Student name: Kristin Schomburg				Date of Care: February 14, 2012  37/40
History of Present Illness (HPI)
Patient Initials: K.H.   Pt Age: 86 	 Gender: F		 Date of Admission: February 7, 2012

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)
-	Mrs. H went to her physician’s office after becoming very weak and was unable to ambulate independently. Patient was admitted due to cellulitis of both lower extremities, shortness of breath, and extreme hypoxia. 

Medical & Surgical history (list the year of the diagnosis/ surgery)   (1 pt)
-	Appendectomy
-	Hernia Surgery
-	Osteoarthritis History
-	Hypertension
-	Knee Replacement (Bilateral)
-	Tonsillectomy
-	History of Blood Transfusions
(Dates were not listed)

Social History   (1pt)
Occupation: Mother of 8.
Lives with: Patient lives in a duplex owned by her son, he and girlfriend live next door and help the patient with her ADLs. 
List family members involved with your patient’s care: Son and his girlfriend.
Habits (Tobacco/Alcohol/ Drugs): None.

Nursing Care:    (1 pt)
Isolation: None
Code Status:  Full 
Pain: 0/10
Fall Risk: Since the onset of weakness and admission, patient is a fall risk because she is unable to ambulate independently.
Hygiene: Full assist, due to arthritis in her hands.
Activity: Up with assistance, at home was using a computer chair to walk with. Doesn’t care to use walker or cane.
Diet: General diet, no special considerations.
List the equipment that is needed or being used to care for this patient?  (e.g. IV, Foley, Oxygen…)
-	IV, Foley, and Oxygen – 6L Nasal Cannula.

Pathophysiology:

Identify the primary disease(s) that will be explained in this paper.    (1pt)
-	Cellulitis, Pneumonia, and CHF.

Describe the pathology of this disease; include any causative factors/ etiologies that can be identified  
(5 pts).
-	Congestive heart failure(CHF): is the inability of the heart to pump sufficiently to meet the metabolic needs of the body, causing decreased tissue perfusion as a result of decreased cardiac output. May be acute or chronic. Can be caused by MI, HTN, CAD, kidney failure; for this patient an MI was discovered on the ECG, so it’s possible that this MI caused the CHF.
-	Pneumonia: is inflammation of the bronchioles, alveoli, interstitial tissues, and occasionally the pleura as a result of infection. In this patient, her immune system and perfusion were compromised by CHF, likely causing the pneumonia.
-	Cellulitis: is an inflammation of the skin and subcutaneous layers with various lesions, including vesicles, bullae, abscesses and plaques. In this patient cellulitis is likely secondary to the systemic condition of CHF, and deficient nutrition may be a contributing factor, patient reported she snacks throughout the day, but doesn’t always eat much. 
-	(Hogan & Hill, 2005)

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 Test	Patient Value	Normal Lab Value	If not normal, why?	
WBC	6.8	4.3-10.8	Normal	
RBC	3.62	4.2-5.9	Low, as people age, RBC may be lower, or the patient may be slightly anemic.	
Hgb	11.3	7.4-9.9	High, likely high to compensate for poor heart and lung function.	
HCT	34.3	40-48	Low, as people age HCT may be lower, or the patient may be slightly anemic.	
PLT	174	150-350	Normal	
(Jacobs, DeMott & Oxley, 2002)

Chemistry Test	Patient Value	Normal Lab Value	If not normal, why?	
Na	139	135-145	Normal	
K	3.1	3.5-5	Slightly low, may be due to a slight deficit in nutrition.	
Cl	101	95-105	Normal	
BUN	21	10-20	Slightly high, is likely due to CHF.	
Cr	0.9	0.7-1.4	Normal	
Glucose	89	70-110	Normal	
Anion Gap	9	7-16	Normal	
Ca	8.5	8.5-10.5	Normal	
CO2	33	22-32	Slightly high, patient was hypoxic at admission, and requires supplementary oxygen to maintain oxygen levels.	
(Jacobs, DeMott & Oxley, 2002)

Urinalysis	Patient Value	Normal Lab Value	If not normal, why?	
Color	Clear, Yellow		Normal	
pH	5	4.5-7.8	Normal	
Protein	Pos 1 + H	Negative	Abnormal, may be due to inefficient organ systems related to CHF.	
Glucose	Negative	Negative	Normal	
Ketones	Pos 2 + H	Negative	Abnormal, may be due to inefficient organ systems related to CHF.	
Blood	Pos 2 + H	Negative	Abnormal, may be due to inefficient organ systems related to CHF.	
Nitrate/Bilirubin/Urobilinogen	Negative	Negative	Normal	
Leuko esterase	Negative	Negative	Normal	
RBC	2-5	0-2	Slightly High, may be due to inefficient organ systems related to CHF.	
WBC	0-2	0-4	Slightly low, may be due to inefficient organ systems related to CHF. 	
Mucus 	1 + H	Negative	Abnormal, is not uncommon to have mucus present in elderly.	
(Jacobs, DeMott & Oxley, 2002)

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: showed bilateral pleural effusions, moderate in right and small in left. Aorta is tortuous and ectatic with calcifications in the aortic knob. 
-	ECG: indications of myocardial infarction.

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)

Generic Name	Trade Name Dose and Frequency	Classification	Why this medication, this patient?	Nursing precautions	Patient Response	
Furosemide	Lasix 20MG/2ML Vial. IV QAM	Loop Diuretic	CHF is causing fluid overload.	Monitor weight, BP and Pulse	Increase in urine output.	
Carvedilol	Coreg 6.25MG Tab. 1 Tab, QAM PO.	Beta-blocker	CHF.	Hold if SBP <95	Decrease in blood pressure.	
Aspirin	Aspirin 81MG Tab E.C. QAM PO	NSAID	Anti-coagulant.	Take with food. Do not crush.	Patient tolerated medication.	
Lisinopril	Prinivil 5MG Tab. QAM PO	Angiotension-converting ENZ INH	CHF.	Hold if SBP <90	Decrease in blood pressure.	
Ceftaroline Fosamil	Teflaro 300MG NaCl 0.9% 250ml. IV Q12	Cephalosporins Replacement Preparations.	Pneumonia.	No notable precautions.	Patient tolerated medication well.	
Enoxaparin	Lovenox 30MG 0.3ml SVR. Sub-Q daily @ 1400.	Anticoagulant.	To prevent complications of former MI.	Do not give arixtra, lovenox, and/or heparin concurrently. To be given deep Sub-Q, in the abdominal wall, alt. injection sites between L and R anteriolateral and  L and R posterolateral.	Not given during shift.	
(Wolters Kluwer, 2011)

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 %:  94% 
6L O2	BP:
114/64
where	Pulse: 66
Rate: 66 where?
Rhythm: Regular	Respirations: 24
Rate: 24
Rhythm: Regular	Temp:
99.4
Route: Oral	Pain:
Rating:   0 /10    Characteristics:          	Ht: 60”
Wt: 60.98kg	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	
Bilateral strength in hands and feet. grasps equal ?

A/O X 3  speech clear?
	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength
ADL Assistance    Yes      Fall Risk:    Yes
Fall Score______________
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment ?  
            Needs support to stand and walk ?	
Patient was not currently ambulating independently. Patient did not get out of bed during my shift.  Fall Score – 7. Patient has severe osteoarthritis which also affects mobility and ADLs.
Did he get up your shift? Assist of 1? 	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _________
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____________________	 
S1, S2, S3 and possible S4 present. Capillary refill: ~3 seconds. No Vein Distention. Edema present in pre-tibial area, grade 2+. 	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	
No Accessory muscle use. Breath sounds clear on left, adventitious sounds present in right lung.
	
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:___________	
Not on a special diet, patient snacks at home rather than eat meals. In hospital patient was on a regular diet. Bowel sounds present in four quadrants. No masses or pain upon palpation. No distention, incisions, drains or wounds. Appendectomy and hernia scars present. No ostomy or Nasogastric tube. No feeding or PEG tubes.	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _________
Drains present:  Y         N       Type_______________	
Skin was pink, warm and dry. Loss of elasticity with age, no tenting in infraclavicular area. Skin texture was even throughout, presence of papular type lesions. Cellulitis present bilaterally on lower legs, right leg was somewhat scaly, left leg was scaly and red. No drainage from either leg. IV(size?)in left hand(sl or what fluids running), skin was not inflamed or red. Stage I pressure ulcer present on right upper buttocks, barrier cream and Q2 turns were used to treat.   	
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:            	Patient not HOH. Patient able to see with glasses. Patient wears dentures.(uppers & Lowers?, partials?) 
	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________	
Urine was light yellow and clear. No Dialysis necessary. Perineum was slightly red due to bowel incontinence, barrier cream was being used. Indwelling Urinary Foley catheter present.  (to BSD? Bed side drainage)  There are other types of catheters so be specific

No need to state if dialysis just mark N	
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)	
High School education. Patient is able to cope well with recent diagnoses, doesn’t express any distress. Mother of eight. Not religious. Lives at home, son and girlfriend live in connecting duplex. Son takes care of the house and girlfriend assists with ADLs. Patient refers to son’s girlfriend as “best friend”.
	
USE THE BACK OF THE SHEET FOR ADDITIONAL SPACE FOR DETAILS. EXPECTATIONS MAY VARY FOR DIFFFERENT COURSES

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

Fatigue related to inadequate tissue oxygenation secondary to congestive heart failure  (are you to use diagnosis here or just describe it like cardiac pump dysfunction? Ask Hedie (Carpenito-Moyet, 2010) .

What does the patient/client need to accomplish?
GOALS/OUTCOMES
(2pts)
Measurable patient centered goals are identified, realistic and contain a time element.

Before discharge, scheduled at 1500, goals for patient would be to identify new ADLs that are realistic based on new diagnosis and fatigue. We will also discuss importance of support from family and friends.	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.

Nurse will discuss fatigue related to recent CHF diagnosis with patient, and discuss how this will affect patients ADLs. We will also discuss ADLs that patient can perform, ADLs that may require assistance. Patient will be on hospice at home, so discussion of hospice is important and how it will affect quality of life. We will also discuss importance of family and family support.
Can you be more specific and write down just what you would discuss with her. What Adl’s can  she do and what should she avoid?
How will the hospice affect her quality of life. 
Spell it out.	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.

In many chronic diseases, fatigue is common, disruptive, and distressing because it interferes with ADLs. It is important to identify values and interests, areas of success and usefulness, and identify sources of hope and realist short- term goals. 
(Carpenito-Moyet, 2010)	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.

Patient acknowledged change in health status and did not express or appear to be in distress. Patient was very happy to be going home, and expressed deep appreciation for son and his girlfriend.  Patient also understood that ADLs would be performed based on day-to-day feeling and fatigue. 

	

References

Carpenito-Moyet, L. J. (2009). Nursing diagnosis, application to clinical practice. (13th ed., pp. 253-259). Philadelphia, PA: Lippincott Williams & Wilkins.
Jacobs, D., DeMott, W., & Oxley, D. (2002). Laboratory test handbook. (3rd ed.). Hudson, OH: Lexi-Comp.
Hogan, M., & Hill, K. (2005). Pathophysiology, reviews & rationales. Upper Saddle River, NJ: Pearson Education.
Wolters Kluwer. (2011). Nursing2012 drug handbook with online toolkit. Philadeplia, PA: Lippincott Williams & Wilkins.
Does Wolters Kluwer have an editor?