexion) 3x15 w/3lb Wall circles 3 sets @ 30 sec Palpation Tests IR/flex/abd 4/5 strength test Horizontal add 3/5 Piano key (-) AC traction test (+) *pain only Equiptment Abnormal carrying angle on left side Held left arm to torso Left shoulder slightly elevated ROM exercises Signs and SYmptoms Athlete iced after assessment, and again that afternoon Use of NSAID's permitted S&S continued 10/22: Skated, pain free stick handling 10/23: wrist shots pain free, slap shots at 50% pain free 10/24: non-contact practice, slap shots at 100% pain free 10/25:"Felt good" 10/26: took part in Hardest shot challenge, no pain, felt good. 10/27: contact practice, took/gave hits no problem, pain free Codman's Pendulum 3 sets of 10 repetitions PROM -increase PROM - Traction Assisted pulley -abd/flex -PROM Wall walks -AAROM Return to Play -AC pad -New pads
Transcript: Evidence-based practice guidelines for instructing individuals with neurogenic memory impairments: What have we learned in the past 20 years? Clinical Case Study Level Ia-ANCDS systematic review "Now I'm not missing everything on my calendar" "There's a new me!" Takeaway . . . Efficacy for metacognitive strategy instruction in middle-age adults with TBI Functional goals Self-monitor performance Level IIa K and the ICF Ehlhardt, L. A., Sohlberg, M. M., Kennedy, M., Coelho, C., Ylvisaker, M., Turkstra, L., & Yorkston, K. (2008). Evidence- based practice guidelines for instructing individuals with neurogenic memory impairments: What have we learned in the past 20 years? Neuropsychological Rehabilitation; an International Journal, 18(3), 300-342. doi:10.1080/09602010701733190 Kennedy, M. T., Coelho, C., Turkstra, L., Ylvisaker, M., Moore Sohlberg, M., Yorkston, K., Chiou, H. H., Kan, P. (2008). Intervention for executive functions after traumatic brain injury: A systematic review, meta- analysis and clinical recommendations. Neuropsychological Rehabilitation; an International Journal, 18(3), 257-299. doi:10.1080/09602010701748644 Kim, Y., Yoo, W., Ko, M., Park, C., Kim, S. T., & Na, D. L. (2009). Plasticity of the attentional network after brain injury and cognitive rehabilitation. Neurorehabilitation and Neural Repair, 23(5), 468-477. doi:http://dx.doi.org.weblib.lib.umt.edu:8080/10.1177/1545968308328728 Sohlberg, M. M., Avery, J., Kennedy, M., Ylvisaker, M., Coelho, C., Turkstra, L., & Yorkston, K. (2003). Practice guidelines for direct attention training. Journal of Medical Speech-Language Pathology, 11(3), xix-xxxix. Sohlberg, M. M & Mateer, C. A. (2010). Attention Process Training: A direct attention training program for persons with acquired brain injury. Youngsville, NC: Lash & Associates Publishing/Training Inc. Dani Perry CSD 675 Spring 2016 Attention Training + Strategy Instruction Computer-based Continuous self-reflection Target Population: acquired brain injury External Evidence Intervention for executive functions after traumatic brain injury: A systematic review, meta-analysis, and clinical recommendations Metacognitive Strategy Instruction Plasticity of the attentional network after brain injury and cognitive rehabilitation PMH: Epileptic seizures and pyogenic brain abscesses Impairment: Moderate cognitive-linguistic disorder -Moderate executive attention -Moderate prospective memory Activity Limitations: Trouble completing household/vocational duties, managing finances, staying focused w/o distractions Participation restrictions: Grocery shopping independently, engaging in conversations w/o becoming "lost," must walk everywhere-cannot drive Breaking complex tasks into steps Game face! Blocking internal/external distractions (Kennedy et al., 2008) Data Collection Results Takeaway . . . Plasticity of the neural networks Redistribution of attentional network resources Effortfull processing increases cognitive flexibility and generalization Aware of need for compensatory strategies Subjective evidence for redistribution of executive attention network (Kim et al., 2009) Level Ia Snapshot . . . Attention Process Training, 3rd Edition P: 42-year-old female with moderate cognitive-linguistic disorder secondary to amygdalohippocampectomy I: Attention Process Training with instruction in cognitive compensatory strategies C: Traditional cognitive rehabilitation therapy O: Increased cognitive functioning for IADLs Clinical Question References Implications Attention Process Training Test Level of Difficulty Accuracy Focus (Ehlhardt et al., 2008) Takeaway . . . Systematic Instruction Errorless learning + vanishing cues Intense/dispersed practice Effective for multiple populations
Transcript: Diminished and Clear Bilaterally No cough PT: 12.7 IN: 1.17 PTT and DIC were not recorded Patient Overview Current Resp Orders Owns a resturant Lives in rural Indiana From Eastern Kentucky Blood cultures Negative Urine cultures Negative Chest X-ray Inspection Albuterol 2.5mg/3mL Budesonide 0.5mg Q12 Breo Ellipta 100/25 1 QD Decrease in ADL Reduced mobility In and out of hospital for 6 months Wounds Artificial urinary sphincter removed 2 weeks prior to admission Possible UTI upon admission Glassgow score 15 Cap Refill of < 3 secs No clubbing No cyanosis No edema CAD COPD Vascular stent Patient's Current Assessment WBC: 7.7 k/cmm RBC: 3.34 mil/cmm Hb: 10 GM/dL HCT: 33.0% Platelets: 223 k/cmm Age: 77 Height 180.3 cm Weight: 72.3 kg Smoking Hx: Yes 1.5-2 ppd not quit Chief Complaint: AMS Cardiovascular Gastrointestinal Genitourioary Musculoskeletal Pyschological Behavioral Learning Respiratory Other Pertinent Data Dyspnea Percussion Medications HR: 61 Resp Pattern: Normal/Nonlabored BP: 134/65 Temp: 36.9 Celcius Kidney Function Albuterol 2.5mg/3mL QID Budesonide 0.5mg Q12 Breo Ellipta 100/25 QD Guafenesin 600mg BID Fluconazole Q24 Amiodarone Metoprolol Family History Occupational History Keep on current medications Draw ABG Start lung expansion Suggest a PFT Follow up with pulmonologist after d/c Smoking cessation classes Pt has COPD Barrel chest Active pace maker Areas of Importance Vitals Hollow sounding Areas of Concern Auscultation Patient Information Coagulation SOB while supine position WOB is nonlabored Clinical Case Study Ivy Tech Community College By: Caitlyn King BUN: 14 mg/dL CrL 0.92mg/dL I/O: 720/0 today, 1078/1085 yesterday Weight: today 72.3 kg, yesterday 73.5 kg Falling asleep Oriented while awake very pale frail skinny barrel chest shallow breathing skin discoloration History CBC Bibasilar opacities Hemithorax Emphysemitus change likely Costerfrenic anges visible Chest staples visible Very short lungs Heart shadow not very defined Mediasteinum visible and normal Plan of Care Test Results No family history was noted. UTI Admitting diagnosis Hx of COPD Dyspnea Glassgow score CXR Lack of Cough Smoking Hx Past medical history Medical hardware Current Meds Cultures Other Past Medical History
Transcript: - Factors that are critically important in the development of venous thrombosis: (1) venous stasis (2) activation of blood coagulation (3) vein damage. These three componants are known as the Virchow triad (Cunha, 2014). - Sepsis is usually caused by a progression of an infection. In the case of this patient his sepsis was a result of a common femoral puncture in his right groin area. - The puncture became infected and the infection caused cellulitis in the patient’s right leg. Organisms on the skin and its appendages gain entrance to the dermis and multiply to cause cellulitis. - If the infection that caused cellulitis is not taken care of it can enter the blood stream causing sepsis. If the sepsis progresses it can lead to septic shock, which will cause a life threatening, drop in blood pressure and potentially kill the patient (Herchline, 2014). Medications - DVT - Sepsis - UTI, not specified - Cellulitis of the right leg - Seizures (chronic) - Acute encephalopathy - Hypotension, unspecified Signs and Symptoms Comparison Negative Thank You! - Continuous pulse Ox Surgical History Outcomes/potential Problems Positive Dyspnea Hypothermia, hyperthermia Weakness Fatigue Heat/pain/swelling/unusual drainage at site of infection entry Tachypnea Hypotension Potential Problems For Tomorrow Initials: CG Encephalopathy in Sepsis - piperacillin/tazobactam (Zosyn)--> to treat cellulitus/septecimia (The patients pain was not assessable at 0730 and 1510 due to Altered Levels of consciousness) Allergies: No known - enoxaparin (Lovenox) --> for treatment of Deep Vein Thrombosis Patients was diagnosed with encephalopathy Patient displayed signs of dyspnea Lowest Blood pressure was 90/56mmhg Tachypnea, patients respiratory rate reached 22 breaths/min which is above the normal range of 12-20 breaths/minute. Patient also displayed an altered level of consciousness. Patient frequently disoriented Patient displayed signs of weakness in extremities Patient displayed shallow respirations Clinical Case Study - aspirin (Ascuprin)--> prevention of myocardial infarction DVT Pathophysiology (Dates for either procedure were not indicated in chart) Recent Findings ➢ The presentation in bladder cancer may resemble urinary tract infection (UTI), or the 2 conditions may coexist (Steinberg, 2014). ➢ The patient’s acute encephalopathy could be caused by hypercapnia r/t COPD (Claudett, 2014). ➢ Sepsis could be the cause of the patient’s encephalopathy (Davis, 2014). ➢ A-fib could have been the cause of the patient’s stroke (Rosenthal, 2014). ➢ Sepsis could be the cause of the patients hypotension. If sepsis progresses it could leap to septic shock (Mayo Clinic, 2011). ➢ Sepsis could be the progression of the bacteria that caused the patient’s Cellulitis (Herchline, 2014). ➢ The patient’s cellulitis was caused by a common femoral puncture in the right groin area. - Stroke - Atrial-fibrillation - Bladder cancer - COPD - multivitamin (Theragran)--> vitamin supplement References - Aspiration/dysphagia diet - Oxygen therapy 2L via nasal cannula - PIV (26 gauge) left antecubitol Typical Signs and Symptoms - Vitals q2hr Encephalopathy is commonly caused by liver problems. An uncommon side effect of sepsis is encephalopathy. Severe or advanced sepsis can cause Myasthenia crisis, which can eventually lead to encephalopathy. (Karnatovskaia, 2012, pp. 144-153). - Decreased vein wall contractility and vein valve dysfunction--> blood pools --> venous stasis promotes clotting --> DVT Vitals and Labs By: Kelsey "Black Cloud" Trujillo Vitals: - Deficient fluid volume r/t shift intravascular volume to interstitial space. Gender: Male - atorvastin (Lipitor) --> decreases cholesterol and prevents myocardial infarction - hydrocodone-acetaminophen--> for pain treatment Age: 80 No further increase in temperature Absence of chills and diaphoresis Pulse and respiratory rate within normal range for client WBC and differential counts returning to normal Negative blood culture results. Basic Info - Ineffective breathing breathing pattern r/t septic shock - Ineffective tissue profusion r/t progression to septic shock as evidence by decreased cardiac output. - Deficient fluid volume r/t shift intravascular volume to interstitial space. Causations and Risk Factors Past Medical History - acetaminophen (Tylenol)--> to treat mild pain Precautions: Seizure, high fall risk, aspiration, and skin integrity 4/22 at 0938 ➢ Low white blood cells can be the result of sepsis ➢ The decrease in the RBCs could be a sign of bleeding/anemia but it can also be from the patience bladder cancer. It could also be the result of sepsis the infection that entered the blood stream could be causing hemolysis ➢ The low hemoglobin could be caused by the patient’s cancer or sepsis, which causes hemolysis. ➢ The low Na could be a sign of dehydration. In dehydration, the body loses fluid and electrolytes. ➢ The decreased Ca could be a sign the patient has low albumin levels in the blood. Albumin is an
Transcript: Progressive mobility levels - bed rest/lateral rotation to sitting up at edge of bed Moderate decline in mental status - acute neurologic deterioration Aspirin 325 mg tab PO daily & 81 mg chewable tab PO once daily Func. class: nonopioid analgesic, nonsteroidal anti-inflammatory, antipyretic, antiplatelet Action: blocks pain impulses by blocking COX-1 in CNS, reduces inflammation by inhibition of prostaglandin synthesis, decreases platelet aggregation Side effects: seizures, coma, intracranial hemorrhage, GI bleeding, thrombocytopenia, agranulocytosis, leukopenia, neutropenia, hemolytic anemia, bronchospasm, anaphylaxis, largyngeal edema, angioedema Pt rationale: prevent MI and stroke due to recent hx of stroke For short term goals cont. Heparin 5000 units/mL SQ q8 hrs Func. class: anticoagulant, antithrombotic Action: prevents conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing inhibitory effects of antithrombin III Side effects: hematuria, hemorrhage, thrombocytopenia, anemia, anaphylaxis Pt rationale: to prevent DVT, PE, MI, stroke Right MCA clot Dysphagia Decreased left upper & lower extremity function Impaired balance/gait Confusion/disorientation Limited mobility Risk for impaired skin integrity Activity/exercise intolerance Muscle weakness Self care deficit Frailty Impaired communication Risk for interrupted family processes Progression since admission Pantoprazole 40 mg IV injection daily reconstituted with 10 mL NS Func. class: proton pump inhibitor Action: suppresses gastric secretion by inhibiting hydrogen/potassium ATPase enzyme system in gastric parietal cell; characterized as gastric acid pump inhibitor because it blocks the ifnal step of acid production Side effects: pancreatitis, rhabdomyolysis, myaglia, pneumonia, Stevens-Johnson syndrome, toxic epidermal nerolysis, anaphylaxis, angioedema Pt rationale: prevent duodenal/gastric/NSAID ulcer due to stress on body from recent stroke, reminaing in lying position for extended period of time, and inactivity Nursing Interventions Transferred from Charlotte Hungerford CT showed MCA infarct - pt sent to HH No TPA or thrombolytic therapies used upon admission Course of tx, anticipated length of stay, and discharge plans undetermined EKG, chest x-ray, CT scan performed Adult Assessment Guide Cont. 1. Client will engage in neuromotor physical activity every day to improve physical function 2. Client will be able to identify her own physical limitations 1. Client/family members will alter the environment to minimize the incidence of falls Adult Assessment Guide Cont. Adult Assessment Guide Cont. Adult Assessment Guide Cont. Long Term Goal Evaluation For Short Term Goals ECG Risk for falls r/t acute ischemic right MCA stroke a/e/b decreased ROM/strength in left upper & lower extremities, impaired gait/balance, sensory impairment, neurologic deterioration Short Term Goals' Evaluation Adult Assessment Guide Cont. Nursing Interventions I will continue to assist the client in progressing to increasing levels of activity tolerance. Following 1 month, I will determine if the patient is able to perform self care without risk. If the patient is unable to perform her own ADLs, then I will encourage her to keep working toward her goal, and reevaluate her techniques to determine if she should alter her pathway and try new methods Social Hx 1. Client will describe methods to avoid injury 2. Client will remain free of falls that result in injury Chest x-ray Lung apices trace bibasilar pleural effusions w/ mild compressive atelectasis 1. First, I will consult with the provider and physical therapy for a safety evaluation before initiating a mobility plan. 2. Then, I will provide the client with resources such as exercise classes, educational and recreational programs, and volunteer opportunities that can enhance socialization and appropriate activity. 3. Next, I will establish a slow pace of care 4. Then, I will instruct the patient to stop the activity immediately and notify the health care provider if she is experiencing new/worsened intensity/increased frequency of discomfort 5. I will also evaluate for medications and diet changes that would afford the patient strength to improve her motor skills Nursing Dx Levothyroxine 100 mcg tab PO daily Func. class: thryoid hormone Action: increases metabolic rate; controls protein synthesis; increase cardiac output, renal blood flow, O2 consumption, body tempearture, blood volume, growth, development at cellular level via action on thyroid hormone receptors Side effects: insomnia, tremors, tachycardia, angina, palpitations, dysrhythmias, thyroid storm, cardiac arrest Pt rationale: hypothyroidism Long Term Goal Evaluation Medications Typical diet: NPO Chewing/swallowing issues: aspiration risk due to left sided weakness resulting from stroke; unable to swallow Mouth: lips, tongue, gums, palate slightly dry & swollen; generalized redness; teeth clean, no debris; saliva thin/watery/plentiful Skin
Transcript: Conclusion :This patient has a decreased Hg/Hct and RBC due to the bleeding ulcer, with blood being excreted in her stool. Potassium is likely low due to vomiting/fluid loss. Chloride is slightly elevated. This can sometimes be due to excessive vomiting or diarrhea. It is still important to monitor, as hyperchloremia can affect O2 transport to the cells. (5) Two Hours Later.... As evidenced by our conversation, symptoms of her untreated mental illness of bipolar disorder were present. She was accusatory of staff, not showing evidence of understanding why requesting pain medication so frequently was bad. She had impulsive episodes of threatening to leave, and yelling at others. Two hours later, she was smiling and stated "I was the only one who cared about her". This is definitely a barrier to learning, as she was not receptive to staff at most times. Other barriers to learning may be that the patient has possible undiagnosed dementia. In collaboration with doctors and other nurses, we all agree that the patient exhibits some signs of dementia. This includes not being able to recall the previous days events, and that she does not recall being previously taught about her disease, or that she has been hospitalized in the past for ulcers. Assessment FIndings Pt C.D. is a 72 yo female who presents to the ED with severe abdominal pain and excessive vomiting. After complete work up by physicians, it is confirmed that she has a micro-perforation in the duodenum and a presumed pre-pyloric ulcer. Pt was placed on NPO status, and a Protonix drip. Doctors informed the staff that education to the patient was provided in the ED. It is now hospitalization day 4. Zosyn 3.375 G /50ml IV Piggyback Dilaudid 1-2 mg IVP PRN Q2 hours Lorazepam 1mg IVP PRN Q12 hours Protonix: 80 mg/100ml IV drip, infuse over 8 hours. Potassium Chloride 10meq/100ml Q1hr X2. C.D. became upset at my response, shaking her head and laughing. She stated that I "did not care about her", and she was going to leave this hospital. When trying to redirect C.D., I informed her I was concerned about her. I asked "Do you know why you have the ulcer?" She replied "No". I then educated her about the large doses of pain medications (NSAIDS, Vicoden) she uses at home, and how that is likely the cause of her ulcer. I discussed how using a lot of pain medications, whether at home or in the hopsital, was not healthy . C.D. again stated I was being accusatory, stood up, and asked to leave. I told her that she legally had the option to leave AMA, but that it is not advised. When her husband told her to sit down and listen to the nurse and doctors, C.D yelled at him, saying "You don't make the decisions in this relationship; Be quiet". (7) -Pt received an upper GI endoscopy to confirm her diagnosis. -H-Pylori testing was also done. (Result came back negative). This test is done to detect the presence of the bacteria H-Pylori, in the GI tract. H-pylori is a gram negative bacteria, found in those with patients who have ulcers. H-pylori lives in about 50% of people, who remain asymptomatic and never develop an ulcer (mechanism uknown)(3) Pt also received an upper GI series X ray with a barium swallow to confirm diagnosis. Patient's Lab Values Vital Signs: HR: 86 BP: 154/85 T: 37.7 (99.86) RR-18 02- 94% 1L02 Extensive Smoking History NSAID abuse for chronic pain -Suggest OT do a mini mental examination to test for orientation and dementia. -Collaborate with social work on suggesting the client possibly be discharged with services for regulation of medications. -If appropriate, refer patient to psychiatry to assess needs for medications and extent of mental illness. -Educate patient on risk factors for disease, and necessary lifestyle changes to prevent an ulcer from reoccurring (smoking cessation, decreased NSAID use, decreased caffeine consumption) (8) -Give information to patient in concise and short form to prevent further confusion and agitation. - Involve C.D.'s husband in teaching and care, for support at home. Nursing Implications for C.D. Psychological: Patient is diagnosed with Bipolar Disorder, although patient is not receiving any psychiatric medications while here in the hospital. Patient denies taking any psychiatric medications, but she is known to be a poor historian. NURSING 612 CLINICAL CASE STUDY The Increased Sodium is also likely d/t excessive vomiting. This patient's BUN is low, which normally is not of concern, since so many factors contribute to a person's BUN. Antibiotics, Liver Damage, and Female sex all contribute to a low BUN. (6) Patient Assessment Patient Assessment.... Peptic Ulcer Disease Barriers To Learning Most common cause is infection from H pylori bacteria. The bacterium causes these ulcers by damaging the mucous coating that protects the stomach and duodenum. Damage to the mucous coating allows stomach acid to get through to the sensitive lining beneath. (1) Other causes are increased acid and pepsin(digestive enzyme found in gastric
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