Student name: 	Paula Ridl				Date of Care:		3/20/12	39.5/40
History of Present Illness (HPI)
Patient Initials: 	MAB	  Pt Age: 83	  Gender:__F___   Date of Admission: 	3/16/12	
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)
83 year old female entered the emergency department from the nursing home with abdominal pain and rectal bleeding possible diverticulitis.  Patient was passing black stools.  WBC was 15,300, and K+ was 2.6.  Patient suffers from dementia so she is not a good source of medical information.  A CT scan was ordered and showed fecal impaction with areas of erosion suggestive of gas.  

Medical & Surgical history (list the year of the diagnosis/ surgery)   (1 pt)
Years for medical and surgical history not listed.
Venous Insufficiency in both legs		GI Bleed
Incontinent – urine				Dementia
HTN						Organic brain syndrome
2012/Dehydration & Weakness		Osteoporosis
Anxiety					Arthritis

Social History   (1pt)
Occupation:  Retired
Lives with? Nursing home – Hawthorne Inn
List family members involved with your patient’s care.  Karen-daughter
Habits (Tobacco/Alcohol/ Drugs)
No Tabacco
No Alcohol
No Drugs

Nursing Care:    (1 pt)
Isolation  None
Code Status:  Full or DNR
Pain  0
Fall Risk  9
Hygiene Dependent
Activity  Total Assistance
Diet  Full Liquid 
List the equipment that is needed or being used to care for this patient?  (e.g. IV, Foley, Oxygen…)
Indwelling Foley Catheter, Hep Lock
Pathophysiology:

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

Describe the pathology of this disease; include any causative factors/ etiologies that can be identified  
(5 pts).
Diverticulitis is a problem of diverticulosis in which there is a perforation in the colonic diverticula and accompanying inflammation.  Common complaints include lower abdominal tenderness, change in bowel habits whether diarrhea or constipation, bloating, and gas.  Most often the patient with diverticulitis will present with pain and tenderness in the LLQ, fever, increased WBC, nausea, vomiting.  Symptoms usually last for a few days unless complications arise, which are caused by localized inflammation and perforation of the diverticula that can development into a small localized abscess.  Complications can consist of perforation with peritonitis, hemorrhage, and bowel obstruction.  Diagnosis of diverticular disease is centered on presenting clinical symptoms and history.  CT scans can confirm the presence of diverticular disease.  Preventing symptoms and complications is the treatment for diverticular disease.  This may include retraining of the bowel and increasing bulk in diet to be able to produce a daily bowel movement.  Acute diverticulitis is usually treated by withholding solid food and administering a broad spectrum antibiotic.  
(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	3.26L	4.1-5.1		Rectal bleeding is a complication of diverticular disease
	Hgb	10.3L	12-16		Rectal bleeding is a complication of diverticular disease 
	HCT	29.3L	36-46		Rectal bleeding is a complication of diverticular disease
PLT	194	150-450
INR	1.0
     Chemistry	Value	Normal	If not, why not?  Please relate to the disease process.
	Na	144	135-145
	K	3.4	3.4-4.5
	Cl	111H	98-107		IV fluids/diarrhea
	BUN	22	6-26
	Cr	0.9	0.5-1.0
	Glucose  119H	70-99		IV fluids
	Other
    Urinalysis
Yellow Clear pH 5.0, Specific Gravity 1.010, Protein Pos 1+H, Blood Pos 3+H, RBC 2-5H, Uric Acid Crystals 4+ H, Urobilinogen Pos 1+H
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:
     ECG / Telemetry
     CT (Cat Scan) – Abdomen – Fecal impaction in colon extending to the mid distal ascending colon
     MRI				  Fecal impaction is a complication of diverticulitis
     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	
Dulcolax (bisacodyl)
10 mg QHS PO/
10-15 mg PO in am or pm	Cathartics & Laxatives/Acts on intestine by increasing motor activity;
thought to irritate colonic intramural plexus	Fecal Impaction	Pregnancy (C), 
breastfeeding/
muscle weakness, 
nausea, vomiting,
 tetany, electrolyte imbalances
	Drug not given	
Milk of Magnesia
(magnesium hydroxide) 1 X at 10 PO/15-60 ml at bedtime	Cathartics & Laxatives/
Increases osmotic pressure draws fluid into colon, neutralizes HCl	Fecal Impaction	Pregnancy (A), renal/cardiac disease, rectal bleeding/flaccid paralysis, circulatory collapse, muscle weakness, hypotension, vasodilation, nausea, vomiting, anorexia, cramps, diarrhea	Drug not given	
Zosyn (piperacillin/
tazobactam) 
100 ml at 25 mls/hr Q8HR IV/6-12 g/day given 2.25 g Q8HR IV	Cephalosporins B Lactam Antibiotics, Misc/Interferes with cell wall replication of susceptible organisms, cell wall swells and bursts –osmotic pressure, tazobactam protects piperacillin from degradation by enzymes	Infection	Pregnancy (B), breastfeeding, renal insufficiency in children, hypersensistivity to cephalosporins, CHF, seizures, GI disease, electrolyte imbalance	Patient tolerated drug
WBC 6.1	
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	Not given	
Potassium Chloride/Dextrose/ Sodium Chloride 1000 ml at 80 mls/hr Q12H 30M IV/ As directed by physician	Replacement Preparations/
Source	Nutrition, Water, & Electrolytes	Allergy to corn or corn products,CHF, renal failure, overhydration, pulmonary edema/Fever, infection, venous thrombosis, phlebitis, extravasation	Patient tolerated	
(Abrams, Pennington, & Lammon, 2009)

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 %:
100%
Room Air	BP:
128/66
Right Arm	Pulse:  88
Rate 88
Rhythm:  Regular	Respirations:  22/min
Rate:  22
Rhythm: Regular	Temp:
97.2
Route: Oral	Pain:
Rating:   0     /10    Characteristics:          	Ht: ___64.02”___
Wt: __67.041 kg_	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	
Alert, confused, not able to follow instructions, oriented to person only, speech is clear	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength
ADL Assistance    Y   N       Fall Risk:    Y   N
Fall Score____9__________
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment   
            Needs support to stand and walk	
ROM limited; Total Assistance with ADL’s including feeding,
Weakness, History of Falls, 
Activity total assistance, Bed Rest, Muscle cramping in right foot
	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: ___<3 seconds_____
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema__Left foot______________	 S1, S2 audible, no S3, S4, no murmurs, gallops or rubs
Heart Rate is 88 regular rate and rhythm, BP is 128/66 Right Arm
Pitting edema in left foot 2+
	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	Thorax symmetric with equal expansion
Lungs resonant, breath sounds vesicular, no rales or wheezes
	
GASTROINTESTINAL:
Diet at home :   Full Liquid    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:    Y       N         Nasogastric:    Y      N  
Feeding tubes/PEG tube   Y      N      Type:___________	Abdomen is round with hyperactive bowel sounds and gas
Abdomen is tender and painful LLQ
Incontinent BM continuous flow-brown, runny
Incontinent Urine – Foley Catheter
Anal and sacral area is erythemic	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _________
Drains present:  Y         N       Type_______________	Color consistent with ethnic background, skin warm and dry and flaky
Nails without clubbing or cyanosis
No suspicious nevi
No rash, ecchymoses on both elbows and arms
Lower legs brawny skin above ankles, Anal and sacral area erythemic	
EENT: 
Ears:     2                       Eyes: 2
Nose:    1                      Teeth:  own teeth          	Patient has 2 ears, 2 eyes, 1 nose, and own teeth
Symmetric?	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type __Foley_______	Urine is Dark Amber and clear
Perineal area is erythemic

	
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 oriented to person only, not a good source of information or history
Patient retired previous occupation Nurse at St. Elizabeth hospital
Family - daughter

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 Impaired Skin Integrity related to impaired mobility as evidenced by blood lab values RBC 3.26, Hgb 10.3, HCT 29.3, rectal bleeding, full liquid diet, and total assistance with activity.
(Swearingen, 2008)
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’s skin remains intact and upon discharge

Goals usually start with Patient will…..
	
Put patient on a turn schedule and assist in position changes q2h.

Monitor skin over bony prominences for erythema	
Turning relieves pressure on sites at risk for skin breakdown.  A posted schedule makes all staff members aware.
(Swearingen, 2008)

Skin over bony prominences is at increased risk for breakdown because of external pressure.
(Swearingen, 2008)	
Patient’s skin remained intact during clinical time.  Turned patient every hour to clean.  
Goal in progress

Checked skin over bony prominences and put pillow under feet.
Goal in progress	
Reference List for all references used in this document.     Use APA format.          (1 pts)	

References
Abrams, A. C., Pennington, S. S., & Lammon, C. B. (2009). Clinical drug therapy rationales for nursing practice (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Porth, C. M. (2011). Essentials of pathophysiology (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Swearingen, P. L. (2008). All in one care planning resource (2nd ed.). St. Louis, MO: Mosby Elsevier.