Student name: 	Paula Ridl				Date of Care:		4/3/12	40/40
History of Present Illness (HPI)
Patient Initials: 	SP	  Pt Age: 51	  Gender:__F___   Date of Admission: 	4/2/12	
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)
51 year old female admitted to hospital with cellulitis, abscess, and pain in the right ankle.  Patient has a history of brittle diabetes, HTN, and high cholesterol.  X-Ray ordered to check vascular blood flow in the ankle.  Also ordered were an ECG and CBC.  Patient to have surgery on 4/3 to debride right ankle.

Medical & Surgical history (list the year of the diagnosis/ surgery)   (1 pt)
Years for medical and surgical history not listed.
Brittle Diabetes		C-Section			HTN
Right Knee Surgery		Chronic Constipation		High Cholesterol
Arthritis			Bronchitis			1999 & 2005 CVA x2
Eye Surgery – Retinal Bleed

Social History   (1pt)
Occupation:  Disabled/Unemployed
Lives with? Husband
List family members involved with your patient’s care.  TP-husband  MS-mother
Habits (Tobacco/Alcohol/ Drugs)
Occasional Alcohol use
Smoker
No Drugs

Nursing Care:    (1 pt)
Isolation  None
Code Status:  Full or DNR
Pain  0
Fall Risk 0  
Hygiene Independent
Activity  Independent
Diet  	1800 Calorie Diet
List the equipment that is needed or being used to care for this patient?  (e.g. IV, Foley, Oxygen…)
Hep Lock 22 gauge
Pathophysiology:

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

Describe the pathology of this disease; include any causative factors/ etiologies that can be identified  
(5 pts).
Cellulitis is a type of bacterial infection involving the skin.  The dermis and subcutaneous layers of the skin are usually involved in cellulitis, and the bacteria involved is usually one found in normal skin flora such as Streptococcus aureus.  Cellulitis can also be brought on by bacteria that are associated with activities such as handling fish, swimming in fresh or salt water, or from animal scratches or bites.  Bacteria can also find entry through wounds and athlete’s foot.  Cellulitis most often occurs on the legs, the hands, and the pinnae of the ears.  Cellulitis lesions are red, swollen, tender plaque like with an irregular border, and can cover a small to wide area.  Fever, erythema, heat, edema, and pain are found in patients with cellulitis.  The lymph system is often implicated in a cellulitis infection, and with recurring infections often weakens lymph drainage, leading to chronically swollen legs.  This eventually leads to lymphedema and dermal fibrosis, and if not treated correctly could lead to septicemia, nephritis, and even death.  Oral and intravenous antibiotics aimed at the specific organism are the best treatment (Porth, 2011).

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	6.1	4.5-11
	RBC	3.42L	4.1-5.1		Lack of protein in diet or ability of body to process protein Diabetes
	Hgb	10.2L	12-16		Lack of protein in diet or ability of body to process protein Diabetes
	HCT	30.5L	36-46		Lack of protein in diet or ability of body to process protein Diabetes
PLT	290	150-450
INR	
     Chemistry	Value	Normal	If not, why not?  Please relate to the disease process.
	Na	134L	135-145	Stress due to hospitalization and surgery ↑ ADH
	K	3.6	3.4-4.5
	Cl	99	98-107
	BUN	17	6-26
	Cr	0.7	0.5-1.0
	Glucose  99	70-99
	Other
    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:  Right Ankle X-Ray to check vascular flow - normal
     ECG / Telemetry  ECG-sinus rhythm normal, normal ECG-test done to check heart efficiency
     CT (Cat Scan) 
     MRI
     Ultra Sound
     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	
Novolog Flexpen (insulin aspart 70/30)
Sliding Scale parameters TID AC SC/
Total Daily dose prior to meal 2-4 inj/day	Antidiabetic, pancreatic hormone/decreases blood glucose by transporting glucose into cells and the conversion of glucose to glycogen	DM	Pregnancy (B) /hypersensitivity to protamine, creosol	Hold on medicine until after patient has surgery	
Novolog 70/30 (insulin aspart  prota 70% aspart 30%) As directed BID SC/2-4 inj/day prior to meals	Insulin/decreased blood glucose by transporting into cells	DM	Pregnancy, hypersensitivity to protamine, creosol/anaphylaxis, hypoglycemia, lipodystrophy	Hold on medicine until after patient has surgery	
Sodium chloride
Flush IV line w/3ml As directed PRN INJ 	Replacement Preparations, Irrigating solutions/Source of water and electrolyte	Hep Lock Flush	Pregnancy (C), Hypertonic solution may cause vein damage/Phlebitis, extravasation, disseminated intravascular coagulation	Patient tolerates medicine	
Dilaudid (hydromorphone HCl)
Per PCA protocol Cont IV/
1-2 mg q4-6hr PRN	Opioid analgesic/Inhibits ascending pain pathways in the CNS, increases pain threshold, alters pain perception	Pain	Pregnancy (C), breastfeeding, children <18 yr, addictive personality, increased intracranial pressure, acute MI, severe heart disease, renal/hepatic disease, bowel impaction, abrupt discontinuation, COPD/Hypersensitivity	Patient tolerates medicine
Pain 0/10	
Diovan (valsartan) 80 mg QAM PO/80-160 mg/day	Hypertensive Agents/Blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II	HTN	Breastfeeding, children, geriatric patients, hypersensitivity to ACE inhibitors, CHF, hypertrophic cardiomyopathy aortic/mitral valve stenosis, CAD, angioedema, renal/hepatic disease/CVA, MI, hepatotoxicity, nephrotoxicity	Patient tolerated medicine
BP 111/62 after med taken	
Narcan (naloxone HCl) 0.1mg PRN IV reversal/0.4-2 mg, repeat q2-3 min if needed max 10 mg	Opioid Antagonist/
Competes with opioids at opiate receptor sites	Respiratory depression from hydromorphone HCl	Pregnancy (C), breastfeeding, children, neonates, CV disease, opioid dependency, seizure disorder, drug dependency, hypersensitivity/seizures, ventricular tachycardia, fibrillation, cardiac arrest, sinus tachycardia, hepatotoxicity, pulmonary edema	Med not given PRN	
Benadryl (diphenhydramine HCl) 25 mg Q4H PRN IV Pruritis/10-50 mg, max 300 mg/day	Enthanolamine Derivatives Antipruritics & Local Anesthetia/Acts on blood vessels, GI, respiratory system by competing with histamine for H1 receptor site; decreases allergic response by blocking histamine	Allergies	Pregnancy (B), breastfeeding, children<2 yr. increased intraocular pressure, cardiac/renal disease, hypertension, bronchial asthma, seizure disorder, stenosed peptic ulcers, hyperthyroidism, prostatic hypertrophy, bladder neck obstruction/seizures, thrombocytopenia, agranulocytosis, hemolytic anemia, anaphylaxis	Med not given PRN	
Benadryl (diphenhydramine HCl) 25 mg Q4H PRN PO Pruritis/25-50 mg Q4-6hr, max 300 mg/day	Enthanolamine Derivatives Antipruritics & Local Anesthetia/Acts on blood vessels, GI, respiratory system by competing with histamine for H1 receptor site; decreases allergic response by blocking histamine	Allergies	Pregnancy (B), breastfeeding, children<2 yr. increased intraocular pressure, cardiac/renal disease, hypertension, bronchial asthma, seizure disorder, stenosed peptic ulcers, hyperthyroidism, prostatic hypertrophy, bladder neck obstruction/seizures, thrombocytopenia, agranulocytosis, hemolytic anemia, anaphylaxis	Med not given PRN	
Teflaro 600 mg Sodium Chloride 0.9% 250 ml (ceftaroline fosamil 600 mg Sodium Chloride) 250 ml at 250 mls/hr Q12HR IV/600 mg IV over 1 hour Q12HR for 5-14 days	Cephalosporins Replacement Preparations/Binds to essential penicillin binding proteins and is active against gram positive and gram negative bacteria	Cellulitis/Abscess	Anaphylaxis, hypersensitivity to penicillins, renal impairment, breastfeeding/Rash, diarrhea, nausea, C.diff., hepatitis, seizure, renal failure	Medication started but infiltration occurred at IV site so medication discontinued- no adverse effects noted except infiltration	
("Mosby’s," 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 %:
99% 
Room Air	BP:
116/67	Pulse:
Rate: 78
Rhythm: Regular	Respirations:
Rate: 16
Rhythm: Regular	Temp:
97.8
Route: Oral	Pain:
Rating:       0 /10    Characteristics:          	Ht: __67.99”_______
Wt: _103.419 kg____	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	
MAE X4, Oriented X3, Speech 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 exhibited full ROM in all joints except right ankle, Patient Independent ADL’s, Independent Activity, Independent Mobility
	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: ___<2 sec______
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema___right ankle _________________	 
S1, S2 audible no S3, S4 no murmurs, gallops or rubs
Heart Rate is 78
BP is 116/67
Extremities are warm, nonpitting edema in right ankle	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	Thorax symmetric with equal expansion
Lungs – resonant, breath sounds vesicular, no rales, wheezes
	
GASTROINTESTINAL:
Diet at home :  Eats anything wants Current Diet:   1800 calorie 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:___________	
Abdomen is round with hypoactive bowel sounds, soft non tender, no masses
At home eats anything she wants, hospital diet 1800 calories
Last BM Monday with use of laxative, chronic constipation with BM only occurring with use of laxatives	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _____18____
Drains present:  Y         N       Type_______________	Skin color consistent with ethnic background
Skin warm and dry.
Nails without clubbing or cyanosis
No suspicious nevi, petechiae or ecchymoses
22 gauge LFA infiltration-discontinued intact	
EENT: 
Ears:   2                         Eyes: Glasses
Nose:   1                       Teeth:  Dentures top & partial bottom          	Patient wears glasses
Patient has full top dentures and partial plate on bottom
Eyes, ears, and nose are symmetrical 
	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________	
Patient had bathroom privileges

	
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 received GED
Developmental level consistent with age of patient

Factory worker now disabled
Jehovah Witness
Husband, Mother, 4 children, 5 grandchildren	
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)
Risk for Infection related to compromised host defenses as evidenced by low lab values of RBC, Hgb, HCT, surgery, stress, smoking, nutritional deficiencies, receiving IV antibiotics.
(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.
	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.	

Patient will demonstrate back proper handwashing technique by discharge

	
Nurse will educate patient on proper handwashing technique	
Proper handwashing with soap aids in the removal of microorganisms that can cause infections.
(Taylor, Lillis, LeMone, & Lynn, 2011)	
Client was responsive to intervention and participated in handwashing 
Goal met	
Reference List for all references used in this document.     Use APA format.          (1 pts)	
References
Carpenito-Moyet, L. J. (2010). Nursing diagnosis application to clinical practice (13th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Drug reference. (2011). In Mosby’s nursing drug reference (24th ed.). St. Louis, MO: Elsevier Mosby
Porth, C. M. (2011). Essentials of pathophysiology (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of nursing the art and science of nursing care (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.