NUR 1020C Fundamentals of Nursing Winter 2012

Rasmussen College-Fort Myers Nursing Process Report Grading Rubric MEDICAL/SURGICAL NUR1020C Student________Anthony Pousson_______Instructor____Mr.T__________Quarter__winter12_

Submit with each Nursing Process Report (NPR) Nursing Process Report (NPR)Supportive Documents Form 1: Client Medical History Form 2: Comprehensive Assessment and Narrative Note Form 3: Pathophysiology (Complete one Form 3) POINTS SCORE 1 1 1 1 1 1 1 1

Form 4: Diagnostic Results for Imaging and Cardiac Studies Form 5: Diagnostic Testing Form 6: Medication and IV Fluids Form 7: Treatments: Nutritional support, supplements, oxygen, wound care, and others Form 8: Nursing Diagnoses 2 physiological, 2- psychological, 2-psychosocial Form 9: NURSING PROCESS REPORT (NPR) FORM (Complete 3 Form 9s)

Assessment-Data (Subjective and Objective) -Data is properly classified under these headings: SUBJECTIVE DATA, OBJECTIVE DATA -Data includes cues (no inferences) -Data is appropriate to validate the nursing diagnosis -Data reflects a complete assessment of the client for the nursing diagnosis Nursing Diagnosis -Is appropriate to the individual client A.E.B. format; Risk for-used P r/t -Is properly stated (Actual-used P r/t NANDA list -Reflects a situation which the nurse can order interventions to treat or prevent

1 format) using the

Client Goal -Is a client goal -Is realistic and attainable -Is measurable -Is properly stated (Includes subject, action verb, performance criteria and target time; special condition is optional) -Does not interfere with other client therapies -Considers clients level of growth and development, and individuality -Has a realistic time frame for achievement

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Nursing Interventions -Are properly classified under these headings: ASSESSMENT DECREASE STRESSORS AND/OR STRENGTHEN LINES OF DEFENSE TEACHING/COUNSELING AND/OR REFERRAL -Concise and includes: an action verb, a descriptive phrase-how, what, where to perform the action, and a time frame-exactly (when, how often, how long) -Clearly stated so other personnel can carry out the orders without question or confusion -Appropriate to the nursing diagnosis and client -Consistent with the medical plan of care -Adequate to achieve the client goal -Are numbered consecutively Scientific Rationale -Are clear, complete and support the use of the nursing orders -Source for each rationale is properly documented (Authors last name, year, p. or pp.) -Are numbered consecutively to match each nursing order Evaluation/Client Goal -Evaluative statement includes whether the goal was met, partially met or not met using criteria stated in the client goal statement -Evaluative statement includes the clients behavior which indicates the goal was met, partially met or not met; and date/time -Includes a Reassessment statement Reference List -Completed according to APA format TOTAL POSSIBLE POINTS 1

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CLIENT MEDICAL HISTORY FORM #1 Student Name Anthony Pousson Room Number: 208A Date of Admission: 3/31/11 Dates of care: 2/9/12 M/F __M Age __84 Admitted with a chief complaint of: Dementia; L femur fx Medical Diagnosis: CHF; Pneumonia; CVA; HTN; A-Fib; Dementia; Acute Dyspnea; Intracranial hemorrhage History of Present Illness: This patient is an 84-year-old man who has been admitted to long term care last March after having an open reduction with internal fixation of his left femur. This patient also has many other health issues that continue to require full care at this facility most notably HTN that appears uncontrolled. The patient is currently denying any complaints of pain but does have difficulty standing, cannot ambulate on his own due to gait and balance instability. The patient was not able to bear weight on his lower extremities and therefore remains at high risk for falls. This patient also has a long standing hx of dementia to add to his deficits. Past Medical History: This patient's past medical hx includes CHF, pneumonia, CVA (hemorrhagic), HTN, A-Fib w/RVR, acute dyspnea, intracranial hemorrhage, right leg MRSA, anemia, dementia, and falls. Past Surgical History: Past surgical hx includes: ORIF of left femur and prostate sx Allergies: NKDA Social History: No tobacco, alcohol or illicit drug use noted in patient's history Family History: Unable to obtain and does not apply to the patient's current care Review of Systems: GENERAL: This patient was receptive during my assessment and was able to perform simple tasks as well as follow simple commands. Pt is of normal stature, approx 6'3 with a weight of 260 lbs. Patient denied pain by stating "no, it doesn't hurt anywhere". Current vital signs: BP-162/87; HR- 67; RR- 18; T- 98.8; O2sat- 96% RA. Pain 0/10. EYES: Right pupil reactive to light and accommodation, left pupil non reactive d/t cataract. Pt denied any vision changes. Pt currently wears eyeglasses. ENT: No dysphagia or hearing loss present. RESPIRATORY: Hx of pneumonia, no current infections of the respiratory system present. Lungs clear in all fields, resps equal and non labored. No cough present. Cap refill <3 seconds. CARDIAC: No chest pain present, apical pulse irregular at a rate of 67 bpm, no exertional dyspnea present, +2 non-pitting edema and redness present to bilateral lower extremities, pt denies calf tenderness. Cap refill <3 seconds, peripheral pulses irregular, present and equal bilaterally. GI: Regular diet, denies abdominal pain or tenderness upon palpation, denies N/V/D, bowel sounds present in all quadrants. Pt is incontinent of stool at night. Bowel movements are normal in color and consistency. GU: Pt is incontinent of urine at night. No dysuria noted. MUSCULOSKELETAL: Pt denies muscle or joint pain, weakness present in bilateral lower extremities with standing and unable to ambulate safely. NEUROLOGICAL: Pt is alert, not oriented to time or place. Pupils as noted above. Gait is unsteady. Grips are strong and equal bilaterally. Speech is clear. SKIN: Skin is intact, pink and dry- redness is present to lower bilateral extremities. PSYCHIATRIC: Hx of dementia, hx of depression. ENDOCRINE: No diabetic hx. Blood glucose within normal limits. No thyroid problems noted. HEMATOLOGY/LYMPHATIC: Pt has a hx of anemia, mild ecchymosis present to bilateral forearms. No swollen lymph nodes present. ALLERGIC/IMMUNOLOGY: No hx of allergies or immunity problems. CURRENT ORDER STATUS Advanced Directive on the chart: Yes Code Status: DNR Activity Level: Out of bed with 2 assist Diet (If NPO, why?): Regular Strict I&O (If yes, why?): N/A Fluid Restrictions (If yes, why?): N/A NUR1020cFundamentalsofNursingSyllabus and Outline-winter2012-resto Page 3

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Neuro Checks (If yes, why?): N/A Telemetry (must check the rhythm twice/shift): N/A Isolation (If yes, why?): N/A Oxygen Therapy: N/A Incentive Spirometry (Q ___________ hours): Dressings and Wound Care: N/A Drains/Catheter/Tubes: N/A Discharge Plan: Pt will continue to receive long term care at a skilled nursing facility. Other important data about the client: Unable to locate information in chart while at facility regarding pathology of intracranial hemorrhage and current status of indication for Plavix therapy. This is of concern.

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RASMUSSEN COLLEGE School of Nursing FORM #3 PATHOPHYSIOLOGY Student Name: Anthony Pousson Client Initials: JK Client Room Number: 206A Explanation of all current and pertinent past Medical Diagnosis Diagnosis: Hypertension Pathophysiology: Hypertension is a systolic blood pressure that is at or above 140mmHg and or a diastolic blood pressure at or above 90mmHg in people who do not have diabetes mellitus. Patients that are diagnosed with DM should keep their blood pressure at or below 130/90. (Ignatavicius & Workman, 2010, p. 796) Textbook Signs and Symptoms: Signs include the above referenced blood pressure ranges. Many patients remain asymptomatic, while others may experience headache, blurred vision, dizziness, or facial flushing. Clients Signs and Symptoms: This patient did not have any of the above named symptoms, but the blood pressure was outside of the normal range at 162/87. Recommended Treatments: Treatment of hypertension may include such things as lifestyle changes, i.e. smoking cessation, caffeine avoidance, moderate alcohol intake, exercise, sodium restriction, and weight reduction. Drug therapy may also be indicated with the use of one or more anti-hypertensive's in the class of beta-blockers, ACE inhibitors, ARBS, calcium channel blockers or diuretics. Current Treatments: This patient is currently taking Lisinopril, Torsemide, Metoprolol and Amlodipine. The patient does not smoke or drink alcohol. Teaching: In this particular patient's case, teaching will be ineffective d/t his hx of dementia. Prevention: Prevention in this patient's case lies with drug therapy.

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RASMUSSEN COLLEGE School of Nursing FORM #4

DIAGNOSTIC RESULTS FOR IMAGING AND CARDIAC STUDIES Client Initials: JK Diagnostic Test Date of Test N/A Test Result Body System Tested N/A MD Treatment Plan for Test Results N/A Nursing Implications for MD Treatment N/A Date of Re-Check N/A

N/A

N/A

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RASMUSSEN COLLEGE School of Nursing FORM #5 DIAGNOSTIC TESTING DIRECTIONS y Describe rationale for selection of laboratory results for your patient. y Identify measuring units and the normal range of each blood specimen. y Indicate each client value as High with an H; Low with an L or Normal with an N. HEMATOLOGY TEST Unit of Meas ure Norm al Rang e Male Date/Time of Test:12/23/11 0645 ET TEST RB HG HC MC MC C B T V H 4.36 9.5 31.6 73 21.8 Result s High N L L L L Low Norm al Date/Time of Test:12/28/11 0644 ET TEST RB HG HC MC MC C B T V H 3.95 8.3 28.6 72 21.0 Result s High L L L L L Low Norm al Date/Time of Test:01/03/12 0747 ET TEST RB HG HC MC MC C B T V H 4.09 8.6 29.5 72 21.0 Result RBC X10e3/ul HG B g/dl HCT % M CV fL MC H Pg MCH C g/dl MP V fL RD W % PLT X10 e3/ul WBC X10e3/ ul neutr ophil % basop hil % eosin %

4.10-5.60

12.5 17.0

36.050.0

8098

27.0 34.0

32.036.0

7.511. 5

11.7 15.0

140415

4.010.5

45.074.0

0.02.0

0.0-8.0

MCH C 30.1

MP V N/A

RD W 20.2

PL T 373

WB C 7.9

neutroph il N/A

basoph il N/A

Eosi n N/A

N/A

N/A

N/A

N/A

MCH C 29.0

MP V N/A

RD W 20.3

PL T 387

WB C 7.5

neutroph il N/A

basoph il N/A

Eosi n N/A

N/A

N/A

N/A

N/A

MCH C 29.2

MP V N/A

RD W 20.5

PL T 533

WB C 7.0

neutroph il N/A

basoph il N/A

Eosi n N/A

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s High Low Norm al L L L L L L N/A H H N N/A N/A N/A

Interpretation of Results: This patient has a hx of iron deficient anemia, therefore the low RBC, HGB, HCT, MCV, MCH, and MCHC would be explained by these values. The increased level of platelets and RDW's is a direct result of the patient's iron deficient anemia. There is no evidence of an increased WBC, therefore a differential was not included in the results. COAGULATION STUDIES Date/Time of Test: NOT PERFORMED TEST PT PTT INR ADDITIONAL INFORMATION Unit of SECONDS SECONDS SECONDS N/A Measure Normal 11.3-14.8 23.7-34.5 0.9-1.2 N/A Range N/A N/A N/A N/A Results High N/A N/A N/A N/A Low Normal Interpretation of Results: NOT PERFORMED

TEST Unit of Measur e Normal Range Male

Sodium Mmo1/L

Potassiu m Mmo1/L

Chlorid e Mmo1/L

CHEMISTRY Carbon Glucose Dioxide Mmo1/L Mg/dl

BUN Mg/dl

BUN/CRE AT

Creatini ne Mg/dl

Calciu m Mg/dl

135-144

3.5-5.1

98-110

22-30

65-99

7-22

10-22

0.58-1.30

8.4-10.2

Date/Time of Test:12/23/11 0645 ET TEST Sodiu Potassiu Chlorid m m e Results 140 4.1 97 High Low Normal N N N

Carbon Dioxide 29 N

Glucose 94 N

BUN 24 H

BUN/CRE AT 22 N

Creatini ne 1.10 N

Calciu m 9.3 N

Date/Time of Test:12/28/11 0644 ET TEST Sodiu Potassiu Chlorid m m e Results 140 4.3 99 High Low Normal N N N

Carbon Dioxide 29 N

Glucose 95 N

BUN 32 H

BUN/CRE AT 27 H

Creatini ne 1.20 N

Calciu m 8.9 N

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Date/Time of Test:01/04/12 0747 ET TEST Sodiu Potassiu Chlorid m m e Results 140 4.3 98 High Low Normal N N N

Carbon Dioxide 30 N

Glucose 81 N

BUN 29 H

BUN/CRE AT 24 H

Creatini ne 1.20 N

Calciu m 9.1 N

Interpretation of Results: This patient's chemistry profile x 3 has been consistently normal, except in the case of the slightly elevated BUN, which is a good indicator of the patient's hx of CHF. BEDSIDE BLOOD GLUCOSE MONITORING NOT PERFORMED URINALYSIS NOT PERFORMED URINE CULTURE NOT PERFORMED OTHER DIAGNOSTIC TESTS DIRECTIONS y Identify other tests (i.e. blood cultures; sputum cultures; wound cultures) y Identify additional diagnostic information (i.e. thyroid profiles; liver profiles) OTHER TESTS DATE/TIM NORMAL RESULT ADDITIONAL INFORMATION E VALUE Iron, Serum 01/04/12 40-155 17 LOW RESULT 0747 Vitamin B01/04/12 211-946 448 NORMAL RESULT 12 0747 Ferritin 01/04/12 30-400 104 NORMAL RESULT 0747 proBNP 12/23/11 0-449 3931 HIGH RESULT 0645 Interpretation of Results (Cite text and page number): The patient's serum iron is extremely low, therefore showing iron deficient anemia. The patient's BNP being elevated well beyond the high normal limit is indicative of the hx of CHF. TEST

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NURSING DIAGNOSES(Minimum of 2- Physiological, 2- Psychological. 2- Psychosocial, including knowledge deficit) FORM #8 PRIORITY # 1 NURSING DIAGNOSIS Ineffective protection RELATED/TO (R/T) Drug therapies AS EVIDENCED BY (AEB) Patients current medication regimen of Plavix and ASA N/A RATIONALE FOR PRIORITIZATION Contraindicated in pathological bleeding. Pt has hx of intracranial hemorrhage. The older adult may have disorders that affect visual acquity such as cataracts. A change in vision, touch and motor ability will create great challenges for older adults in any environment. Hypertension is a systolic blood pressure at or above 140mmHg and/or a diastolic blood pressure at or above 90mm Hg in people who do not have diabetes mellitus. Patient has a surgical history of open reduction internal fixation Patient has a history of falls Patient is diagnosed with Dementia

Risk for falls

N/A

Decreased cardiac output

Increased peripheral vascular resistance

Patient's uncontrolled hypertensive state and BP of 162/87

Impaired physical mobility

Neuromuscular impairment

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Risk for falls Chronic confusion

N/A Neurological dysfunction

The patients demonstration of unstable gate during assessment N/A The patients inability to orient to place and time

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Nursing Process Report Form FORM #9 Most pressing (#1)Nursing Diagnosis (R/T and AEB): Ineffective Protection related to Drug therapies as evidenced by patients current medication regimen of Plavix and Asprin Diagnosis Definition: Decrease in the ability to guard self from internal or external threats such as illness or injury Scientific Rationale (including references) Contraindicated in pathological bleeding. Patient has a history of intracranial hemorrhage. (Judith

hopfer deglin, and April hazard vallerand, 2010, p. 216) . Judith hopfer deglin, and April hazard vallerand. (2010). Davis's drug guide for nurses (p. 216). Philadelphia, PA: F A Davis

Assessment Data y Subjective Assessment N/A

Nursing Interventions3 under each category Assessment Assess and review lab values to include CBC and PT/INR values Assess the patients risk for falls Assess the patients vital signs

Rationales: Assessment To ensure the patient is not currently hemodynamicaly stable To reduce the risk of bleeding and prevent further injury To ensure the proper administration of medication Decrease Stressors and/or Strengthen Lines of Defense

Objective Assessment Patient is currently taking Plavix and Asprin Patient has a history of falls Patient has a history of Intracranial hemorrhage Patient had ecchymosis on his forearms during assessment

Decrease Stressors and/or Strengthen Lines of Defense Ensure the appropriate use of bed/wheel chair alarms Ensure patient is readily available for lab draws.

Using bed alarms will ensure the patients safety and decrease the risk for further injury from falls. Keeping lab values up to date will allow for early detection of hemorrhage

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Measurable and Realistic Outcomes y Short Term Obtain current PT/INR values within 24 hours Ensure appropriate safety measures/assistance are in place during ambulation Teaching Counseling Teaching Counseling y Long Term Prevent patient falls during my remaining weeks at heartland. The patients current diagnosis of dementia will not allow for further teaching as it will be ineffective. N/A Using the proper safety measures during patient ambulation will reduce the patients further risk for falls

Short Term Outcome: _____ Met Describe: Long Term Outcome: _____ Met Describe: Attach all teaching material Nursing Process Report Form FORM #9 Most pressing (#2)Nursing Diagnosis (R/T and AEB): Risk for falls R/T: N/A AEB:N/A

_____ Partially Met

_____ Not

_____ Partially Met

_____Not Met

Diagnosis Definition: Increased susceptibility to falling that may cause physical harm

Scientific Rationale (including references) The older adult may have disorders that affect visual acuity such as cataracts. A change in vision, touch and motor ability can create challenges for older adults in any environment. (Ignatavicius & Workman, 2010, p.18) Ignatavicius, D. D., & Workman, M. L. (2010). Medical surgical nursing: Patient centered collaborative care (p. 18). St. Louis, Missouri: Saunders.

Assessment Data y Subjective Assessment Patient stated he needed assistance to use the latrine since it is hard for me to stand by myself

Nursing Interventions3 under each category Assessment Assess vital signs

Rationales: Assessment To ensure pt is hemodynamically stable prior to ambulating as this could determine fall risk. To ensure unwanted hazards Page 12

Assess the patients environment NUR1020cFundamentalsofNursingSyllabus and Outline-winter2012-resto

NUR 1020C Fundamentals of Nursing Winter 2012

in the long term care facility y Objective Assessment Patient has a history of falls Patient has a diagnosis of dementia Patient is currently x2 person assist for ambulation Assess the patients mood prior to ambulation such as cords, unlocked bed, nonslip pads are in place, prior to ambulating the patient for activities of daily living. To ensure the patients temper and stressors are within normal limits as these can affect his ability to understand safety concerns which may result in carelessness or increased risk taking without consideration of consequences.

Measurable and Realistic Outcomes y Short Term N/A

Decrease Stressors and/or Strengthen Lines of Defense Address the patients environmental factors associated with falling.

Decrease Stressors and/or Strengthen Lines of Defense Addressing and correcting these deficiencies will create a safe physical environment for the patient Assess the patients ability to use the call bell, side rails and bed controls, these measures will help the patient cope in an unfamiliar environment Proper use of these safety mechanisms will early warn staff and assistive personnel of the patient trying to ambulate. Allowing for further reduction of falls. Teaching Counseling

Long Term N/A .

Orient the client to the environment

Ensure the proper use of Bed/Wheel chair alarm

Teaching Counseling N/A The patients current diagnosis of dementia will not allow for further teaching as it will be ineffective. Short Term Outcome: _____ Met Describe: Long Term Outcome: _____ Met Describe: Attach all teaching material _____ Partially Met _____ Not

_____ Partially Met

_____Not Met

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Nursing Process Report Form FORM #9 Most pressing (#3)Nursing Diagnosis (R/T and AEB): Decreased cardiac output related to increased peripheral vascular resistance as evidenced by patients uncontrolled hypertensive state and blood pressure of 162/87 Diagnosis Definition: Inadequate blood pumped by the heart to meet the metabolic demands of the body. Scientific Rationale (including references) Hypertension is a systolic blood pressure at or above 140mmHg and/or a diastolic blood pressure at or above 90mm Hg in people who do not have diabetes mellitus. (Ignatavicius & Workman, 2010, p.796)

Ignatavicius, D. D., & Workman, M. L. (2010). Medical surgical nursing: Patient centered collaborative care (p.796). St. Louis, Missouri: Saunders.

Assessment Data y Subjective Assessment Patient did not voice any complaints of headache or blurred vision

Nursing Interventions3 under each category Assessment Assess and review vital signs

Rationales: Assessment Assessing vital signs such as blood pressure and Apical pulse, will allow for proper administration of hypertensive medications Assessing changes in skin color such as facial flushing can indicate significant changes in blood pressure Assessing for headaches or changes in vision can indicate and increased hypertensive state.

Objective Assessment Patient has a Hx of hypertension Patient has a Hx CHF Patient is currently taking hypertensive medications

Assess patient changes in skin color

Continue to monitor patient for complaints of headaches or changes in vision

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Measurable and Realistic Outcomes y Short Term Monitor blood pressure values every 4 hours Decrease Stressors and/or Strengthen Lines of Defense Decrease Stressors and/or Strengthen Lines of Defense Assess daily intake/output Assessing daily intake and output to include daily weight can decrease the effects of CHF which can increase the risk for a hypertensive state Administering medications as indicated will control blood pressure values decreasing the risk for stroke Promoting rest can reduce cardiac workload. Teaching Counseling The patients current diagnosis of dementia will not allow for further teaching as it will be ineffective. Teaching Counseling

Long Term Ensure the patient stays consistent with blood pressure medications on time over the next 14 days

Administer medication as prescribed

Promote rest

Short Term Outcome: _____ Met Describe: Long Term Outcome: _____ Met Describe: Attach all teaching material

_____ Partially Met

_____ Not

_____ Partially Met

_____Not Met

References Ignatavicius, D. D., & Workman, M. L. (2010). Medical-surgical nursing (p. 796). St. Louis, MO: Saunders Elsevier. Judith hopfer deglin, and April hazard vallerand. (2010). Davis's drug guide for nurses (p. 216). Philadelphia, PA: F A Davis.

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