Client Situation
C.M. is a 76 year-old female admitted to St. Martha’s Hospital on October 18th,
2005. She was brought to emergency via ambulance/stretcher as initiated by
friend/caregiver. She presented with weakness that had been worsening x1 month, with
vomiting the previous day (and nothing to eat since) and leg pain (duration not indicated).
Subsequent diagnosis was weakness/general decline. Since her admission to the medsurg floor, she has had an episode of pneumonia that has since resolved. She also had a
fall on Jan. 8th that required stitches posterior head with no imagining evidence or further
trauma. She has a fall assessment conducted on Feb. 12th and is evaluated as at high risk
for falls. Although there is little evidence in the chart of activity intolerance, the client
stated to me that after ambulation she feels she must rest to catch her breath and she is
fatigued.
On Feb. 24th lab values indicated RBC 2.61 (L) and HGB 80 (L). She received 1
unit of packed red cells and her values for the next day were RBC 3.14 (L) and HGB 96
(L). Her stool was tested for occult blood but came back negative. Client has a history of
Afib, probable ischemic heart disease, cerebrovascular disease with post TIA’s,
hypertension and anemia of chronic disease. Diagnostic imaging shows cardiomegaly.
Presently, she has no pneumonia, P=73, R=20, T=36.5, BP=98/62 and O2 sats are 98%
on R/A. She is taking Acebutolol 200mg for hypertension and arrhythmias, ECASA
81mg for prevention of TIA’s, and ferrous sulphate 300mg for anemia.
Client also has diagnoses of rheumatoid and osteoarthritis and osteoporosis and
she has had multiple joint surgeries. These medical conditions limit the client’s functional
ability due to painful joints (most recent is neck pain), deformed joints, limited ROM,
weakness and instability on her feet. She requires one person assist for transfer,
ambulation and self-care (bathing, dressing). Set-up is required for oral care and feeding.
The client has a bed alarm on at all times and is belted into chair whenever seated. She
must be supervised in the bathroom as well. She is taking Prednisone 5mg od,
Azathiaprine 50mg od and Hydroxychloroquine 200mg bid for rheumatoid arthritis. To
treat osteoarthritis, she is taking calcium carbonate 1200mg od, vitamin D 800units od
and Actonel 35mg od.
C.M. is on a cardiac diet as tolerated and has no difficulties swallowing. She has
upper dentures. During her course in hospital she has had frequent episodes of mouth
sores and she is presently taking Nystatin cream for the corners of her mouth. Her has a
poor appetite and eats approximately 25% of meals. The doctor had noted that she looks
thinner since admission and charts show she has lost weight in the past month (132lb
down to 129lb). Labs done on Jan. 29th show albumin 32.3 (L) and total protein 55.4 (L).
Dietary consults have been made to address this issue. Client has GERD and is taking
Lansoprazole 30mg bid and has a history of chronic gastritis.
C.M. has an indwelling foley catheter draining clear, yellow urine. She has a
history of nocturia, chronic urethral syndrome with bladder atony and chronic renal
insufficiency. She gets up to the bathroom for bowel movements. Her last BM was Mar.
5th. She has a history of chronic constipation and has been prescribed Colace 100mg bid,
Lactulose 30ml bid and Domperidone 10mg tid to increase gastric mitility. In 2001 she
had a colostomy for bowel obstruction and it has been reversed since the same year.
C.M. is a Roman Catholic and she received Sacrament of the Sick Jan. 10th. She
has a grade nine education and has worked as a house keeper and in a local grocery store.
She is a pleasant lady and speaks clearly although she displays confusion as she is not
accurate in her assessment of why she is in hospital at this time. Since admission she has
been diagnosed with Dementia and has episodes of confusion and agitation. She has been
noted on the chart for restlessness and some agitation at bedtime. Trazadone 50mg od
and Zopiclone 7.5mg od have been prescribed for night time administration. This client
has a DNR order. Client has medication allergies to penicillin and maxeran.
Scientific Rationale
Osteoarthritis (OA) is a degenerative bone disease and is the most common and
frequently disabling bone disorder. In elderly patients, limitations in ROM may reduce
their ability to perform activities of daily living. Clinical manifestations include pain,
stiffness and functional impairment. Pain management and optimizing functional ability
are major goals of nursing interventions.
Rheumatoid arthritis (RA) falls under the category of diffuse connective tissue
diseases. This condition is chronic and characterized by diffuse inflammation and
degeneration in the connective tissues. In RA, the autoimmune reaction occurs primarily
in the synovial tissue. This abnormal inflammation results in the loss of articular surfaces
and joint motion. Clinical manifestations vary but may include joint pain, swelling
warmth, and lack of functioning. Signs of advanced RA are obvious joint deformities of
the hands and feet. Since RA is a systemic disease, there are often other clinical features
present. The most common problems are fever, weight loss, fatigue, anemia, lymph node
enlargement and Raynaud’s phenomenon (cold and stress induced vasospasm causing
episodes of fingers blanching or cyanosis. Because the frequency of anorexia, weight
loss and anemia are high with advanced RA, nutritional assessment and interventions are
key to minimizing the effects of these conditions. Meals should be small and frequent
and the foods should contain optimal levels of vitamins, protein and iron for tissue
building and repair. Nursing management should aim to reduce pain, sleep disturbances,
fatigue, altered mood and limitations of mobility.
Chronic pain is constant or intermittent pain that persists beyond 6 months and it
serves no useful purpose. If pain persists, it may become the client’s primary disorder.
The effects of chronic pain include suppression of immune function, depression, fatigue
and disability. Often times, elderly people are reluctant to seek help with even severe pain
as they view it as part of normal aging.
Dementia is a broad term for a syndrome characterized by a general decline in
higher brain functioning, such as reasoning. What often follows is a pattern of eventual
decline in the ability to perform basic activities of daily living. To diagnose dementia, at
least two domains of altered functioning must exist, such as memory and at least one of
the following: language, perception, judgement, problem-solving and visuospatial
function. Nursing interventions focus on client safety, reducing anxiety and agitation,
promoting independence in self-care, maintaining adequate nutrition, providing social
stimulation and fostering self-esteem and managing disturbed sleep patterns.
Client Goal: Client will not have falls
Client Outcome
1. Client will demonstrate the proper use of assistive devices.
2. Client will increase daily activity, if feasible.
Nursing Diagnostic Statements and Interventions
1. Risk for falls r/t altered mobility 2nd to arthritis…. r/t effects of antihypertensive
(acebutolol)
- orient client to surroundings and point out call bell
- keep bed at lowest position
- keep side rails up at all times
- use seatbelt when in chair
- assist client to use walker in proper manner
- assist client to transfer and ambulate
- do not leave client unsupervised in bathroom
- ensure client’s bed alarm is on and respond promptly when it sounds
- ensure client has no-slip foot ware
- ensure client’s walk ways are clear of obstructions
- allow client time to adjust to position changes and assess orthostatic hypotension
2. Impaired physical mobility r/t decreased strength and endurance 2nd to
osteoarthritis…r/t pain and fatigue 2nd to rheumatoid arthritis….amb limitations in
ROM, reluctance to move due to pain and the need for assistance to transfer and
ambulate.
- Assess client’s present level of ROM functioning to obtain a baseline
- Teach client how to perform passive ROM exercises and the rational for doing so
- Assist client with passive ROM exercises
- ROM’s will be performed slowly
- Nurse will support limbs above and below the joint
- Assist client to gradually progress to active ROM as tolerated
- Ensure client avoids prolonged periods of lying in bed and sitting in chair
- Assist client to reposition frequently (at least q2h)
- Ensure client is proper positioning and alignment to prevent complications
- Observe client’s use of walker and provide teaching as necessary
- Administer analgesics before procedures or activity, if indicated
3. Chronic pain r/t tissue trauma and reflex muscle spasms 2nd to arthritis (OA and
RA) amb client’s verbal reports of pain in joints and with movement.
- Assess client’s perception of pain
- perform PQRST of pain
- Have client rate pain on 0-10 scale to obtain base line and to compare effectiveness
of pharmacological interventions
- Reassess pain with scale 30 mins after administration of pain meds
- Document response to pain meds
- Document and report unrelieved pain
- Teach client non-pharmacological pain and assist them guided imagery
- Teach client deep breathing exercises
- Provide pain meds as prescribed
4. Impaired oral mucous membrane r/t drying effects of prolonged use of steroids
(prednisone) amb xerostomia and client reports of oral dicomfort
- Evaluate client’s ability to perform oral care
- Assist client to perform oral care twice per shift
- Apply Nystatin cream to corners of mouth
- Provide ice chips and emesis basin so client can sooth mouth and spit out water
- Provide client with soft swabs to use as needed
- Assess client’s oral mucosa for further signs of breakdown
- Avoid commercial mouth washes, as they are drying to membranes
5.
-
Imbalanced nutrition: less than body requirements r/t decreased desire to eat 2nd
to anorexia (associated with RA) amb weight loss noted by physician, weight loss
of 3lbs, muscle weakness, decreased albumin (32.3).
weigh client daily
monitor lab values
plan care so that unpleasant procedures do not precede mealtime
provide a pleasant, relaxed atmosphere for mealtime
teach client to rest before meals
maintain good oral hygiene before and after ingestion of food
offer frequent, small meals with snacks
offer commercial supplemental drinks if indicated
ensure referrals to dietary have been made
ensure client is receiving meals with foods they find appealing
teach client the importance of proper nutrition
6. Risk for constipation r/t decreased peristalsis 2nd to unknown etiology…. r/t side
effects of medications (calcium, iron, aspirin)
- perform abdominal assessment for distention, firmness, pain, bowel sounds
- monitor bowel movement frequency and characteristics of stool
- encourage client to drink 8 glasses of water/day, unless contraindicated
- ensure diet has adequate amounts of bulk foods (fruit, vegetables, bran)
- ensure client gets exercise as tolerated
- establish a regular time for elimination
- monitor for vagal stimulation (dizziness, slow pulse)
- provide a warm glass of water 30mins before breakfast as it may act as a stimulant
to bowel evacuation
- Administer bowel medications as ordered
7. Risk for infection r/t compromised host defences 2nd to arthritis, 2nd to
immunosuppressant medication (prednisone, azothiaprine)….r/t site for organism
invasion 2nd to presence of invasive lines (catheter)…r/t increased vulnerability of
elderly 2nd to decreased immune response and multiple chronic diseases
-
-
perform meticulous hand washing before and after care and in between sites of
contact
monitor for signs and symptoms of infection (rising WBC count, urine cloudiness,
redness, swelling, pain, tenderness and heat at invasive line sites (catheter), lab
results for C&S, elevated temp, diaphoreses, increased respirations and pulse and
rhythms, mental status, orientation, LOC, any delayed healing and recognize that
fever and chills may not be present in the elderly
evaluate patency catheter
keep urine drainage bag below level of bladder to prevent reflux and stasis
keep urine drainage bag off floor
Meticulously clean catheter and meatus daily
Obtain cultures of any suspicious drainage or urine
Ensure all visitors wash their hands before approaching client
Teach client proper hand washing technique
Ensure optimal nutrition and encourage client to eat small frequent meals
8. Impaired gas exchange r/t decreased O2 carrying capacity 2nd to anemia amb RBC
3.14, HGB 96, PC: Pneumonia
- Monitor lab values
- Provide supplemental oxygen prn as ordered
- assist and encourage client to perform deep breathing, cough, provide client with
incentive spirometer to use q4h
- assist client to get up to chair and ambulate as tolerated to mobilize secretions
- auscultate lung fields and breath sounds, monitor pulse, respirations, O2 sats
Assist client to turn/reposition (even if just to shift weight) hourly
- Assess pain and provide pain medications as needed
- Assess effectiveness of pain interventions
- Administer packed red blood cells as ordered
9. Self-care deficits bathing, dressing, toileting r/t muscular weakness and joint
deformity 2nd to arthritis (RA, OA) amb inability to bath, dress and ambulate
one’s self
- assess client’s level of ability to participate in care
- promote optimal participation in care
- provide choices and request preferences during self care
- encourage client to express feeling about self care
- position and set up for client that maximizes their ability to perform self care
- document client’s abilities so other staff coming on can continue to encourage
independence
- provide safety in the bathroom with no slip mat and hand rails
- keep instructions simple for client when confused
- orient client to equipment
- encourage client to wear glasses during care whenever possible
10. Risk for loneliness r/t change in usual residence 2nd to relocation for long-term
care
-
encourage client to talk about feelings of loneliness
mobilize the person’s support system of neighbours and friends
help client to identify activities that keep her busy
initiate referrals to community based groups that contact the socially isolated
11. Risk for impaired skin integrity r/t dry, thin skin and decreased dermal vascularity
2nd to aging
- Assess skin qshift for any evidence of breakdown (reddened areas, areas that do
not blanch, noting size (especially over bony prominences
- Ensure to wash reddened areas gently with mild soap, rinse thoroughly to remove
soap and pat dry
- Gently massage healthy skin around affected areas to stimulate circulation, being
careful to not massage over reddened areas
- Protect healthy skin with moisturizer
- Maintain adequate nutrition and water intake
- Weigh client and monitor serum albumin
- Assist client to change position q2h and shift weight at least q1h