Professional Documents
Culture Documents
COLLEGE OF NURSING
Student: Shannon OShea
Patient Initials: BF
Age: 54
Gender: Male
Procedure:
1 CHIEF COMPLAINT:
My legs were red and swollen.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
A 54-year-old patient who looks older than his actual age. Patient came to hospital for an acute attack of his chronic
cellulitis and edema to bilateral lower extremities. Patient states that the swelling and pain in his lower legs has made it
hard to walk the past few days. He states he needed to constantly rest and elevate his legs to help with the swelling and
pain. Patient has been seen at Bayfront hospital several times in the last few months for cellulitis and COPD. The patient
is down to 3 cigarettes a day, and is unable to use nicotine patches due to his allergies. Patient was counseled on smoking
cessation. Patient had chest x-ray and a bilateral ultrasound of the lower extremities. The CXR shows probable bibasilar
scarring, and the ultrasound was negative for DVTs.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
2014
Operation or Illness
Patient was hospitalized 14 times in 2014 for COPD and cellulitis.
Tumor
Stroke
Stomach Ulcers
Seizures
Mental
Problems
Health
Kidney Problems
Hypertension
(angina,
MI, DVT
etc.)
Heart
Trouble
Gout
Glaucoma
Diabetes
Cancer
47
Bleeds Easily
Brother
Asthma
45
Arthritis
Brother
Father
Anemia
Mother
Cause
of
Death
(if
applicable)
Lung
72
Cancer
64 Lung Cancer
Environmental
Allergies
2
FAMILY
MEDICAL
HISTORY
Alcoholism
2015
Unknown
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years? 2014
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS
Medications
NAME of
Causative Agent
Penicillin
Bactrim
Anything derived
from egg or horse
serum
Iodine
NO
Eggs
Chocolate
Lobster
5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Cellulitis is an inflammation process usually caused by a staphylococcus or streptococcus infection (Osborn, Wraa,
Watson & Holleran, 2014). The inflammation affects the skin and subcutaneous tissue, but is non-necrotizing. The
incidence of cellulitis is equal in men and women, and is not age specific. There is an increased risk for individuals who
are obese or those with venous insufficiency. The inflammatory process is often not reported, so it is hard to track the
prevalence of the disorder. Cellulitis often develops after a patient receives a cut, laceration, ulcer or surgical wound
(Osborn, Wraa, Watson & Holleran, 2014). Due to these openings in the skin organisms are able to easily enter the body.
Once inside the dermis they begin to multiply. All though any area of the body can be affected, the lower extremities and
face are two of the most common sites for cellulitis. A patient with Cellulitis will present with redness, tightness, swelling
and tenderness. In addition, the skin may have blisters or abscesses. With Cellulitis the patient may experience chills,
fever, vomiting and a headache. To diagnose Cellulitis a patients white blood cell count will be measured, and a wound
culture may be taken. Treatment of cellulitis is with antibiotics. The patient should have blood samples taken to identify
the cause of infection, and more specific antibiotics can then be given. Rest, pain management and elevation of the
affected site should also be used in treatment. The patient might also require a consult to wound care. Treatment of
cellulitis is important, if not treated the bacteria could travel to the patients blood stream and they can develop septicemia.
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF), home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: aspirin
Concentration
Dosage Amount: 81 mg
Route: PO
Frequency: Daily
Pharmaceutical class: salicylates
Home
Hospital
or
Both
Indication: Prophylaxis of transient ischemic attacks and myocardial infarctions.
Adverse/ Side effects: Tinnitus, GI bleeding, dyspepsia, epigastric distress, nausea, abdominal pain, anorexia,
hepatotoxicity, vomiting, anemia, hemolysis, rash, urticaria.
Nursing considerations/ Patient Teaching: Use cautiously in patients with bleeding disorders, ulcers, chronic alcohol use,
hepatic or renal disease. Administer after meals or with food to minimize gastric irritation. Should be withheld for 1 week
prior to any surgeries.
Name: diltiazem, Cardizem
Concentration
Route: PO
Frequency: Daily
Pharmaceutical class: Calcium Channel Blockers
Home
Hospital
or
Both
Indication: Hypertension, angina pectoris, supraventricular tachyarrhythmias or rapid ventricular rates in atrial fib or
flutter.
Adverse/ Side effects: Anxiety, confusion, dizziness, drowsiness, headache, weakness, psychiatric disturbances, blurred
vision, epistaxis, tinnitus, cough, dyspnea, arrhythmias, heart failure, peripheral edema, chest pain, bradycardia, anorexia,
constipation, diarrhea, dysuria, polyuria, Steven-Johnson syndrome, flushing, sweating, photosensitivity, hyperglycemia,
anemia, leukopenia, thrombocytopenia, muscle cramps, joint stiffness, tremors, gingival hyperplasia.
Nursing considerations/ Patient Teaching: Contraindicated in sick sinus syndrome, 2nd or 3rd degree heart blocks, systolic
BP< 90 mmHG, recent MI or pulmonary congestion. Do not take with grapefruit juice. Monitor blood pressure and pulse
prior to therapy. Monitor ECG during treatment, may cause prolonged PR interval.
Name: diphenhydramine, Benadryl
Concentration
Dosage Amount: 25 mg
Route: PO
Frequency: PRN, HS (at bedtime)
Pharmaceutical class: Antihistamines
Home
Hospital
or
Both
Indication: Relief of allergic symptoms caused by histamine release.
Adverse/ Side effects: Drowsiness, dizziness, headache, blurred vision, tinnitus, hypotension, palpitations, anorexia, dry
mouth, constipation, nausea, dysuria, urinary retention, photosensitivity, chest tightness, thickened bronchial secretions,
wheezing.
Nursing considerations/ Patient Teaching: Use cautiously in severe liver disease, angle-closure glaucoma, seizure
disorders, prostatic hyperplasia, peptic ulcer, hyperthyroidism. Increased risk of CNS depression with other antihistamines,
alcohol, opioid analgesics and sedatives.
Name: famatodine, Pepcid
Concentration
Dosage Amount: 20 mg
Route: PO
Frequency: Daily
Pharmaceutical class: Histamine h2 antagonists
Home
Hospital
or
Both
Indication: Management of gastroesophageal reflux disease.
Adverse/ Side effects: Confusion, dizziness, drowsiness, hallucinations, headache, arrhythmias, constipation, diarrhea,
nausea, erectile dysfunction, gynecomastia, agranulocytosis, aplastic anemia, neutropenia, thrombocytopenia.
Nursing considerations/ Patient Teaching: Assess for epigastric or abdominal pain and frank or occult blood in the stool
or emesis. Monitor CBC during therapy. Administer with meals or immediately afterward and at bedtime to prolong effect.
Name: furosemide, Lasix
Concentration
Dosage Amount: 40 mg
Route: PO
Frequency: Daily
Pharmaceutical class: Loop diuretics
Home
Hospital
or
Both
Indication: Hypertension, edema due to heart failure, hepatic impairment or renal disease.
Adverse/ Side effects: Blurred vision, dizziness, headache, vertigo, hearing loss, tinnitus, hypotension, anorexia,
constipation, diarrhea, dry mouth, dyspepsia, nausea, vomiting, pancreatitis, excessive urination, Steven-Johnsons
Syndrome, photosensitivity, pruritis, rash, hyperglycemia, dehydration, hypocalcemia, hypochloremia, hypokalemia,
hypomagnesaemia, hyponatremia, hypovolemia, metabolic alkalosis, aplastic anemia, agranulocytosis, hemolytic anemia,
leukopenia, thrombocytopenia, muscle cramps, paresthesia, fever.
Nursing considerations/ Patient Teaching: Use cautiously in severe liver disease, electrolyte depletion, diabetes,
hypoproteinemia, severe renal impairment.
Name: potassium chloride
Concentration
Route: PO
Frequency: Daily
Pharmaceutical class: Mineral and electrolyte
Home
Hospital
or
Both
replacement
Indication: Treatment and prevention of potassium depletion
Adverse/ Side effects: Confusion, restlessness, weakness, arrhythmias, ECG changes, abdominal pain, diarrhea, nausea,
vomiting, GI ulceration, paralysis, paresthesia.
Nursing considerations/ Patient Teaching: Contraindicated in hyperkalemia, renal impairment. Use cautiously in cardiac
disease, diabetes and patients receiving potassium sparing drugs. Monitor serum potassium before and periodically during
therapy. Monitor for symptoms of toxicity.
Name: vancomycin
Concentration: 278 ml
Route: IV
Frequency: Q12
Pharmaceutical class: Anti-infective
Home
Hospital
or
Both
Indication: Treatment of life-threatening infections. Particularly in staphylococcal infections.
Adverse/ Side effects: Ototoxicity, hypotension, nausea, vomiting, nephrotoxicity, rashes, eosinophilia, leukopenia,
phlebitis, back and neck pain, anaphylaxis, chills, fever, red man syndrome, superinfection.
Nursing considerations/ Patient Teaching: May cause ototoxicity and nephrotoxicity with other toxic drugs. Use
cautiously in renal impairment, hearing impairment, intestinal obstruction or inflammation.
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Cardiac
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The patients normal home diet shows that he is meeting
majority of his daily food group goals. The only group that
Breakfast: BLT sandwich, hash browns and fruit
is being neglected according to the input in his dairy intake.
This means the patient is not getting enough calcium in his
Lunch: Chicken Stir Fry, salad and fruit
diet. According to My Plate the patient is taking in too
much sodium, which can increase his hypertension, and risk
Dinner: Seafood (fresh fish), rice and vegetables
for heart disease. Lastly, the patient is under the suggested
amount of iron, this could lead to anemia. The patient
Snacks: Graham crackers, pudding
should add some more red meats or fortified cereal to
increase his iron level.
Liquids (include alcohol): 2 hot teas, juice, a lot of water,
a few alcoholic beverages
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My wife
How do you generally cope with stress? or What do you do when you are upset? I normally have a few drinks or go
for a walk with my wife.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Yes, last year when I lost my job I became pretty depressed and overwhelmed.
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
vs. Inferiority
Despair
Identity vs.
Role Confusion/Diffusion
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: The goal of this developmental stage is to be productive. Whether through relationships or work a person in
this stage should contribute to society productively. If this doesnt occur the patient experiences stagnation, and lead to
decreased motivation to guide them to the next developmental stage (Treas & Wilkinson, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: I believe
my patient is in the self absorption/ stagnation stage of life due to his illness limiting his availability to work. In the past year
the patient lost his job and was placed on disability. I believe this has caused a severe delay on my patients development due to
him feeling lost and inadequate. I believe the only portion of my patients life that isnt stagnant is his relationship with his
wife.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: The patients
disease process has caused him to lose his job, and in turn lose his home. I believe this has severely impacted his stage of life
because he feels empty without working, and put him in a stagnant stage of his life.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? The patient thinks that bed bugs caused his cellulitis. He claims that
in their old apartment the infestation was really bad, and he thinks that is what led to him developing cellulitis.
What does your illness mean to you? The patient feels his illness makes him dirty, and at times he feels paralyzed.
+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?____Yes________________________________________________
Do you prefer women, men or both genders? __Women____________________________________________
Are you aware of ever having a sexually transmitted infection? __No_________________________________
Have you or a partner ever had an abnormal pap smear? No____________________________________
Have you or your partner received the Gardasil (HPV) vaccination? __No________________________________
Are you currently sexually active? __Yes______ If yes, are you in a monogamous relationship? ____Yes__________
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? _____None_____________________________
How long have you been with your current partner?___25 years.___________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? _No._________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No.
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Liquor
How much? 3-4 drinks per day
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Possible asbestos from working as a plumber when he was 18 years old.
5. For Veterans: Have you had any kind of service related exposure? N/A
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine: Everyday
Other:
Gastrointestinal
Immunologic
Genitourinary
Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: O Neg
Other:
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 8-9 x/day
Bladder or kidney infections
Hematologic/Oncologic
Metabolic/Endocrine
Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:
Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 11/10/15
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 11/10/15
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:
Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:
Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Childhood Diseases
Measles (German measles)
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:
Other:
Other:
General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
Is there any problem that is not mentioned that your patient sought medical attention for with anyone? No
Any other questions or comments that your patient would like you to know? No.
10 PHYSICAL EXAMINATION:
General Survey: Patient is
AOx4. Patient is a 54 y.o white
male who appears older than
actual age. He is sitting in bed
comfortably. He shows no sign of
distress at this time.
Height: 60
Pulse: 85
Respirations: 18
Weight: 207
BMI: 27.9
Blood Pressure: (include location)
Left Arm: 158/82
SpO2 : 98%
Room Air
Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular
No JVD
GU
Urine output:
Clear
Cloudy
Color:
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness
Musculoskeletal:
Full ROM intact in all extremities without crepitus
Strength bilaterally equal at ____5___ RUE ___5____ LUE ___5____ RLE & ___5____ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
Biceps: +2
Brachioradial: +2
Patellar: +2
Achilles: +2
10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need prior
to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as Ultrasounds,
X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then include why
you expect it to be done and what results you expect to see.
Lab
Trend
Analysis
WBC: 5.2
4.1
Dates
(11/4/2015)
(11/10/2015)
Hgb: 11.9
13.3
(11/4/2015)
(11/10/2015)
Hct:
(11/4/2015)
(11/10/2015)
Platelet: 155
230
((11/4/2015)
(11/10/2015)
Sodium: 140
141
(11/4/2015)
(11/10/2015)
Potassium: 3.1
3.9
(11/4/2015)
(11/10/2015)
Chloride: 105
105
(11/4/2015)
(11/10/2015)
CO2: 23.4
27.4
(11/4/2015)
(11/10/2015)
Glucose: 144
119
(11/4/2015)
(11/10/2015)
BUN: 7
11
(11/4/2015)
(11/10/2015)
Creatinine: 0.7
0.7
(11/4/2015)
(11/10/2015)
Calcium: 8.6
8.9
(11/4/2015)
(11/10/2015)
Vancomycin: 13.0
(11/10/2015)
36.1
39.3
15 CARE PLAN
Nursing Diagnosis: Ineffective peripheral tissue perfusion rt an inflammatory response damaging skin and underlying tissue aeb red, flaky skin, edema and
extremity pain.
Patient Goals/Outcomes
1.
2.
3.
4.
1.
Nursing Diagnosis: Acute pain rt inflammatory changes in tissue secondary to cellulitis aeb complaints of pain, discomfort and fatigue.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
1. Patients pain level will remain under 5
out of 10 throughout the entire shift.
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
*F/U appointments
*Med Instruction/Prescription
Are any of the patients medications available at a discount pharmacy? *Yes No
Rehab/ HH
Palliative Care
References
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (Tenth ed.). Maryland Heights, Missouri:
Mosby Elsevier.
Osborn, K., Wraa, C., Watson, A., & Holleran, R. (2014). Caring for the Patient with Diabetes. In Medical-Surgical Nursing: Preparation for
Practice (2nd ed., pp. 1417-1464). Upper Saddle River, NJ: Pearson Education.
Treas, L., & Wilkinson, J. (2014). Development: Infancy through Middle Age. In Basic Nursing (pp. 163-164). Philadelphia, Pennsylvania: F.A Davis
Company.