Student name: Caprice Hudson	Date of Care:3-19-12
History of Present Illness (HPI)
Patient Initials: F.S.   Pt Age:  91  Gender: M   Date of Admission: 3-18-12
	
Review the last 24 hours of nursing notes and the admitting physician’s history and physical exam to answer the items below, summarize the notes you read in your own words. 

Tell the story of how your patient ended up in the hospital:   (1pt) Mr. F.S. is a 90-year-old male who was transferred from Provena Samaritan United Medical Center for shortness of breath. His past medical history is significant for hypertension, COPD, systolic CHF, sinus bradycardia s/p pacemaker, mitral regurgitation s/p bioprosthetic mitral valve replacement, CKD stage 3, and atrial flutter s/p RF catheter ablation, and atrial fibrillation. 
He was admitted for shortness of breath on Mar 11 and was discharged on Mar 16. His shortness of breath was considered secondary to systolic CHF exacerbation. He was treated with IV furosemide and then converted to po torsemide. During hospitalization he developed atrial flutter with RVR and underwent RF ablation by Dr. R.. After ablation he was started with amiodarone and was sent home. 
After discharge he was doing ok until this morning when he noticed gradually worsening shortness of breath. He has no shortness of breath when he is resting but had significant shortness of breath with exertion. He denied orthopnea and paroxysmal nocturnal dyspnea. He mentioned that he had worsening cough although he denied sputum. He denied fever, or chills. He denied chest pain. 

Medical & Surgical history (list the year of the diagnosis/ surgery)   (1 pt)

Medical: HTN, CKD, COPD10/19/2011 , CHF, pure hypercholesterolemia10/19/2011 , anemia, mitral valve regurgitation July 8th, 2011, sinus bradycardia July 11th, 2011

Surgical: Vasectomy, CABG, pacemaker inserted and mitral valve replacement, tonsillectomy

Social History   (1pt) He informs me that he no longers drinks but last year he admits to drink a glass of wine once a day. He is a previous smoker he quit 6/30/1960. He smoked for 30 years and he denies use of illicit drugs.

Occupation: F.S. is a retired farmer he worked for 25 years and has been retired for 31 years.

Lives with? Patient lives with his wife in Vermillion County	

List family members involved with your patient’s care. His wife is listed as the emergency contact

Habits (Tobacco/Alcohol/ Drugs) Patient is a former smoker; Quit date: 6/30/1960; 1 packs/day for 30 years (30 pk-yrs); Types: Cigarettes. Pt also admits to 3.5 oz of alcohol/week; 7 glasses of wine per week 

Nursing Care:    (1 pt)

Isolation No isolation

Code Status:  Patient has a DNR order 

Pain Records indicate no complaints of pain for the patient

Fall Risk: Patient is high fall risk

Hygiene Based on his limited activity level patient may receive a bed side bath.

Activity: Activity for this patient may be limited due to his shortness of breath with exertion. Orders include up with assistance and bedroom privileges

Diet patient is on a cardiac diet and he has fluid restriction of 1500     and this includes his IV

List the equipment that is needed or being used to care for this patient?  (e.g. IV, Foley, Oxygen…) Supplemental oxygen, IV, compression cuffs and urinal.

Pathophysiology:

Identify the primary disease(s) that will be explained in this paper.    (1pt) Pleural effusion 
Describe the pathology of this disease; include any causative factors/ etiologies that can be identified  A pleural effusion is a buildup of fluid between the tissue that lines the lung and chest cavity. A transductive pleural effusion is caused by fluid leaking into the pleural space (PubMed). This kind of effusion is commonly caused by CHF in which my patient has and may have caused him to develop a pleural effusion due to the pressure, or low protein content in his blood vessesls (PubMed). My patients chief compliant was shortness of breath especially with movement. shortness of breath is one of the symptoms of a pleural effusion followed by chest pains with deep breath, my patient did not have chest pain or any other symptoms such as: cough, fever, hiccups, and rapid breathing (PubMed). There are several test that can be used to diagnose a pleural effusion they include: Chest x-ray, chest CT scan, pleural effusion analysis, Thoracentesis, Thoracic CT and a ultrasound of the chest (PubMed). My patient had a chest x- ray and a CT scan. The chest x-ray and the ct both showed a pleural effusion. The CT showed more images of the lungs such as a small pleural effusion on the left lung and a large one on the right lung. The goal of treatment is to remove the fluid, prevent fluid build up again and treating the cause of the fluid buildup. I think that my patients pleural effusion is related to his heart failure and according to PubMed, treatment would include diurectics and other medications that treat heart failure my patient is taking  Amiodarone, Carvedilol, and torsemide.

(5 pts).

What laboratory tests and diagnostics are used to diagnose this pathology, identify below which ones your patient has done and relate the results to the pathology. (5pts)
Laboratory Testing
     Hematology Value	Normal	If not, why?  Please relate to the disease process
	WBC 	8.31	4.00-11.00 103/ul-WNL

	RBC 	3.30	4.10-5.70 10 6/ul- Pts anemia may be related to his like of iron in his blood cells, the patient takes ferrous sulfate for iron replacement

	Hgb 	10.0	12.0-18.0 g/dl 10 3/ul Hemoglobin levels may be related to the patients anemia

	HCT 	30.4	37.0-52.0% Pt Pt has anemia and may have a lack of iron in his blood cells

PLT	 98.0	140-400 10 3/ul upon admission the patient had a high troponin level which may indicate the patient is at risk for MI. The patients platelet could be related to the use of aspirin which can reduce PLT. 

INR 	1.7	0.9-1.1 Ratio Pt admits to consumption of alcohol daily the INR is elevated which may be indication of a decrease in liver function.

     Chemistry	Value	Normal	If not, why not?  Please relate to the disease process.
	Na	132	135-145 mmol/L -Pt. is taking torsemide which reduces sodium and chloride absorption

	K	4.5	3.6-5.0 mmol/L-WNL

	Cl	91	101-111 mmol/L -Pt. is taking torsemide which reduces sodium and chloride absorption

	BUN	75	6-20 mg/dl- patient has chronic renal failure the elevated BUN is related to the decreased function of his kidneys

	Cr	3.65	0.50-1.20 mg/dl patient has chronic renal failure the elevated Cr is related to the decreased function of his kidneys

	Glucose 113	60-90 mg/dl Patient is not diabetic but the patients body is experiencing various disease process which causes stress and may increase glucose levels

	Other: Troponin elevated at 0.10, SEG elevated at 80.2, Lymphocytes low at 5.3%, monocytes elevated at 13.8 and the absolute monocytes are elevated at 1.15 and absolute lymphocytes are low at 0.44
    Urinalysis 

Diagnostic Imaging:
a.	In your own words why is this test done- relate it to the pathology

b.	If abnormal, what changes in your nursing care need to be made?

     Chest X-ray:  Yes. Patient has a small right pleural effusion and right mid to lower lung shows atelectasis but he is negative for a pneumothorax 
     
ECG / Telemetry  N/A
     
CT (Cat Scan) Pt had a CT which showed bilateral pleural effusion which appears small on the left and large on the right. There is also bilateral compressive atelectasis. His right middle lobe has some scarring, and there is minimal scarring in his lingual. Pt is negative for gross mediastinal lymphadenopathy and his 
pacemaker device is in place. Pt has a hyperdense nonsimple 15 mm diameter right upper pole renal cortical cyst. This appearance suggests a hemorrhagic cyst.

     MRI N/A
     Ultra Sound N/A
     Other: 

Medications
List all medications your patient has used in the last 24 hours including: 
1.	Medication name (generic) with prescribed dose & frequency, 
2.	The usual dose & frequency, 
3.	Classification & mechanism of action, 
4.	Why this medication is being used for this patient, 
5.	What nursing precautions considerations do you need to know to SAFELY administer / monitor this medications and lastly 
6.	Evaluate the medications effectiveness for this patient (patient response).  (10 pts)

Name (generic) 
prescribed dose 
& frequency, 
usual dose & frequency	Classification/
Mechanism 
of action	Why use this 
medication 
for this 
patient?	Nursing precautions/ 
safety considerations
To administer this medication	Evaluation
Patient response	
Amiodarone 200 mg tablet, daily, normal dose is 600-800mg/day after loadin dose of 800-1600mg/ day for 1-3 weeks	ANTIARRHYTHMICS, this drug decreases peripheral vascular resistance through noncompetitive inhibition of alpha and beta receptors

	my patient is taking this medication related to his heart failure	major adverse effects for my patient include sinus arrest, and dysrhythmias,  and AV block 

		
Aspirin chewable tablet 81 mg daily, normal dose is 50-325 mg/day	ANALGESIC/ANTIPYRETICS, SALICYLATES, this drug blocks pain impulse and may cause vasodilation due to its antipyretic action

	My patient is taking this medication to reduce platelet, which reduces risk for a clot and MI or stroke	Major adverse effects include: thromocytopenia, laryngeal edema,  and anaphylaxis 		
Carvedilol tablet 12.5mg, 2 times daily with meal, normal range is 6.25 twice a day	ALPHA/BETA-ADRENERGIC BLOCKING AGENTS, antihypertensive, this drug causes a decrease in cardiac output, vasodilation and reduces peripheral vascular resistance
	my patient is taking this drug for hypertension and because he has chf this could also help him	Major adverse effects include bradycardia, and bronchospasm		
dronabinol (MARINOL) capsule 2.5 mg daily, normal range is twice a day before lunch or supper (PubMed)
	ANTIEMETIC/ANTIVERTIGO AGENTS, this medication stimulates appetite and reduces N/V in patients
	I think this drug is used to help stimulate the patients appetite	major adverse effects for my patient would be a fast heartbeat, and drowsiness		
famotidine (PEPCID) tablet 20 mg, 2 times daily, normal range is 10-160 mg and <50 ml/min 
	HISTAMINE H2-RECEPTOR INHIBITORS, inhibits histamine from binding to the H2 receptor site which decreases gastric secretions

		Major adverse effects include seizures, dysrhythmias, and pneumonia because this would compromise his breathing and he already has COPD 
		
Ferrous sulfate tablet 324 mg, 2 times daily, normal range is 100-200 mg t.i.d.	IRON REPLACEMENT, this drug replaces iron needed in red blood cells development

	my patient is taking this related to his anemia	Major adverse effects include hypersensitivity reactions, may trigger allergic reaction mechanism		
lactobacillus rhamnosus (gg) (CULTURELLE) capsule 10 billion cell daily, normal range is 5-10 billion cells 
	ANTIDIARRHEAL MICROORGANISMS AGENTS

	is used to replace lost bacteria and to prevent diarrhea	adverse effects include gas 7 bloating		
Multivitamin tablet daily, normal range is 	Multivitamin preparations 				
tiotropium bromide (SPIRIVA) 18 mcg capsules with inhalation device 1 capsule daily, normal range is 1 cap/day
	GENERAL BRONCHODILATOR AGENTS,anticholinergic causes bronchodilation and decreased cGMP by inhibiting achetycholine at receptor site

	My patient is taking this medication for his COPD and prevention of bronchospasm	Major adverse effects for my patient are chest pain, and angioedema		
torsemide (DEMADEX) tablet 40 mg daily, normal dose is 5-20 mg/day up to 200 mg/day 
	LOOP DIURETICS this drug inhibits absorption of chloride, sodium and water

	my patient could be taking this medication for his HTN or his chf or edema do to CKD	Major adverse effects that concern me is hypotension and chest pain and changes in his ECG	
albuterol-ipratropium (COMBIVENT) 18-103 mcg/actuation inhaler 2 puff, EVERY 4 HOURS PRN

	BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS causes bronchodilation

	My patient has copD and this medication will prevent bronchospasm	Major adverse effects are paradoxical bronchospasm, and dysrhythmias	
inhalational spacing device SPACER ONLY 1 each, EVERY 4 HOURS PRN
	RESPIRATORY AIDS,DEVICES,EQUIPMENT

zolpidem (AMBIEN) tablet 5 mgAT BEDTIME PRN, MAY REPEAT X 1, normal dose is 10mg at bedtime for 7-10 days only

	SEDATIVE-HYPNOTICS,NON-BARBITURATE, this drug causes CNS depression 

	My patient is using this medication for sleep	major adverse for my patient includes effects include suicidal ideation, and sever allergic reaction, , 	

PHYSICAL ASSESSMENT DATA (collect own data on clinical day)     (Use Taylor Chapter 25 & N201 materials as resources)  (5 pts)     All subjective 
& objective data is collected and recorded using appropriate terminology. Data not collected or requiring elaboration is explained in the blank spaces.  
Pulse Ox %:	BP:	Pulse:
Rate:
Rhythm:	Respirations:
Rate:
Rhythm:	Temp:

Route:	Pain:
Rating:         /10    Characteristics:          	Ht: _________
Wt: _________	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	

	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength
ADL Assistance    Y   N       Fall Risk:    Y   N
Fall Score______________
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment   
            Needs support to stand and walk	

CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _________
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____________________	 
	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	

GASTROINTESTINAL:
Diet at home :                 Current Diet:   
Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools 
Palpation: Pain, Mass etc
Inspection: distention, incisions, scars, drains, wounds
Ostomy:    Y       N         Nasogastric:    Y      N  
Feeding tubes/PEG tube   Y      N      Type:___________		
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _________
Drains present:  Y         N       Type_______________		
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:            	
	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________	

	
PSYCHOSOCIAL/CULTURAL:
Educational level
Developmental level       
Coping methods          
Health Beliefs
Occupation (previous if retired)
Religion & what it means to pt.
Personal/Family Data    (Think about home environment, family structure, and available family support)	Pt. completed 2 yrs of college he is an elderly 91 year old male . He informs me that he has a lack of sleep while being in the hospital. The health care providers are always in his room taking blood and running test and taking vitals. Pt believes that age impacts his health. The patient has been relatively healthy up until 2 years ago when he had his heart surgery. The patient believes eating a healthy diet and exercise is important to his health. He informs me that he was able to play tennis 3 times a week up until 89 years of age. He also followed a diabetic diet as his daughter did before she passed away, she had juvenile diabetes since she was 18 months. He has 3 grandchildren who he sees sometimes; they live in Indianapolis.

USE THE BACK OF THE SHEET FOR ADDITIONAL SPACE FOR DETAILS. EXPECTATIONS MAY VARY FOR DIFFFERENT COURSES

Other: Priority Nursing Diagnosis: (Use NANDA format) (2pts) 

What does the patient/client need to accomplish?
GOALS/OUTCOMES
(2pts)
Measurable patient centered goals are identified, realistic and contain a time element.
	What can the nurse do to help resolve the problem?
IMPLEMENTATION
Nursing Interventions
(2pts)
Specific nursing actions can easily be linked to the outcomes.  The interventions are realistic and appropriate to the patient's current status.	Why will the nurse do these actions?

SCIENTIFIC RATIONALE
Be sure to include source using APA format
(2pts)
Rationales for each intervention contain comprehensive scientific reasoning that succinctly identifies why the intervention was selected.  Citation is provided.	How did the patient/family respond to the nurse’s actions? 
EVALUATION
Client Response 
(2pts)
Includes all the following: 
1.Client’s response to the intervention(s),
 2. Status of goals and outcomes, (ie goal met, in progress or revised) 
3. Modifications to the plan of care.	

				
Reference List for all references used in this document.     Use APA format.          (1 pts)

Carle Epic. Carle Foundation Hospital
Carpenito-moyet, L.J. (2008). Nursing Diagnosis. Application to clinical Practice (12th 	ed., pp
Skidmore-Roth, L. (2011).. Mosbys 2012 Nursing Drug Refrence. St. Louis: Mosby.
Dronabnol. (2010). In PubMed. Retrieved from 	http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000403/
Pleural effusion. (2010). In PubMed. Retrieved from					http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001150/