170: Med-Surg - Concept Map #1

61 year old woman with hx of chronic UTIs and Sepsis --> immunodeficient --> Bacteria present in urine and presence of open wounds --> hopelessness and fatigue --> closely monitor for signs of new or worsening infection --> education

Nursing Diagnosis #1

• Risk for Infection r/t immunocompromised immune system, Stage 4 pressure ulcer on right ischial tuberosity, fatigue, and indwelling catheterization evidenced by septic shock and reoccurring UTIs.

Nursing Diagnosis #2

• Impaired Skin Integrity r/t physical immobilization and impaired circulation evidenced by ischial tuberosity stage 4 pressure ulcer that isn’t healing, new patches of dryness on L ischial tuberosity, and diminished sensation to pain and pressure in lower extremities.

Nursing Diagnosis #3

• Knowledge Deficit r/t lack of interest in learning about proper nutrition and infection as manifested by passivity of care and followe through of simple related tasks.

Nursing Diagnosis #4

• Impaired Urinary Elimination r/t chronic disease (PPMS) and neurogenic bladder as evidenced by permanent, indwelling Foley catheter.

Comobiditites

• Sepsis w/o septic shock
• Acute encephalopathy
• PVD
• Hyperglycemia
• Tachycardia
• Hypolipidemia

Interventions

Pathophysiology of this Patient's Symptoms

Pathophysiology

of Multiple Sclerosis

Risk for Systemic Infection (sepsis)

Nursing Diagnosis

High Risk of Developing Sepsis:

results when an infectious insult triggers an inflammatory reaction that then spills over to involve systemic symptoms. Inflammation and coagulation play a major role.

MS is a life-long inflammatory disease that effects the nerves of the brain and spinal cord. Over time the inflammatory response causes demyelination, which is responsible for the electrochemical transmission of impulses between the brain and spinal cord and the rest of the body. The areas particularly affected include optic nerves, pyramidal tracts, posterior columns, brainstem nuclei, and the ventricular region of the brain. PPMS involves a steady and gradual neurological deterioration without remission of symptoms.

Rationale:

1. Since this pt. has a chronic problem with UTI, consuming an adequate amount of fluids will promote urine formation and subsequent voiding, which flushes pathogens from the urethra and bladder (Elsevier, 2012).

2. Systematic inspection can identify impending problems early

3. Reduce bacterial contamination to prevent infection at vulnerable points of entry

4. Hand hygiene is the first line of defense against health-care acquired infections

Interventions:

1. Encourage to maintain a fluid intake of at least 2500 ml/day.

2. Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether client is experiencing changes in sensation or pain. Pay special attention to high-risk areas such as bony prominences, skinfolds, the sacrum, and heels.

3. Maintain sterile teqnique for all invasive procedures, i.e. catheter changes.

4. Be sure to have proper hand hygiene when caring for this pt. Also be sure to wear gloves when providing care and washing hands between patients.

ASSESSMENT

LT Goal: Pts. UTI will have been treated and pt. will remain free from infection by the end of the month.

Evaluation: Still in progress/will check blood and urinalysis lab work.

ST Goal: Pt. should be able to state the symptoms of infection of which to be aware of by end of shift.

Evaluation

Patient

Date of birth: 01/07/1955

61 y.o. African American

Female

Clinical Manifestations

Physical signs of increased risk

Impaired Skin Integrity

• Resident at Clovernook Health Care Pavilion (assisted-living facility) since 2015.
• Code Status – Full Code
• Allergies - Codeine & Penicillin's
• Admitting Dx:
• Primary Progressive MS (primary)

• Decreased urine output
• Skin cool to the touch
• Slow capillary refill
• Diminished peripheral pulses
• Decreased motility
• increased respiratory rate
• Constipation

Interventions:

1. Turn and position pt. every two hours. Provide support with pillows. Since this pt. has diminished sensation to pain and pressure, pillows between her feet, under her hip and neck will help prevent rubbing and skin tearing.

2. Assess client's nutritional status. Refer for a nutritional consult, and/or institute dietary supplements as necessary.

3. Ensure that bed linens remain wrinkle free.

4. Request lab tests to evaluate hemoglobin/hematocrit, albumin, protein.

Rationale:

1. Since this pt. has diminished sensation to pain and pressure, pillows between her feet, under her hip and neck will help prevent rubbing and skin tearing.

2. Inadequate nutritional intake places individuals at risk for skin breakdown and compromises healing.

3. Wrinkled sheets can cause friction and shearing of the patients skin.

4. Albumin <3.5 correlates with increased incidence of pressure ulcers.

• Open wounds - poor skin integrity
• UTI - indwelling catheter
• Malnutrition (underweight, not enough fluid intake, doesn't eat enough)
• Chronic Disease - inflammation and immunodeficient
• Increased sugar and acetone present in urine
• Shallow depth of respirations
• PVD

Evaluation:

• Still in process.
• Stage 4 pressure ulcer is slowly beginning to heal with treatment of the Wound vac.
• Pt. is using pillows to support common pressure areas.

ST Goal: Patient should demonstrate an understanding of the plan to heal skin and prevent re-injury by end of shift.

LT Goal: Pts. Stage 4 ulcer will show significant signs of progression in healing process by end of the month.

Problem List:

Knowledge Deficit

• VS: BP: 118/83 RU arm, HR: 89 R radial, weak, +1, R: 16 shallow, unlabored, regular, T: 97.9˚F, O2: 99% per RA, Pain: 4/10
• General Appearance:
• (S) Pt. states that she has trouble remaining comfortable, especially throughout the night. She also states that she is always cold.
• (O) The temperature of the room was very warm. Pt. was covered with a sheet and was not wearing any clothing below the waist.
• (O) Sheets were covered in crumbs.
• Diet and Nutrition:
• (S) Pt. stated that she sometimes has difficulty swallowing because she is unable to sit up in a 90˚ r/t pain in her lower back.
• (S) Pt. states that she doesn’t always feel the need to eat because she doesn’t have an appetite.
• Hair, Skin, Nails:
• (S) Pt. states that she experiences constant discomfort r/t stage 4 pressure ulcer on right ischial tuberosity.
• (O) Her skin was very dry, especially around her R and L heals and her R and L lower buttocks.
• (O) Red, skin lesion present on R ischial tuberosity covered with dressing. Dressing status was clean, dry, intact; drainage amount was scant.
• Cardiovascular:
• (O) Posterior tibial pulses and dorsalis pedis pulses were diminished bilaterally.
• (O) RLE: Edema, non-pitting
• (O) LLE: Edema, non-pitting
• Musculoskeletal
• (S) Pt. states that she uncomfortable and is unable to regain comfort on her own and requires assistance.
• (S) Pt. states that she becomes easily fatigued when performing simple tasks such as turning and positioning, having conversations for long periods of time, and during ROM exercises.
• (O) Mobility Status: Immobile
• (O) Partial paralysis: Lower extremities.
• (O) ROM: Very limited.
• Pt. requires passive ROM exercises daily in RLE and LLE. Assessing this was difficult because of contractures in lower extremities. Limited ROM also noted in fingers and R wrist.
• (O) Permeant joint contractures present in R and L feet. Contracture present in R wrist.
• Neurology
• (S) Pt. stated her pain today was an 4/10, but could not pinpoint exactly where the pain was coming from.
• (S) Pt. stated frequently feels a tingling sensation her R and L feet.
• (S) Pt. states that she is never comfortable with the temperature in her room and feels cold.
• (S) Pt. stated that she if she isn’t thirsty, she doesn’t feel the need to sip on water throughout the day.
• (O) Her judgement was slightly impaired when it came to the importance of self-care and maintaining a sense of independence.
• (O) Sensory perception: Her ability to respond meaningfully to pressure r/t discomfort was very limited. She cannot communicate discomfort except for moaning or restlessness. She has a sensory impairment which limits the ability to feel pain or discomfort over ½ the body. Sensation was absent bilaterally in RLE and LLE.
• (O) Motor response was diminished in RUE and LUE. No motor response in RLE and LLE..
• Elimination
• (S) Pt. states that she is often unaware of when she has passed a bowel movement. The only sign of passing is a relief of pressure..
• (O) Pt. has an indwelling catheter in place r/t neurogenic bladder.
• Urine Observation:
• Color: Brown, slight reddish coloring (blood)
• Clarity: Turbid, mucous present
• Odor: Pungent odor
• Output: 25 mL/hr (LOW)
• Catheter tubing was cloudy and seemed to have sediment stuck to the tubing walls.

Medications

Rationale:

1. Information building begins with with explaining simple concepts and moves on to explanations of complex application situations.

2. The client brings to the the learning situation a unique personality, their own established social interaction patterns, cultural norms and values, and environmental influences.

3. Understanding past information is essential to acquiring new knowledge. Brief sessions focus attention on essential information.

4. Education in self-care must take into account this patients physical, sensory, mobility, and physiological chnages r/t their age and MS diagnoses.

Interventions:

1. Present material that is most significant to the client first (fluid intake, nutrition, ROM excersizes); present additional material once client's most pressing educational needs have been met.

2. Assess clients previous knowledge and resistance or blocks to incorporating new information into the current lifestyle.

3. Repeat and reinforce information during several brief sessions.

4. Observe slient's ability and readiness to learn (mental acuity, when they aren't fatigued).

Laboratory/Diagnosis Tests

Everything

highlighted in pink from assessment

Evaluate:

LT: Completed: Pt. stated that she will start to drink more water throughout the day and will eat as much of meals as she can. Re-evaluate progress weekly.

ST: This was set as a ST goal but will need constant monitoring weekley to see true effectiveness.

LT Goal: Explain 2 changes you plan to incorporate into your daily routine that will promote health maintenance by the end of the week.

ST Goal: I would like to see this pt. effectively explain the importance of their health situation and maintain control of their life by end of shift.

Hematology

WBC: 7.1 Normal

RBC: 4.33 Normal

HGB: 11.3 Low

HCT: 38.4 Normal

MCV: 88.7 Normal

MCH: 26.2 Normal

MCHC: 29.5 Low

RDW: 14.4 Normal

Platelet: 398 Normal

MPV: 6.8 Normal

Neutrophils: 56.2

Lymphs: 29.2 Normal

Monocytes: 5.8 Normal

EOS: 6.0 Normal

BASO: 0.5 Normal

• Baclofen

o 20 mg Tablet/Orally/q.d. r/t MULTIPLE SCLEROSIS

• Bisacodyl Delayed Release

o 5 mg Tablet/Orally/q.d. prn r/t CONSTIPATION

• Capsicum Oleoresin Cream

o 0.075%/Topically/q12hrs prn r/t NEUROPATHY PAIN

• Simethicone

o 80 mg Tablet/Orally/q6hrs prn r/t INDIGESTION

• Fleet Oil Enema (Mineral Oil)

o 1 unit/Rectally/q.d. prn r/t CONSTIPATION

Known allergies: Codeine and Penicillin's

Urinalysis:

Color: brown

Clarity: turbid

Specific Gravity: 1.010 Normal

Urine pH: 5.6

Urine Nitrite: Neg

Urine Glucose: Neg

Urine Protein: 2+

Urine Ketones: Neg

Urine Bilirubin: Neg

Urine Blood: 3+

Urine WBC: <50

Urine RBC: 750

Urine Culture Setup

Mucous: present

Triple phosphorous: present

Impaired Urinary Elimination

"Interventions:

1. Give fluids to keep pt. hydrated

2. Empty drainage bag often and as needed

3. Assess laboratory data including, urinalysis and WBC

count

4.Observations of changes in mental status:, behavior or level of consciousness"

References

Rationale:

1. Fluid promotes urine production and flushes bacteria from the urinary tract

2. A regular pattern of urination enhances bacterial clearance, reduces urine stasis and prevents reinfection. Chronic catheters increase the risk for infection.

3. The inflammatory response associated with infection leads to WBC and WBC in the urine and identification of the causative organism is necessary for selecting the most effective antibiotic.

4.Accumulation of residual uremic and electrolyte imbalance can be toxic to the central nervous system. This is very commonly seen in the elderly.

Evaluation:

Ongoing - monthly labs will need to be drawn in order to determine if the pt. is free from UTI.

Expected Outcome:

Pt is free of UTI as evidenced by clear, non-foul smelling urine, normal WBC count and absence of fever, chills, flank pain, urgency and frequency by end of month.

• Ackley, B., and Ladwig, G (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. Maryland, Missouri. Elsevier.
• Ignatavicius, D. D., and Workman, L. M. (2012). Medical Surgical Nursing: Patient Centered Collaborative Care (eighth edition). St.Louis, Missouri. Elsevier.
• Giardi, M. (2014). NANDA –I Nursing Diagnoses
• Suggestions for the Care of Populations. Retrieved from http://health-conditions.com/nanda-nursing-diagnosis-list-2015-2017/
• National Guideline Clearninghouse (2015). Nursing Management of the Patient with Multiple Sclerosis. Retrieved from https://www.guideline.gov/summaries/summary/38259
• Silvestri, A (2014). Saunders Comprehensive Review for the NCLEX-RN® Examination, 6th Edition. St. Louis, Missouri. Elsevier.
• National Multiple Sclerosis Society (2016). Primary Progressive MS. Retrieved from http://www.nationalmssociety.org/What-is-MS/Types-of-MS/Primary-progressive-MS

Lindsay Valle NUR170 Concept Map 1 08/12/2016