PACIFIC LUTHERAN UNIVERSITY
SCHOOL OF NURSING
NURSING PROCESS PAPER FOR NURS 340 SITUATIONS - ADULT HEALTH I
Date(s) of care: Week 4 Number of days in hospital: Age of pt (decade): 90s
8
Occupation(s)/Significant Social History Allergies: none
Widowed/ unemployed Weight: 152lbs
Vital Signs Day of Care: ** note vaules and state a reason why it might be abnormal
Day 1: BP 160/90 HR 103 Resp Rate 18 Temp 97.9
O2 Sat 95% Pain 4
Intake & Output previous 24 hrs Intake & Output this shift
Day 2: BP 152/70 HR 92 Resp Rate 16 Temp 98.9
O2 Sat 89 Pain 7
Intake & Output previous 24 hrs Intake & Output this shift
Primary (Admitting) Medical Diagnosis:
Motor Vehicle Accident resulting in right tibial and fibula fractures and a left femur fracture
Secondary Medical Diagnosis:
COPD, Smoker, Diabetes Mellitus, Asthma
Surgery: No surgery was needed
History of Present Illness:
Patient drove her car into a tree when she accidently hit the gas pedal instead of the brake. She was taken
to the Tacoma General Emergency Room where she was treated.
Definition and Pathophysiology of admitting diagnosis?
If the patient had a surgery to treat the diagnosis, explain the surgery and why it was appropriate for this
diagnosis.
The fractures were set without needing surgery.
Risk Factors (list risk factors noted in the book; circle or underline those that apply to your patient; if
you add one that is not listed in the book, please indicate this):
Osteoporosis, decreased muscle mass, advancing age, trauma, tumors, contact sports,
Signs and Symptoms (list the signs and symptoms that are usually associated with this diagnosis as noted
in the book; circle or underline those that apply to your patient; if you add one(s) that is/are not listed in
the book, please indicate this):
Pain, tenderness, swelling, limited range of movement, aggravated pain during movement, inability to
walk, limb deformity, open wound, crepitus, muscle spasm
Secondary diagnosis: Give a definition and brief patho explaining how each secondary diagnosis can
affect or be affected by the primary diagnosis/hospitalization.
Patient is chronic smoker. She is currently using a nicotine patch to prevent nicotine withdrawal.
Nicotine interferes with the proliferation of red blood cells, fibroblasts and macrophages leading to an
increased chance of bacterial infection, heightened peripheral vasoconstriction, decreased micro
perfusion. Smoking also leads to increased incidents of non union.
Steroids in asthma medication can lead to bone loss and osteoporosis.
COPD leads to shortness of breath which will interferes with the patient’s desire to perform physical
activities, which may prevent her from regaining the maximun amount of function in her lower limbs.
Diabetes Mellitus causes fracture healing to take two to three times longer and increases the chances of
non-union or delayed union.
Diagnostic Tests and/or Procedures:
X-Rays of the legs
Blood tests
*Laboratory Data from admission to most recent (plus significant lab work, i.e.: PT/PTT
Tests Admission Recent TG/MHS Norms Interpretation of results: Specific for this pt? If unknown ?
Ordered Results Results Abnormal: Elevated Low
Hematology Studies Hematology Studies
WBC 12.3 14.9 4.0-12.0 TH/mm3 The patient is fighting an infection
3
RBC 3.32 3.32 4.0-5.5 mil/m Blood is pooling in the patient’s legs.
Hbg 9.9 10.0 12.0-16.0 g/dL Blood is pooling in the patient’s legs
Hct 30.2 30.4 37-47% Blood is pooling in the patient’s legs
MCV
MCH
MCHC
RDW
Plt 150-450 th/mm3
WBC Differential VSR VSR WBC Differential
Neuts 45-77%
-Segs/PMN’s
-Bands
Lymphs 12-44%
Monos 7.0 13.0 4.0-13.0%
Eosin 0 -5.0%
Basos 0-1.5%
Abs neuts 1.8-7.8 th/mm3
Abs lymphs 0.8-3.3 th/mm3
Abs monos 0.2-1.0 th/mm3
Abs eosin 0.0-0.4 th/mm3
Abs basos 0.0-0.2 th/mm3
Platlet/RBC studies Platelet & RBC Specific Studies
Plt estimate ADEQ
Aniso
Poly
Poik
Ovalocytes
RBC frags
Reactive lymphs
Serum Chem Serum Chemistries
Na+ 133 none 135-148 mEq/L
K+ 4.0 none 3.6-5.3 mEq/L
Cl- 97-107 mEq/L
CO2 24-33 mEq/L
HC03 24-33 mEq/L
BUN 38 none 8-24 mg/dL This indicates a high protein level
Creatinine 1.0 0.8-1.5 mg/dL
Glucose 167 none 65-120 mg/dL Patient is diabetic
Additional Chemistries Additional Chemistries: Enzymes
SGOT/AST
Alk Phos
SGPT/ALT
Serum Protein
Serum Albumin
Globulin (calc)
A:G
Calcium
Phosphorous
Magnesium 1.7-2.2 mg/dL
Triglyeride
Cholesterol??
Amylase
Lipase
Prealbumin 18-45 mg/dL
C-reactive 0-0.1 mg/dL
protein
Coagulation Studies
PT 12.4 None 9.2-13.0 sec
INR 1.18 none 0.0-3.5
Normal mean
PTT 25.5 none 21-31 sec
Normal mean
Urinalysis
Color
Appearance
Sp Gr
PH 1.003-1.030
Urine Protein N
Urine Glucose N
Ketones N
Bilirubin N
Occult blood N
Urobilinogen
Albuterol, 2.5mg, Bronchodilators Asthma and Chest pain, Assess lungs and respiration before
inhalation COPD restlessness giving medication to the patient
Insulin(Novolin), Antidiabetes Diabetes Hypoglycemia Watch for signs of and symptoms
sliding scale, SQ Hormones mellitus anaphylaxis of hypoglycemia. Tingling in the
Lipodystrophy extremities, chills, cool skin
Levofloxacin, Antiinfectives Respiratory Seizures, Watch for signs of anaphylaxis
500mg, oral tract infection arrhythmias
Lisinopril, 10mg, Antihypertensives Hypertension Cough, Pt should consider other lifestyle
oral hypotension modifications to manage her
hypertension.
BP should be checked before
administering meds
Metoprolol, 25mg, Antianginal, Hypertension Fatigue, Requires extra attention to blood
oral antihypertensives weakness, sugar in diabetic patients
bradycardia Check BP before administering
Prednisone, 60mg, Corticosteroid Asthma Peptic ulceration, Can cause hyperglycemia,
oral thromboembolism especially in patients with diabetes
Ranitidine, Antiulcer agents Prevention of Confusion, Assess for abdominal pain.
150mg, oral stress ulcers dizziness, Can cause false positives for urine
headache protein
Risperidone, Antipsychotics Schizophrenia Dizziness, Ensure the patient actually
0.5mg, oral insomnia swallows medication.
Watch for mood changes
Nursing Care Plan
Student Name/Date: __________________________
Expected Outcomes
(Short term (8-48 hr.) Nursing
Nursing Diagnosis Outcome Evaluation
(Dx, related to, & as evidenced
reasonable expectations Interventions/Rationale
stated in measurable, List all interventions for each nsg. dx (Patient outcome noted as met
by)
behavioral terms, i.e., action (include patient/family teaching) or unmet/responses described)
verbs)
Ineffective Airway Maintain a patent airway Administer medications such as Unmet. Patient
Clearance related to COPD during hospital stay. bronchodilators or inhaled steroids experienced several
exacerbation as evdienced as ordered. Rationale: coughing fits during the
by increased mucus Bronchodilators decrease airway shift. In general she is
secretion and coughing resistance secondary to doing very well. She is
bronchoconstriction. coughing less and
coughing more effectively
Auscultate breath sounds every two than she was previously.
hours. Rationale: if the nurse is
aware of a fluid build up she can
take steps to clear it from the
airway
Help the client deep breathe and
perform controlled coughing. Have
the client inhale deeply, hold breath
for several seconds, and cough two
or three times with mouth open
while tightening the upper
abdominal muscles. Rationale: This
Relate methods to enhance technique can help increase sputum
secretion removal before clearance and decreases cough
the end of the shift. spasms. Controlled coughing uses
the diaphragmatic muscles, making Met. Patient has been
the cough more forceful and taught how activity,
effective. liquids, and her incentive
spirometer help keep her
Encourage activity and ambulation airway clear. She was able
as tolerated. Rationale: Body to verbalize back to the
movement helps mobilize nurse this information.
secretions and can be a powerful
means to maintain lung health.
Encourage fluid intake of up to
2500ml/day within cardiac and
renal reserve. Rationale: Fluids
help minimize mucosal drying and
maximize ciliary action to move
Have cyanotic free skin secretions. It also thins secretions
during hospital stay making them easier to move.
Encourage the patient to use an
incentive spirometer. Rationale: Met. Patient has had no
The incentive spirometer has been signs of cyanosis. Her lips
proven to be an effective tool in and skin have maintained
helping prevent atelectasis and there color, and her
rention of bronchial secretions. capillary refill is normal.
Administer Oxygen as ordered.
Rationale: Oxygen helps correct
hypoxemia.
Monitor respiration patterns,
including rate, depth, and effort.
Rationale: allows the nurse to
determine if patient is having
increased difficulties breathing
Check pulse oxygen saturation
levels every two hours. Rationale:
determines how well the patient is
oxygenated and if another
intervention is need.
References:
Ackley, B.J. and Ladwig, B.G. (2008).Nursing Diagnosis Handbook: An Evidence-Based Guide to
Planning Care, 8th edition. St. Louis: Mosby.
Lewis, S.M., Heitkemper, M.M. and Dirksen, S.R.. Eds. O’Brien, P.G. Giddens, J. F., and Bucher, L.
(2004) Medical Surgerical Nursing: Assessment and Management of Clinical Problems, 6th edition. St.
Louis: Mosby.
Hopfer Deglin, J. and Hazard Vallerand, A. (2007). Davis’ Drug Guide, 10th edition. Philadephia: F.A.
Davis Company.
Pagana, K. D and Pagana, T.J. (2003) Diagnostic and Laboratory Test Reference, 6th edition. St. Louis:
Mosby.
DISCHARGE PLANNING GUIDE
Anticipated date of discharge: Week 5
Discharge to: Daughter
Functional Assessment
Independent Assist (specify) Total Care
eating yes
bathing yes
dressing yes
toileting yes
transferring yes
ambulating yes
taking medications correctly yes
house keeping yes
yes
preparing meals
If the patient has deficits, you need to plan for a safe discharge:
If able to live at home, but unable to drive or lift heavy objects, what is the plan for housekeeping,
transportation for grocery shopping or doctor appointments?
Patient is independent and capable of all tasks routinely expected of someone her age
Does the patient have help at home? 24 hours a day? Prior to hospitalization was the patient responsible for
the care of others (children, spouse, elderly parent)? Have arrangements been made for care of others while in
the hospital and after discharge?
Patient lives with her grown daughter. The daughter is capable of taking care of herself.
Multidisciplinary Team
Referral in hospital Needs after discharge
Social Work/Case Manager
Respiratory therapist Yes. Does the patient need home
oxygen or nebulizers
Physical therapist What assistive equipment is
needed at home to create a safe
environment? Are there stairs
in/out of house? Room location?
Cane/walker/crutches?
Occupational therapist Shower seat? Elevated toilet
seat? Extenders? Set up of
kitchen?
Visiting Nurse IV medications? Special
assessments? Dressing changes?
Home Health care worker Which ADLs?
State how the discharge needs identified above will be addressed.
Patient has a home nebulizer to treat her asthma. She will have regular appointments with her primary
care provider to assess her lungs and check on the state of her airways.
What teaching does the patient need before discharge?
Patient doesn’t need any teaching. She is very familiar with how to use her medication.