Student name: Michael Hoke		Date of Care: 03/27/2012   35/40

History of Present Illness (HPI)
Patient Initials: DM  Pt Age: 65  Gender: F  Date of Admission: 03/23/2012

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)

The patient presented to the hospital from home with complaints of abdominal pain and was diagnosed with acute diverticulitis. 

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

Hypertension
Chest surgery
Skin cancer
Abdominal surgery
Hernia repair
Cholecystectomy 
Hysterectomy
Hypoplastic Right kidney
Arthritis
Orthopedic surgery on knees (bilateral)
Hyperlipidemia
Anemia
Obesity

(No dates were listed)

Social History   (1pt)
Occupation: Unemployed
Lives with? Lives with her husband
List family members involved with your patient’s care.
	- Husband
Habits (Tobacco/Alcohol/ Drugs)
	-No drugs
	-No smoking
	- No alcohol
	- No substance abuse
	- No suspected abuse
Nursing Care:    (1 pt)
Isolation: Standard precautions
Code Status: Full
Pain: 0 on a 0-10 scale
Fall Risk: 0 on a 0-10 scale
Hygiene: Independent 
Activity: Independent (tolerated the activity well)
Diet: Soft diet
List the equipment that is needed or being used to care for this patient?  (e.g. IV, Foley, Oxygen…)
	Patient had a blue 22 gauge IV in her right forearm.
Pathophysiology:

Identify the primary disease(s) that will be explained in this paper.    (1pt)

Acute Diverticulitis	

Describe the pathology of this disease; include any causative factors/ etiologies that can be identified  
(5 pts).

Diverticulitis is a complication of diverticulosis in which there is inflammation and gross or microscopic perforation of diverticula. One of the most common complaints of diverticulitis is pain in the lower left quadrant accompanied by nausea and vomiting, tenderness, a slight fever, and an elevated WBC count. These symptoms usually last several days, unless complications occur and usually are caused by inflammation of the diverticula with perforation and development of small localized abscesses. 

(Porth, 2011, p. 716)

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 Value       If not, why?
WBC	10.4	4.1-10.9x103	High due to Acute diverticulitis	
RBC	2.75	4.3-6.2x106	Low due to anemia	
Hgb	9.9	13.2-16.2 gm/dL	Low due to anemia	
HCT	27.6	40-52%	Low due to anemia and possibly medication	
PLT	        213	140-450x103		

  Chemistry 	              Value            Normal value	    If not, why? 	        
Na	138	37-145 mEq/L		
K	4.3	3.6-5.0 mEq/L		
Cl	105	98-110 mEq/L		
BUN	47	7-21 mg/dl	High due to lisinopril 	
Cr	2.44	0.5-1.4 mg/dl	High due to lisinopril 	
Glucose	98	65-110 mg/dL		

Urinalysis

Urine color	Yellow	
Urine appearance	Clear	
Urine pH	5.0	
Specific Gravity	1.010	

Diagnostic Imaging:
a.	a.	In your own words why is this test done- relate it to the pathology
b.	b.	If abnormal, what changes in your nursing care need to be made?
     Chest X-ray : PA and lateral chest radiographs obtained cardiac silhouette is enlarged trachea is midline. A mass lesion is seen superimposing in the hilar region. This mass is unchanged in appearance in size from the study made 12/5/2008.

Impression:

1.	cardiomegaly
2.	stable mass lesion in right lower lung field
3.	Degenerative changes of aorta
4.	Chest is otherwise normal
     CT (Cat Scan): None
     MRI: None
     Ultra Sound: None

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	
Cyanocobalamin
Vitamin B-12
1000 mcg 
Mo@08/SL

	Vitamin 

For deficiencies	Vitamin B12 deficiency from inadequate diet, total gastrectomy, or other condition, disorder, or disease, except malabsorption, related to pernicious anemia or other GI disease	N/A	Patient was not deficient.	
Acetaminophen 

Tylenol

650 mg

Q6H PRN/PO/PAIN

	Analgesic 

Thought to produce analgesia by inhibiting prostaglandin and other substances that sensitize pain receptors. Drug may relieve fever through central action in the hypothalamic heat-regulating center. 	Patient was taking the medication due to pain. 	Warn patient that high doses may cause liver damage	Patient did not have pain. 	
Sodium Chloride

100 ml @100 mls/hr

Q8HR/IV	Electrolyte Replacement

Replaces sodium and chloride and maintains levels.
	Patient was taking to maintain electrolytes.	Monitor electrolyte balances	Patient had electrolytes that were in the normal lab value ranges. 

	
Omeprazole 
Prilosec
20 mg 
QAM AC/PO

	Antiulcer/Proton pump inhibitor

Inhibits proton pump activity by binding to hydrogen-potassium adenosine triphosphatase, located at the secretory surface of gastric parietal cells, to suppress gastric acid secretion.

	Patient was on the medication due to abdominal pain. (decreased acidity to cut down pain)	There may be an increased risk of spine, wrist, and hip fractures associated with proton pump inhibitors.
	Patient didn’t have any abdominal pain. 	
Lisinopril
Prinivil
20 mg
QAM/PO

	Angiotensin converting enzyme inhibitor (ACE inhibitor)

Causes decreased production of angiotensin II and suppression of the renin-angiotensin- aldosterone system	Patient was on the medication due to elevated blood pressure. 	May increase BUN, creatinine potassium and bilirubin levels	Patient still has high blood pressure even after taking the drug. 	
Piperacillin Sod/Tazobactam Sod 3.375 gm/Sodium Chloride

100 mls @25 mls/hr
Q8HRS/IV

	Antibiotic

Inhibits cell-wall synthesis during bacterial multiplication
	I do not know why the patient was on this medication unless she had some sort of bacterial infection that wasn’t charted anywhere or perhaps she was given the med for the indication of appendicitis and peritonitis. 	May decrease hemoglobin levels	Patient had decreased hemoglobin probably due to the medication as well as the noted anemia. 	
(Comerford, 2012) 
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% room air
	BP: 
179/80
Left forearm 
supine	Pulse: 68
Rate: 68
Rhythm: Regular	Respirations:
Rate: 20
Rhythm: Regular	Temp: 
97.5
Route:
tympanic	Pain:0
Rating: 0/10    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, 	Patient was O/A X3 ; birth year, name and location

Speech was clear

	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength
ADL Assistance    Y   N       Fall Risk:    Y   N
Fall Score__0_
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment   
            Needs support to stand and walk	Patient is independent

Patient did not need any supportive devices

Patient stood from a sitting position in one movement

Patient could use the restroom on her own

Patient showered on her own. 

Patient has full range of motion.

CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _________
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____________________	No murmurs, or neck vein distention, 

Capillary refill >3 seconds

No edema
	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	Breath sounds were clear and regular.
	
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:___________	Diet is soft 

BS X4 quadrants

Patient on 24H Urine 

Rounded abdomen, no tenderness, soft, no scars, drains, or wounds. 

No pain, or masses

Patient did not defecate. 	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: __19_
Drains present:  Y         N       Type_______________	Skin color- pink
No turgor- skin is elastic   Skin pink, warm, dry, elastic.
No rashes
No drains
Skin was warm, dry, smooth
Nail beds were pink
Nail plates were clear
No bruising	
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:            	No hearing aids/adequate hearing 
Patient had glasses for reading-vision is adequate
Nose is patent
Teeth are false-top and bottom dentures
	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________	Color: yellow
Appearance: clear
Patient urinated 500 mls
Did not see patients genitals

No pain
	
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 was Baptist
Patient is unemployed ? retired?
Lives with husband
Last completed bachelor’s degree
Strong family structure 
Patient had a good sense of humor 
	
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)

Acute pain and risk for infection  She was not in pain on your assessment so was this a priority? What is it related to and evidenced by?

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.	
Promote adequate nutrition and fluid intake. Patient will drink 24 oz of water over a 3 hour period and will eat at least 75% of her meal.  To eat 75% in 3 hr also? Probably should have turned that around a little and put time on end.

	Ensure patient has fresh water. Encourage the patient to eat.how would you do this? What other ways besides verbal encouragement could you have done? 	The reason the patient should intake adequate nutrition and drink enough water is to increase the bulk of the stool. 
(Porth, 2011, p. 716)
	The patient was cooperative to 
the interventions she drank 24 oz of water 
in a 3 hour period she accomplished that
goal 100% and she also ate 75% of her
breakfast; she accomplished that goal 
100% as well. 	
Reference List for all references used in this document.     Use APA format.          (1 pts)	

1.      Comerford, K. C. (Ed.). (2012). Nursing 2012 drug handbook (32nd ed.). Philadelphia:    Wolters Kluwer Lippincott Williams and Wilkens.
2.      Porth, C. M. (2011). Essentials of pathophysiology (3rd ed.). Philadelphia: Wolters Kluwer Lippincott Williams and Wilkins.