Running head: PROCESS PAPER
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Process Paper: Osteomyelitis and Cellulitis
Lori A. Risner
Kent State University Stark College of Nursing
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Process Paper: Osteomyelitis and Cellulitis
Introduction
On Septmeber 18, 2010, M.S. was admitted to Timken Mercy Hospital with an
admitting diagnosis of osteomyelitis of the left great toe and cellulitis of the left leg.
M.S. is a 50 year old white male who resides in Strasburg, Ohio with his girlfriend’s
daughter and her father. He recently moved to Ohio from West Virginia, where we was
born and raised. He is 5 feet 7 inches and weighs 143 pounds 4.45 ounces. He has no
known allergies and activity level is up as tolerated. He is unemployed but tries to pick
up part time jobs when able. He does not carry insurance He has now been hospitalized
for four days and wishes to go home. His past medical and surgical history limits his
mobility thus making him a fall risk patient. Prior to this visit, his last hospitalization
was January 1, 2001.
Client’s Profile
The primary medical diagnosis on admission for M.S. was osteomyelitis of the
left great toe and cellulitis of the left leg. Other medical diagnoses that will be discussed
in this section are pertinent parts of M.S.’s past medical history, which include alcohol
abuse and vertebral fracture.
Osteomyelitis. Osteomyelitis is the inflammation and destruction of bone that is caused
by bacteria, mycobacteria, or fungi (Schmitt, 2008). It can be spread from an infected
tissue that is nearby the bone or blood borne organisms (Schmitt, 2008). Staphyloccus
aureus is the most common causative agent; however Escherichia coli, Pseudomonas,
Klebsiella, Salmonella, and Proteus organism have also been known to cause infection
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(Black & Hawk, 2009). In the case of M.S., it was caused by an open wound which
allowed for Staphylococcus aureus to enter. He had a callus on his left great toe that he
removed with a knife, not using sterile technique. This allowed the pathogens to enter his
body and cause infection. Males are affected more commonly than females, and the risk
for infections increases with IV drug use, diabetes, immunocompromising diseases, or a
history of bloodstream infections (Black et al., 2009). “Osteomyelitis tends to occlude
local blood vessels, which causes bone necrosis and local spread of infection” (Schmitt,
2008). Limiting the spread of osteomyelitis may be difficult if the patient has a history of
malnutrition, alcoholism, or liver failure (Black et al., 2009). Patients with osteomyelitis
usually experience signs and symptoms that include weight loss, fatigue, fever, and
localized warmth, swelling, erythema, and pain (Schmitt, 2008).
When a patient presents with localized bone pain, osteomyelitis is suspected and
the physician will order a complete blood count, erythrocyte sedimentation rate (ESR), Creactive protein, along with an X-Ray of the affected bone(Schmitt, 2008). At first, the
white blood cell count may not be elevated as noted in most infections; however the ESR
and the C-reactive protein will be elevated (Schmitt, 2008). If the infection has been
brewing for more than 2-4 weeks in the client, the X-Rays will show periosteal elevation,
bone destruction and soft-tissue swelling (Schmitt, 2008). If the client’s symptoms are
acute, a CAT scan or a Magnetic resonance imaging (MRI) may be ordered also. These
scans are done to identify abnormalities and to determine if any abscesses are present
(Schmitt, 2008). A culture and sensitivity will be ordered in order to determine the bone
pathogen and decide which antibiotic will be the most effective for the infection. Besides
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antibiotics, surgery may be needed to remove any abscesses or debride necrotic tissue
(Schmitt, 2008).
Cellulitis. Cellulitis is an acute bacterial infection of the skin and subcutaneous tissue
(Dhar, 2007). “Cellulitis is most often caused by group A hemolytic streptococci or
Staphylococcus aureus” (Dhar, 2007). Streptococci cause an infection that is rapidly
spread because enzymes produced by the organism break down cellular components that
would usually localize and slow down the spread of the infection (Dhar, 2007). If the
cellular components are destroyed, they do not have the ability to localize the infection
and it spreads throughout the body. Staphylococcal cellulitis is usually more localized
and typically occurs with an open wound (Dhar, 2007). In the case of M.S., his left leg
cellulitis was the result of Staphylococcus aureus, as evident by his prescribed antibiotic
(Zosyn) and his cultures.
Cellulitis is most common in the lower extremities and tends to be unilateral in
most patients (Dhar, 2007). Signs and symptoms of cellulitis include skin that is hot, red,
and edematous with indistinct borders. Clients may also present with fever, chills,
tachycardia, headaches, hypotension, and confusion, but many clients do not appear to be
ill (Dhar, 2007). Cellulitis is diagnosed with a physical examination and sometimes
accompanied by a wound or blood cultures. Antibiotic therapy is used to treat most
cellulitis infections. If an abscess does form, incision and drainage may be required to
remove the drainage. Blood cultures were drawn and antibiotic therapy was started on
M.S.
Alcohol Abuse. M.S. has been abusing alcohol since the age of ten. To put this into
perspective, he has been drinking about a case of beer each day for 40 years. The
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definition of alcohol abuse is “recurrent, harmful use of alcohol with failure to fulfill
major school, work, or home responsibilities” (McKinley, 2005, p. 41). This differs from
alcohol dependence, which is defined as “a disease that includes 4 symptoms: craving,
loss of control, physical dependence, and tolerance” (McKinley, 2005, p. 41). “Alcohol
abuse results in specific health problems, including alcohol withdrawal syndrome;
hepatic cirrhosis, and pancreatitis; and cancers of the liver, oropharynx, and esophagus”
(Black et al., 2009, p.16). Problem drinkers often do not present with manifestations of
dependence upon assessment (Black et al., 2009). Alcohol abuse cannot be diagnosed on
the basis of a set amount or frequency of alcohol consumption. Alcohol withdrawal
syndrome usually occurs in people who have relied on alcohol for weeks or months and
who suddenly have to quit drinking (McKinley, 2005).
“The complex mechanisms of alcohol intoxication, tolerance, dependence, and
withdrawal are not completely understood, but a clear relationship exists between alcohol
and alterations in neurotransmission in the brain” (McKinley, 2005, p. 41). The main
neurotransmitter that is affected by alcohol is Y-aminobutyrate A (GABAA) (McKinley,
2005). This neurotransmitter allows more chloride to enter the neuron, making the cell
membranes less likely to depolarize, thus inhibiting the cell. The result of short term
alcohol abuse is depression of the behavioral inhibitory centers in the cerebral cortex and
the reticular activating system, causing euphoria, exaggerated feelings of well being, and
reduced self control (McKinley, 2005).
“The pathophysiological effects of long-term alcohol use involves the same
neurotransmitters but are complicated by tolerance and physical dependence as
contributing factors to the problem of withdrawal of alcohol” (McKinley, 2005, p. 41).
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The result of long term alcohol use is a decrease in the GABAA inhibitory function. If a
person continues to drink alcohol on a daily basis, the central nervous system learns to
adapt, thus reducing the initial short-term effects. Clinical manifestations of alcohol
withdrawal syndrome include fluid volume deficits, autonomic hyperactivity,
hallucinations, agitation, anxiety, sensitivity to light, nausea, and vomiting (Axen,
Koranda, & McKay, 2004). An increased heart rate, blood pressure, and respiratory rate
may also be present (Axen et al., 2004). Many patients who abuse alcohol are also
deficient in vitamins and minerals. “Folic acid and thiamine are two key vitamins to be
administered to a patient in alcohol withdrawal” (Axen et al., 2004, p. 17). M.S. was
ordered both of these in order to control his withdrawal symptoms.
Medical History
M.S. had no significant past medical history apart from a motor vehicular
accident in 1988 that resulted in lower extremity paresthesia. He encountered a vertebral
fracture which was fused with a bone graft that was taken from his hip. This accident
also resulted in bilateral plantar flexion. A spleenectomy was also performed to remove
the ruptured spleen which occurred during the accident in 1988. He has a past medical
history of muscle wasting to his bilateral extremities. He has no past medical history of
diabetes mellitus, congestive heart failure, vision or hearing problems. His family history
is also pretty insignificant. Both his mother and his father are in their 70’s with no
pertinent medical problems. He also has a 45 year old brother that is healthy.
Gordon’s Functional Assessment
M.S. began experiencing pain in his left big toe on September 18, 2010. At this
point he made the decision to visit the emergency department at Timken Mercy Medical
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Hospital. Upon arrival at the emergency department, the nurse did an assessment. The
results of this assessment were charted and are as follows: Patient came in complaining of
pain and swelling of his left great toe. Ankles are swollen bilateral and in plantar flexion.
Patient stated that as a result of a car crash in 1988, he can only walk on his tip toes. This
caused a callus to develop on his left toe which he decided to cut off himself. An ulcer
formed that increased in size. There was swelling and redness of the entire left foot that
extended up the calf. Patient rated his pain a 6 on a scale of 1-10. He described the pain
as radiating, stabbing, and constant with no relieving factors. He did not present with a
fever or chills. Patient complained of a non productive cough, but stated that it was most
likely from smoking. The emergency department sent M.S. for an X-ray of his left foot
and osteomyelitis was diagnosed. The emergency department transferred him to 8 main
to be admitted. Refer to attachment 1 for Gordon’s Functional Health Pattern Chart for
assessment performed on September 21, 2010.
Laboratory Data
M.S. had blood work drawn on September 18, 2010 and again on September 20,
2010. The laboratory results were indicated that the antibiotic therapy was effectively
treating the bacteria infection. It also indicated that the body’s stress response was active
and helping to fight off the infection. Laboratory results are as follows. All Normal
ranges and interpretation were obtained from Medical- Surgical Nursing; Clinical
Management for Positive Outcomes (Black et. Al, 2009).
Diagnostic
Blood Draw
Results from
9/18/10
Results from
9/20/10
Normal Range Interpretation
WBC
14.9mm^3
9.6mm^3
5,00010,000mm^3
An increased WBC
count is indicative
of an infection.
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Blood draws
indicate that
antiobiotic therapy
is working abd
infection is being
controlled.
RBC
5.10mm^3
4.73mm^3
4.7-6.1mm^3
Within normal
range; Dropped a
little on test #2. No
indication of
anemia,hemorrhage
or hemolytic
disorders.
HgB
15.8g/dL
14.6g/dL
13.5-18.0 g/dL
Within normal
range; HgB
dropped a little r/t a
decrease in RBC
on test #2. No
signs of anemia or
hemorrhage.
Oxygen carrying
portion of blood is
adequate.
Hct
45.3%
42.4%
42-52%
Within normal
range;
Percentvolume of
RBCs is adequate
PLT
369mm^3
306mm^3
150,000450,000mm^3
Within normal
range; No signs of
thrombocytopenia
or hemolytic
disorders
MCV (Mean
Corpuscular
Volume)
88.8 um^3
89.6um^3
76-100um^3
Within normal
range; This
measures
erythrocyte size
and Hcg count
MCHC (Mean
Corpucsular
Hemoglobin
Concentration)
34.9g/dL
34.4g/dL
32-36g/dL
Within normal
range; Measures
average
hemoglobin
concentration
within 100 mL of
packed RBCs.
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Neutrophils
55%
40.7%
55-70%
A Decreased
Neutrophil count is
related to antibiotic
therapy to treat the
infection
Lymphocytes
32.4%
44.0%
20-40%
An increased
lymphocyte count
is related to
infectious process
and invading
bacteria; Needed to
help fight off
infection.
Monocytes
9.1%
12.3%
2-8%
An increased
Monocyte count is
related to invading
bacteria and the
infectious process;
body’s defense
mechanisms.
Eosinophils
0.7%
2.0%
1-4%
A decreased
Eosinophil count is
related to the stress
response of the
body when
handling an
invasion of
bacteria.
Basophils
0.6%
0.9%
0.5-1%
Within Normal
Range
Electrolytes
Results from
9/18/10
Results from
9/20/10
Normal Range
Interpretation
Sodium (Na+)
141 mEq/L
138 mEq/L
135-145 mEq/L
Within Normal
range; No
hypernatremia
or
hyponatremia
present; Patient
is receiving IV
NaCl 0.9%
running at 10
mL/hour
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Potassium (K+)
4.2 mEq/L
4.2 mEq/L
3.5-5.0 mEq/L
Within Normal
Range; No
electrolyte
imbalance; No
hyperkalemia
or hypokalemia
present
Calcium (Ca+)
8.7mg/dL
8.5 mg/dL
8.2 - 10.6
mg/dL
Within Normal
range; No
electrolyte
imbalance
Chloride (Cl-)
104 mEq/L
103 mEq/L
98-107 mEq/L
Within Normal
Range; No
electrolyte
imbalance
CO2
25
27
Normal 21-32
Within Normal
Range
BUN
4mg/dL
6mg/dL
7-18mg/dL
Decreased
BUN may be
the result of
imbalanced
nutrition.
Creatinine
0.56mg/dL
0.60mg/dL
0.6-1.2mg/dL
Decreased
creatinine
levels may be
the result of
muscle atrophy
and inadequate
dietary protein
Albumin
3.4g/dL
Not available
3.4-5.4g/dL
Within Normal
Range
Uric Acid
1.5mg/dL
Not available
2.1 to 8.5
mg/dL
Decreased Uric
acid may be the
result of a lack
of sufficient
protein in the
diet or a lack of
a sufficient
presence of
some minerals
in the body
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Glucose
91mg/dL
11
Not available
70-110mg/dL
Within normal
limits; No
indication of
diabetes
mellitus
Normal ranges and interpretation retrieved from Black et. Al, 2009.
Medication Information
M.S. was ordered a variety of medications, each with different indications and
therapeutic effects. He was ordered two antibiotics (Vancomycin and Piperacillin) that
were indicated to treat his Osteomyelitis and Cellulitis (Black et al., 2009). The
effectiveness of these medications was tracked through his white blood cell counts (Black
et al., 2009) and trough draws. Two days after antibiotic therapy was initiated, M.S.’s
WBC count dropped from 14.9 mm^3, which is out of therapeutic range to 9.6 mm^3
which is considered within normal range. He was also on a pain medication
(Hydrocodone) to decrease the chronic pain in his back that was a result of his car
accidents many years ago. The Nicotine patch was initiated in order to control withdrawal
symptoms from cigarette smoking (Black et al., 2009). He has smoked since he was ten
years old; this patch helps decrease the cravings for a cigarette. He was also ordered
Thiamine and Folic acid, which are used to treat vitamin deficiencies (Black et al., 2009).
He does not eat the most well balanced meals at home, therefore he needed replacement
therapy. Further information on the ordered drugs is listed below. All medication
information was retrieved from Davis’s Drug Guide for Nurses- Version
13.0.1/2010.1.11
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Medication
Order
Piperacillin/
tazobactam
IV 10mL/hr
q24h
piperacillin/taz
obactm 9GM
(sodium
chloride 0.9%)
for Zosyn
continuous IV
240 mL infuse
at 10mL/hr
Started at 2229
Antiinfective
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Indication and Action
Therapeut
ic Effects
Side Effects
Indications
Appendicitis,
peritonitis; Skin and
skin structure
infections;
Community acquired
and nosocomial
pneumonia
Death of
susceptible
bacteria
Seizures, confusion,
dizziness, headache,
insomnia, letharagy,
pseudomembranous
colitis, diarrhea,
constipation, drug
induced hepatitis,
nausea, vomiting,
interstitial nephritis,
rashes, urticaria,
bleeding, leucopenia,
neutrpenia,
thrombocytopenia,
pain at IV sitefever,
super infection
Half Life
0.7-1.2
hours
Action
Piperacillin binds to
bacterial cell wall
membrane, causing
cell death. Spectrum is
extended with other
penicillins;
Tazobactam
inhibitsbeta-lactamase,
which is an enzyme
that can destroy
penicillin.
Safe Dose?
IV adults:
3.375 g
every 6
hours
IV Route
Onset: rapid
Peak: end of
infusion
Duration: 46 hours
Nursing Assessment: Assess patient for infection (vital signs, redness, sputum, urine, stool, and WBC). Obtain past
medical history. Obtain specimens for culture and sensitivity prior to therapy. Assess for signs and symptoms of
anaphylaxis (rash, pruritus, laryngeal edema, and wheezing)
Patient Teaching: Advise patient to report any signs and symptoms of super-infection (black, furry overgrowth on
tongue, loose or foul smelling stool)and allergy. Alert healthcare provider if diarrhea or fever occurs, especially if blood
is present in stool.
Medication
Heparin
Sodium
anticoagulant
Order
Indication and Action
Therapeut
ic Effects
Heparin
Sodium
5000
units SQ
q8h
Indications
Prophylaxis and treatment of
various thromboembolic
disorders including: Venous
thromboembolism,
Pulmonary emboli, Atrial
fibrillation with
embolization, Atrial
fibrillation with
embolization & Peripheral
arterial thromboembolism.
Used in very low doses (10–
100 units) to maintain
patency of IV catheters
(heparin flush).
Prevention
of
thrombus
formation
and
prevention
of
extension
of existing
thrombi.
Schedule
d at 1400.
Half Life
5–6 min
Side Effects
GI: drug-induced
hepatitis.
Derm: alopecia
(long-term use),
rashes, urticaria.
Hemat: bleeding,
anemia,
thrombocytopenia
(can occur up to
several weeks after
discontinuation of
therapy).
Local: pain at
injection site.
MS: osteoporosis
(long-term use).
Safe Dose?
SC (Adults):
5000 units q
8–12 hr
IV Route
Onset: 2060min
Peak:2hr
Duration: 812hrs
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Action
Misc: fever,
Potentiates the inhibitory
hypersensitivity.
effect of antithrombin in
factor Xa and thrombin; In
low does prevent the
conversion of prothrombin
by its effects on factor Xa.
Nursing Assessment: Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; black,
tarry stools; hematuria; fall in hematocrit or blood pressure; guaiac-positive stools). Notify health care professional if
these occur. Assess patient for evidence of additional or increased thrombosis. Symptoms will depend on area of
involvement. Monitor patient for hypersensitivity reactions (chills, fever, urticaria). SC: Observe injection sites for
hematomas, ecchymosis, or inflammation.
Medication
Nicoderm
Order
Indication and Action
Therapeutic
Effects
Side Effects
Safe Dose?
21 mg patch
given at
2228
Indications
Adjunct therapy 9with
behavior modification)
in the management of
nicotine withdrawal in
patients desiring to
give up cigarette
smoking.
Lessened
sequelae of
nicotine
withdrawal
(irritability,
insomnia,
somnolence,
headache,
and
increased
appetite).
Headaches,
insomnia, abnormal
dreams, dizziness,
impaired
concentration,
nervousness,
weakness, sinusitis,
tachycardia, chest
pain, hypertension,
abdominal pain,
abnormal taste,
constipation, dry
mouth, diarrhea,
burning at patch
site, erythema,
prutitis, cutaneous
hypersensitivity,
rash,
dysmenorrheal,
arthralgia, back
pain, and myalgia.
Transdermal:
Patients
smoking
greater than
10 cigarettes a
day- Begin
with Step 1
(21 mg/day)
for 6 weeks
followed by
Step 2 (14
mg/day) for 2
weeks, and
then Step 3 (7
mg/day) for 2
weeks
Transdermal
Route
Onset: rapid
Action
Provides a course of
nicotine during
controlled withdrawal
from cigarette smoking
Half Life
1-2 hours
Peak: 2-4
hours
Duration:
unknown
Nursing Assessment: Prior to therapy, assess smoking history, (number of cigarettes smoked daily, smoking patterns,
nicotine content preferred brand, degree to which patient inhales smoke). Assess patient for signs and symptoms of
smoking withdrawal (irritability, drowsiness, fatigue, headache, nicotine craving) periodically during nicotine
replacement therapy. Evaluate progress in smoking cessation periodically during the therapy. Monitor for nausea,
vomiting, diarrhea, increased salivation, abdominal pain, heachacedizziness, auditory and visual disturbances, weakness,
dyspnea, and hypotension, as these are signs of overdose.
Patient Teaching: Explain to the patient the necessity of immediate smoking cessation upon initiation and throughout
therapy. Encourage the patient to participate in smoking cessation programs while using the patch. Review the
instruction sheet that is enclosed with the produce. Emphasize the importance of regular visits to the healthcare provider
to monitor progress of smoking cessation. Instruct patient on application and use of the patch. Apply patch at the same
time each dayKeep the patch in a sealed pouch until ready to apply. Apply to clean dry skin of upper arm or torso free of
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14
oil, hair, scars, cuts, burns, or irritation. Keep patch in place while showering. Swimming, or bathing. Advise patient that
the patch may cause dizziness. Caution patient to avoid driving or other activities that require alertness until response of
medication is know.
Medication
Folic Acid
Order
Folic Acid 1
mg PO hs
Given 2227
Indication and Action
Therapeut
ic Effects
Indications
Prevention and
treatment of
megaloblastic and
macrocytic anemias
Restoratio
n and
maintenan
ce of
normal
hematopoi
esis.
Action
Required for protein
synthesis and red blood
cell function.
Stimulates the
production of red
blood cells, white
blood cells, and
platelets.
Side Effects
Rashes, irritability,
difficulty sleeping,
malaise, confusion,
and fever
Safe Dose?
1 mg/day
initial dosage
then0.5
mg/day
maintenance
dose
Route PO
Onset: 30-60
min
Peak: 1 hour
Half Life
unknown
Duration:
unknown
Nursing Assessment: Assess patient for signs of megaloblastic anemia (fatigue, weakness, dyspnea) before and
periodically during therapy. Monitor plasma folic acid levels, hemoglobin, hematocrit, and reticulocyte count before and
periodically during therapy.
Patient Teaching: Encourage patient to comply with diet regimen recommended by the healthcare provider. Explain that
the best source of vitamins are in a well balanced diet with foods from the four basic food groups. A diet low in vitamin
B and folate will be used to diagnose folic acid deficiency. Foods high in folic acid include vegetables, fruits and organ
meats; heat destroys folic acid in foods. Advise patient to consult healthcare provider if rash occurs.
Medication
Order
Indication and Action
Therapeut
ic Effects
APAP/Hydr
ocodone
(vicodin)
1 tablet PO q6h
prn; Max Dose
4 grams
Opioid
analgesics;
antitussive
Last given
0310
Indications
Used mainly in
combination with
nonopioid analgesics
(acetaminophen/ibupro
fen) in the
management of
moderate to severe
pain; Antitussive
(usually in
combination products
with decongestants).
Decrease
in severity
of
moderate
pain &
Suppressio
n of the
cough
reflex
Action
Half Life
2.2 hours
Side Effects
CNS: confusion,
dizziness, sedation,
euphoria,
hallucinations,
headache, unusual
dreams. EENT:
blurred vision,
diplopia, miosis.
Resp: respiratory
depression. CV:
hypotension,
bradycardia. GU:
urinary retention.
Misc: physical
Safe Dose?
2.5-10 mg q
3-6 hours prn
PO Route
Onset: 10-30
min
Peak: 30-60
min
Duration: 46 hours
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15
Bind to opiate
receptors in the CNS.
Alter the perception of
and response to painful
stimuli while
producing generalized
CNS depression;
Suppress the cough
reflex via a direct
central action
dependence,
psychological
dependence,
tolerance.
Nursing Assessment: Assess blood pressure, pulse, and respirations before and periodically during administration. If
respiratory rate is <10/min, assess level of sedation. Physical stimulation may be sufficient to prevent significant
hypoventilation. Dose may need to be decreased by 25–50%. Initial drowsiness will diminish with continued use. Assess
bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk, and
laxatives to minimize constipating effects. Stimulant laxatives should be administered routinely if opioid use exceeds 2–
3 days, unless contraindicated. Assess type, location, and intensity of pain prior to and 1 hr (peak) following
administration. When titrating opioid doses, increases of 25–50% should be administered until there is either a 50%
reduction in the patient’s pain rating on a numerical or visual analogue scale or the patient reports satisfactory pain relief.
A repeat dose can be safely administered at the time of the peak if previous dose is ineffective and side effects are
minimal. Prolonged use may lead to physical and psychological dependence and tolerance. Assess cough and lung
sounds during antitussive use. Labs: May cause plasma amylase and lipase concentrations.
Patient Teaching: Advise patient to take medication as directed and not to take more than the recommended amount.
Severe and permanent liver damage may result from prolonged use or high doses of acetaminophen. Renal damage may
occur with prolonged use of acetaminophen or ibuprofen. Doses of nonopioid agents should not exceed the maximum
recommended daily dose. Instruct patient on how and when to ask for and take pain medication. May cause drowsiness
or dizziness. Advise patient to call for assistance when ambulating or smoking. Caution patient to avoid driving or other
activities requiring alertness until response to the medication is known. Advise patient to change positions slowly to
minimize orthostatic hypotension. Caution patient to avoid concurrent use of alcohol or other CNS depressants with this
medication. Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.
Medication
Order
Indication and Action
Therapeut
ic Effects
Side Effects
Vancomycin
HCL
IV 100 ml/hr
q12h
Vancomycin
HCL 1 gm in
NaCl 0.9% 1
GM in NaCl
0.9% 100 mL
started at 10:00
Indications
Treatment of
potentially life
threatening infections
with less toxic antiinfective are
contraindicated. Useful
in staphylococcal
infections, including:
endocarditis,
meningitis,
osteomyelitis,
pneumonia,
septicemia, and soft
tissue infections.
Bactericid
al action
against
susceptible
organisms
EENT: ototoxicity.
CV: hypotension.
GI: nausea,
vomiting. GU:
nephrotoxicity.
Derm: rashes.
Hemat: eosinophilia,
leukopenia. Local:
phlebitis. MS: back
and neck pain. Misc:
hypersensitivity
reactions including
anaphylaxis, chills,
fever, "red man"
syndrome (with
rapid infusion),
superinfection.
Antiinfective
Action
Binds to bacterial cell
Half Life
5-8 hours
Safe Dose?
IV adults:
500mg q6h
or 1 g q12h
PO Route
Onset: rapid
Peak: end of
infusion
Duration:
12-24 hours
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16
wall, resulting in cell
death
Nursing Assessment: Assess patient for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at
beginning of and throughout therapy. Obtain specimens for culture and sensitivity prior to initiating therapy. First dose
may be given before receiving results. Evaluate eighth cranial nerve function by audiometry and serum vancomycin
levels prior to and throughout therapy in patients with borderline renal function or those >60 yr of age. Prompt
recognition and intervention are essential in preventing permanent damage. Monitor intake and output ratios and daily
weight. Cloudy or pink urine may be a sign of nephrotoxicity. Assess patient for signs of superinfection (black, furry
overgrowth on tongue; vaginal itching or discharge; loose or foul-smelling stools). Report occurrence. Observe patient
for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify health
care professional immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment
close by in case of an anaphylactic reaction. Labs: Monitor for casts, albumin, or cells in the urine or decreased specific
gravity, CBC, and renal function periodically during therapy. May cause increased BUN levels.
Patient Teaching: Instruct patient to report signs of hypersensitivity, tinnitus, vertigo, or hearing loss. Advise patient to
notify health care professional if no improvement is seen in a few days. Patients with a history of rheumatic heart disease
or valve replacement need to be taught importance of using antimicrobial prophylaxis prior to invasive dental or medical
procedures.
Medication
Order
Indication and Action
Therapeut
ic Effects
IV 102 ml/hr at
bedtime
Thiamine HCl
(Vitamin B 1)
100 mg in
NaCl 0.9%
Indications
Treatment of thiamine
deficiencies.
Replaceme
nt in
deficiency
states
Side Effects
Safe Dose?
Restless, weakness,
tightness of the
IV adults: 5Vitamins
throat, pulmonary
100 mg 3
edema, respiratory
times daily
Action
distress, vascular
Required for
collapse,
Half Life
PO Route
carbohydrate
unknown
hypotension,
Onset: hour
Last started at
metabolism
vasodilation, GI
22:13
bleeding, nausea,
Peak: days
cyanosis, prutitis,
sweating, tingling,
Duration:
urticaria, warmth
days-weeks
Nursing Assessment: Assess patient for signs and symptoms of thiamine deficiency (anorexia, GI distress, irritability,
palpitations, tachycardia, edema, paresthesia, muscle weakness and pain). Assess patient’s nutritional status (diet,
weight) prior to and throughout therapy.
Thiamine
Patient Teaching: Encourage patient to comply with dietary recommendations of healthcare provider. Explain that the
best source of vitamins is a well balanced diet with foods from the four basic food groups. Teach patients which foods
are high in Thiamine ( cereals, pork, fresh vegetables).
Medication
Dextrose
Caloric
Order
40 mL/hr
Dextrose 5%
water 1000mL
given at 22:20
Indication and Action
Therapeut
ic Effects
Side Effects
Safe Dose?
Indications
IV: Lower
concentration (2.511.5%) injection
Provision
of calories;
Prevention
and
Inappropriate insulin
secretions, fluid over
load, hypokalemia,
hypomagnesemia,
IV (adults)
0.5-0.8
g/kg/hr
Running head: PROCESS PAPER
Source
provides hydration and
calories.
Action
Provides calories
17
treatment
of
hypoglyce
mia
hypophosphatemia,
local pain/irritation
at IV site, glycouria,
hyperglycemia
Half Life
unknown
PO Route
Onset: rapid
Peak: rapid
Duration:
brief
Nursing Assessment: Assess the hydration status of patients receiving IV dextrose. Monitor intake and output and
electrolyte concentrations, Assess patient for dehydration or edema. Assess nutritional status, function of GI tract, and
caloric needs of the patients. Monitor IV site frequently for phlebitis and infection.
Patient Teaching: Explain the purpose of the dextrose to the patient. Instruct the diabetic patient on the correct method
of self- blood glucose monitoring. Advise patient on when and how to administer dextrose products for hypoglycemia.
All medication information was retrieved from Davis’s Drug Guide for Nurses- Version
13.0.1/2010.1.11
Diagnostic Tests and Treatments
M.S. had many doctor’s orders in his medical chart. He was ordered a consult
with social services on 9/20/10. The purpose of this consult was to determine if his health
care needs will be met once discharged from the hospital. Social service looks out for the
health and well-being of all patients and makes referrals as needed.
A vancomycin trough was ordered in order to monitor the levels of the
antimicrobial drug vancomycin in the blood. “When a vancomycin dose is given, its
concentration rises in the blood, peaks, and then falls. The next dose is timed to be given
in anticipation of the falling level” (Lab Tests Online, 2010). The goal of this test is to
overlap the doses so that the minimum concentration is always maintained in the blood.
Trough levels are collected just prior to the next ordered dose (Lab Tests Online, 2010).
The result of M.S. trough was 5.6mcg/ml. This falls in the normal range for trough
values, which is 5-10mcg/mL (Lab Tests Online, 2010). If the trough level is above the
maximum level, the patient is at risk for toxicity.
Running head: PROCESS PAPER
18
Other orders include an EKG, Complete Blood Count Platelet Differential (results
listed above), Uric Acid (1.5mg/dL), lipid profile, hemoglobin concentration (15.8g/dL;
14.6g/dL), metabolic panel, liver profile, and a culture and sensitivity of the blood and
wound. The results of many of these tests were not yet available to view. The results of
the blood and wound cultures are as follows:
Specimens
Preliminary
Results
Collected
Verified
Right Arm Blood
Culture
No growth after 48
hours
9/19/10 @ 0241
9/21/10 @ 0243
Left Arm Blood
Culture
No growth after 48
hours
9/19/10 @ 0241
9/21/10 @ 0243
Left Wound Culture
2nd Swab, drainage
squeezed out per Dr.
request; Gram stain
final; No WBS seen;
No organisms seen
9/19/10 @ 0823
Nursing Care Plan
The following plan of care was developed for M.S. to promote optimal comfort,
reduce the risk of injury or infection, and encourage health promotion behaviors through
use of patient teaching and appropriate nursing interventions. As stated earlier, M.S. only
visits the doctor if he believes it is absolutely necessary. He does not have health
insurance and cannot afford doctor visits. He does not see the importance of yearly
check-ups or screenings. The focus of his care plan would be focusing on the importance
of health maintenance behaviors, thus increasing his knowledge on health promotion
behaviors.
Primary Nursing Diagnosis
Ineffective Health Maintenance R/T lack of education or readiness, lack of
Running head: PROCESS PAPER
access to adequate health care services and insufficient knowledge of effects of tobacco
and alcohol use AEB only going to the doctor in the event of a crisis, smoking a pack a
day since age 10, drinking a case a day since age 10, no yearly check-ups, screenings, or
vaccinations, and a diet that does not revolve around the four basic food groups
(Carpenito-Moyet, 2010, p. 789).
Goals
As a nurse it is very important to set realistic goals that your clients can work
towards. If the clients know that their goals are out of their reach, they will not work as
hard to achieve them. It is our job to encourage the clients to really work at reaching both
their short term and long term goals.
Short Term Goal
M.S. will verbalize understanding of and intent to engage in health maintenance
behaviors; such as the value of smoking and alcohol cessation, the significance of eating
a well balanced diet, and be able to state the importance of receiving vaccinations, yearly
check-ups and screenings.
Long Term Goal
M.S. will promote optimal health by engaging in the health maintenance
behaviors that he verbalized intent to consider; such as joining a smoking cessation
program and support group for chronic alcohol use, setting up yearly check-ups to receive
vaccinations & screenings and by a change in eating habits to maintain adequate vitamins
and minerals to help maintain a healthy weight.
Interventions
1. Explain to M.S. primary and secondary prevention measures to increase his
19
Running head: PROCESS PAPER
knowledge on health maintenance throughout hospital visit and have him
verbalize understanding of each prevention measure by discharge. Rationale:
Many injuries or health threatening situations can be prevented or decreased if
immunizations, health education, safety programs, and healthy lifestyle or
detected early with screening and treated promptly (Carpenito-Moyet, 2010, p.
801).
2. Discuss the benefits of smoking cessation with M.S., such as decreased blood
pressure, improved dental hygiene, improved circulation, lower risk of cancer,
and fewer respiratory infections at discharge planning. Rationale: To assist a
person to initiate a health behavior change, the nurse needs to provide information
to increase perceptions of the seriousness of the behavior and how if the behavior
continues, the patient is at higher risk for disease (Carpenito-Moyet, 2010, p.803).
3.
Assess M.S.’s nutritional intake while hospitalized, noting amount of each food
group eaten at each meal. Reinforce daily the basics of balanced nutritional intake
including choosing a plan that encourages a high intake of complex carbohydrates
and proteins, while limiting the intake of fats and sugars; the importance of
choosing a variety of different foods to obtain adequate vitamins and minerals;
and the importance of not skipping any meals. Rationale: Presenting high calorie
and high protein food when the client is most likely to eat will increase the
likelihood that they will consume adequate calories and protein (CarpenitoMoyet, 2010, p. 421).
4. Identify strategies to improve access for the vulnerable populations (uninsured,
unemployed, poor) during hospital visit; Set up a consult with social services
20
Running head: PROCESS PAPER
before discharge.; Encourage participation in community centers once
discharged.; Advise M.S. to consider generic alternative medications. Rationale:
Low-income families usually focus on meeting basic needs and seeking help with
curing illness, not preventing it. The cost of medications and office visits are
barriers for the poor (Carpenito-Moyet, 2010, p. 801).
Evaluation of Goals
After counseling M.S. on the importance of health maintenance behaviors and
primary/secondary prevention measures, he verbalized understanding and said he
intended on making some lifestyle changes that included smoking cessation and
preventative visits to the healthcare provider for vaccinations and screenings. The long
term goal will be met if M.S. adheres to these plans and seeks healthcare routinely.
Secondary Nursing Diagnosis
Risk for infection R/T history of infections, alcoholism, malnutrition, impaired
mobility and smoking AEB current hospitalization for osteomyelitis and cellulitis, history
of smoking a pack a day and drinking a case a day since the age of ten, history of residual
lower extremity paresthesia, splenectomy and vertebral fracture, antibiotic therapy due to
increased WBC count, poor nutritional intake, and poor personal hygiene (CarpenitoMoyet, 2010, p. 330).
Short Term Goal
M.S.’s WBC count will remain in the therapeutic range of 5,000-10,000 mm^3
during hospital stay and will have a decrease in the signs and symptoms of infection
including redness, edema, heat, pain, and fever by discharge.
Long Term Goal
21
Running head: PROCESS PAPER
M.S. will report risk factors associated with infection and precautions needed to
avoid contracting an infection. These factors include meticulous hand washing technique,
being able to describe the transmission of infection and describing the influence of
nutrition on prevention of an infection by discharge (Carpenito-Moyet, 2010, p. 336).
Interventions
1. Wash hands before and after all contact with M.S. or any specimens
collected; Gloves should for potential contact with blood or body fluids
during each assessment. Rationale: Hand washing is one of the most
important means to prevent the spread of infection and gloves provide a
barrier from contact with infectious secretions (Carpenito-Moyet, 2010, p.
336).
2. Encourage and maintain caloric and protein intake in the diet for healing
during each meal. Rationale: To repair tissues, the body needs increased
protein and carbohydrate intake and adequate hydration for vascular
transport of oxygen to the site and wastes away from the site (CarpenitoMoyet, 2010, p. 337).
3. Administer prescribed antimicrobial therapy (IV 10mL/hr q24h
piperacillin/tazobactm 9GM & IV 100 ml/hr q12h Vancomycin HCL 1
gm) within 15 minutes of scheduled dose. Rationale: Atibiotics
administered at proper intervals ensure maintenance of therapeutic levels
and minimize length of stay in the hospital (Carpenito-Moyet, 2010,
p.337)
4. Assess wound site every 24 hours and during dressing changes along with
22
Running head: PROCESS PAPER
vital signs every shift; document any abnormal findings such as changes in
drainage, swelling, redness, pain, and edema. Rationale: Subtle changes
in vital signs may be an early sign of sepsis.
5. Encourage ambulation for short, frequent walks (at least 3 times daily)
with assistance if unsteady. Rationale: Researchers have shown that early
mobilization has better outcomes than bed rest after an injury, a medical
procedure, or as a treatment of a medical condition (Carpenito-Moyet,
2010, p. 397).
Evaluation of Goals
After initiation of infection control procedures, M.S. could effectively
communicate the reasons for meticulous hand washing and demonstrated procedure by
end of shift on 9/21/10. M.S.’s WBC count dropped from 14.9 mm^3 on 9/18/10 to
9.6mm^3 on 9/20/10, which is within therapeutic range. M.S.’s left great toe should a
significant reduction in edema and redness, and no fever was present on 9/21/10. He
verbalized the importance of adhering to a dietary plan that was high in complex
carbohydrates and protein to promote wound healing.
23
Running head: PROCESS PAPER
1
Attachment 1
FUNCTIONAL HEALTH PATTERNS DATA BASE
Student Name: Lori Risner
AREA OF HEALTH
HEALTH/PERCEPTI
ON
HEALTH
MANAGEMENT
General Survey,
perceived health
& well-being, selfmanagement
strategies, utilization of
preventative health
behaviors
and/or services.
SUBJECTIVE DATA
OBJECTIVE DATA
INDIRECT DATA
*Identify source of
indirect data
INTERPRETATION
(effective patterns or
barriers/potential barriers)
M.S. stated that he does not come to the doctor
unless he absolutely has to. He said that he was
involved in a motor vehicular accident in 1988
that left him with bilateral paresthesia and this
limits his everyday activities. He stated that he
does not have a job or insurance and does not
have money to pay for doctor visits. Patient
stated that he does not get yearly check up exams
as for he does not see the purpose of them. He
stated that he does not get blood pressure
screenings or preventative vaccines. He did not
recall his immunization history, but stated he
could call and ask his mother. He does not take
vitamins or any medications at home. He also
denied a shower. M.S. stated that he has been
smoking cigarettes and drinking alcohol since
the age of 10 and does not plan on quitting. He
smokes 1-2 packs a day and drinks about a case
daily also. He denies using any other drugs.
Patient states that he does not exercise on a
regular basis, but he tries to move around as
much as he can. M.S. said that his house is
handicap assessable and he does not have
problems getting around. He states that his
M.S. is a 50 year old male admitted with
osteomyelitis of the left great toe and
cellulitis of the left lower leg. who is
unkept and has poor hygiene. Poor oral
hygiene with missing teeth was observed.
Vital signs were within normal limits for
an adult (T 97.7, P 78, R 16, BP 118/86,
Pain 7/10 in back, Pulse Ox 97%) Dime
sized ulcer was assessed in the plantar
aspect of great toe. +3 edema was present
on the great toe. +2 edema was present
on the left lower leg. M.S.’s activity level
was up as tolerated, however he never
got out of bed. No withdrawals from
alcohol or cigarettes were noted, however
a nicotine patch (21 mg) was in place and
patient was receiving folic acid PO (1
mg) to decrease the chance of
withdrawal.
Medical chart stated
that M.S. was originally
from the woods of West
Virginia. Past medical
history revealed that he
has not been to the
hospital since 2001.
From the data collected, it
was clear that M.S. has
limited knowledge on
health management. His
biggest barrier is his lack
of insurance which limits
his health management. He
does have at least one
supporter at home (his
girlfriend’s daughter),
which is very beneficial.
His history of smoking and
drinking and decreased
interest to quit is a harmful
barrier to his life. Luckily
for M.S., he came to the
hospital early enough that
he did not have to get his
toe amputated.
Running head: PROCESS PAPER
2
girlfriend’s daughter really helps him and
supports him at home.
NUTRITIONAL/
METABOLIC
Patterns of food and fluid
consumption,
Weight, skin turgor.
(Skin, Hair, Nails; Head
& Neck;
Mouth, Nose, Sinus;
swallowing, Ht., Wt)
M.S. stated that his eating habits are not the most
ideal. He states that in a typical day he rarely eats
breakfast instead he will drink a pot of coffee for
breakfast, eat a sandwich for lunch followed by a
light snack, and then maybe eat a bowl of cereal
late at night. He stated that he does not drink
very much water, but he really enjoys drinking
milk. He also stated that he has a few beers in the
evening. He said that he is satisfied with his
height and weight. He stated that the hospital
food was much better than anything he had at
home so at least there was one good thing about
being there.
M.S. is 5 feet 7 inches and weighs 143
pounds 4.45 ounces. He is on a regular
diet. After observing him eat breakfast
and lunch, he has a very good appetite.
He finished 100% of both meals. No
eating or swallowing difficulties were
observed. M.S. feeds himself with no
assistance. His mouth was pink and moist
and had many teeth missing or with
dental caries. His skin was warm, dry,
and intact (besides the left great toe) and
normal for his race. Hair was within
normal limits. Nails were in good
condition. No pain or swelling was noted
during assessment of the sinuses’, and no
cold was present. Edema was noted in
his left leg (+2) and left great toe (+3).
Skin turgor was less than 3 seconds. No
bruises were noted. His temperature was
97.7 F oral at 0800.
Medical chart said he
has a history of muscle
wasting that resulted as
a result of his bilateral
paresthesia from a car
accident in 1988.
Medical chart stated
that a social service
consult was ordered for
M.S.
Having a nice healthy diet
is very important when
fighting off an infection.
With a history of muscle
wasting, M.S. should
increase his protein intake.
Seems like M.S. makes the
best of the resources that
he has at home and eats
when he can. He lack of
oral care could lead to
problems with chewing and
swallowing down the road.
It is good that he drinks a
lot of milk to help keep his
bones strong, but he needs
to drink more water also.
Running head: PROCESS PAPER
ELIMINATION
Patterns of excretory
function &
Elimination of waste;
relevant labs,
Medications, impacting,
etc.
(Abdominal - bowel and
bladder)
ACTIVITY/EXERCIS
E
Patterns of exercise &
daily living,
self-care activities
include major
body systems involved.
(Thoracic & Lung;
Cardiac;
Peripheral vascular;
Musculoskeletal,
vital signs)
3
M.S. stated that he has had no problems with
elimination. He stated that he is continent of both
bowel and bladder. He stated that he voids
(urine) about 5 times daily. He does have
patterns of urgency with urination. M.S. stated
that he usually has one bowel movement daily.
He stated that he does not have discomfort or
straining during a bowel movement. M.S. stated
that he has occasional constipation, but does not
take any medications to relieve it.
M.S. was continent of both bowel and
bladder. He had an output of 1200 ml
during 0800 report. He urinated one time
into a bedside urinal. The urine was clear
yellow without odor. He did not have a
bowel movement during the shift. Upon
assessment, his abdomen was soft and
non tender. There was no abdominal
distention. Bowel sounds were present x
4. M.S. stayed in bed the whole shift.
M.S. is currently taking
hydrcodone (vicodin)
PO 500mg tab every 6
hours prn for pain.
M.S. stated that he is not able to exercise on a
daily basis. He said that he does get up and move
around as much as he can and that he enjoys
going outside. He stated that he is not the type of
person to just sit on the couch all day. He said
that his condition limits his activity level. He
stated that he does not current have a job, but he
picks up part time work. He performs activities
of daily living independently, but he said that his
girlfriend’s daughter helps around the house and
with cooking. He stated that he misses being able
to walk around without a cane and that his back
pain makes life a little tough. He stated that he
gets out of breath easily and that he must take
frequent breaks when performing activities.
Patient states that he smokes 1-2 packs a day and
drinks about a case daily also
Upon assessment, I observed that activity
intolerance was present. Vital signs were
within normal limits for an adult (T 97.7,
P 78 regular & strong, R 16 regular, BP
118/86, Pain 7/10 in back, Pulse Ox
97%) Respiratory: Lungs were
diminished bilaterally in all lobes.
Cardiac: Muscular-Skeletal: Bilateral
atrophy was noted in LE. Assistive
device (cane) was used for ambulation.
ROM is limited. Gait was unsteady.
Activities of daily living we performed
with minimal assistance of 1.
Medical Chart orders
include EKG, complete
blood count with
differentials, metabolic
panel, and a lipid
profile. Medical chart
indicates Patient has a
past medical history of
muscle wasting and is a
fall risk. Medication
Chart indicated that
M.S. is currently taking
hydrcodone (vicodin)
PO 500mg tab every 6
hours prn for pain. He
is also on a Nicotine
patch (21mg) to
decrease cravings.
Elimination patterns can be
affected by immobility,
eating habits, medication
side effects, and infections.
M.S.’s muscle wasting is a
result of his back injury
that occurred during a car
crash. This, along with his
back pain and bilateral
paresthesia limits his
ability to ambulate and
perform activities of daily
living with out
complications. His
smoking and drinking
habits have lead him to
have SOB with activities
and activity intolerance. If
smoking cessation
occurred, M.S. would have
fewer issues related to
dyspnea. It is a good thing
that he has some support at
home and that he does not
have to do all the house
Running head: PROCESS PAPER
4
SEXUALITY/
REPRODUCTION
Satisfaction with present
level of
Interaction with sexual
partners
(Breast; Testes;
AbdominalGenitourinaryreproductive)
M.S. stated that his girlfriend passed away in the
Spring of 2010 and that he has not had any
interest in dating or sexual activity. He said that
he is happy with where he is in life and that he
does not have a history of any STI’s. Patient
stated he did not have a family history of prostate
cancer, but he himself has never be checked.
M.S. was within normal limits for
assessment of Genitourinary system. No
pain or edema in perineal area.
No history of prostate
cancer or STIs in
medical chart.
SLEEP/REST
Patterns of sleep, rest,
relaxation,
fatigue
(Appearance, behavior)
M.S. stated that he does not get much sleep at
night. He stated that he usually stays up pretty
late (2 a.m.) and then gets up around 0800-0900.
He states that he has trouble relaxing because of
his back pain. He usually does not take a
daytime nap. M.S. stated that when he wakes up
he usually does not feel rested. He complains of
SOB and sometimes feels fatigued. Patient
stated that he slept well last night.
Upon assessment, M.S. did not appear
fatigued. He laid in bed and watched
television throughout the shift. No signs
of insomnia were present.
None.
work alone. Pain
management is very
important to increase
activity tolerance also. If
pain is not managed, M.S.
is less likely to exercise.
It is very unfortunate that
M.S.’s girlfriend passed
away and this could lead to
sexual frustration if proper
coping mechanisms are not
established. Even though
he does not have a history
of prostate cancer, it is a
very poor choice to not get
yearly checks. Prostate
cancer that is detected early
has a better chance of
successful treatment.
It is very important that
clients with infections get
adequate sleep at night.
The body needs this time to
rejuvenate and prepare for
the next day. If a client is
fatigued, the tissues are not
getting adequate oxygen
thus causing exhaustion. It
is important for clients with
chronic pain to develop
relaxation techniques to
distract them from their
pain. I think this is a good
idea for M.S. and I did
patient teaching on
Running head: PROCESS PAPER
5
COGNITIVE/
PERCEPTUAL
Patterns of thinking &
ways of
Perceiving environment,
orientation
Mentation, neuron status,
glasses,
Hearing aids, etc.
M.S. says that he is usually in a pleasant mood
and that he is a pretty calm person. He stated that
he has had no loss of short term or long term
memory. Patient complains of pain in back
(7/10). Describes it as constant and radiating.
M.S. stated that he wears glasses to read but does
not need a hearing aid. He stated that he
sometimes acts before he thinks of the
consequences.
M.S. was alert and orientated x 3 (person,
place, and time). PERRLA was present.
Pupil reaction time was brisk. Grasps
were strong bilateral. UE push/pulls were
strong bilateral. No numbness or tingling
present. No signs of confusion were
present during assessment or throughout
the day.
No past medical history
of anxiety or depression
in medical record.
ROLE/RELATIONSHI
P
Patterns of engagement
with others,
Ability to form &
maintain meaningful
Relationships, assumed
roles;
Family communication,
response,
Visitation, occupation,
community
involvement
M.S. stated that he enjoys being around other
people and that he talks to his neighbors daily.
They enjoy having bonfires together. Patient
stated that he has a good relationship with his
girlfriend’s daughter and her father. M.S.’s
family lives in West Virginia therefore he does
not see them on a daily basis, he does however
keep in contact by telephone. M.S. stated that he
was not very involved in his community. His
girlfriend past away in the spring, and he has no
intention of looking for another mate anytime
soon. Patient stated that he is unemployed
because of his disability
M.S. had no visitors on 9/21/10. He
showed no signs of separation anxiety or
depression, however. M.S. demonstrated
proper communication techniques.
Since no visitors came
in on 9/21/10, no
information was
available in this area.
SELF-PERCEPTION/
SELF-CONCEPT
Patterns of viewing &
valuing
M.S. stated that he thinks he is doing pretty well
considering his circumstances. He said that he
knows he should visit the doctor more often, he
just can’t afford it. He stated that he is happy to
Upon assessment, M.S. did not appear to
have any concerns about body image. He
knew his limitations and worked with
what he had. No showed no signs of
No past medical history
of psychological
disorders or consults
with therapists. No
distraction techniques such
as getting a hobby.
M.S. was very pleasant and
seemed to handle himself
very well. He enjoyed
engaging in conversation
and his think process
seemed normal for an
adult. The only concern
would be him cutting off
the callus on his toe and
thinking it would heal on
its own. If he continues to
take medical precautions
into his own hands, he
could end up back in the
hospital with other
infections.
Dealing with the loss of a
loved one can be very
detrimental. M.S. seemed
to be dealing with the loss
very well and he uses his
girlfriends daughter as
inspiration to get by. He
treats her like a daughter.
Barriers would include his
chronic use of alcohol
while visiting with his
neighbors because it is
harmful to the body.
The biggest barrier to this
would be the disorder
itself. M.S. has been living
with impaired mobility for
Running head: PROCESS PAPER
6
Self; body image &
psychological
state
still be alive after his car accident many years
ago.
psychological disorders and he answered
all questions that were asked.
record of depression or
suicide attempts.
COPING/STRESS
TOLERANCE
Stress tolerance,
behaviors, patterns
of coping with stressful
events &
level of effectiveness,
depression,
anxiety.
M.S. stated that the primary way in which he
deals with stress is to just walk away and come
back to the problem when he feels more
prepared. He does not like to get himself too
worked up because that usually just leads to
other problems. He stated that his biggest
concerns were financial issues. He does not
carry insurance. He stated that his biggest loss in
the past year was his girlfriend. He said that he
misses her a lot, but she helps him get through
each day. His condition also makes his life a
little stressful because he can no longer do a lot
of the things he used to be able to do. He cannot
work, unless he finds small side jobs, therefore
money is a concern for him.
Upon assessment, no signs of crying,
wringing of hands, or clenched fists were
present. His vital signs were all within
normal limits, therefore the body’s
mechanism for deal with stress was
working properly. T 97.7, P 78, R 16, BP
118/86, Pain 7/10 in back, Pulse Ox
97%)
No past medical history
of depression of anxiety
disorders in M.S.’s
medical record.
VALUE/BELIEF
Patterns of belief, values,
Perception of meaning of
M.S. stated that he does not usually go to church.
He said that he does hold strong beliefs about the
value of life and that he things everyone in your
Not assessed
Non available
quite some time, and he
seems to do pretty well.
Now he is in the hospital
for infections, which limits
his mobility even more.
This may lead him to
feeling bad for himself.
Even though he does not
keep up with health
maintenance practices, he
seems to really value his
life. He needs to realize
though that if he continues
on this path, that his life
may be cut short.
If a person is not able to
successfully deal with daily
stressors, an array of
physical reactions will be
the result. Walking away
from a problem and then
coming back is a good
technique to deal with
stress. M.S. should also
confide in others when he
has a problem. They can
help reduce the stress level
and encourage a healthy
lifestyle. M.S. has been
through a lot, but he needs
to realize he is in
inevitable. He needs to
seek healthcare guidance
when problems arise.
Religious guidance can be
very beneficial. As long as
someone has perceptions
Running head: PROCESS PAPER
life that
guide choices or
decision; includes
but is not limited to
religious beliefs
life serves a purpose. He usually relies on
himself to make personal decisions, but he
knows he does have the love and support of
people around him.
7
about the meaning of their
life, then it really does not
matter what religion you
are or if you have a religion
at all. It is good that M.S.
believes that everyone has
a purpose for being here
and that he knows he has
people around him that
support him. If he tries to
keep all of his problems to
himself, he could cause
more health problems.
http://www.merck.com/mmpe/sec10/ch119/ch119b.html?qt=cellulitis&alt=sh
http://web.ebscohost.com.proxy.ohiolink.edu:9099/ehost/pdfviewer/pdfviewer?vid=5&hid=13&sid=34256bf2-7be4-47d6-9473-ec40e4bc6b07%40sessionmgr10
Running head: PROCESS PAPER
1
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cin
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e o m ye l i t i s & a l t = s h
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