Student name:	 Kristin	Schomburg				Date of Care: March 27, 2012  39.5/40
History of Present Illness (HPI)
Patient Initials: E.E. 		 Pt Age: 74 Gender: F   	Date of Admission: March 21, 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. E went to bed on the evening of March 20 and woke in the middle of the night with abdominal pain. She went to the bathroom, became very dizzy and passed out. When she woke up she called 911 and was admitted for hypotension and abdominal pain.

Medical & Surgical history (list the year of the diagnosis/ surgery)   (1 pt)
-	Appendectomy & Choleystectomy
-	Tubal ligation
-	Bout of throat cancer
-	Right sided breast cancer & lumpectomy (1996)
-	Colonoscopies & EGD within last five years

Social History   (1pt)
Occupation: Mother of six.
Lives with: Alone.
List family members involved with your patient’s care: One daughter.
Habits (Tobacco/Alcohol/ Drugs)
-	Smokes approximately 1 PPD. Has cut back from 3 PPD. 
-	No alcohol use. 

Nursing Care:    (1 pt)
Isolation: None
Code Status:  Full
Pain: Ranges from 0-5
Fall Risk: Yes
Hygiene: Partial Assist
Activity: Bed rest with bathroom privileges
Diet: Full liquid
List the equipment that is needed or being used to care for this patient?  (e.g. IV, Foley, Oxygen…)
-	Two 22g IV’s one in left wrist, one in right hand.

Pathophysiology:
Identify the primary disease(s) that will be explained in this paper.    (1pt)
- Small bowel obstruction

Describe the pathology of this disease; include any causative factors/ etiologies that can be identified: 
-	Small bowel obstruction is a blockage of the intestine which leads to intestinal distention by gas and air, pooling of gastric and biliary secretions, and loss of fluids, electrolytes, and proteins (Hogan & Hill, 2004).  
-	Etiology is unknown; Mrs. E was having regular daily bowel movements consisting of soft, formed fecal matter.
(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 Test	Patient Value	Normal Lab Value	If not normal, why?	
WBC	6.2	4.0-11.0	Normal	
RBC	3.86	3.63-5.04	Normal	
Hgb	12.7	12-15.3	Normal	
HCT	35.5	34.7-45.1	Normal	
PLT	139	150-450	Low, likely a splenic reaction to the SBO.	
(Jacobs, DeMott & Oxley, 2002)

Chemistry Test	Patient Value	Normal Lab Value	If not normal, why?	
Na	139	135-145	Normal	
K	3.2	3.4-4.5	Low, a nutritional imbalance from being NPO.	
Cl	104	98-109	Normal	
Ca	9.2	8.8-10.2	Normal	
Mg	1.7	1.3-2.2	Normal	
BUN	20	6-26	Normal	
Cr	0.6	0.5-1.0	Normal	
GFR	98	75	Normal	
CO2	29	23-31	Normal	
Anion Gap	10	13-19	Low, protein is low, likely from nutritional imbalance from being NPO.	
Glucose	143	70-99	Elevated	
Total Protein	5.7	6.4-8.3	Low, likely from nutritional imbalance from being NPO.	
Albumin	3.5	3.4-5.2	Normal	
(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?
-	CT of Pelvis and Abdomen: showed dilated loops of mid-small bowel with normal sized loops in the proximal and distal suggesting possible incomplete small bowel obstruction.
-	I will take extra time to listen to bowel sounds and palpate the abdomen, noting any changes or inconsistencies. 

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	
Levofloxacin
	Levaquin
750mg/D5W150mL
100mL/HR IV	Antibiotic	Infection of small bowel.	Infuse doses of 750MG over 90 minutes	Patient tolerated well.	
Nicotine
	Habitrol
21MG/24HR  QAM Transdermal Patch	Autonomic Drug	Nicotine Addiction	Put new patch in new location.	Patient tolerated well.	
Fat Emulsion	Liposyn II 20%
IV 250mL 
Daily @ 1000	Caloric Agent	Patient has not been eating due to SBO	Infuse 250mL of 20% lipids to equal 500mL of 10%	Patient tolerated well.	
Hydromorphone HCl	Hydromorphone HCl
0.4mg/mL
30mL	Opioid Analgesic	Pain Control	Document dose given @ 0600, 1400, & 2200 on PCA	Patient had some nausea.	
Naloxon HCl	Narcan
0.4mg/mL Amp
IV PRN	Antidote, opioid antagonist	Reverse effects of Hydromorphone HCl	For respiratory depression <8 resp/min stop PCA, give Narcan 0.1mg IV stat, call MD. Repeat 0.1mg Q 2 minutes PRN up to 0.4mg.	N/A	
Flagyl	Metronidazole
100mls/hr
1 100ml Bag	Antiprotozoals	Prevent bacterial infection of SBO.	Monitor liver function, edema, and stool character.	Patient tolerated well.	
Peripheral Perinteral Nutrition	Clinimix
50mls/hr	Nutritional Supplement	Nutritional supplement	Monitor hemoglobin and chemistry labs.	Patient tolerated well.	
(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 %: 93
3L O2 by NC	BP:  148/82
Manual, upper L. arm	Pulse: 82 Apical
Rate: Regular
Rhythm: Irregular	Respirations: 30
Rate: Regular
Rhythm: Regular	Temp: 99.4F

Route: Oral	Pain: 
Rating:   0      /10    Characteristics:          	Ht: 64.02”
Wt:  84.45kg	
NEUROLOGICAL: 
 MAE:   Y  X 4              PERLA:    Y   - bilaterally   
Strength Equal:   Y          Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	Strength was equal bilaterally in hands and feet with dorsi flexion and plantar flexion. Speech was clear, patient was A & O X3. No sensory deficits detected. 

	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength
ADL Assistance    Y         Fall Risk:    Y  
Fall Score: 2
Activity/Mobility Status: Needs support to stand and walk	Patient required assistance with bath in the bed and toileting. Patient felt too dizzy and weak to get up to commode, so a bed pan was used. Patient refused to sit-up in chair for lunch, afraid that the movement would make her to nauseas to eat.  

CARDIOVASCULAR: 
Heart sounds:  S1  & S2
Peripheral Pulses, Capillary refill: 2-3 sec.
Neck Vein Distention:     N      Edema    N
Location of Edema: N/A	S1 and S2 present. Heart rhythm was irregular, but the rate was consistent, palpated radial and then auscultated apical.  No bruit’s indicated in carotids. Peripheral pulses present bilaterally and graded 2+ in radial pulses, dorsal pedal pulses, and posterior tibial pulses. No edema in pretibial area.  
	
RESPIRATORY:
Accessory muscle use:      N
Breath Sounds: Location, character	Ronchi present in brachial sounds and over right lung. Left lung sounded clear, no adventitious sounds. 
Patient was coughing but was not able to produce mucus. 	
GASTROINTESTINAL:
Diet at home :  General        Current Diet:  Full Liquid 
Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools 
Palpation: Pain, Mass etc
Inspection: distention, incisions, scars, drains, wounds
Ostomy:       N         Nasogastric:        N  
Feeding tubes/PEG tube       N      	Bowel sounds were present in all four quadrants. Patient had a soft, formed bowel movement on the morning of 3-27, with the aid of a rectal suppository.  Some pain present upon palpation in upper right and left quadrants. Bell was slightly distended. Two small scars present from appendectomy and choleystectomy, were fully healed, slightly palpable and flesh colored.	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: 15
Drains present:  Y            	Multiple ecchymotic lesions present on arms from multiple IV access attempts. Skin was very thin and lacked elasticity. Slight infraclavicular tenting was present. Aside from arms, skin was pink, warm and dry. Small blister under right breast. Sacrococcygeal area was not blanching. 
2 IV sites, one 22g in right hand, one 22g in left wrist. Left wrist was causing patient some discomfort. Sites were not pink or red or producing heat.	
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:            	Patient had macular degeneration and wore glasses. Patient had dentures, uppers and lowers. Patient did not have any difficulty hearing. 
	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis      N 
Inspection of genitals
Catheter:     N      	Urine was yellow and clear. No pain with urination. No discharge, lesions, or unusual odors present perineum. Patient was urinating appropriately, approximately 600mL of urine in six hours.  

	
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)	Patient has a high school education. Age appropriate developmental level and coping methods. No specific health beliefs, health isn’t a huge priority. 
Patient is a mother of six. Christian, but no specific religious beliefs.
Patient has six children, husband is deceased. Family appears to be supportive, one daughter visits frequently.

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)
-	Activity intolerance related to inadequate energy sources secondary to inadequate diet and prolonged bed rest.

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.	
-	To eat 50-75% of all meals before discharge. 
-	To sit in the chair for at least an hour three times per day everyday.

	-	Nursing student will discuss importance of eating more, as it will help to increase strength and overall wellbeing. Daughter will help to encourage eating.
-	Nursing student will discuss the importance of sitting in the chair and make a plan with the patient to eat all three meals in the chair.	- Increasing oral intake will help increase strength and balance, and patient will be able to perform ADLs with minimal assistance and with out experiencing vertigo. Sitting in the chair will help to decrease risk of pneumonia and pressure ulcers (Carpenito-Moyet, 2010).

	-	Patient did not respond well to suggested goals. Patient is concerned with feeling nauseous, and despite teaching, doesn’t understand that decreasing the risk for pneumonia is more important than the possibility of feeling nauseous. 
-	The use of an anti-emetic may be very beneficial for this patient, and was discussed with her nurse.
-	Goals will be reassessed after use of anti-emetic is approved or not.    	
Reference List for all references used in this document.     Use APA format.          (1 pts)	

Carpenito-Moyet, L. J. (2009). Nursing diagnosis, application to clinical practice. (13th ed., pp. 60-63). Philadelphia, PA: Lippincott Williams & Wilkins.
Hogan, M., & Hill, K. (2004). Pathophysiology, reviews & rationales. (1st ed., Vol. 1, pp. 245-246). Upper Saddle River, NJ: Pearson Education, Inc.
Jacobs, D., DeMott, W., & Oxley, D. (2002). Laboratory test handbook. (3rd ed.). Hudson, OH: Lexi-Comp.
Wolters Kluwer. (2011). Nursing2012 drug handbook with online toolkit. Philadelphia, PA: Lippincott Williams & Wilkins.