Student name: Rachel Walker		Date of Care:	February 21, 2012	37/40		
History of Present Illness (HPI)
Patient Initials: V.D.	  Pt Age: 77	  Gender: F   Date of Admission: February 19, 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)
Pt. had a bladder stimulator placed a week ago in Bloomington by Dr. Miller. She has been on cephalexin since the procedure. The last 5 days she has developed diarrhea which progressed to nausea and vomiting. She began complaining of abdominal pain in the last 48 hrs.

Medical & Surgical history (list the year of the diagnosis/ surgery)   (1 pt)
(diagnosis date for medical history is unknown) Emphysema, Diabetes, COPD, GERD, Heart disease, Hypercholestoremia, Hypertension, MI, C-Diff

Appendectomy (1952), Hysterectomy (1976), Cholecystectomy (1990), Bladder Sling (2001), Heart Catheterization (1990, 2008, 2011), Bladder Stimulator (2012)

Social History   (1pt)
Occupation: Retired
Lives with? Husband
List family members involved with your patient’s care. No one presently involved in patient’s care. Doctor gave consult and referral for home health services
Habits (Tobacco/Alcohol/ Drugs) N/A

Nursing Care:    (1 pt)
Isolation Contact C-Diff+
Code Status:  Full or DNR
Pain 6/10
Fall Risk 3
Hygiene Pt. performs with assistance
Activity Up with assistance to BSC.
Diet: Regular
List the equipment that is needed or being used to care for this patient?  (e.g. IV, Foley, Oxygen…)
Oxygen: 2L/NC   IV: 20 gauge/ RAC  Foley catheter

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

Describe the pathology of this disease; include any causative factors/ etiologies that can be identified  
(5 pts).
Gastroenteritis is an inflammation of the stomach and intestines. It causes diarrhea, vomiting, and nausea. The common causes of gastroenteritis are virus, bacteria, intestinal parasites, and food poisoning. Ways to prevent spreading the infection is by frequent hand hygiene, cleaning/disinfecting soiled areas immediately, and avoid cross contamination. Typically this disorder of the stomach is self limiting but in severe cases it may be treated with antibiotics.
(Understanding Pathophysiology Fourth Edition) (Huether & McCance, 2008, pgs. 946-947)

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	9.1	(5.0-10.0)
	RBC	3.23L	(4.2-5.4)	Dietary deficiency and anemia can cause the low RBC, Hgb,  and Hct
	Hgb	10.4L	(12-16)
	HCT	30.2L	(37-47)
PLT	195	(150-400)
INR	N/A
     Chemistry	Value	Normal	If not, why not?  Please relate to the disease process.
	Na	131L	(136-145)	Dehydration from vomiting and diarrhea which caused imbalanced electrolytes
	K	3.5	(3.5-5.0)
	Cl	100	(98-106)
	BUN	13	(10-20)
	Cr	0.9	(0.5-1.1)
	Glucose 122	(50-100) 	Glucose level is abnormal as diabetic patient’s insulin was withheld per doctor due to poor dietary intake
	Other
    Urinalysis N/A

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:
 Chest and abdominal x-ray done r/o acute disease in the chest and r/o displacement of the bladder stimulator, continue to monitor patient for abdominal distention or pain, vital signs, and inflammation/drainage of the surgical site
     ECG / Telemetry
     CT (Cat Scan)
     MRI Ultrasound

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	
Aspirin  81mg, 1 chewable tablet, PO QAM 	Non-opioid analgesic/Blocks pain impulses in CNS,reduces inflammation by inhibition of prostaglandin synthesis; antipyretic action results from vasodilation of peripheral vessels; decreases platelet aggregation	Interventional medication for hypertension	Monitor for increased PT OR APTT, bleeding time
Rapid pulse, pulmonary edema, dizziness, confusion, seizures, anemia	Patients blood pressure remained within a normal range	
Imuran (Gen-Azathioprine) 50mg, 1 tablet, PO QAM	Immunosuppressant/Produces immunosuppression by inhibiting purine synthesis in cells	Interventional medication  for rheumatoid arthritis 	Monitor for infection/increased temp, I&O, ROM, hepatotoxicity, nausea, vomiting, stomatitis, esophasgitis, jaundice	No complaints  of pain in joints when ambulating or sitting down	
Lamictal (Lamotrigine)200mg, 2 tablets 100mg each, PO, QAM 	Anticonvulsant/ Unknown Moa, may inhibit voltage sensitive sodium channels	Interventional medication to prevent seizures	Monitor for seizure activity,rash,altered mental status, dizziness, ataxia, headache, fever,tremor,anxiety, abdominal pain	Patient did not have any seizures during my shift	
Lovenox (Enoxaparin) 40mg, SC, Daily @ 1400	Anticoagulant, antithrombotic
Binds to antithrombin III inactivating factors Xa/IIa resulting in higher ratio of anti-factor Xa to IIa	Interventional medication to prevent DVT’s and it thins the blood	Monitor for neurologic symptoms, bleeding gums, Hct, hgb, CBC, coagulation test, fever, confusion,nausea, vomiting, hemorrhage, anemia	Patient  did not complain of pain or swelling in upper or lower extremities and no DVT’s reported	
Rocephin
(ceftriaxone) 1gm in sodium chloride 0.45% 50 mL,IV, 200 Ml/hr Q24hr	Cephalosporins, 3rd generation/bactericidal; inhibits cell wall mucopepticle synthesis	Interventional medicine to treat infection	Monitor serum drug levels if renal failure or malnutrition and anticoagulant, neutropenia, leucopenia, or anemia	WBC  decreased	

Zofran 
(Ondansetron) 4mg(2mL), IV, QID, PRN	Nausea/vomiting MOA: selectively antagonizes serotonin 5Ht3 receptors	Interventional medication to prevent nausea/vomiting	Monitor ECG if electrolyte abnormalities, CHF, or Bradyarrhythmias , headache, constipation, fatigue, diarrhea, hypoxia	No nausea or vomiting from patient during my shift	
Wellbutrin SR (bupropion HCL) 150mg, 1 tablet, PO, BID	Other Antidepressant/ Smoking cessation unknown, exact MOA action for depression unknown inhibits neuronal, uptake of norepinephrine and dopamine	Interventional medication to help induce smoking cessation	Monitor CR. At baseline , suicidality, unusual behavior changes, especially during initial dose	Pt did not express a desire to smoke during my shift	
Citation	www.epocrates.com (2012, Epocrates, INC.)				

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 %:

90% with 2L/NC	BP:

156/82 
LA in semi-fowlers position	Pulse:
Rate: 112
Rhythm: irregular +3 bounding
Which pulse?	Respirations:
Rate: 30
Rhythm: irregular, fast shallow breaths	Temp:
99.8F
Route:
Tympanic	Pain:
Rating: 0/10    Characteristics:N/A          	Ht: 5’ 2”____
Wt: 126lbs=57.27KG	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	
Alert and oriented X 2 ( name and place), sensory and speech clear 

What was she disoriented in?
	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength
ADL Assistance    Y   N       Fall Risk:    Y   N
Fall Score_______3_______
Activity/Mobility Status:    Independent: no 
            Needs assistance with equipment   
            Needs support to stand and walk	

Limited ROM on L/R arm	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: __>3_______
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____________________	 
	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	
Wheezing and diminished breath sounds in lungs bilaterally. Respiratory easy on O2 @ 2L and sitting in a semi fowler’s position in the bed.
	
GASTROINTESTINAL:
Diet at home : Regular                Current Diet:   Regular
Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools
2/21/2012,  runny greenish –yellow small x1                      
Palpation: Pain, Mass etc
Inspection: distention, incisions, scars, drains, wounds
Ostomy:    Y       N         Nasogastric:    Y      N  
Feeding tubes/PEG tube   Y      N      Type:___________	

Abdomen soft and non-tender. BS X 4 QUADS

INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: ____20_____
Drains present:  Y         N       Type_______________	Skin warm and pink
No tenting, rashes, bruises
Wound noted in chart on R dorsal gluteal area (unable to assess) Nurse refused removal of wound coverage dated for 2/19/2012	
EENT: 
Ears:   N/A                       Eyes: Brisk
Nose:   Patent                      Teeth: Dentures 
                                              Full or partial?          	Oral care completed and dentures were placed. Pt’s daughter requested dentures be removed. Dentures put in appropriate container and  placed on bedside table per daughters’ request
	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals  ?  Probably during bath
Catheter:  Y    N      Type__Foley___________	
Yellow, Clear, 920cc, no pain

Cath care done?
	
PSYCHOSOCIAL/CULTURAL:
Educational level  ask her
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)	
Alert and Oriented X 2
 Cognitive
 effective coping methods
 Pt. believes she is in fair health
 Retired from what? Maybe has occupation related disease or illness 
Active Catholic and talked about participating in “Lent” went and attending mass upon discharge
Does not have much support at home. She lives with her husband whose health is declining. Husband currently has a home health nurse. Patient will also have home health services upon discharge
	
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 imbalanced nutrition: less than body requirements r/t inability to ingest and dysfunctional eating pattern and problems with insulin regulation
“Pt. stated I do not like chewing for a long time and don’t want to eat.”

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.	

Client will
Consume adequate nutrition and identify nutritional requirement by the end of the shift

	
Encourage Pt to eat food without beverages or offer nutritional supplementary shake 

Educate patient on importance of adequate nutrition and how it helps in the healing process from surgery or illness

How is it important to the diabetes?

Maybe accu checks q 6 hours?  With insulin coverage per sliding scale? If ordered by physician?	
Such supplements can be used to increase calories and protein without interfering with voluntary food intake

The patient’s perception of actual intake may differ

(Gulanick & Myers, 2007,pg. 135-136)	
Client ate 20% of breakfast and drank 60% of Ensure.

Client was receptive to nutritional education at 100%

Goals met at 100%

I could have offered to sit with patient during meal, suggest more ways to assist patient with eating meals, or encourage daughter to bring in food	
Reference List for all references used in this document.     Use APA format.          (1 pts)	

Gulanick, M., & Myers, J. (2009). Nursing care plans (6th ed.). St. Louis, MO:Mosby  Elsevier.
.
 Huether, S., & Mc Cance, K. (2008). Understanding pathophysiology (4th ed.). St. Louis, MO: Mosby Elsevier.
Pagana, K. D. (2009). Mosby’s diagnostic and laboratory test reference (9th ed.). St. Louis, MO: Mosby Elsevier.
www.epocrates.com(2012), Epocrates, INC.