Running Head: ADULTS NURSING PROCESS PAPER Adults Nursing Process Paper Sara Rothacher Kent State University 1 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 2 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). 3 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). 4 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 5 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 6 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. 7 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 8 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). 9 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). 10 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). 11 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. 12 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 14 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 17 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 .