Adults Nursing Process Paper

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Running Head: ADULTS NURSING PROCESS PAPER
Adults Nursing Process Paper
Sara Rothacher
Kent State University
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Running Head: ADULTS NURSING PROCESS PAPER
Client Profile
My patient GP was an 86 year old Caucasian, female. GP was admitted to the floor on
January 9th 2012 with a diagnosis of confusion. GP was also admitted due to dehydration to do
poor oral intake, a left breast mastectomy, myocardial infarction(MI) and congestive heart
failure (CHF). GP weighed 175 lbs. and was 5 feet 4 inches tall. She was married with two
children and 4 grandchildren. GP stated that she has a history of smoking 1 pack a day for 40
years but had successfully quit smoking 18 years ago. GP has a medical history of chronic
obstructive pulmonary disease (COPD), diabetes mellitus (DM), hyperlipidemia,
hypothyroidism, lumbar spinal stenosis, coronary artery disease (CAD), hypertension (HTN) and
a right knee replacement.
Past Medical/Surgical History
On January 14th 2012, GP had a left breast mastectomy including a blood transfusion
post op. GP stated that this procedure was done because she had precancerous cells
throughout her left breast that became worrisome. She stated that there was a history of
breast cancer in her family including her grandmother and two cousins. On November 27th
2007, GP had a coronary artery bypass graft surgery (CABG) due to a significant narrowing of
several arteries in her heart. Burton Sobel, MD and author of the journal Coronary Artery
Disease states that the narrowing of the arteries is most commonly caused by smoking, high
cholesterol and diabetes which GP has a history for all (Sobel, 2012). On January 18th, 2012, GP
had a PA and lateral chest x-ray done due to her shortness of breath. This x-ray resulted in
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Running Head: ADULTS NURSING PROCESS PAPER
findings of lung volume slightly diminished and present pulmonary edema. These findings
support her diagnosis of CHF. GP had an echocardiogram done on January, 20th 2012 due to
her diagnosis of CHF as well. GP’s right knee replacement took place three months prior to her
admission, October, 19th 2011.
Concept Care Map
-
See Concept Care Map.
Pathophysiology
Confusion is defined as a mental state marked by alterations in thought and attention
deficit, followed by problems in comprehension (Black & Hawk, 2009).
Dehydration is defined as a loss of water from the extracellular fluid volume. This is a
common and serious fluid imbalance that leads to hypovolemia. Symptoms occurring from
dehydration are low blood pressure, weak pulse, and an increased capillary refill (Black & Hawk,
2009).
A breast mastectomy is a removal of the breast, axillary lymph nodes, and overlying
skin, with the muscle left intact (Black & Hawk, 2009).
A myocardial infarction is also known as a heart attack. This can be caused by
atheroscleosis which is a buildup of plaque in the walls of the arteries. Symptoms of an MI are
chest pain, shortness of breath, jaw pain, numbness or tingling in the arms, and back pain
(Black & Hawk, 2009).
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Running Head: ADULTS NURSING PROCESS PAPER
Congestive heart failure is defined as a physiological state where the heart cannot
pump enough blood to meet the metabolic needs of the body. Symptoms of CHF are fatigue,
edema, shortness of breath and increased urination (Black & Hawk, 2009).
COPD is a disorder affecting the movement of air in and out of the lungs due to
obstructive bronchitis, emphysema and asthma. COPD is commonly caused by years of
excessive daily smoking of tobacco. Symptoms of COPD are chronic-productive cough,
shortness of breath, wheezing and chest tightness (Black & Hawk, 2009).
Diabetes Mellitus is a chronic, progressive disease characterized by the body’s ability to
metabolize carbohydrates, fats and proteins, leading to high blood glucose levels known as
hyperglycemia. DM causes symptoms of increased thirst, urination frequency, fatigue, blurred
vision, sudden weight loss or gain, and poor wound healing (Black & Hawk, 2009).
Hyperlipidemia is an elevated level of lipids in the blood causing no symptoms but
increasing the risk of heart attack, stroke and coronary artery disease. Hyperlipidemia is
commonly caused by either lifestyle contributors such as obesity, lack of exercise and smoking
tobacco or by medical conditions such as diabetes, kidney disease, pregnancy and underactive
thyroid gland (Black & Hawk, 2009).
Hypothyroidism is defined as a deficiency of thyroid hormone resulting in slowed body
metabolism, decreased heat production, and decreased oxygen consumption by the tissues.
This condition is manifested by dry skin, forgetfulness, depression, cold intolerance, and weight
gain. Hypothyroidism can be caused by an autoimmune disorder, hyperthyroidism treatments,
radiation therapy or medications, (Black & Hawk, 2009).
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Running Head: ADULTS NURSING PROCESS PAPER
Lumbar spinal stenosis is a narrowing of the spinal canal, nerve root canals or foramen.
It is due to excessive bone growth from chronic stress on the bone. Low back pain and
weakness, numbness and decreased sensation in the legs are common symptoms of lumbar
spinal stenosis (Black & Hawk, 2009).
Coronary artery disease is the narrowing of small blood vessels that supply blood and
oxygen to the heart caused by a buildup of plaque in the arteries of the heart. Chest pain, or
angina, is the most common symptom of CAD, along with fatigue, shortness of breath and
weakness (Black & Hawk, 2009).
Hypertension is defined as high blood pressure over a period of 10 consistent days or
longer. A persistent elevation of the systolic blood pressure at a level of 140mmHg or higher
and a diastolic blood pressure of 90mmHg or higher. Hypertension can be caused by smoking,
diet high in salt, fat and cholesterol, and several heart, kidney and liver conditions (Black &
Hawk, 2009).
Assessment Data
Vitals and a head to toe assessment were obtained on GP at 0800 the morning of
January 24th, 2012. Her temperature was 98.2 degrees Fahrenheit, pulse was 68 beats per
minute, respirations were 14 breaths per minute, blood pressure was 135/72, pulse oximetry
95% and she stated her pain level as a 7 on a verbal scale ranging from 0 to 10 with 10 being
the most extreme pain imaginable. GP described the pain as “sharp and stabbing” in her right
knee at the incision line from her knee replacement 2 months prior. GP was given 500mg of
Acetaminophen to make her more comfortable. GP was alert and oriented to person, place and
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Running Head: ADULTS NURSING PROCESS PAPER
time. Her pupils were reactive and within normal limits and PERRLA was noted. Generalized
weakness was documented due to weak hand grasps and pedal pushes bilaterally.
Skin Assessment
GP’s skin was pale, dry and warm. She had an excoriated wound on her coccyx and a
surgical incision on her right groin from her recent coronary artery bypass graft surgery. She
had #24 IV running in her right forearm with NS at 50mL/hr. The IV site looked be without
redness, swelling or drainage. GP received a 15 on the Braden Scale. The Braden Scale is a
universally accepted tool in the healthcare field that identifies individuals who may be at risk
for developing bed sores. It is based on a numerical score given to each category with 6 being
the lowest score and 23 being the highest. A score of 16-15 puts the patient at minimal risk, 1413 is a moderate risk and 12 or less puts the patient at a high risk for bed sores (Black & Hawk,
2009).
Cardiovascular Assessment
GP’s radial pulses were strong and equal. Her left dorsalis pulse was strong and her right
dorsalis pulse was weaker. All extremities had a capillary refill less than 3 seconds. No edema
was noted. Her skin turgor was non-tenting and her nail beds were pink. GP’s apical pulse was
strong and even with a rate of 68 beats per minute.
Respiratory Assessment
Lung sounds were diminished, clear and unlabored in all lobes. GP was on oxygen 3
liters through nasal cannula. She had an occasional nonproductive, cough present. No sputum
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Running Head: ADULTS NURSING PROCESS PAPER
was obtained. GP complained of occasional shortness of breath and dyspnea on exertion
(shortness of breath during activity).
Gastrointestinal Assessment
Bowel sounds were present in all four quadrants. GP stated that her last bowel
movement was earlier that morning. Her abdomen was soft and nondistended. She had just
finished her breakfast which she ate 75% of.
Assessment Notes/Education
During the assessment I spoke with GP about the importance of increasing her activity
level. She showed willingness to comply with the care plan the hospital and physical therapy
had in mind for her. I informed her that she had orders to be up in her chair for at least 4 hours
out of the day and to wear her SCD’s at all times when in bed. I educated GP on range of
motion techniques to use as a form of stationary exercises and how important it was to
complete daily. I reviewed the importance of avoiding cold weather, air and foods to prevent
asthma exacerbation with GP. As found in a recent study by several nursing professionals in the
Jan Original Research Journal, avoiding cold substances (food, air and weather) is a lifestyle
many COPD patients have invested in (Chen, Chen, Lee, Ying, & Weng, 2008, p. 600). I also
stressed the need to keep compliance with her medications including bronchodilators,
antihypertensives, and insulin. Optimizing self-management practices can promote a patients
quality of life (Chen, Chen, Lee, Ying, & Weng, 2008, p. 601) GP showed understanding of the
teaching and seemed receptive to her orders.
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Running Head: ADULTS NURSING PROCESS PAPER
GP was ordered a regular diet which meant she could chose to eat whatever she had an
appetite for. She stated that her appetite had recently increased from the day of admission.
When reviewing the chart, I noticed that GP had been eating anywhere from 50-100% of her
meals in the last couple of days. I educated her on the importance of avoiding foods high in
cholesterol because of her history of hyperlipidemia and HTN, as well as avoiding foods high in
sodium to avoid complications with her diagnoses of CHF and CAD and potentiating her risk of
hyperkalemia due to her ordered administration of KCl 20 mEq PO daily. We also spoke about
the importance of complying with her diabetic orders and keeping proper control of her blood
sugars. I was unable to obtain her HgA1C results but GP insisted that she kept a good record of
blood sugar maintenance.
Labs and Diagnostics
-
See Lab and Diagnostics table; pages 13-14.
Medications
-
See Medications table; pages 14-17.
Analysis
The primary nursing diagnosis I chose for GP was Impaired Gas Exchange related to
edema of the lungs, compromised oxygen transport secondary to diagnosis of CHF and COPD as
evidenced by decreased pulse Ox, O2 per nasal cannula 4Liters and shortness of breath. I made
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Running Head: ADULTS NURSING PROCESS PAPER
this the primary diagnosis because according to the priority rule of the ABC’s (airway, breathing,
circulation), GP’s impaired ventilation and perfusion are the first step in prioritizing emergent
conditions.
Primary Nursing Diagnosis:
Impaired Gas Exchange r/t edema of the lungs, compromised
oxygen transport secondary to diagnosis of CHF and COPD , AEB
decreased pulse Ox, O2 per nasal cannula 3 Liters, shortness of
breath, DOE and decreased hemoglobin levels.
Short Term Goal:
GP will show no signs of respiratory distress such as increased
pulse, rapid respirations, nasal flaring, mouth breathing or
hypoxia within 8 hours.
Interventions:
1) Assess for signs of respiratory distress such as increased
pulse, rapid respirations, nasal flaring, mouth breathing and
hypoxia (Craven & Hirnle, 2009, p. 1330).
2) Monitor pulse oximetry every hour or keep pt on a
continuous monitor to assure the level of 95% or higher (Craven
& Hirnle, 2009, p. 1329).
Long Term Goal:
GP will demonstrate adequate gas exchange as indicated by a
pulse oximetry reading of 95% or higher within 30 days.
Interventions:
1) Educate pt on pursed –lip breathing to increase back pressure
in the airways which eases exhalation and prevents air trapping
(Craven & Hirnle, 2009, p. 834).
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Running Head: ADULTS NURSING PROCESS PAPER
2) Instruct pt to keep head of the bed elevated 30 degrees or
higher to promote an open airway and maximum chest
expansion (Craven & Hirnle, 2009, p. 1329).
Evaluation:
Short term goal met. Interventions and care plan were made.
GP demonstrated willingness and cooperation of interventions.
Long term goal unable to assess due to patient discharge.
Teaching interventions accomplished and GP verbalized
understanding.
The secondary nursing diagnosis I chose for GP was Activity Intolerance related to
diagnosis of COPD, CHF and edema of the lungs and generalized weakness as evidenced by
shortness of breath, dyspnea on exertion and pain on movement. I chose this diagnosis due to
the fact that if GP’s activity remains decreased, her health issues will only further in severity.
Without a proper activity level, GP is at risk for pressure ulcers, foot drop, vascular issues
including thrombus formation and deep vein thrombosis and atelectasis due to pooling of
secretions in the lungs (Clinic, 2011).
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Running Head: ADULTS NURSING PROCESS PAPER
Secondary Nursing
The secondary nursing diagnosis I chose for GP was Activity
Diagnosis:
Intolerance r/t compromised oxygen transport secondary to
diagnosis of COPD, CHF and edema of the lungs and generalized
weakness, AEB shortness of breath, dyspnea on exertion, pain on
movement, O2 per N.C of 3L, Albuterol inhaler 2.5mg/0.5mL q6h,
Atrovent inhaler 0.5mg q6h.
Short Term Goal:
GP will participate in physical activity with changes in respirations
no lower than 12 breaths per minute or higher than 20 breaths
per minutes and a heart rate no lower than 60 beats per minute
and no higher than 100 beats per minute within 3 days of
admission.
Interventions:
1) Monitor vital signs and obtain a baseline O2 saturation
(Craven & Hirnle, 2009, p. 775).
2) Instruct pt on range of motion activities and encourage
that they be performed daily (Craven & Hirnle, 2009, p.
776).
Long Term Goal:
GP will demonstrate improvement of oxygen transport during
activity with respirations between 12 and 20 bpm, no signs of
nasal flaring, mouth breathing, shortness of breath or dyspnea on
exertion within the next 30 days.
Interventions:
1) Gradually increase activity as tolerated (Craven & Hirnle,
2009, p. 776).
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Running Head: ADULTS NURSING PROCESS PAPER
2) Instruct pt on the importance of “rest periods” and energy
saving techniques when performing ADL’s (Craven &
Hirnle, 2009, p. 778).
Evaluations:
Short term goal unable to assess due to end of shift. Teaching
interventions accomplished and GP verbalized understanding.
Long term goal unable to assess due to patient discharge.
Teaching interventions accomplished and GP verbalized
understanding.
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Running Head: ADULTS NURSING PROCESS PAPER
13
Labs and Diagnostics
Table 1
Test
Normal Value
Pt’s Results
Analysis
Sodium
135-145
138
WNL (Within Normal
Limits)
Potassium
3.5-5.0
3.8
WNL
Chloride
95-105mEq/L
98mEq/L
WNL
CO2
23-29
30
BUN
5-20mg/dL
24
Creatinine
0.6-1.3mg/dL
0.81
Increased, likely due
to diagnosis of COPD
and poor gas
exchange.
Increased, likely due
to diagnosis of CHF
and the decreased
blood flow to the
kidneys.
WNL
Normal Values obtained from: Nurse’s manual of laboratory and diagnostic tests (4th
ed).
Table 2
Test
Normal Value
Pt’s Results
Analysis
White Blood Cell
5,000-
6.8
WNL
Count
10,000million/mm3
Red Blood Cell Count
4.6-6.2 million/mm3
3.60
Decreased, likely due
to her recent blood
transfusion post-op
mastectomy
Running Head: ADULTS NURSING PROCESS PAPER
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Hemoglobin
13.5-18 g/dL
10.1
Hematocrit
40-54%
33.3
Platelets
150,000-450,000
259,000
1/14/2012
Decreased, likely due
to excessive blood
loss during her recent
mastectomy
(1/14/2012)and
hemodilution due to
fluid retention from
COPD.
Decreased, likely due
to recent blood
transfusion post op
mastectomy
(1/14/2012) and
dehydration on
admission. As well as
hemodilution due to
fluid retention from
COPD.
WNL
Normal values obtained from: Nurse’s manual of laboratory and diagnostic tests (5th
ed).
Medications
Table 3
Medication
Class/Action
Dosing
Side Effects
Albuterol –
(Proventil)
-Selective Beta-2
adrenergic
agonist
2.5mg/0.5mL
inhaled q6hr
Anxiety
Dizziness
Drowsiness
Headache
Insomnia
Nervousness
-Bronchodilator
- To
prevent/relief of
bronchospasms
Reason
administered to
GP
GP complained
of shortness of
breath and
dyspnea on
exertion (DOE).
Running Head: ADULTS NURSING PROCESS PAPER
Atrovent (Ipratropium)
-Anticholinergic
0.5mg inhaled
q6hr
Anxiety
Dizziness
Insomnia
Dry mouth
Headache
GP complained
of shortness of
breath and DOE.
30mg
Subcutaneous
daily
Anemia
Confusion
Epistaxis
Diarrhea
Dizziness
500mg q6hrs
daily PO, PRN
Nausea
Vomiting
GP was low
activity and at
risk for deep
vein thrombrosis
and possible
embolism
formation.
GP complained
of pain at her
insicion site in
her right knee.
- Bronchodilator
Enoxaparin –
(Lovenox)
-To block
acetycholines
affects on the
bronchi and
bronchioles to
relax smooth
muscles and
cause
bronchodilation
-Antithrombotic
- Inactivates
clotting factors
Acetaminophen –
(Tylenol)
-Inhibits
coagulation
-Antipyretic
-Nonnarcotic
analgesic
Hepatic failure
with long term
use
- Relief of mild to
moderate pain
Carvedilol – (Coreg)
Cozaar – (Losartan)
-Nonselective
beta-adrenergic
blocker
12.5mg b.i.d.
PO
Antihypertensive
-Angiotensin II
100mg daily PO
receptor
antagonist
Antihypertensive
15
Abdominal pain
Jaundice
Rash
Fatigue
Dizziness
Depression
Blurred vision
Abdominal pain
Dizziness
Fatigue
Headache
Insomnia
Hypotension
Nasal
congestion
Diarrhea
GP has a history
of HTN.
GP has a history
of HTN.
Running Head: ADULTS NURSING PROCESS PAPER
Hydrochlorothiazide 25mg daily PO
– (HCTZ)
Benzothiadiazide
Levothyroxine –
(Synthroid)
Antihypertensive
-Diuretic
-Thyroid
0.125mg daily
hormone
PO
replacement
Lasix –
(Furosemide)
-Sulfonamide
40mg IV q12hrs
Antihypertensive
-Diuretic
Potassium Chloride
-Potassium
source
Novolin R
Dizziness
Fever
Headache
Insomnia
Hypotension
Blurred vision
Fatigue
Headache
Insomnia
Muscle
weakness
Weight gain
Restlessness
Dizziness
Fever
Blurred vision
Muscle spasms
Increased thirst
Confusion
Anxiety
-Maintenance of
K+ levels.
Irregular heart
beat
-Antidiabetic
Increased thirst
Increased
urination
Hypoglycemia
-Insulin to
control
hyperglycemia
Normal Saline 0.9%
NaCl
20mEq PO daily
16
-Hydration and
blood volume
maintenance
Subcutaneous
ac & hs Sliding scale:
150-200: 4 units
201-250: 8 units
251-300: 10
units
301-350: 12
units
>350: Call
physician
50mL/hr IV #24
gauge
Bruising at
injection site
GP has a history
of HTN and a
diagnosis of CHF
with edema of
the lungs.
GP has a history
of
hypothyroidism.
GP had a
diagnosis of CHF
with edema of
the lungs.
GP was currently
taking a
potassiumwasting diuretic
(Lasix) and
needed KCL to
maintain her K+
levels.
GP has a
diagnosis of
Diabetes
mellitus.
Pruritis
Erythema
Lipodystrophy
Fluid overload
Hypokalemia
GP was on IV
medications
(Lasix, KCl) that
involved a
primary
Running Head: ADULTS NURSING PROCESS PAPER
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maintenance
fluid.
Medication References: Davis’s Drug Guide (12th ed.)
REFERENCES
Black, J., & Hawk, J. (2009). Medical-Surgical Nursing. St. Louis, Missouri: Saunders Elsevier.
Cavanaugh, B. (2010). Nurse’s manual of laboratory and diagnostic tests (5th ed.). Philadelphia,
Pennsylvania: F. A. Davis Co.
Chen, K.-H., Chen, M.-L., Lee, S., Ying, H., & Weng, L.-C. (2008). Self-management behaviours for patients
with COPD: a qualitative nursing study. Jan Oringinal Research .
Clinic, M. (2011, August 12). COPD. Retrieved February 18, 2012, from Mayo Clinic:
http://www.mayoclinic.com/health/coronary-artery-disease/DS00064
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of Nursing. Philadelphia: Lippincott Williams & Wilkins.
Hopfer, J., Vallerand, A., & Sanoski, V. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia: F. A.
Davis Co.
Sobel, B. (2012). Coronary Artery Disease. Coronary Artery Disease .
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