Nursing Care Plan For Ineffective Tissue Perfusion

STUDENT NAME

CLINICAL DATE

Section 1: Physical Assessment DATE/TIME INITIAL ASSESSMENT 11/09/09

Date/Time* Explanation of Abnormal Assessment Factors

Possible Related Nursing Diagnoses

Thin Obese Emaciated Well-developed Well-nourished No Acute Distress Height 5'8" Weight 271.3 BMI 41.2 Admitting Vital Signs BP: 154/71, PULSE: 84, PAIN: 0, RESP.: 18 , TEMP: 95.9

11/09/09 1330

Latex Allergy Response Latex Allergy Response, Risk for

Today’s Vital Signs BP: 128/60, PULSE: 80, PAIN: 0, RESP: 20, TEMP: 97

11/10/09 Stated that BP was usually low in the morning.

CHIEF COMPLAINT: Peripheral Vascular Disease PAST MEDICAL HISTORY: CHF, Peripheral Vascular disease, IDDM, Seizure disorder, anxiety disorder, Osteoarthritis, Malignant Neoplasm Prostate, Depressive disorder, hyperlipidema, hypothyroidism, Hypokalemia ALLERGIES:NKA PAST SURGICAL HISTORY: Total Knee Replacement (rt knee)

Systolic BP was elevated.

I. PHYSIOLOGIC ASSESSMENT A.

OXYGENATION 1.

BREATHING Gordon’s Pattern of Activity and Exercise

Respiratory Rate 20

Rhythm: Regular Depth: Deep Dyspneic Accessory muscle use

No distress Labored

Irregular Shallow Apneic       sec. Tachypneic

BREATH SOUNDS/LOCATION of FINDINGS Cl -Clear       Pleural Rub       Cr -Crackles       Rh- Rhonci      Wh –Wheezing       R- Rales      D -Decreased      A -Absent      Oxygen Therapy: RA FiO2       L / or %

NC

Mask

Trach

Airway Clearance, Ineffective Aspiration, Risk for 11/10/09 0730 Stated had pneumonia Breathing Pattern, Ineffective Gas Exchange, Impaired a few weeks ago. No information found in the Infection, Risk for Sudden Infant Death Syndrome, medical record. Risk for Suffocation, Risk for Ventilation, Impaired, Spontaneous Ventilatory Weaning Response, Dysfunctional

Other

O2 Saturation: N/A q       hr Continuous pulse oximeter Pulse Oximetry Readings (Identify on R.A. or O2):      _;      _;       Chest Config:

Symmetrical

Asymmetrical

Flail

Cough:

No cough Weak Strong Frequent Infrequent Nonproductive Productive Description:       Color       Odor       Viscosity       Incentive Spirometer Shape of Chest: AP diameter 1:2, barrel, pectus excavatum, (highlight or document) kyphotic; other      Drainage: Chest Tube/Pleuravac: Suction     cm of water N/A Medications R/T Breathing: 2.

R

Yes

L No

Water seal only

Type      

CIRCULATION Gordon’s Pattern of Activity and Exercise

Heart Rate (Radial Pulse) 80 Rhythm Irregular Heart Sounds: Describe chest area:barely audible/ No murmurs detected. At brachial artery: Lub dub, pause, lub pause dub, lub dub Neck Veins (45o angle): Flat Distended D – Doppler BP: R128/60 L 130/62 Apical Pulse:UTA A – Absent Arterial Pulses Right/ Left

B

C

R

3+ 3+       3+ 3+

Capillary Refill: Nail bed Color:

Brisk <3 sec. Pink

Chest Pain:

No

Edema:

Yes

None Generalized Other      

     

1+ - Barely Palpable 2+ - Weak 3+ - Normal 4+ - Full Bounding

DP

PT

F

A

2+

Location L/R LE, (R/L ankles 3+) (R/L LE: 2+ ) WOSC Freshman Clinical Assessment Form

11/10/09 0715 Upon auscultation of the brachial artery, the heart sounds were irregular. R/L LE 3+ pitting edema both ankles.

Describe      Pitting 1 +

2+Pitting edema RLE, and R/L ankles.

2+ Pitting edema

A

Prolonged >3 sec.       sec. Pale Cyanotic Non-pitting

11/09/09 1330

-1-

3+

4+

Cardiac Output, Decreased Fluid Balance, Readiness for Enhanced Fluid Volume Deficit Fluid Volume Excess Fluid Volume, Risk for Deficit Fluid Volume, Risk for Imbalanced Tissue Perfusion, Ineffective (specify: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral)

Pacemaker:

2.

Type      

N/A Permanent External Rate      Location:     

Has a history of Ischemic heart disease, CHF, Peripheral Vascular Disease, and hypertension. Bilateral pedal pulses were absent

CIRCULATION (Continued)

Homan’s sign: Left: pos. neg. Calf redness/tenderness: Left: yes Anti-embolism stockings: Sequential compression device: Other      

Related Nursing Diagnoses

11/10/09 0715 Has a history of seizures.

Confusion, Acute Confusion, Chronic Environmental Interpretation Syndrome, Impaired Infant Behavior, Disorganized Infant Behavior, Readiness for Enhanced Organized Infant Behavior, Risk for Disorganized Intracranial, Decreased Adaptive Capacity Memory, Impaired Thought Processes, Disturbed

Right: pos. neg. Right: yes no Remove/Replaced q shift Remove/Replaced q shift

no N/A N/A

IV’s / INVASIVE LINE MONITORING Type/Port ID** Solution Rate

Date/Time Explanation of Abnormal Assessment Factors

Dosage

Location

Site Code*

NONE             *SITE CODE: C S R I DI -

**ID INFUSION DEVICE: p pump pca+ PCA g gravity

Clear Swelling Redness Inflamed Dsg Dry & Intact

Medications R/T Circulation: Yes No Type Asprin 325mg QD, Lopressor 50mg PO q12h, Zaroxolyn 10mg po QD, Lasix 40mg po QD, ,Nitroglycerin 0.4mg subling, Q 5minx3 PRN Chest pain 3.

NEUROLOGICAL

Level Of Consciousness: Awake Alert Oriented x 4 (time, place, person, event) Restless Drowsy Sedated Confused Glasgow Coma Scale: a) Best eye opening: 4 Spontaneously

3 To Speech

2 To Pain

b)

Best verbal response: 5 Oriented 4 Confused 3 Inappropriate words 2 Incomprehensible sounds

c)

Best motor response:

6 Obeys commands 4 Withdraws 2 Extension (decerebrate)

1 None

1 None

5 Localizes to pain 3 Flexion (decorticate) 1 None

Total Glasgow Coma Scale 15 / 15 (Add a, b, c above) PERRL Pinpoint Dilated, but reactive to light Unequal: R>L

L>R

Fixed Dilated, nonreactive Dolls eyes Other

Brain Stem Signs:N/A       (+/-) cough       gag       corneal       Babinski       Communication:

Verbal Writes notes Mouths words Nods head appropriately to yes/no questions

Medications R/T Neurological Condition: Lamictal 50mg po bid , 4.

Yes

No

Type Topamax 100mg po QD , 11/10/09 0715

NEUROVASCULAR

WOSC Freshman Clinical Assessment Form

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Extremities Examined: U/LE CSM q       hr Traction/Cast: N/A Type       Color: Pink Reddened Blue Blanched Temperature: Cool Warm Hot Movement: Active Passive Limited Sensation: Numbness Tingling Pain Restraints: N/A Type       CSM q       hr Restraint Protocol Instituted Remove/Replaced q shift

Partial loss of voluntary Dysreflexia, Autonomic movement of Dysreflexia, Risk for upper/lower extremities Autonomic Peripheral Neurovascular Rt side weakness Dysfunction, Risk for LE cool to touch, shiny, waxy appearance; UE warm. Venous Stasis noted. States feet and legs are numb and tingly.

B. NUTRITION Gordon’s Nutritional-Metabolic Pattern

Date/Time Explanation of Abnormal Assessment Factors

Abdomen:

Soft

Bowel Sounds: Flatus: Yes

Firm Active No

Hard

Distended      cm.

Tender

Hyper

Hypo

Absent

Diet: Type ADA/ LOW SODIUM NPO TPN Tube feeding Meal: Breakfast Lunch Dinner % taken 100% taken       Type gastric tube       N/A Placement Verified Purpose: Feeding Decompression Other Formula: Type       Rate      cc’s q       hrs N/A Suction: N/A Intermittent Low continuous Drainage: Describe       Mucous Membranes: Moist Pink Dusky Other Dentures:

Full

Dry

Upper

Cracked

Lower

Sores

N/A

Diet toleration: Anorexia Nausea Vomiting Weight Loss: Amount       Time Period      N/A 24o Intake UTA 24o Output UTA Balance: Positive Blood Glucose Monitoring q 4 hrs Time/Result 1130 227 Self-feed

Assist-feed

Patches

Negative N/A

Swallowing precautions

Related Nursing Diagnoses

Breastfeeding, Effective Breastfeeding, Ineffective Abdomen is Breastfeeding, Interrupted distended. Dentition, Impaired Failure to Thrive, Adult ADA diet r/t IDDM, Fluid Volume, Deficit and low sodium diet Fluid Volume, Deficit, Risk for r/t hypretension/ heart Infant Feeding Pattern, failure Ineffective Nausea Pt is Obese, stated Nutrition: Imbalanced, Risk for that he has gained More Than Body alot of weight in the Requirements past few months. Nutrition: Imbalanced, Less Than Body Requirements Nutrition: Imbalanced, More Stated that he Than Body Requirements sometimes sneaks Nutrition, Readiness for Enhanced food that he is not Oral Mucous Membranes, supposed to eat. Impaired Self-Care Deficit, Feeding Swallowing, Impaired FSBS 227 11/10/09 0730

Medications R/T Nutrition: Yes No Type Magnesium chloride 128mg po QD, Potassium bicarbonate 120mEq liq po QID,Sitagliptin 50mg po QD, glyBuride 10mg QAM 0800, Novolog (sliding scale) C. ELIMINATION Gordon’s Pattern of Elimination 1.

BOWEL

Stool:

Formed Loose Impacted Last BM 11/10/09 Color: brown Regular Irregular

Outlet:

Rectum

Colostomy

Output: Tube Drainage       cc’s Stoma: N/A Surrounding Skin: Toileting:

Pink D/I

Self

Ileostomy

Edema Excoriated

Assist

Rectal Tube

Fistula

Describe: N/A Dusky Other      

History Laxative Use:

No

11/10/09 0800 Prescribed several medications that have constipation as a possible side effect. Takes several medications to prevent constipation.

Constipation Constipation, Perceived Constipation, Risk for Diarrhea Incontinence, Bowel Nausea

Yes

Medications R/T Bowel: Yes No Type Milk of Mag suspension 30 cc liq po QD PRN, Dulcolax 1 suppository rectally QD PRN, Colace 200mg po bid, miralax 17gm po bid, 2.

URINARY

Voiding Straight Catheter q       hrs Indwelling Foley 3-way cath (irrigation) External cath Other       Other: Bladder Training Catheter Care Hourly Urine Output Bladder Irrigation: Continuous Manual Solution:       GU Drainage:

Urine: Color: Patterns: Dysuria Genitalia:

Clear Cloudy Sediment Odor: Faint Light Yellow Dark Yellow Orange Clots Incontinent Polyuria Nocturia Oliguria Retention No Anomalies

Medications R/T Bladder:

Fluid Volume, Risk for Imbalanced Incontinent most of Infection, Risk for the time, but tries to Incontinence, Functional Incontinence, Reflex use a urinal. States Incontinence, Risk for Urge that he has to “pee a Incontinence, Stress lot” at night. (nocturia) Incontinence, Total Has a history of Incontinence, Urge malignant neoplasm Tissue Perfusion, Ineffective prostate. Urinary Elimination, Impaired Urinary Elimination, Readiness for Enhanced Urinary Retention 11/10/09 0700

Other      

Anuria

Discharge Yes

Offensive Hematuria Urgency

Excoriation

Other

No Type Detrol LA 4mg po QD

D. ACTIVITY/REST Gordon’s Pattern of Activity and Rest/ Pattern of Sleep & Rest WOSC Freshman Clinical Assessment Form

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Range of Motion: Active Passive Limitations Bed Mobility: Self Assist: Partial Total Assistive Devices: Type Wheel chair CPM: Right Left N/A Joints: Tenderness Pain Ordered Activity level:      

Sleep Patterns: Usual # Hours 3 to 4 hrs Special Needs:       Medications R/T Activity/Rest:

N/A

Swelling

Yes

WOSC Freshman Clinical Assessment Form

Activity Intolerance Activity Intolerance, Risk for Unable to perform Disuse Syndrome, Risk for Diversional Activity Deficient active ROM. Fatigue Stated that he Mobility, Impaired Bed sometimes has pain, Mobility, Impaired Physical Mobility, Impaired Wheelchair swelling, and Perioperative Positioning tenderness in joints, Injury, Risk for but that he was not in Sedentary Lifestyle pain at the moment. Sleep Deprivation Sleep Pattern, Disturbed Diagnosed with Sleep, Readiness for Enhanced insomnia. States Transfer Ability, Impaired sometimes has a hard Walking, Impaired time sleeping. 11/10/09 0730

No abnormalities

# Last 24 hours 4hrs No Type Ambien 5mg po qhs x’s 60days

-4-

Date/Time Explanation of Abnormal Assessment Factors 11/10/09 0745 States that he sometimes has pain in his LE.

E. Comfort

Yes Describe:       Last Medicated:      

Pain/Discomfort: No Pain Scale: (0-10) 0 Location:       Quality:        PRN Analgesic/Narcotic Other Modalities:      

PCA

Epidural

Medications R/T Comfort:

Yes No Type Robaxin 500mg po q8h PRN spasms ,Lortab 5mg q4h PRN pain, Tylenol 325mg q4h PRN pain      

F. SEXUAL Gordon’s sexuality-Reproductive Pattern Reproductive: LMP______ Premenopausal Postmenopausal

Male Hysterectomy: Ovaries Removed Ovary/Ovaries Remain Breast: Symmetrical Asymmetrical Describe:       Self Breast/Testicle Exams: Yes No Freq:       Cancer Screen: Date 5/09 Test prostate cancer Result malignant Date       Test       Result       (Breast, Pap, Prostate) Sexual/Fertility Concerns None Hormone Replacement None for sexuality

Medications Related to Sexuality:

Yes

No Type:      

II. SAFETY AND SECURITY Temperature: 97

Route Taken:

Oral

Tympanic

Ax.

Rectal

Temporal

Skin: Turgor: Location:sternum

Elastic Tented Taut Shiny Hot Warm Cool Dry Clammy Diaphoretic Location: face Pink Pale Cyanotic Flushed Jaundiced Mottled Other Brown Bony Prominences: Skin Intact Reddened Gray Pressure Sore Stage:       Location:       Temp: Color:

11/10/09 0700 Needs assistance w/dressing, total assistance w/ toileting, personal hygiene, and bathing.

Wound Location : NONE Wound:

N/A Sutures Staples Drain Dehiscence Evisceration Healing by secondary intention Other Dressing: N/A Dry/Intact Open to Air Stained Saturated Changed: q______hrs wet to dry Other Describe:       Isolation/Precautions: Standard Precautions Additional      fd      Protocols: Braden Scale Restraints Special Bed Other      

Physical: General Movement:

Unassisted

Supervised Assisted Hemiparesis/plegia Quadriparesis/plegia

Bathing/Hygiene: Oral Care:

Self Self

Assist Assist

Total

Assistive Devices: N/A Type: Wheelchair Weight Bearing Status: FWB L PWB Precautions:

Swallowing

Seizure

Spinal

Unable Paraparesis/plegia

Partial

PM Care

R PWB

NWB

Fall

Subarachnoid

Perception: Gordon’s Cognitive-Perceptual Pattern Vision Deficits: Blind (legally) Hearing Deficits: Deaf Other:      

Precautions: none

HOH

Glasses Hearing Aid(s):

Danger to Self

Contacts L R

Wears glasses Bilat.

Danger to Others

Self Mutilation Suicide

Alcohol and Drug Withdrawal

Medications R/T Safety and Security: Yes Pt.’s Highest Level of Education: High school

WOSC Freshman Clinical Assessment Form

No Type:      

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Related Nursing Diagnosis

Comfort Pain, Acute Pain, Chronic Sexual Sexuality Patter, Ineffective Sexual Dysfunction Safety and Security Temperature Hyperthermia Hypothermia Temperature, Risk for Imbalanced body Thermoregulation, Ineffective Skin Infection, Risk for Injury, Risk for Latex Allergy Response Latex Allergy Response, Risk for Protection, Ineffective Skin Integrity, Impaired Skin Integrity, impaired, Risk for Tissue Integrity, Impaired Physical Falls, Risk for Growth, Risk for disproportional Mobility, Impaired Physical Perioperative Positioning Injury, Risk for Trauma, Risk for Self-Care Deficit, Bathing/Hygiene Self-Care Deficit, Dressing/Grooming Self-care Deficit, Toileting Surgical Recovery, Delayed Wandering Perception Energy Field, Disturbed Environmental Interpretation Syndrome, Impaired Infant Behavior, Disorganized Infant Behavior, Disorganized, Risk for Infant Behavior, Readiness for Enhanced organized Poisoning, Risk for Self-Mutilation Self-Mutilation, Risk for Sensory/Perception, Disturbed (specify): Visual, Kinesthetic, Auditory, Gustatory, Tactile, Olfactory Suicide, Risk for Unilateral Neglect Violence, Risk for OtherDirected Violence, Risk for Self-Directed

III.

LOVE AND BELONGING Gordon’s Pattern of Coping & Stress Tolerance

Adjustment, Impaired

1. Emotional State a. What seems to be the client’s mood? Withdrawn Flat Affect

Depressed Elevated

Normal for Age/Culture Anxious Euphoric

Fearful Expressive

Uncooperative Other

2. Client’s Life Experience Gordon’s Pattern of Values & Beliefs a. How have previous life experiences affected the client’s perception of the current health problems? Pt stated that he smoked until he was 54 years old, ate whatever he wanted, and that he used to drink alcohol frequently. He stated that he thought that was the reason he had “heart problems, high blood pressure, and diabetes.

b. How has life changed as a result of the current health problem? Stated that now his family has to visit him at the nursing home instead of his “own house”. Stated that he is no longer able to get around like he used to. Stated that he was unhappy that he was gaining weight and couldn’t be as active as he used to be. c. Describe any signs or symptoms that may indicate actual/potential physical/emotional abuse. NONE 3. Family Gordon’s Role-Relationship Pattern a. What is the client and family’s perception of the illness/admission? Pt stated that his family was sad that he wasn’t at home.

Caregiver Role Strain Caregiver Role Strain, Risk for Communication, Impaired Verbal Communication, Readiness for Enhanced Community Coping, Ineffective Community Coping, Readiness for Enhanced Delayed Development, Risk for Family Coping: Disabled Family Coping: Readiness for Enhanced Family Processes, Dysfunctional: Alcoholism Family Process, Interrupted Family Processed, Readiness for Enhanced Growth and Development, Delayed Loneliness, Risk for Parental Role Conflict Parent/Infant/Child Attachment, Impaired, Risk for Parenting, Impaired Parenting, Impaired, Risk for Parenting, Readiness for Enhanced

What evidence indicates that family life has changed? Pt is living at the English Manor instead of at home with his wife.

b.

Related Nursing Diagnoses

How do family members seem to be coping? UTA directly from the family. Pt. stated that his

Role Performance, Ineffective Social Interaction, Impaired Social Isolation Violence, Risk for

family was “coping with it just fine”.

c.

What supportive behaviors from family/significant others are evident? According to pt and staff the pt’s family members visit every day or every other day.

4. Erikson Developmental Stage Integrity vs. Despair a. What tasks are appropriate for this stage of development? Looks back on good times with gladness, on hard times with self-respect, and on mistakes and regrets with forgiveness, will find a new sense of integrity and a readiness for perceived wrongs, and dissatisfied with the life they've led. b. How has this health problem interfered with accomplishing the development tasks for this client? Pt’s developmental stage doesn’t seem to be affected. c. What evidence indicates negative or positive developmental resolution? Pt has a sense of fulfillment about life and a sense of unity within himself and with others.

IV.

SELF-ESTEEM: Gordon’s Pattern of Self perception & Self Concept a. How is the client’s self-esteem threatened by this illness/admission? Pt stated that he was

unhappy being overweight. b. What is the client’s perception of body image and how has it changed? Stated that he had never been so physically unfit and over weight until he was diagnosed with DM and unable to walk due to a “bad knee”. He stated that he was unhappy about being over weight, the fact that he was unable to walk and be an active person, but that he had a wonderful life. Stated that he was not happy about what happened to him but that he “accepted how things were”, and was thankful for what he did have, and the things he was able to do. .

WOSC Freshman Clinical Assessment Form

Related Nursing Diagnoses Self-Esteem

1. Self-Esteem and Body Image

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Adjustment, Impaired Anxiety Body Image Disturbed Doping, Defensive Coping, Ineffective Coping, Readiness for Enhanced Death Anxiety Decisional Conflict (Specify) Denial, Ineffective Fear Grieving, Anticipatory Grieving, Dysfunctional Grieving, Dysfunctional, Risk for Hopelessness

c. What fears/concerns were expressed by the client that relate to client’s present illness? 2. Culture: Gordon’s Pattern of Values & Beliefs a. What is the client’s ethnic background? African American b. How does culture/language influence communication between client/family and healthcare workers? Pt wants to be informed regarding his health status. c. Which communication factors are relevant and why do you think so? (Touch, personal space, eye contact, facial expressions, body language) Eye contact, facial expressions, therapeutic touch, active listening, and body language are all relevant communication factors. Effective communication skills help establish a good nurse-patient relationship, allows for the exchange of information, and permits the pt to feel comfortable, relevant, and respected.

WOSC Freshman Clinical Assessment Form

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Personal Identify, Disturbed Post-Trauma Syndrome Post-Trauma Syndrome, Risk for Powerlessness

d.

Who seems to be making the healthcare decisions in the family? The patient

e. Based on your observations, what role does each family member play? The wife and children have become caregivers secondary to the staff at the nursing home. f. Who is responsible for care of a sick family member at home? The patient’s family members. g.

What cultural practices related to hospitalization need to be considered? None

3. Spirituality a. What spiritual/religious beliefs does the client express? Baptist

b.

V.

What spiritual practices related to hospitalization need to be considered? Allow patient time for personal prayer, access to church services, and likes to watch religious T.V. programs.

SELF-ACTUALIZATION Gordon’s Pattern of Health Perception & Health Management

1. What is the client’s/family’s current level of understanding of their health/illness problem? Pt understands that he is elderly and that it is very unlikely that he will ever fully recover. 2. What type of relationship exists with healthcare providers? Pt is very respectful and trusts healthcare providers to take care of him.

VI. Education/discharge planning: (M.E.T.H.O.D.) MEDICATIONS: Lamictal 50mg po bid, Mobic 15mg po qd, Januvia 50mg po qd, Synthroid 0.1mg po qd, Reglan 5mg po bid, Lopressor 50mg po q12h. (hold if systolic b/p <90 or pulse <60), Asprin 325mg po qd, Slow-Mag 128mg po qd, Topamax 100mg po qd @1800, Ambien 5mg po qhs x60days, Lasix 40mg po qd, Potassium 120mEq liq po qid, Metolazone 10mg po qd, Nexium 40mg po qd, Cardura 2mg po qhs, Detrol LA 4mg po qd, Colace 200mg po bid, Miralax 17g po bid 1 scoop in 8oz water, Glyburide 10mg qam0800 w/meal, Refresh tears 1gtt ou qhs, Nitroglycerin 0.4mg po sublingual q 5min x 3 PRN CP, Robaxin 500mg po q8h prn spasms, Robitussin DM 2tsp liq po q6h prn cough, Lortab 5mg q4h prn pain, Tylenol 325 mg po q4h prn pain/temp, Milk of Magnesia susp 30mL liq po QD prn constipation, Dulcolax 1 supp rectally QD prn constipation. Advise client to monitor: blood glucose q4h, blood pressure, pulse and daily weight. Instruct client on s/s of hypoglycemia (abdominal pain, sweating, hunger, weakness, dizziness, headache, tremor, tachycardia, anxiety). Inform client to adhere to all follow up appointments w/ physician to monitor his fluid and electrolyte balance, thyroid function, CBC, renal and hepatic function. Instruct the client to take B/P and pulse,prior to taking Lopressor. Hold if systolic B/P is <90 or pulse <60. ENVIRONMENT: Teach client and family about the importance of implementing fall precautions, keeping the home free from clutter, installing handicap safety accessories (shower seat, hand grab bars, grip mat, raised toilet seat, ect.) THERAPIES: Educate on DVT’s s/s (pain, swelling, tenderness, discoloration or redness of the affected area, and skin that is warm to the touch) and prevention. (ROM exercises passive and active w/in limits). Refer to Physical Therapy. HOME CARE: Pt and family will be encouraged to monitor FSBS, pulse, blood pressure, daily weight, check for any peripheral edema. (teach how to use scale: 1+ 2+ 3+ 4+) Contact case manager for a Home health care referral. (pt. will need extensive assistance w/ ADL’s) Teach patient the importance of meticulous foot care. (Wash feet with warm water and mild soap, and dry them well, particularly between the toes. Inspect feet and apply moisturizing cream every day but not between toes.)

WOSC Freshman Clinical Assessment Form

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Powerlessness Powerlessness, Risk for Rape-Trauma Syndrome Rape-Trauma Syndrome, Compound Reaction Religiosity, Impaired Religiosity, Readiness for Enhanced Religiosity, Risk for Impaired Relocation Stress Syndrome Relocation Stress Syndrome, Risk for Self-Mutilation Self-Mutilations, Risk for Sorrow, Chronic Spiritual Distress Spiritual Distress, Risk for Spiritual Well-Being, Readiness for Enhanced

Self-Actualization Health Maintenance, Ineffective Health Seeking Behaviors (Specify) Home Maintenance, Impaired Knowledge, Deficient (Specify) Knowledge, Readiness for Enhanced (Specify) Noncompliance Therapeutic Regimen: Community, Ineffective Management of Therapeutic Regimen: Families, Ineffective Management of Therapeutic Regimen: Management, Effective Therapeutic Regimen: Management, Ineffective Therapeutic Regimen: Management, Readiness for Enhanced

OUTPATIENT THERAPIES: Educate the pt regarding the importance of physical therapy sessions and following up with a nutritionist. (Refer to physical therapist and nutritionist.) DIET: Reeducate the pt about the importance of an approved ADA diet. (print out pamphlet from ADA website www.diabetes.org) Reiterate how important it is to adhere to low sodium diet and an approved ADA diet to help maintain health status. (Refer client and family to a nutritionist for more extensive education.)

****NOTE: You must be specific in your discharge education.

WOSC Freshman Clinical Assessment Form

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Western Oklahoma State College Nursing 1119, 1129, 1123, 2219 & 2229 NORMAL RANGE

TEST WBC RBCs

Hgb

ADMISSION DATE 7/10/09

LAB VALUES

MCV MCH MCHC RDW Retic. Platelet Neutrophils Lymphocytes Monocytes Eosinophils Basophils Sodium

Chloride

Potassium CO2 Magnesium

Calcium

BUN Creatinine

Identify  WNL Significance/Trends

UTA

UTA

UTA

4 - 5.2

UTA

UTA

UTA

UTA

8.2

8.8

High Could be due to the patient having poor heart function (CHF). If the pt had pneumonia at the time of the test, that could’ve been the cause. (pt stated he had pneumonia a few weeks ago) The pt is also on Nexium which alters Hgb levels. Could also be due to prostate cancer.

37% - 47%

UTA

UTA

UTA

UTA

78 - 102

UTA

UTA

UTA

UTA

25 -35

UTA

UTA

UTA

UTA

31 - 37

UTA

UTA

UTA

UTA

11.5% 14.5%

UTA

UTA

UTA

UTA

0.5 - 2.3%

UTA

UTA

UTA

UTA

130 - 140

UTA

UTA

UTA

UTA

UTA

UTA

1.9 -8

UTA

UTA

19% - 48%

UTA

UTA

UTA

3% - 9%

UTA

UTA

UTA

0 - 7%

UTA

UTA

UTA

0-2%

UTA

  UTa     

UTA

137 -145

UTA

138

UTA

98 -107

UTA

110

UTA

3.5 -5.1

UTA

4.6

UTA

22 - 30

UTA

23

UTA

1.5 - 2.4

UTA

UTA

UTA

UTA

8.2

UTA

UTA

UTA

UTA

6.0 -8.5

UTA

UTA

UTA

20 - 36 sec

UTA

UTA

UTA

10-20

UTA

15

UTA

0.6-1.2

UTA

1.5

UTA

INR

PTT

Date 10/06/09

UTA

8.4 -10.2

PT

Date 8/07/09

4.5 -13.5

12-16%

Hct

Student Name: Patient Initials/Age/Sex PB/83/M

WOSC Freshman Clinical Assessment Form

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UTA UTA UTA UTA

WNL HIGH Could be mean the pt has anemia, pt is on a med (Topamax) that frequently causes anemia. Could be dehydration, or from the pt eating too much salt. W/O a total lab report it is hard to pin point the cause. WNL WNL UTA

LOW Could be due to bone problems or age, the pts use of laxatives and diuretics, or could be due to kidney problems since the creatinine level is high. Could also be a problem with the pituitary gland since the T4 is low and TSH is WNL. W/O a total lab report it is hard to pin point the cause. UTA UTA UTA

WNL HIGH May mean that the kidneys are not functioning

Glucose AST ALT Acid Phosphate LDH

Amylase Lipase Phosphorus Alk. Phos. Total Bilirubin

Cholesterol Uric acid Total Protein

Albumin Globulin Digoxin level Theophylline level Dilantin level

T4

TSH ANION GAP

                 

239

UTA

14 -36

UTA

UTA

UTA

9 -52

UTA

UTA

UTA

0.0-4.3

UTA

UTA

UTA

140-280

UTA

UTA

UTA

ADMISSION DATE

Date      

Date      

     

LAB VALUES

12-52

UTA

UTA

UTA

3.1-34.6

UTA

UTA

UTA

2.5 - 4.5

UTA

UTA

UTA

38 -126

UTA

UTA

UTA

0.1 -1.3

UTA

UTA

UTA

<100

UTA

UTA

UTA

250 - 750

UTA

UTA

UTA

6.3 - 8.2

UTA

UTA

UTA

3.5 - 5

UTA

UTA

UTA

2.3 - 3.5

UTA

UTA

UTA

N /A

N /A

N /A

10 to 20 mcg/mL

N /A

N /A

N /A

10-20µg/ml

N /A

N /A

N /A

ADMISSION DATE

Date 8/07/09

Date 10/06/09

0.5 to 1.9

NORMAL RANGE

TEST

     

UTA

NORMAL RANGE

TEST

PSA

74-106

properly, or could be due to the pt taking Nexium which can raise creatinine levels. HIGH Has IDDM Could be due to non-adherence to diet regiment. UTA UTA UTA UTA

Identify  WNL Significance/Trends UTA UTA UTA UTA UTA

UTA

LAB VALUES

5.53-11

UTA

UTA

4.88

0.485-4.68

UTA

UTA

1.68

5-15

UTA

5

UTA

0-4

0.08

UTA

UTA

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

WOSC Freshman Clinical Assessment Form

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UTA UTA UTA UTA UTA N/A N/A

N/A

Identify  WNL Significance/Trends Low Pt has been diagnosed with hypothyroidism, but since his TSH level is not high and the Calcium level is also low, it could mean that the pituitary gland is responisble for the hypothyroidism. Further test would need to done to determine exact cause. WNL WNL

WNL                        

ADULT LABORATORY/ DIAGNOSTIC TOOL URINALYSIS (UTA) Date      Color      Appearance      Spec. gravity      Protein       Glucose      Ketones       Bacteria       Blood     

WOSC Freshman Clinical Assessment Form

#1 ABGS (UTA) #2 ABGS (UTA) Date      Date      pH      pH       pCO2      pCO2      pO2      PO2      B.E       B.E.      O2 sat      O2 sat      Bicarb      Bicarb      

(UTA) 2. ABG ANALYSIS(UTA)

1. ABG ANALYSIS

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Western Oklahoma State College Nursing 1119, 1129, 1123, 2219 & 2229

Student Name Patient Initials/Age/Sex PB/83/M Clinical Date11/10/09

DIAGNOSTIC/RADIOLOGIC TEST and DESCRIPTION OF TEST

OTHER DIAGNOSTIC TESTS AND RADIOLOGIC TESTS DATE RESULTS SIGNIFICANCE OF TEST RESULTS/NURSING INTERVENTIONS (i.e client preparation for test/during test/after test)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

(UTA)

WOSC Freshman Clinical Assessment Form

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Student Name Nursing 1119, 1129, 1123, 2219 & 2229

Patient Initials/Age/Sex PB/83/M Clinical Date11/10/09

Developmental Stage Integrity vs. Despire Psychosocial Crisis Conflict between sense of personal integrity & despair over regretted life events. Health-Illness Continuum: Maximum Health

Health

Illness

Death

According to Maslow, identify needs based on Maslow’s hierarchy. Star or highlight the most outstanding need(s). Justify identified need(s) with specific objective and subjective findings from the physical assessment, medications, lab, and other diagnositic test results DIRECTIONS:

I.) Biological and Physiological Needs (Oxygen needs, elimination, nutrition, hydration,sex, rest, activity, shelter, Basic Life Needs) 1. History of Ischemic heart disease 2. History of CHF 3. History of Peripheral Vascular disease 4. Diagnosed with Malignant Neoplasm prostate 5. Venous Stasis 6. History of seizures 7. Diagnosed withHypertension 8. 2+ and 3+ pitting edema on lower extremities 9. IDDM 10. States that he doesn’t adhere to ADA diet 11. Obese 12. Incontinent 13. FSBS 227 14. Requires total assistance for hygiene and bathing 15. Needs assistance with bed mobility 16. Requires total assistance with toileting needs 17. Requires Total assistance with transfers 18. Pt was soiled with urine 19. Stated Pain in legs and feet at times 20. Skin on LE shiny, waxy, and discolored 21. States has a hard time sleeping 22. States feet and legs are numb and tingly sometimes 23. absent bilateral pedal pulses 24. Brachial artery (irregular heart beat) II.) Safety Needs (protection, security, order, law, limits, stability, etc) 1. Fall precautions 2. Wears glasses 3. Immobility 4. Rt sided weakness

III.) Belongingness and Love Needs (family, affection, relationships, work group, etc) 1. Father of three 2. Grandfather of 5 3. Pt stated that his family comes to visit every day or every other day 4. IV.) Esteem Needs (achievement, status, responsibility, reputation) 1. Pt stated that is a proud retiree from the US Air force 2. Pt stated that he was in law enforcement before he “got sick” 3. Staff stated that the pt was a very nice man, who was a joy to work with and be around. 4.       V.) Self actualization (personal growth and fulfillment) 1.       2.       3.       4.      

WOSC Freshman Clinical Assessment Form

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INDIVIDUALIZED CLIENT NURSING DIAGNOSIS BASED ON MASLOW’S HIERARCHY Prioritize in accordance to Maslow’s Hierarchy 1. Ineffective Tissue Perfusion: Peripheral 2. Impaired Urinary elimination 3. Impaired physical mobility 4. Imbalanced nutrition: More than body requirements 5. Self-care deficient: hygiene and bathing

WOSC Freshman Clinical Assessment Form

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Western Oklahoma State College Nursing 1119

Student Name Brenda Hood Patient Initials/Age/Sex PB/83/M Clinical Date11/10/09

Medical Diagnosis (Top priority): Peripheral Vascular Disease Brief Pathophysiology of Medical Diagnosis with signs and symptoms my patient is/has exhibited starred *or highlighted : Peripheral artery disease is due to atherosclerosis. This is a gradual process in which a fatty material builds up inside the arteries. The fatty material mixes with calcium, scar tissues, and other substances and hardens slightly, forming plaques of arteriosclerosis. These plaques block, narrow, or weaken the vessel walls. Blood flow through the arteries can be restricted or blocked totally. Atherosclerosis is known for affecting the arteries of the heart (coronary arteries) and the brain (carotid arteries). Over the long term, the high blood sugar level of persons with diabetes can damage blood vessels. This makes the blood vessels more likely to become narrowed or weakened. Plus, people with diabetes frequently also have high blood pressure and high fats in the blood, which accelerates the development of atherosclerosis. Of the peripheral arteries, those of the legs are most often affected. Other arteries frequently affected by atherosclerosis include those supplying blood to the kidneys or arms. When an artery is blocked or narrowed, the part of the body supplied by that artery does not get enough blood or oxygen. Decreased blood flow/oxygen, can injure nerves and other tissues. Some people with peripheral artery disease may need to have the limb amputated. Rates of amputation are particularly high among African Americans and Hispanics with diabetes. If arteriosclerosis is in both limbs, the intensity is usually different in each. Symptoms include: change of color of the legs, cold legs or feet, leg pain at rest or exercise, loss of hair on legs, muscle pain in thighs calves or feet, numbness of legs or feet, cyanosis, gait abnormalities, weak or absent pulse in limb

Labs and Diagnostic tests that confirm or are related to the medical diagnosis) : Ankle-brachial index (ABI) is one of the most common tests used to diagnose PAD. It compares the blood pressure in your ankle with the blood pressure in your arm. To get a blood pressure reading, the physician uses a blood pressure cuff and a special ultrasound device to evaluate blood pressure and flow. Doppler ultrasound or duplex scanning can evaluate blood flow through blood vessels and identify blocked or narrowed arteries. An angiography can be done by injecting a dye into blood vessels; this test allows the physician to view blood flow through your arteries as it happens. The physician is able to trace the flow of the contrast material using imaging techniques such as X-ray imaging or procedures called magnetic resonance angiography (MRA) or computerized tomography angiography (CTA). Catheter angiography is a more invasive procedure that involves guiding a catheter through an artery in your groin to the affected area and injecting the dye that way. Although invasive, this type of angiography allows for simultaneous diagnosis and treatment - finding the narrowed area of a blood vessel and then widening it with an angioplasty procedure or administering medication to improve blood flow. A sample of your blood can be used to measure your cholesterol and check levels of homocysteine and C-reactive protein.

Primary Nursing Interventions for Disease Processes Listed: The primary nursing intervention for patients with diabetes and peripheral vascular disease is to help reduce the risk of foot and leg amputations. Provide patient with meticulous foot care. Wash feet with warm water and mild soap, and dry them well, particularly between the toes. Inspect feet and apply moisturizing cream every day but not between toes. To prevent pressure on legs and feet, make sure the pt changes position every 2 hours and performs range-of-motion exercises, if possible. Use protective padding, foot cradles, or an alternating-pressure mattress to reduce the risk of pressure injuries. Teach pt. how to promote circulation. Help him devise a ROM exercise program to develop circulation and enhance venous return. Instruct him to stop exercising if he feels pain. Stress the importance of following a weight loss program, controlling diabetes, controlling hyperlipidemia and hypertension. Elevate edematous legs as ordered.

WOSC Freshman Clinical Assessment Form

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Western Oklahoma State College Nursing 1119, 1129, 1123, 2219 & 2229

#5 Pt Problem: Unable to bathe self or perform basic hygiene Nursing Diagnosis: Selfcare deficit: hygiene and bathing r/t weakness in upper and lower extremities

Student Name Patient Initials/Age/SexPB/83/M Clinical Date11/10/09

#1 Pt Problem: Edema of the lower extremities. Nursing Diagnosis: Ineffective Tissue Perfusion: Peripheral r/t interruption of vascular flow aeb: cool temp. LE, shiny, waxy, discolored legs; absent pedal pulses, R/LLE 2+ and 3+ pitting edema, venous Medical Diagnosis: insufficiency

1. Peripheral Vascular Disease

#2 Pt Problem: Incontinence Nursing Diagnosis: Impaired urinary elimination r/t a swollen prostate

2. IDDM 3. Malignant Neoplasm Prostate 4. CHF

#4 Pt Problem: Obesity

#3 Pt Problem:

Nursing Diagnosis: Imbalanced nutrition: More than body requirements r/t excessive intake in relation to metabolic need.

Nursing Diagnosis: Impaired physical mobility r/t partial loss of voluntary movement of upper and lower extremities.

RATIONALE FOR CHOOSING NURSING DIAGNOSIS TO COMPLETE CONCEPT MAPS FOR: (i.e. Airway a basic need according to Maslow’s )

I chose Ineffective tissue perfusion first because the pt has peripheral vascular disease. With the edema and venous stasis, it makes him more susceptible to DVT’s which can cause death or amputation. I chose impaired urinary elimination next because the pt was diagnosed with prostate cancer. As a nurse, I can’t do anything about the cancer, but maybe I can help relieve some of the symptoms, one being urinary incontinence. I chose impaired physical mobility next because if my pt was able to be more active, then he might be more able to loose weight; in turn that could help with his diabetes and heart disease. I chose self care deficit because the pt is totally dependent on nursing for ADL’s.

WOSC Freshman Clinical Assessment Form

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Western Oklahoma State College Nursing Department

Student Name:

# 1 Nursing Diagnosis Concept Map Subjective Data Pt. stated that he sometimes has pain in his leg and ankles. Pt states that his feet and legs are numb and tingly sometimes. Stated that the doctor said he had a “bad heart”, high cholesterol, and that his arteries were getting “clogged up”.

Objective Data Lower extremities: shiny, waxy, discoloration of the skin; cool skin temp; absent pedal pulses; 2+ and 3+ pitting edema. Loss of hair on the legs; BP 154/71; FSBS 227

Nursing Diagnosis Ineffective tissue perfusion: peripheral r/t interruption of vascular flow aeb shiny, waxy, discolored skin, cool skin temperature, absent pedal pulses, 2+ and 3+ pitting edema

Short Term and Long Term Outcome (must be measurable) Pt will identify changes in life style needed to increase tissue perfusion by the end of my shift. Pt will verbalize knowledge of treatment regimen, including appropriate ROM exercises and medications and their actions and possible side effects by discharge from hospital.

WOSC Freshman Clinical Assessment Form

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Nursing Interventions 1. Check the dorsal pedis pulses bilaterally. 2. Elevate edematous legs as ordered. 3. Stress the importance of following a weight loss program, controlling diabetes, controlling hyperlipidemia and hypertension. 4. Note skin color and feel the temperature of the skin. 5. Observe for signs of deep vein thrombosis including pain, tenderness, swelling in the calf and thigh and redness. 6. Provide patient with meticulous foot care. Wash feet with warm water and mild soap, and dry them well, particularly between the toes. Inspect feet and apply moisturizing cream every day but not between toes. 7. Use protective padding, foot cradles, or an alternating-pressure mattress to reduce the risk of pressure injuries.

Scientific Nursing Rationale 1. Diminished or absent peripheral pulses indicate arterial insufficiency with resultant ischemia NDHB 845 2. Elevation increases venous return and helps decrease edema. NDHB 846 3. All of these risk factors for atherosclerosis can be modified. NDHB 847 4. Skin pallor or mottling, cool or cold skin temperature, or an absent pulse can signal arterial obstruction, which is an emergency that requires immediate intervention. NDHB pg845 5. Thrombosis with clot formation is usually first detected as swelling of the involved leg and then as pain. NDHB 846 6. Ischemic feet are vulnerable to injury; meticulous foot care can prevent further injury NDHB 846 7. Ischemic feet are vulnerable to injury; meticulous foot care can prevent further injury NDHB 846

Evaluation of Short Term and Long Term Outcomes (met or not met and why) Goal met pt was able to identify changes in lifestyle needed to increase tissue perfusion. Goal met pt was able to verbalize knowledge of treatment regimen.

WOSC Freshman Clinical Assessment Form

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