NURSING CARE PREPARATION

Student Name: Elizabeth B. Archibald Date of Care: 10/03/2017

Unit/Room Number: MedSurg/315 Date of Admission: 09/28/2017

Age: 92 y/o Ethnic/Cultural Preferences: Caucasian
Gender: F Allergies: Celery and Neo-synephrine
Eriksons Developmental Level: Code Status: Full code
Ego Integrity vs. Despair

Primary Diagnosis: MRSA in lungs/sputum, CHF, Hyponatremia.

Co-morbidities: Diabetes, Kidney Disease, Anemia, Constipation, Abdominal Pain, Dependent Edema, Cellulitis.

Discharge Plan: None

Integrated Pathophysiology

MRSA in lungs/sputum: MRSA stand for Methicillin-resistant Staphylococcus aureus. Patient has been
diagnosed with MRSA Pneumonia. Staph is a bacterium that is naturally on our skin and inside our nares.
Patient was immunocompromised, and exposed to staph in the clinical setting. Therefore, patient acquired a
community based MRSA Pneumonia.

CHF: Patient has right sided heart failure. The cause of patients heart failure is unknown, due to limited chart
information regarding this aspect of patients co-morbidities. Right sided heart failure can be due to valvular
defects (Tricuspid, or Aortic), and causes distended JVD, abdominal enlargement, and peripheral edema due
to fluid retention.

Hyponatremia: This means low levels of sodium in the body. The patient probably has hyponatremia due to a
combination of using diuretics to treat the heart, and multiple enemas administered yesterday. This is a hard
condition to fix for this patient, because patient has heart failure (= cannot eliminate diuretics), is refusing oral
medications (=cannot give NA supplement), is not eating (=cannot increase amount of sodium given), and will
not allow an IV (=cannot give NS IV).

Data Collection
Diet (Type): Consistent Carb 1600 KCAL IV (Fluid type, rate, access type): No
I&O (MD order/Nursing Order/Frequency): BID CBG (Yes/No, frequency):
Fall Risk/Safety Precautions (Yes/No): Yes Activity (What is ordered): Ambulate TID in room
only.
Wound Care (Yes/No): No Oxygen (Yes/No, Delivery method, how much): Yes,
Nasal Cannula, 2 L/M Maintain above 92%
Drains (Yes/No, Type): No Last BM: 10/02; large, brown, formed.
Other Tubes: No
ASSESSMENTS
Integumentary:
Cellulitis to lower extremities.
Bruising to SQ area on abdomen where insulin is
given.
Medial right heel appears to be forming a small ulcer.
Size= 0.5 inch in diameter.
Ear/Nose/Throat:
Patient is hard of hearing.
She breathes easily from both patent nares.
Patient has the ability to swallow. Her trachea is
midline.
Cardiac:
6/6 heart murmur auscultated on all 5 heart points.
Dysrhythmia also auscultated.
Swelling to lower extremities.
Cellulitis present to bilateral lower extremities, due to
poor perfusion.
JVD unable to examine due to sagging skin.
Patient has severe +4 pitting edema.
Unable to palpate PMI, due to patient being
extremely uncomfortable, with limited moving ability.
Head and Neck:
Patient complains of neck pain.
Friends brought a vibrating neck pillow, and patient
seems to like that.
Patient does not complain of any head pain.
Thorax/Lungs:
Wheezing heard over all lung fields.
Crackles heard at posterior bases.
Patient on nasal cannula at 2 L/M
Patient has MRSA pneumonia.
Musculoskeletal:
Patient has spinal spondylosis, and complains about
back/neck pain. Patient enjoyed having her back
rubbed, and expressed some relief from the vibrating
pillow placed on her lower back.
Patient has kyphosis.
Genitourinary:
Oliguria, patient is wearing depends because she is
unable to get to toilet/bedside commode quickly
enough.
Neurological:
Patient is alert and oriented x4.
PERRLA.
Ability to grips and pick items up.
Ability to stand and walk with walker present.
Talks clearly, and easily.
Can sit up on her own.
Does not get dizzy, or confused.
Gastrointestinal:
Radiographs taken 10/1 show non-obstructed
distribution of bowel gas. No evidence
pneumoperitoneum. Sternotomy wires.
Thoracolumbar spondylosis. Small bilateral pleural
effusions. 3.1 CM mass to RIGHT lower lung
corresponds to benign fat-density mass seen at CT.
Impression: Non-obstructed distribution of bowel gas.
Small bilateral pleural effusions.
Patient complains of severe stomach pain, especially
to right flank. She is convinced she has appendicitis.
Doctor rules this out with a CT. CT confirms
radiographs taken 10/1. Patient is full of large, hard
stool.
Patients body is not metabolizing pills correctly.
Patient pass a large formed stool yesterday, and
medications were found in the stool solid/intact. The
body is not able to use medication.
Other (Include vital signs, weight):
T 97.9 F
P 80
R 12
BP 105/53
PAIN 5/10
CBG @1200 = 240
CURRENT MEDICATIONS

Generic & Classificati Dose/Route Onset/Peak Intended Adverse Nursing Implications for this client.
Trade Name on / Action/Therapeutic reactions (No more than one that is related to
Rate if IV use. Why is this the identified adverse reaction in the
client taking med? previous column)
CA 1 CAP PO @ 30 Decrease angina Hypotension Make sure that patient repositions
Diltiazam ER Channel 0900 SID minutes/2-3 slowly.
240 MG Blocker hours
K Sparing 1 TAB PO Unknown/1- Decrease fluid load Increased Assist patient to the bathroom every
Spirolacton Diuretic 0900 SID 3 hours urination hour.
e 25 MG
Digoxin Cardiac 1 TAB PO 30-120 Help the heart to Digoxin toxicity Monitor patient for signs and
0.125 MG Glycoside 0900 SID min/2-8 be slower, but symptoms of toxicity, i.e.: vomiting.
hours stronger.
Sulfa/Trimet Sulfa Anti- 1 TAB PO Rapid/2-4 Erradicate GI Upset Assess patient for GI upset.
h infective BID hours Pneumonia
 DIAGNOSTIC TESTING

Date Lab Test Patient Values/ Interpretation as related to Pathophysiology

Normal Values Date of care cite reference & pg #
10/3 Sodium 118 LOW- Possibly due to diuretics, and frequent
135 145 enemas.
mEq/L
10/3 Potassium 4.6
3.5 5.0
mEq/L
10/3 Chloride 80 LOW- Secondary to low NA.
97-107 mEq/L
10/3 Co2 27
23-29 mEq/L
10/3 Glucose 193 HIGH- Diabetic
75 110 mg/dL
10/3 BUN 77 HIGH- Secondary to long term HTN, and heart
8-21 mg/dL failure.
10/3 Creatinine 2.32 HIGH- Secondary to long term HTN, and heart
0.5 1.2 failure.
mg/dL
Uric Acid
Plasma
4.4-7.6 mg/dL
10/3 Calcium 9.2
8.2-10.2 mg/dL
Phosphorus
2.5-4.5 mg/dL
10/3 Total Bilirubin 0.7
0.3-1.2 mg/dL
10/3 Total Protein 6.6
6.0-8.0 gm/dL
10/3 Albumin 3.8
3.4-4.8gm/dL
Cholesterol
<200-240
mg/dL
10/3 Alk Phos 88
25-142 IU/L
10/3 SGOT or AST 36
10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
10/3 WBC 28.1 HIGH- Pneumonia
4.5 11.0
10/3 RBC 3.64
female: 4.2-
 4.87 x 10
10/3 HGB 10.1
female: 11.7-
16.1 g/dL
10/3 HCT 29.3 LOW- Secondary to kidney disease
female: 38-
44%
10/3 MCV 80.6
85-95 fL
10/3 MCH 27.7
28 32 Pg
10/3 MCHC 34.4
33-35 g/dL
10/3 RDW 15.4 HIGH- Secondary to kidney disease
11.6-14.8%
10/3 Platelet 409
150-450

DIAGNOSTIC TESTING

Date UA Interpretation as related to

Normal
Results Pathophysiology cite reference & pg
Range
#
Color/Appearance
pH
Spec Gravity
Protein
Glucose
Ketones
Blood

Date Other Interpretation as related to

(PT, PTT, INR, Normal Pathophysiology cite reference & pg
Results
ABGs, Cultures, Range #
etc)
9/28 Sputum Neg. Positive for MRSA
9/28 Quantaferon Gold NEG. NEG.
TH

Date Interpretation as related to

Radiology Results Pathophysiology cite reference & pg
#
10/1 X-Rays Radiographs taken 10/1 show
non-obstructed distribution of
 bowel gas. No evidence
pneumoperitoneum.
Sternotomy wires.
Thoracolumbar spondylosis.
Small bilateral pleural
effusions. 3.1 CM mass to
RIGHT lower lung corresponds
to benign fat-density mass seen
at CT.
Impression: Non-obstructed
distribution of bowel gas.
Small bilateral pleural
effusions.

Scans
EKG-12 lead
Telemetry

DAR NURSING PROGRESS NOTE

Date: 10/3/17
Time: 1100
Diagnosis: Imbalance nutrition: Less than body requirements R/T
patient unwilling to eat any food, as evidence by patient refusing to eat or drink because she wants to die.
Action: Talked to patient about eating, and the fact that her stomach may hurt because she took medications
on an empty stomach. Found out that she loves vanilla ice cream. Asked patient if she would like some vanilla
ice cream. She agreed.
Response: Patient ate a half a cup of ice cream. Student even got patient to try a couple of bites of jello.
Signature: Liz, student RN

Date: 10/3/17
Time: 1300
Diagnosis: Deficient Knowledge R/T patient thinking that she has appendicitis AEB patient crying in pain and
stating that it feels like appendicitis.
Action: Nursing student approached doctor regarding patient believing that she has appendicitis. Doctor
states that labs and imaging is not consistent with this diagnosis.
Response: Discussed with patient that doctor does not think that patient has appendicitis, because her labs
and imaging do not indicate it. Patient is okay with this information.
Signature: Liz, student RN
PATIENT CARE PLAN

Problem #1 Decreased cardiac output R/T dysrhythmias AEB a radial pulse that does not match apical pulse.
Desired Outcome: Patient will state that she does not feel short of breath or fatigued by the end of the shift.
Nursing Interventions Client Response to Intervention
1. Administer heart medications as prescribed by doctor. 1. Patient refused medications. I encouraged
her to take them by educating her on how they
will help her.
2. Titrate oxygen so that patients SPO2 stays above 92% as 2. Patient wore her nasal cannula all day, and
ordered by doctor. SPO2 stayed at 98% all day.

3. Have patient take a nap mid-day, and eat nutritious 3. Patient refused to eat anything but Jello and
foods to preserve the energy that she has. ice cream. She slept most of the day.

Evaluation
Patient slept most of the day, and was sleeping when I left. She seemed to be fatigued despite interventions.

Problem #2 Excess Fluid Volume R/T ineffective systolic action AEB peripheral edema, and cellulitis.
Desired Outcome: Patient will show a decrease in leg swelling by the end of the shift.
Nursing Interventions Client Response to Intervention
1. Have patient elevate legs while patient is sitting 1. Patient did well with legs raised, and kept
watching TV. them up while visiting with her friends.

2. Gently massage feet with them in an elevated position to 2. Patient LOVES massages and she even wanted
encourage venous return. by to massage her back (which I did).

3. Apply ted hose as ordered by doctor. 3. Patient allowed application of ted hose,
without complaining.
Evaluation
Edema did not decrease within one shift, but we are taking the right interventions to help the patient.

Problem #3 Acute Pain R/T intestinal obstructions AEB patient moaning and wincing when moving.
Desired Outcome: Patient will be free from pain and comfortable by the end of the shift.
Nursing Interventions Client Response to Intervention
1. Administer pain meds as ordered by doctor. 1. Patient took her pain meds without
hesitation.
2. Apply a warm blanket to patient every 1 hour. 2. Patient liked her warm blanket over her
stomach and back.
3. Use distraction to keep patients mind off of pain. 3. Patient loves to talk about Bridge the card
game.
Evaluation
Patients pain level decreased from a 5/10 to a 4/10 by the end of the shift.