Student name: Rachel Walker		Date of Care: March 20, 2012    39/40
History of Present Illness (HPI)
Patient Initials: J.J.  Pt Age: 65   Gender: F   Date of Admission: March 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. came to emergency room with complaints of weakness, dizziness, chills, severe sharp aching abdominal pain, and dysuria x 5 days after Chemotherapy treatments. Nausea and coming  x 3-4days.

Medical & Surgical history (list the year of the diagnosis/ surgery)   (1 pt) 
Hysterectomy (1988), GERD (2003), Diabetes (1997), HTN (1999), MI (2005),  Anemia (2004), Leukemia (2008) Depression (2001) Neutropenia (3/19/2012) Chemotherapy  (3/2012)

Social History   (1pt)
Occupation: Retired Accountant 
Lives with? Lives with a 24 hour caregiver and has one daughter
List family members involved with your patient’s care. Caregiver is POA and very involved in Pt. care. Pt. daughter lives out of state but pays to provide 24 hour care for her mother. Daughter is actively supportive of Pt and communicates via phone with physicians and legal /financial obligations.
Habits (Tobacco/Alcohol/ Drugs) Pt. denies any tobacco/alcohol/drug use.

Nursing Care:    (1 pt)
Isolation Yes (Neutropenic)
Code Status:  Full or DNR
Pain 2/10 on scale of 0-10
Fall Risk Yes
Hygiene Independent
Activity up at lib with assistance
Diet Diabetic (sugar substitutes)
List the equipment that is needed or being used to care for this patient?  (e.g. IV, Foley, Oxygen…)
Oxygen: 2L/NC IV:  R Chest 0.9 NS@ 100mL/hr

Pathophysiology: 

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

Describe the pathology of this disease; include any causative factors/ etiologies that can be identified  
•	(5 pts).  Neutropenia is an abnormal decrease of the neutrophil level in blood. Neutrophils affect the body's ability to fight off infections. The decreased blood level is considered life threatening when less than or equal to 500. Neutrophils are a type of white blood cell also known as polymorphonuclear leukocytes. There are five major types of white blood cells: basophils, eosinophils, lymphocytes, monocytes, and Neutrophils. Some white blood cells, called granulocytes, are filled with microscopic granules that are little sacs containing enzymes. Neutrophils, eosinophils, and basophils are all granulocytes and are part of the immune system with nonspecific, broad activity. Neutrophils contain enzymes that help the cell kill and digest microorganisms through phagocytosis. The mature neutrophil has a segmented nucleus shape. Neutrophils are made in the bone marrow and released into the bloodstream with a life-span of about three days. Persons are considered immunocompromised and must be placed in isolation to avoid becoming sick from anyone. Known causes of this are acute leukemia, infection, rheumatoid arthritis, vitamin B12 deficiency, and chronic splenomegaly. S/S are fevers, chills, decreased bone marrow production, chronic infections, and septicemia. Treatments are antibiotic and/or antifungal medications to help fight infection; administration of white blood cells growth factors (such as recombinant granulocyte colony-stimulating factor (G-CSF), granulocyte transfusions, corticosteroid therapy, or intravenous immune globulin. (Huether & McCance, 2008)(Mosby, 2009) 
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 	3.6	L	(4.0-11.0 10^3/Ul)				
	RBC	1.95	L	(3.63-5.04 10^6/uL)
	Hgb	5.8	L	(12.0-15.3 g/Dl)
	HCT	16.8	L	(34.7-45.1)
PLT	49	L	(150-450 10^3/Ul)
INR
•	Results are indicative of impaired immune system related to Leukemia as evidenced neutropenic diagnoses.	
     Chemistry	Value	Normal	If not, why not?  Please relate to the disease process.
	Na	135		(135-145 meq/L)
	K	3.9		(3.4-4.5 meq/L)
	Cl	100		(98-109 meq/L)
	BUN	29	H	(6-26 mg/L)
	Cr	1.4	H	(0.5-1.0 mg/L)
	Glucose  151    H	(50-100)
	*Results for glucose high as insulin was held per physician. BUN and CR are indicative of dehydration.
    Urinalysis Protein 2+ H, Blood 3+ H, Nitrate Pos H, Bilirubin Pos 1+ H, Leukocyte Esterase Pos 3+H, RBC 5-10 H, WBC Tn+c H, Squamous Epithelial Cells 1+ H, Bacteria  4+ H
•	Results are indicative of UTI and one of routes for blood loss 5.8 Hgb.

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: N/A
     ECG / Telemetry N/A
     CT (Cat Scan) N/A
     MRI N/A
     Ultra Sound N/A
     Other: N/A

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	
Carvedilol, 625mg, BID, PO 	Beta-Blocker/selectively antagonizes alpha 1 adrenergic receptors; antagonizes beta 1 and beta 2 adrenergic receptors	Interventional medication for BP	Monitor for CHF, heart block, bradycardia severe, angina exacerbation, asthma	Patients blood pressure remained within a normal range	
Furosemide, 20mg, BID, PO	Diurectics Loop/Inhibits loop of Henle and proximal and distal convoluted tubule sodium and chloride resportion	Interventional medication preventative measure for edema	Monitor for hypokalemia, electrolyte imbalance, metabolic alkalosis, anemia, hypovolemia	Patient appears to not have any edema bilaterally of the upper/lower extremities	
Glipizide, 7.5mg, Qam, AC, PO	Sulfonylureas/stimulates pancreatic islet beta cell insulin release	Interventional medication for diabetes	Monitor for Cr at baseline	Patient blood glucose level declined back within normal range of 80-100	
Citalpram Hydrobromide, 20mg, Qam, PO	Antidepressants/ mechanism for smoking cessation unknown; exact moa for depression unknown, inhibits neuronal uptake of norepinephrine and dopamine	Interventional medication for depression	Monitor for suicidality, depression, psychiatric disorder, dry mouth, headache, agitation, nausea, constipation, insomnia, tinnitus, anorexia	Patient appeared calm and displayed age appropriate behaviors	
Lomotil (diphenoxylate/atropine), 1 tab, QID, PO, PRN	Anti-diarrhea/difenoxine binds gut wall opioid receptors, inhibiting peristalsis; subtherapeutic atropine present to discourage overdose	Interventional medication for diarrhea	Monitor for respiratory depression, ileus, pancreatitis, toxic megacolon, angioedema, anaphylaxis, nausea, vomiting, anorexia, abdominal pain	Patient diarrhea decreased	
Ondansetron 4mg, Q8h, IV, PRN	Anitemetics/selectively antagonizes serotonin 5- HT3 receptors	Interventional medication for nausea	Monitor ECG if electrolyte abnormalities, CHF, or bradyarrhythmias, 	Patient stated no nausea was present	
Ferrous Sulfate 300mg, 1 tab, TID, PO	Minerals/Iron Homeostasis	Interventional  medication to increase hemoglobin 	Monitor for constipation	Shift ended before able to assess	
Morphine Sulfate, 2mg, Q6H,KC	Opioids/binds to various opioid receptors, producing analgesia and sedation 	Interventional medication for pain	Monitor for respiratory depression, apnea, hypotension, cardiac arrest, shock, somnolence, dizziness, abdominal pain, edema, dry mouth, flushing	Patient reported pain deduction by 50%	
Prilosec, 20mg, Qam, AC, PO	Proton-PPI / Inhibits gastric parietal cell hydrogen-potassium ATPase C proton pump inhibitor	Interventional medication for GERD symptom relief	Monitor for hypersensitivity to drug, Stevens Johnson syndrome, pancreatitis, interstitial nephritis	Patient reported relief of heart burn	
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 %: 
93%, 2L/NC, Sitting upright on bedside	BP: 121/57
RA sitting upright on bedside	Pulse: Apical
Rate: 91
Rhythm: Regular	Respirations: 
Rate: 22
Rhythm: shallow	Temp: 96.2F

Route: Oral	Pain:
Rating:      2  /10    Characteristics:  dull aching        	Ht: __ 5’ 8”_______
Wt: _79.09kg________	
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 3 ( name, date, place)

Speech clear?
	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength
ADL Assistance    Y   N       Fall Risk:    Y   N
Fall Score________4______
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment   
            Needs support to stand and walk	*Client normally up ad lib but needs assistance due to orthostatic hypotension from standing and walking caused from receiving blood transfusion??

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____________________	 
Peripheral Pulses 2+which pulses?	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	Diminish breath sounds throughout lungs bilaterally. Respiratory effort easy on oxygen 2L/NC. Sitting up in a high? fowler’s position.
	
GASTROINTESTINAL:
Diet at home :  General         Current Diet:  Diabetic 
Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools 
3/20/2012
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: ___18______
Drains present:  Y         N       Type_______________	Skin warm and pink
No tenting or bruises
	
EENT: 
Ears: N/A                      Eyes: Brisk
Nose:  Patent             Teeth:    see notes        	Dentures were inspected for cracks or blemishes and appear to be in good condition and fit patients mouth appropriately
	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
*Urine not seen but did void at 10:45am 3/20/2012
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________	
Up to bathroom with assist?

	
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)	
Bachelors Degree in Accounting (1973)
Patient is cognitive, exhibiting effective coping methods, and has a strong Catholic religious background. Currently, perceives’ health to be declining and stated at times she was afraid to die. Now she is seeking the “Lord” and has a strong faith in her religion. Retired Accountant and widow. Presently, lives with a 24 hr caregiver. Pt.’s daughter lives in another state and is very helpful with support and care of patient. 	
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)
Ineffective Protection related to abnormal blood profile as evidenced by WBC  3.6, RBC  5, Hg 5.8, and neutrophils <4
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 verbalize importance of persons / personnel wearing PPE equipment prior to entry by when?

Patient will verbalize three s/s of neutropenia by when?

Educate patient neutropenic status and what it means

Educate pt on common s/s of neutropenia	
Patients’ need for  knowledge to assist with self-advocacy

Patients’ need to be able to describe s/s of neutropenia to assist with self-care

(Gulanick & Myers, 2007, pg. 238)
	Client was receptive to information provided
Goal Met.
Client stated reminding several staff to use the mask, and PPE equipment.

No modifications at this time.

Client was receptive to information and verbalized understanding by stating three s/s of neutropenia.  Client appeared information seeking. 
Goal Met.
No modifications at this time.	
	Reference List for all references used in this document.     Use APA format.          (1 pts)

Epocrates, INC. www.epocrates.com. (2012). 
Huether, S., & McCance, K. (2008). Understanding pathophysiology (4thed.). St. Louis, 
MO: Mosby Elsevier.
Mosby. (2009). Mosby's dictionary of medicine, nursing, & health professions. St. Louis, 
	MO: Mosby Elsevier.
Pagana, K. D., & Pagana, T. J. (2009). Mosby’s diagnostic and laboratory test reference (9thed.). St. Louis, MO: Mosby Elsevier.