NURSING 110 & 111 NURSING CARE PREPARATION

Student Name: Elizabeth Archibald Date of Care: 2/14/17

Unit/Room Number: 10-2 Med Surgical Date of Admission: 02/13/2017

Age: 73 y/o 02/03/1944 Ethnic/Cultural Preferences: Caucasian
Gender: Male Allergies: NKDA
Eriksons Developmental Level: Ego Code Status: Full Code
integrity

Primary Diagnosis: Sepsis to left carpus.

Patient C/O general weakness upon admittance to E.D.

Co-morbidities: Arthritis, former tobacco dependence, AFib, idiopathic anemia, cervical

spinal fusion, blepharitis, benign prostatic hyperplasia, hard of hearing, previous
bleeding disorder.

Discharge Plan: No discharge plan as of this time.

Integrated Pathophysiology: Septic Arthritis

Septic arthritis is an infection in the joint. This patient has this joint infection in his left
wrist. The infection can come from a bacterial, fungal, or viral infiltration and spread.
Symptoms of septic arthritis include: Intense pain to the area, erythema, edema, fever,
chills, and stiffness to the joint.

One type of septic arthritis is when the body reacts to another infection that is going on
already, such as in the bladder. Women can get reactive infectious arthritis from a
vaginal infection, and both men and women can get it from sexual intercourse. A
person can also get this from preparing/eating food with a significant number of bacteria
on it.

In order to diagnose septic arthritis, the PCP will perform many diagnostic evaluations,
including: a chemistry, urinalysis, and a joint tap. Treatment is regimen of antibiotics,
anti-pyretics, and anti-inflammatories. Sometimes the patient will require surgical repair.

https://medlineplus.gov/infectiousarthritis.html

Data Collection
Diet (Type): Regular IV (Fluid type, rate, access type): IVC, NS @
25 ML/HR
I&O (MD order/Nursing Order/Frequency): CBG (Yes/No, frequency): No
Monitor BID
Fall Risk/Safety Precautions (Yes/No): Yes Activity (What is ordered): Bed Rest, with
frequent position change
Wound Care (Yes/No): No Oxygen (Yes/No, Delivery method, how much):
No
Drains (Yes/No, Type): No Last BM: Saturday, charge nurse notified.
Will monitor. This status may change
Diet (Type): Regular
I&O (MD order/Nursing Order/Frequency):
Monitor BID
Fall Risk/Safety Precautions (Yes/No): Yes
Wound Care (Yes/No): No
Drains (Yes/No, Type): No
Other Tubes: No
ASSESSMENTS
Integumentary:
-Skin irritation present to anterior thorax
secondary to placement of EKG.
-Multiple bruising to bilateral lower
extremities.
-Bruise to right hand from previously
attempted IVC placement.
-All extremities (bilateral hands and feet)
are cold to the touch.
-Feet are very dry, and flakey. Nails are
dark, have a fungal infiltration.
Eyes/Ear/Nose/Throat:
-Eyes are symmetrical and free of
discharge, and conjunctivitis.
-Blepharitis present.
-Patient is hard of hearing, but ears look
symmetrical, and are free of abrasions/
lacerations.
-Throat is moist and pink.
-Patient has all his teeth, and keeps up on
flossing and brushing of teeth.
IV (Fluid type, rate, access type): IVC, NS @
25 ML/HR
CBG (Yes/No, frequency): No
Activity (What is ordered): Bed Rest, with
frequent position change
Oxygen (Yes/No, Delivery method, how much):
No
Last BM: Saturday, charge nurse notified.
Will monitor. This status may change
secondary to electrolyte infusion and
antibiotic regimen.
Head and Neck:
-No abnormal findings.
-Face is symmetrical. Color is pink with
good tissue perfusion. Hair is thick and
free of xerosis, pediculitis.
-Trachea is midline, and lymph nodes
are not enlarged.
Thorax/Lungs:
Chest is symmetrical, and breathing is
equal.
Lungs= CTA.
Eyes/Ear/Nose/Throat:
-Eyes are symmetrical and free of
discharge, and conjunctivitis.
-Blepharitis present.
-Patient is hard of hearing, but ears look
symmetrical, and are free of abrasions/
lacerations.
-Throat is moist and pink.
-Patient has all his teeth, and keeps up on
flossing and brushing of teeth.
Cardiac:
Patients heart has a regular rhythm.
There is no murmur, or extra heart
sounds auscultated. Patient has a history
of AFib.
Patient is unable to feel either of his feet.
Lower limbs are swollen- L>R.
Right radial, posterior tibial, and pedal
pulses were thread and herd to feel.
(maybe a 1+ or less)
Left radial, posterior tibial, and pedal
pulses bounding (3+).
Doppler confirms these findings.
Genitourinary:
Patient did not urinate during my shift, but
approx. +/- 100 mL of urine sitting in the
urinal next to the bed. This urine was
dark amber. Encouraged patient to drink
water as tolerated.
Thorax/Lungs:
Chest is symmetrical, and breathing is
equal.
Lungs= CTA.
Musculoskeletal:
Patient is a fall risk. He cannot ambulate
without assistance.
Patient has shoulder, hip, knee, and wrist
pain r/t arthritis.
Arthritis in the left wrist has become
septic.
Left wrist, arm and shoulder are
inflamed; and hot to the touch.
Patient states that he has a hard time
ambulating at home, and that this
hinders many of his ADLS.
Gastrointestinal:
Patient has not had a BM since
Saturday.
He does not report any GI discomfort.
Patient is on antibiotics, and magnesium/
potassium infusions. The charge nurse
recommends seeing how patient
Genitourinary: Gastrointestinal:

Patient did not urinate during my shift, but
approx. +/- 100 mL of urine sitting in the
urinal next to the bed. This urine was
dark amber. Encouraged patient to drink
water as tolerated.
Patient has not had a BM since
Saturday.
He does not report any GI discomfort.
Patient is on antibiotics, and magnesium/
potassium infusions. The charge nurse
recommends seeing how patient
responds to this because asking the
doctor for a laxative.

Patient states that he has been fasting,

because he has a hard time ambulating.
Difficulty ambulating has contributed to
having less groceries in the house, and
the inability to prepare most of his meals.
Neurological: Other (Include vital signs, weight):

Alert and oriented X4 (person, place, T- 97.5 F

time, situation). P- 69 BPM
R- 18 BPM
B/P 103/70 mm/HG
SPO2 98% on room air
Weight 213 #

CURRENT MEDICATIONS

Generic Classific Dose/ Onset/ Expected Adverse Nursing Intervention for this
Name ation Route/ Peak outcome reaction client. (consider expected
& Trade Rate if IV (One outcome and adverse
Name common reaction)
adverse
reaction)
S Furose Loop 20 mg 2-10 Increase fluid Fluid Monitor intake
a mide
Diuretic IV minutes output volume and output
m Lasix
p
deficit Monitor for signs/
l symptoms of
e dehydration
Beta 100 MG 15 min Prevention of Weakness Monitor A/O- CNS
Metoprol Blocker PO QD (O) MI Fatigue
ol @ 0900 Unknow
(Toprol n (P)
XL)
Magnesi Electrol 400 MG 60 mins Stabilize Hyper Regularly check MG
um yte PO BID (O) magnesium magnesium levels
Oxide @ 0900 Unknow level R/T
(Mag- n (P) hypo
Ox) magnesium
 e dehydration
Beta 100 MG 15 min Prevention of Weakness Monitor A/O- CNS
Metoprol Blocker PO QD (O) MI Fatigue
ol @ 0900 Unknow
(Toprol n (P)
XL)
Magnesi Electrol 400 MG 60 mins Stabilize Hyper Regularly check MG
um yte PO BID (O) magnesium magnesium levels
Oxide @ 0900 Unknow level R/T
(Mag- n (P) hypo
Ox) magnesium

Opioid 10 MG 10-30 Pain Respiratory Monitor V.S for decreased

Hydro/ Analge Norco min (O) management depression respiration.
APAP sic and 325 30-60 R/T arthritis
(Norco1 MG min (P)
0) APAP
PO TID
@ 0900
Leukotr 10 MG With 24 Decrease Mood Monitor mood for
Montelu iene PO QD H (O) nasal changes confusion, agitation, etc.
kast Antago @ 0900 3-4 H (P) Mucosal
(Singulai nist production
r)
NF- Anti- 150 MG 4 weeks Mood Suicidal Assess mood, cognition,
Bupropi Depres PO QD (O) stabilization thoughts depression.
on HCL sant @ 0900 6 Depressant
Oral ER months
(Contrav (P)
e)

Anti- 900 MG/ Rapid Resolve Phlebitis @ Monitor IVC for erythema,
Clindam Infectiv 100 ML (O) present IV site pain, edema.
ycin e NS Q8H End of septicemia
IVPB infusion
(P)
Magnesi Electrol 2 MG/ Rapid Stabilize hyper Regularly check MG
um yte 100 ML (O) magnesium magnesium levels
IVPB NS End of level R/T
100 ML/ infusion hypo
HR (P) magnesium
IVPB
Electrol 100 MG/ Rapid Stabilize hyperkalem Regularly check K levels
Potassiu yte 100 ML (O) potassium ia
m NS End of level R/T
IVPB 100 ML/ infusion hypokalemia
HR (P)
IVPB

DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays, CT, MRI, U/S,
etc.]
NOTE: Adult values indicated. If client is newborn or elder, normal value range may be
different.
 Date Lab Test Patient Values/ Interpretation as related to patients
Normal Date of care diagnosis cite reference & pg #
Values
2/13 Sodium 128 Low --- patient has low electrolytes r/t
135 145 mEq/
L
improper nutrition at home.
2/13 Potassium 3.3 Low --- patient has low electrolytes r/t
3.5 5.0 mEq/
improper nutrition at home.
L
2/13 Chloride 92 Low --- patient has low electrolytes r/t
97-107 mEq/L
improper nutrition at home.
2/13 Co2 22
23-29 mEq/L
2/13 Glucose 108 High --- elevated glucose is a stress
75 110 mg/dL
response.
Patient does not have DM.
2/13 BUN 25 Patient has elevated BUN can be R/T
8-21 mg/dL
cardiac decompensation. http://
www.mayomedicallaboratories.com/test-
catalog/Clinical+and+Interpretive/81793
Additionally, we learned in class that
ACE inhibitors are hard on the liver and
kidneys.
2/13 Creatinine 0.74
0.5 1.2 mg/
dL
Uric Acid
Plasma
4.4-7.6 mg/dL
2/13 Calcium 9.0
8.2-10.2 mg/dL
Phosphorus
2.5-4.5 mg/dL
2/13 Total Bilirubin 1.0
0.3-1.2 mg/dL
2/13 Total Protein 7.2
6.0-8.0 gm/dL
2/13 Albumin 3.4 Low Albumin is secondary to improper
3.4-4.8gm/dL
nutrition at home.
Cholesterol
<200-240 mg/dL
2/13 Alk Phos 54
25-142 IU/L
2/13 SGOT or AST 13
10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
2/13/17 WBC 9.5
4.5 11.0
2/13/17 RBC 4.82
male: 4.7-5.14 x
10

2/13/17 HGB 14.2

male: 12.6-17.4
g/dL

2/13/17 HCT 42.9 Low, R/T anemia.

male: 43-49%
 10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
2/13/17 WBC 9.5
4.5 11.0
2/13/17 RBC 4.82
male: 4.7-5.14 x
10

2/13/17 HGB 14.2

male: 12.6-17.4
g/dL

2/13/17 HCT 42.9 Low, R/T anemia.

male: 43-49%

2/13/17 MCV 89.1

85-95 fL
2/13/17 MCH 29.5
28 32 Pg
2/13/17 MCHC 33.2
33-35 g/dL
2/13/17 RDW 14.5 High RDW is secondary to low platelets.
11.6-14.8%
Less platelets means that there is a
greater width between the red blood
cells.
2/13/17 Platelet 82 Low---Patient has idiopathic anemic.
150-450

DIAGNOSTIC TESTING

Date UA Norm Interpretation as related to Pathophysiology

Resul cite reference & pg #
al
ts
Range
2/14/1 Color/ Clear- DK Dark urine is r/t dehydration.
7 Appearance yellow Yello
w
2/14/1 pH 5.0-8. 6.0
7 0
2/14/1 Spec Gravity 1.005- 1.020
7 1.020
2/14/1 Protein NEG 1+ Secondary to elevated BUN
7 https://labtestsonline.org/understanding/
analytes/urinalysis/ui-exams?start=1
2/14/1 Glucose NEG NEG
7
2/14/1 Ketones NEG 2+ Secondary to fasting at home.
7 https://labtestsonline.org/understanding/
analytes/urinalysis/ui-exams?start=1
2/14/1 Blood NEG 1+ Unable to find a relevant cause.
7
2/14/1 Bilirubin NEG 1+ Unable to find a relevant cause.
7
Date Other Norm Interpretation as related to Pathophysiology
(PT, PTT, INR, Resul cite reference & pg #
al
ABGs, ts
Cultures, etc) Range
2/13/1 SED RATE 0-20 43 *High-
7 mm/ MM/
 analytes/urinalysis/ui-exams?start=1
2/14/1 Blood NEG 1+ Unable to find a relevant cause.
7
2/14/1 Bilirubin NEG 1+ Unable to find a relevant cause.
7
Date Other Norm Interpretation as related to Pathophysiology
(PT, PTT, INR, Resul cite reference & pg #
al
ABGs, ts
Cultures, etc) Range
2/13/1 SED RATE 0-20 43 *High-
7 mm/ MM/
HR HR
2/13/1 CRP Negati Positi *Abnormal-
7 ve ve
2/13/1 TSH 0.4-4. 3.26
7 6 uUI/ uUI/
mL mL
2/13/1 MAGNESIU 1.8 1.9-2. Low MG is secondary to improper nutrition
7 M 7 mg/ at home.
dL
2/13/1 Neutrophils 40-70 84.1 High neutrophils are secondary to
7 % % inflammation of wrist.
2/13/1 LYMP 14-48 8.7% Low- possible undiagnosed rheumatoid
7 % arthritis???
http://tucson.com/lifestyles/health-med-fit/
to-your-good-health-low-lymphocyte-count-
is-cause-for/article_5d6c4d41-e7bb-5ca2-
aab9-6c3fcc9684ba.html
2/14/1 PTT 24.5-3 25.4
7 2.8
SECS
2/14/1 PT 9.3-11. 12.6 Prolonged R/T diagnosed bleeding
7 4 disorder.
SECS https://labtestsonline.org/understanding/
analytes/pt/
2/14/1 INR 0.9-1. 1.24 Calculated from PT.
7 20 https://labtestsonline.org/understanding/
analytes/pt/
Date Interpretation as related to Pathophysiology
Radiology Results
cite reference & pg #
2/13/1 X-Rays 3 view left These radiographs are consistent with a
7 shoulder- diagnosis of arthritis.
Degenerativ
e narrowing
of
glenohumer
al joint
space with
underlying
osteopenia
but no
visualized
fracture or
dislocation.

4 view left
wrist-
 analytes/pt/
2/14/1 INR 0.9-1. 1.24 Calculated from PT.
7 20 https://labtestsonline.org/understanding/
analytes/pt/
Date Interpretation as related to Pathophysiology
Radiology Results
cite reference & pg #
2/13/1 X-Rays 3 view left These radiographs are consistent with a
7 shoulder- diagnosis of arthritis.
Degenerativ
e narrowing
of
glenohumer
al joint
space with
underlying
osteopenia
but no
visualized
fracture or
dislocation.

4 view left
wrist-
Degenerativ
e changes
involving
carpal bones
along the
radial
aspect, no
evidence for
fracture
dislocation
of radius
and ulna.
Scans
EKG-12 lead
Telemetry

DAR NURSING PROGRESS NOTE

Priority Diagnosis: Deficient oral care- 2/14/17 @ 1000 AM
Data- Patient states that he has a cavity and gets food stuck in it. He states that the
only way to clean it out is with a tooth pick.

Action- Student went to the cafeteria and got a tooth pick from one of the wait staff.
Additionally, student went into the clean linen supply closet and collected: A comb,
toothpaste, tooth brush, and mouth wash with a rinse basin.

Response- The patient was very happy to have these things. Later that day, student
nurse realized that patient smelled better.

Signature- Liz, RN student

Priority Diagnosis: AFIB- 2/14/17 @ 1100 AM

Data- Patient has a history of AFIB--- Assessment shows that:
-Right radial, posterior tibial, and pedal pulses were thread and herd to feel. (maybe a
1+ or less)
-Left radial, posterior tibial, and pedal pulses bounding (3+).
-Doppler confirms these findings.

Action- I spoke with Dr. Mital about my findings. I expressed my concerns, asked if
patient has a current history of clots, asked why patient was not on an anti-thrombolytic
prophylactically, and asked about ted hose/SCUDS.

Response- Doctor informed me that patient has a history of abnormal reactions to anti-
thrombolytic drugs (previous GI bleed), and has CT disease. This is why we are are not
utilizing anti-platelet aggregators and/or ted hose/SCUDS. Doctor states that I can apply
warm blankets and elevate feet.

Signature- Liz, RN student

 PATIENT CARE PLAN
Patient Information (Include data to support selected nursing diagnostic statement):
See Above

Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by
(AEB).
Problem #1 Failure to thrive R/T being admitted to the hospital for general weakness
AEB electrolyte imbalance, and inability to perform ADLs.
Desired Outcome: Patient will be set up with a full-time care giver, home health, or be
placed in a facility that can give him around the clock care before he is discharged
from the hospital.
Nursing Interventions Predicted Client Response to Intervention
1. Nurse will contact a social worker to 1. The client will most likely enjoy this
come in and discuss placement/living idea, since he willingly admits that he
options with client. cannot do most things himself, and he like
company.
2. While patient is in the hospital he will 2. Patient states that he has been fasting
had three balanced meals a day, because it is hard for him to get around.
obtaining all the vitamins and nutrients
necessary for a healthy body system.

3. Patient will receive help with his
ADLs, such as: showering, dressing,
brushing teeth, etc.
4. Patients health status will be
maintained by running lab work as
needed, monitoring vital signs, and
taking daily weights.
3. Patient loves company and loves to
chat.
He states that he has not been able to get
around at home, and this hinders many
ADLs.
4. Patient likes having help. He stated
that he was looking forward to seeing
[the nurse] again every time she left.

Evaluation
Failure to thrive is the most important nursing diagnosis. This is the reason that the
patient is in the hospital.

Problem #2 Fall risk R/T decline in ambulation AEB bilateral lower peripheral
neuropathy, and need for a wheel chair.
Desired Outcome: Patient will not have any accidents, or falls for the entire stay at
the hospital.
Nursing Interventions Client Response to Intervention
1. Patient will have call light next to him 1. Patient likes having the call light next
whenever the nurse leaves the room. to him because it is also the speakers to
the television.
2. Patient will have all items close to the 2. Patient enjoyed that student put bag
bed for easy reaching. on a table next to him so that he could
easily grab what he needed.
Problem #2 Fall risk R/T decline in ambulation AEB bilateral lower peripheral
neuropathy, and need for a wheel chair.
Desired Outcome: Patient will not have any accidents, or falls for the entire stay at
the hospital.
Nursing Interventions Client Response to Intervention
1. Patient will have call light next to him 1. Patient likes having the call light next
whenever the nurse leaves the room. to him because it is also the speakers to
the television.
2. Patient will have all items close to the 2. Patient enjoyed that student put bag
bed for easy reaching. on a table next to him so that he could
easily grab what he needed.
3. Nurse will check on patient every 3. Patient likes company.
hour to avoid patient getting out of bed
for something that the nurse can get.
4. Patient will do exercises with PT 4. PT came to see and work with patient
every day. at the end of the students shift.

Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if
needed):
Patient did not have any accidents today.