CRITICAL THINKING SUMMARY
Student: Kathryn Kaufman
Client Dx: Jejunal Stricture, Diverticulitis, Pericarditis, HTN, GERD, Asthma, Gout, DVT with
hemorrhagic CVA.
Age: 67
Allergies: Celebrex, Lisinopril, Norvasc, Robaxin
The MEDICAL DIAGNOSIS that brought the client to the hospital is:
Abdominal pain, nausea, and weight loss of 20 lbs. in the last month
PATHOPHYSIOLOGY of diagnosed disease: (From text)
GOUT: “Hyperuricemia (serum concentration greater than 7 mg/dL) can but does not
always cause monosodium urate crystal deposition. However, as uric acid levels increase,
the risk becomes greater. Attacks of gout appear to be related to sudden increases or
decreases of serum uric acid levels. When the urate crystals precipitate within a joint, an
inflammatory response occurs, and an attack of gout begins. With repeated attacks,
accumulations of sodium urate crystals…are deposited in peripheral areas of the body,
such as the great toe, the hands, and the ear. Renal urate lithiasis (kidney stones), wth
chronic renal disearse secondary to urate deposition, may develop.”
SYMPTOMS typically seen with this diagnosis include (as identified in your text):
Manifestations of the gout syndrome include acute gouty arthritis (recurrent attacks of
severe articular and periarticular inflammation), tophi (crystalline deposits accumulating in
articular tissue, osseous tissue, soft tissue, and cartilage), gouty nephropathy (renal
impairment), and uric acid urinary calculi.
CLIENT’S SYMPTOMS of the diagnosed disease include:
Patient noted some pain in her joints when she was up and moving, and had some stiffness
when walking around with assistance.
NUTRITIONAL ASSESSMENT:
Height (actual or estimated): 167.6 cm Weight (actual or estimated): 92.0 kg
Estimate Ideal Body Weight (Male: 105lb + 6 lb/inch > 5’. Female: 100lb + 5lb/inch > 5’): 130 lbs.
Does this client have characteristics of a well-nourished person? Yes/No
Explain your answer.
The patient appeared to be physically unwell from general appearance. Her skin looked pale
and sunken at her eyes; her hair was dull-looking; her energy level was depleted, although
she did ambulate in the halls with standby assist, which indicated that her muscle strength
was good. She was obese, with her BMI at 33; she mentioned that she had had a weight
loss of about 20 lbs. during the last month.
Since this patient was admitted to the hospital on 01/29, she had not had much of an
appetite. She had little to no appetite due to her abdominal pain, and was nauseated after
eating. She was placed on total parenteral nutrition (TPN) at 55 ml/hr, and tolerated it. When
an exploratory laparotomy was done to further understand patient’s condition, duodenal
and jejunal ulcers were found, as well as jejunal stricture. Patient had a small bowel
resection to resolve these issues, but no changes in patient’s appetite occurred, and
abdominal pain remained. This resulted in a continued lack of appetite from the patient, and
generalized weakness from insufficient caloric intake.
PSYCHOSOCIAL STAGE OF DEVELOPMENT
What is the client’s developmental stage?
Ego integrity vs. Despair
Has he/she met the necessary accomplishments? Yes/No
Explain.
The patient seemed to be anxious about her hospital stay, but when the student asked her
about her life and family, she responded in a way that intimated a sense of pride in her
family and who she was as a person. She was cooperative, and eager to know what was
going on with her health. She seemed frustrated and uncertain because her health was not
improving. The student entered the room once to find her crying with her husband. She
sounded eager to be home and in a familiar place after being in the hospital for almost
three weeks, but also slightly depressed that she was not getting much better.
How is this illness affecting the client’s ability to meet these necessary accomplishments?
The patient’s frustration with her health kept her focus mainly on what was going on with
that, and not as much on her sense of accomplishment in life. She was showing signs of
acceptance of her condition, but it was obvious she did not like it. She was showing signs
of depression because the cause of her illness was still unknown (or at least the solution)
after so much time.
NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS
Indicate below the 2 priority nursing diagnoses that are most relevant for your client.
#1 NURSING DIAGNOSIS (problem r/t)
Imbalanced nutrition, less than body requirements r/t lack of appetite.
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Patient is not able to keep food down or eat without nausea; patient’s appetite is decreased,
and has been on TPN for calorie intake.
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Patient will be able to eat at least 50 percent of meals within 1 week, and be free of signs of
malnutrition.
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Weigh the patient daily in acute care, weekly in extended care at the same time (usually
before breakfast), and with the same amount of clothing (Ladwig & Ackley, 2011, p. 526).
2. For the client who is malnourished and can eat, offer small quantities of energy-dense
and protein-enriched food, served in an appetizing fashion, at frequent intervals (Ladwig &
Ackley, 2011, p. 527).
3. Provide companionship at mealtime to encourage nutritional intake (Ladwig & Ackley,
2011, p. 527).
#2 NURSING DIAGNOSIS (problem r/t)
Readiness for enhanced coping r/t patient crying from frustration about hospital stay.
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Patient was found crying with spouse because of frustration over having no appetite and
being in the hospital for almost three weeks. Patient is frustrated because the she has not
been seeing any positive outcomes of her hospital stay in regards to her perceived health.
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Patient will state awareness of at least three possible environmental changes that may
contribute to decreased coping, and seek at least one new coping strategy within two
weeks from now.
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Encourage the patient to use spiritual coping mechanisms (if applicable) such as faith
and prayer (Ladwig & Ackley, 2011, p. 306).
2. Empower the patient to set realistic goals and to engage in problem solving (Ladwig &
Ackley, 2011, p. 306).
3. Use empathetic communication and encourage the patient to verbalize fears, express
emotions, and set goals (Ladwig & Ackley, 2011, p. 306).
COMPLICATIONS:
If this client’s condition were to worsen, what would be the most likely reason and why?
Most likely, this patient’s condition would worsen because of further malnutrition due to
abdominal pain, lack of appetite, and nausea after eating. Her condition could also worsen
because of the amount of anxiety she feels about not knowing what is wrong with her, and
that she is not seeing any positive results. This could take away some of her appetite,
however it will make it harder for her to keep eating.
How would you know this is happening?
This could most easily be noted as happening when the patient’s food intake is decreasing
and her level of anxiety is increasing. She would become weaker, and probably would not
be able to keep down very much of the food she actually is consuming.
What will you do if this happens?
This patient has an order (though it has not yet been filled) for a nasogastric tube to be
placed. If she continued to have the same issues with eating and appetite, it is likely that
the doctor would want the NG tube to be placed, and have her begin enteral feedings as she
tolerates them. The student/nurse would provide as much encouragement to the patient as
possible to reassure her, and would try to reduce her anxiety levels as much as possible,
while still making sure she knows the seriousness of the situation
PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS
MEDS/IVs/TX/DIET
(Include dose, route,
frequency)
REASON PRESCRIBED
(Drug Classification,
What is it treating?)
NURSING
IMPLICATIONS FROM
TEXT
(Checking for adverse
reactions, preparation
& administration
concerns)
TPN 2,000
infusing @ 55ml/hr in
Dextrose 5% in Water
Allopurinol 300mg/1
tab, by mouth, daily
Potential injury during
central line placement,
sepsis, and metabolic
complications.
Limits amount of caloric
intake via TPN to about
2300cal/day. Not
recommended for full
nutritional needs. I&O
should be monitored (Davis’
Drug Guide, 2014).
Xanthine oxidase
inhibitors: prescribed for
treatment of gout.
Rash, hypersensitivity,
hypo-/hypertension,
drowsiness, nausea,
diarrhea, vomiting,
bone marrow
depression.
Monitor I&O; may affect
kidney function. Monitor for
joint pain and swelling in
patients with gout. Watch for
skin rash (Davis’ Drug Guide,
2014).
Anticoalgulants: prescribed
for post-surgery measures.
Alopecia, bleeding,
anemia, heparininduced
thrombocytopenia, pain
at injection site, fever.
Assess for signs of bleeding
and hemorrhage, bruising,
etc. Monitor for
hypersensitivity reactions
(Davis’ Drug Guide, 2014).
Vasodilators: prescribed
for high blood pressure.
Dizziness, drowsiness,
headache, tachycardia,
sodium retention.
Make sure to check blood
pressure and heart rate
immediately before giving
(should be above 60 bpm).
Monitor throughout therapy
(Davis’ Drug Guide, 2014).
Hormones: given for
hormone replacement of
thyroid hormones.
Headache, irritability,
abdominal cramps,
diarrhea, vomiting,
hyperthyroidism,
weight loss.
Assess apical pulse and BP
before giving, assess for
tachyarrhythmias and chest
pain (Davis’ Drug Guide,
2014).
Antiulcer agents:
prescribed for duodenal
and jejunal ulcers.
Abdominal pain,
diarrhea, nausea,
vomiting, constipation,
flatulence.
Assess patient routinely for
epigastric and abdominal
pain and for frank and occult
blood in stool, emesis, or
Hydralazine 50mg/2
tabs, by mouth, twice
daily
Misoprostol 100 mcg/1
tab, by mouth, 3 times
(What data is important to
know before & after giving)
To provide caloric and
nutritional supplication to
the diet for a patient who
needs additional support.
Heparin 5,000
units/1mL, subQ, every
8 hours
Levothyroxine
(Synthroid) 100 mcg/1
tab, by mouth, daily
CLIENT DATA FROM YOUR
ASSESSMENT
gastric aspirate (Davis’ Drug
Guide, 2014).
daily with meals
Pantoprazole 40mg/1
tab, by mouth, twice
daily
Propranolol 160 mg/1
cap, by mouth, daily
Sodium chloride 0.9%
10 ml IVPush, every 8
hours at end of shift.
(Norco/Vicoden)
Acetaminophen
hydrocodone, 2 tab, as
needed every 4 hours
(Zofran)
Proton pump inhibitors:
prescribed for treatment of
GERD and duodenal ulcers.
Headache,
pseudomembranous
colitis, abdominal pain,
hyperglycemia, bone
fracture.
Assess patient routinely for
epigastric and abdominal
pain and for frank and occult
blood in stool, emesis, or
gastric aspirate (Davis’ Drug
Guide, 2014).
Beta-blockers: prescribed
for prevention MI and
management of HTN.
Fatigue, weakness,
dizziness, arrhythmias,
bradycardia, pulmonary
edema, mental
depression.
Assess BP and HR
frequently during therapy,
assess for orthostatic HTN;
monitor I&O, take daily
weight. Assess for rash
frequently (Davis’ Drug
Guide, 2014).
Mineral/electrolyte
replacements/supplements:
prescribed for replacement
of electrolytes; patient has
low sodium.
Heart failure,
pulmonary edema,
edema.
Assess fluid balance (I&O,
weight, edema, lungs);
assess for signs of
hyponatremia/hypernatremia
(Davis’ Drug Guide, 2014).
Opioid analgesics:
prescribed as needed for
abdominal pain.
Confusion, dizziness,
sedation, hypotension,
constipation,
dyspepsia, nausea.
Assess BP, pulse, and
respirations throughout
therapy. If resp. are <10/min,
may need to decrease dose
to avoid hypoventilation.
Assess bowel function
(Davis’ Drug Guide, 2014).
Antiemetics: prescribed as
needed for patient nausea.
Headache, dizziness,
drowsiness,
constipation, diarrhea.
Assess patient for nausea,
vomiting, abdominal
distention, and bowel
sounds prior to and after
giving. Assess for
extrapyramidal effects
(Davis’ Drug Guide, 2014).
Antiemetics: prescribed as
needed for patient nausea.
Neuroleptic malignant
syndrome, confusion,
disorientation,
sedation, bradycardia.
Monitor BP, pulse, and
respirations frequently
during therapy. Assess level
of sedation (may cause resp.
depression) (Davis’ Drug
Guide, 2014).
Ondansetron 4mg/2ml
IVPush, as needed
every 6 hours
(Phenergen)
Promethazine 6.25 mg
/0.25mL, IVPush, as
needed every 6 hours
Analgesics: prescribed as
needed for patient pain.
Tramadol 50 mg/1 tab,
by mouth, as needed
every 4 hours
Seizures, dizziness,
headache, constipation,
nausea, abdominal
pain, anorexia,
diarrhea.
Assess pain before giving;
assess BP, pulse, and
respirations before/during
therapy; not recommended
for patients dependent on
opioids; monitor patient for
seizures (Davis’ Drug Guide,
2014).
Analysis of Diagnostic Tests
DIRECTIONS:
1.
List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical
treatments (i.e. medications) and provide the patient values for each test. Explain why they are
pertinent for this patient.
2.
List any screening diagnostic and laboratory tests that are not within normal limits. Explain why
these tests are increased or decreased in relation to your patient's medical condition.
Diagnostic/Lab Test
Sodium
Urea Nitrogen
Glucose
Patient Values
Analysis of Values
133 (L)
The patient’s Na+ levels could
be low because she has been
vomiting some after eating.
Hydralazine can also cause
fluctuation in electrolytes.
27 (H)
A high BUN can be caused by
her allopurinol; these higher
levels will be seen to decrease
after 2-3 days. May also be
increased from propranolol.
104 (H)
Could be elevated because the
patient is receiving a TPN in
D5W drip. Propranolol can also
increase glucose levels.
Patient has not been
Calcium
8.0 (L)
Total protein
Albumin
4.7 (L)
1.8 (L)
Surgery: Exploratory laparotomy
Surgery: Small bowel resection
consuming a large amount of
calcium in her diet – has not
really been consuming much of
anything. This could contribute
to it being low.
The patient’s level of protein
could be decreased because
she has not been consuming
very much protein (and keeping
it down).
Pantoprazole can cause some
abnormality in liver function
tests.
Found: a duodenal and jejunal
ulcer. Patient is receiving
pharmacological treatment for
ulcers.
Patient has had a small bowel
resection, and has been healing
nicely, though she has not been
improving in appetite or much
with pain levels.
References:
Davis’ Drug Guide. (2014). Nursing Central. Unbound Medicine. Retrieved from
www.nursing.unboundmedicine.com.
Ladwig, G. B. & Ackley, B.J. (2011). Guide to nursing diagnosis (3rd ed.). Maryland Heights, MO: Mosby.
Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). Brunner & Suddarth’s textbook of medical-surgical
nursing (12th ed.). Philadelphia, PA: Lippincott.