Clinical Study 1

Monica Diaz October 08, 2008 Clinical Study Criteria Client’s Initials: E.A.

Age: 68

Gender: M

Dates Cared For: 09/26/08-09/27/08

Admitting Medical Diagnosis: Colitis Secondary Medical Diagnosis: Medical History: Colon Cancer (2007). Chemotherapy. Colectomy (9/2007). Liver Cancer (2/2008). Hypertension. 1) 2) My patient was admitted to the hospital on 09/24/08. He was seen in the Emergency Room for severe dehydration, diarrhea, and vomiting x 3 days. The patient came in with a fever of 104.1, patient was also complaining of abdominal pain. 3) Neuro: Alert and oriented x 3. PERRLA. Speech clear. Follows commands. Push pulls strong and equal, both hands and feet. MS: Active range of motion all extremities. Hand grasps equal and strong. 5/5 RUE, 5/5 LUE, 4/5 RLE, 4/5 LLE. Gait steady ambulates with one-person assist. Skin: Temperature: 103.4 oral. Pink, warm, diaphoretic. Turgor brisk. No skin breakdown noted. Cardio: BP: 103/58. HR: 107. Apical pulse strong and regular. Pedal pulses weak and equal. Capillary refill < 3 seconds. Homan’s negative bilaterally. Small amount of nonpitted edema on lower left leg. Resp: RR: 24. Chest rises and falls symmetrical. Clear breath sounds. No cough. 02: 96% @ room air. GI: Abd. soft, non-distended. Bowel sounds x 4 quadrants. Diarrhea x 2 last night. Patient wearing a brief. Nutrition: Soft diet. Taking fluids in well. Patient states no appetite x 2 days. GU: Bladder soft and non-tender. Patient denies any difficulty and pain while voiding. Continent of moderate amount of amber colored urine 260 ml. Urinal at bedside. Pain: Patient denies any pain.

Equipment: IV in right AC. No redness or edema around IV site noted. Patent and running at 100 mL/hr. 4) 5) Low lab values: CBC: WBC: 3.0, RBC: 3.13, Hgb: 9.8, Hct: 28.8, Platelet: 124. Sodium: 128. High lab values: CRP: 11.77. WBC: Low levels are an indication of treatment or a disease. While giving care to the patient I would have to demonstrate good septic technique to reduce the chances of the patient inheriting a secondary infection for the reason that the patient is more susceptible to infections. RBC, Hgb, and Hct: Low levels of these tests indicate possible anemia, which can be from chemotherapy or radiation. Anemia can cause weakness, dizziness, fatigue, and SOB which can increase the risk for patient injury. Platelet: Low platelets are a side effect of chemotherapy for cancers. Persons with this condition bruise easily and can hemorrhage. Because of possible hemorrhage the following should be incorporated in the patient care avoid giving aspirin, use soft toothbrush for cleaning teeth, when shaving use electric shaver. Sodium: Hyponatremia indicated a low level of sodium in the blood, which can be caused by liver problems and certain chemotherapy drugs. Hyponatremia can cause the patient to have poor appetite and muscle weakness. CRP: Elevated CRP values indicate acute inflammation or cancer. Not on chart: Stool sample to rule out C. Diff for the reason the patient has been diagnosed with Colitis, has been having severe diarrhea, and is on antibiotics, Flagyl. 6) Plenty of fluids. Reducing fluid intake can lead to weakness and exhaustion because the patient is already losing water through diarrhea. Make sure patient drinks ample fluids to make up for the water lost via diarrhea. Have patient drink a certain number of ml’s of water within a given time and have water pitcher at bedside. Low fiber diet will let the bowels rest and minimize Colitis symptoms. Offer patient smaller meals and more snacks, this will minimize ulcerative colitis symptoms. Since my patient does not have an appetite I will offer him fruits and juices more often to make up for the missed meal. 7) 8) 9)

10) Medication: Protonix. Dose: 40 mg IV daily. Classificatoin: Gastric acid pump inhibitors. Decreases acid secretions in hypersecretory conditions. Nursing Intervention: Assess patient for abd. pain and for blood in stool or emesis. Medication: Imipenem/cilastatin. Dose: 500 mg IV PB Q8hr. Classification: carbapenems. Treatment of abd. infections. Bactericidal action against susceptible bacteria. Nursing Intervention: Assess patient for infection. Check vital signs appearance of stool and monitor WBC, if necessary obtain stool specimens. Medication: Nystatin Dose: 100,000 units PO QID. Classification: Anti-fungal. Treatment of intestinal candidiasis. Nursing Intervention: Inspect oral mucous membranes before medication. Increased irritation of mucous membranes may indicate need to discontinue. Medication: Flagly. Dose: 500 mg PO Q8hr. Classification: anti-infective, antiprotozoals, and anti-ulcer agents. Treatment for anaerobic infections such as intraabd. infections. Nursing Intervention: Monitor intake, output, and daily weight. Obtain specimens for culture. 11) Nursing diagnosis: Imbalanced nutrition: Less than body requirements. Related to: Malabsorption, diarrhea, decreased intake, poor appetite, nausea and vomiting. As evidence by: Decreased calcium, weight loss, pedal edema, and muscle wasting. Expected outcome: Increase patient’s nutritional status, as evidence by weight gain, controlled diarrhea, normal serum electrolytes, and decrease nausea and vomiting. 12) Encourage family to bring food from home as appropriate to the patient’s diet. Rationale: Patients with specific ethnic or religious preferences may not be able to eat hospital food. Review the importance of nutrition, the need for specific minerals and vitamins. Rationale: Patients may not understand the importance in a balanced diet, importance of maintaining adequate caloric intake; especially patients with severe infections. Also, foods high in calories and protein will promote weight gain and nitrogen balance.

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