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Medical Diagnoses: Activity Intolerance related to exertional discomfort, Risk for falls and Anxiety


School of Nursing

Clinical Assessment Worksheet

 

Student:  ­­­­­­­­­­­­­­­­­_______________                                                                                                                    Dates of Care:  7/19,720

 

Age:   86                             Gender:  Female

 

Race:  White                         

 

 Code Status:  Full Code

 

Weight:   132                  Height:  5’2”

 

Allergies:  Dilaudid, Hydromorphone, Codeine Phosphate, Erythromycin

 

 

 

 

Date of Admission: 7/17/

 

 

Reason for Admission (patient’s words): Pain in lower abdomen,  patient said has irritable bowel syndrome so knows when pain is severe

 

 

Medical Diagnosis: Inflammatory Colitis

 

 

Surgery this admission (include date): N/A

 

 

Discharge Plan Needs: Management of health conditions, medication side effects, avoid irritating foods

Chronic Illnesses/ Previous Health Issues:

Angina, Cardiomyopathy, Irritable bowel syndrome, arthritis, gastroesophageal reflux disease, hypertension, congestive heart failure

 

Previous Surgeries (include year):

Cholecystectomy   2008

Hip Replacement   2004

Appendectomy   >5 yrs ago

Ovary removed   >5 yrs ago

Back/Fat pads removed   >5 yrs ago

Angioplasty   xxxx

 


Nursing Diagnoses (3 – prioritized):

 

1: Activity Intolerance related to exertional discomfort as evidenced by dyspnea, patient verbalizing feeling short of breath, patient needing assistance with activities of daily living, verbal report of weakness,  and need for frequent breaks during activity.

 

2: Risk for falls related to impaired balance as evidenced by patient walking with unsteady gait, verbalizing need for assistance because feels off balance, and patient needing to urinate frequently, and patient verbalizing uses cane all the time at home.

 

3: Anxiety related to unfamiliar environment and feelings of confinement as evidenced by patient verbalizing feelings of worry because staying in hospital and being away from home.

 

Diet:  Clear liquids 7/19 until 0930.  Regular heart healthy diet after 0930 7/19.

 

Activity:  Up with assist of 1, Falls risk, bed alarm in place

 

IV Access:

        Saline Lock

    X  Continuous IVFs

 Solution & Rate:  0.9% Sodium Chloride 1000mL 75cc/hr

 

 


I&O:

   X  Voiding

        Foley Catheter

        NG Tube

 

 

Wound Care:

 

Drains:

 

 

 


Pulmonary Care:

     O2   2    L/min via   X   NC         Mask

 

     IS q      hrs.                    MDI            HHN

 

 


Blood Sugar/ Accuchecks/ Insulin:



Describe Pathophysiology of current illness(es) and include how relates to patient’s signs and symptoms:
Inflammatory colitis is a condition where the mucosal layers of the colon become inflamed.  Multiple ulceration and shedding of the colonic epithelium can cause bleeding and irritation.  Prior to patient arriving in emergency room, she had a bowel movement and bright red blood was seen on the toilet paper.  Sometimes there is bleeding when passing stool because of the inflamed ulcers.

Irritable bowel syndrome is a common GI condition that results from a functional disorder of intestinal motility.  The change in motility is often a related to neuroendocrine dysregulation, infection, or other inflammatory disorders.  Peristaltic waves are affected and common symptoms are constipation, diarrhea or combination of both.  My patient had diarrhea all day 7/16 and came the following day to the emergency room with abdominal pain.  Patient states has had irritable bowel syndrome for years and is aware of signs and symptoms and knows when she needs to seek care.

She also experiences nausea because of poor perfusion of the GI system.  Gastroesophageal reflux disease is backflow of gastric or duodenal contents into the esophagus.  The symptoms sometimes mimic a heart attack.  It is likely my patient has GERD due to her motility disorder. 

Angina refers to pain or pressure in the chest due to insufficient blood flow, resulting in decreased oxygen when there is an oxygen demand in response to physical exertion or stress.  My patient is frequently short of air and has had episodes of angina after activity, whether strenuous or not.

Hypertension is a multifactorial condition and is the result of a change in one or more factors affecting peripheral resistance or cardiac output.  The body’s control systems that monitor and regulate pressure are also altered.  My patient had a recent angioplasty so it is possible that the main cause of her hypertension is decreased vasodilatation of the arterioles related to dysfunction of the vascular endothelium.

Cardiomyopathy is a heart muscle disease associated with cardiac dysfunction.  It is described as a series of events that impair cardiac output.  Decreased stroke volume stimulates the sympathetic nervous system and the renin-angiotensin-aldosterone response resulting in increased systemic vascular resistance and increased sodium and fluid retention.  This causes increased workload on the heart.  My patient shows signs of dyspnea during activity and fatigue.

Congestive heart failure is a fluid overload condition associated with heart failure.  It is the inability of the heart to pump sufficient blood to the meet the needs of the tissues for oxygen and nutrients.  Heart failure can result from chronic hypertension which my client is being treated for, and symptoms are shortness of breath, edema, and fatigue.  My patient said she always feels short of breath and is often fatigued even after just going to bathroom or doing minimal activity.  Arthritis is inflammation of the joint and can affect muscles, bones, cartilage, ligaments, tendons, and joints.  My patient has had a hip replacement and stated that her knees sometimes hurt.  Inflammation is caused by the immune response and degeneration occurs after proliferation of newly formed synovial tissue infiltrated with inflammatory cells.  (Smeltzer, Bare, Hinkle, & Cheever, 2010).

LAB VALUES/ TEST RESULTS:

 

Important Labs to Monitor:

Why (consider diagnosis, pre-existing conditions, medications, complications, etc)?

HGB

Colitis, GI bleeding, Infection in GI tract

HCT

Colitis, GI bleeding, Infection in GI tract

Total Protein

Nutritional status, low total protein is an indicator of poor nutritional status.  Hardening artifact could be preventing absorption of nutrients from GI tract.  Diarrhea

Albumin

Nutritional status.  Diarrhea

 

 

 

 

Hematology:

Test Name

Normal Values

Date: 7/19/xxxx

Date: 7/20/xxxx

Date

Significance for this patient

WBC

4.50-10.70

5.00

4.56

 

 

RBC

3.90-5.20

3.67

3.47

 

 

HGB

11.9-15.5

10.6

10.0

 

Infection, anemia, oxygen, hemorrhage

HCT

35.6-45.5

32.5

30.3

 

Infection, anemia, oxygen, hemorrhage

PLT

140-500

225

212

 

 

Chemistry:

Test Name

Normal Values

Date: 7/19/xxxx

Date: 7/20/xxxx

Date:

Significance for the Patient:

GLU

72-112

92

NO Lab Values

 

 

BUN

6-20

10

Today

 

 

CREAT

0.44-1.03

1.06

 

 

Assess kidney function

NA+

135-144

138

 

 

 

CL-

100-111

108

 

 

 

K+

3.6-5

3.8

 

 

 

CO2

23-32

23

 

 

 

Ca+

8.5-10.1

8.8

 

 

 

 

Other Chemistry:

Test Name

Normal Values

Date: 7/19

Date: 7/20

Date:

Significance for this Patient:

Total Protein

6.4-7.9

4.8

NO Lab Values

 

Nutritional status, low total protein is an indicator of poor nutritional status.  Hardening artifact could be preventing absorption of nutrients from GI tract. Most likely low because patient experience diarrhea before coming to ER, then clear liquids until 7/19

Albumin

3.4-4.7

2.8

Today

 

Nutritional status.  Patient had diarrhea before coming to ER, clear liquids only after until 7/19

AST

14-37

18

 

 

 

ALT

11-65

12

 

 

 

ALP

31-115

59

 

 

 

TBIL

0.4-1.5

0.7

 

 

 

Magnesium

 

 

 

 

 

Phosphorus

 

 

 

 

 

 

Coagulation:

Test Name

Normal Values

Date:

Date:

Date:

Significance for this Patient:

PT

 

 

 

 

 

INR

 

 

 

 

 

PTT

 

 

 

 

 

 

ABGs/ Arterial Blood Gases:

Test Name

Normal Values

Date:

Date:

Date:

Significance for this Patient:

pH

 

 

 

 

 

pCO2

 

 

 

 

 

pO2

 

 

 

 

 

HCO3-

 

 

 

 

 

O2 Sat

 

 

 

 

 

BE

 

 

 

 

 

Urine:

Test Name

Normal Values

Date:

Date:

Date:

Significance for this Patient:

Color

 

 

 

 

 

Clarity

 

 

 

 

 

Specific Gravity

 

 

 

 

 

pH

 

 

 

 

 

Glucose

 

 

 

 

 

Ketones

 

 

 

 

 

Nitrates

 

 

 

 

 

RBCs

 

 

 

 

 

WBCs

 

 

 

 

 

Protein

 

 

 

 

 

Other Labs:

Test Name

Normal Values

Date:

Date:

Date:

Significance for this Patient:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pertinent X-rays or other Imaging Studies: CT ABD/Pel w/ IV cont., CT angiogram of the abdomen w/contrast.  There is minimal bibasilar subpleural scarring within the lungs.  Hepatic cysts measuring up to 1.8cm in diameter are appreciated.  Calcified granulomata are seen within the spleen.  There is mild bilateral renal atrophy.  At the superior pole of the right kidney, there is a 1.2cm cyst.  The adrenal glands and pancreas appeared normal.  Beam hardening artifact within the right hemipelvis and right lower quadrant secondary to a right hip prosthesis is noted.  There is no evidence for mesenteric, retroperitoneal or pelvic lymphadenopathy.  Severe artheromatous calcification is seen within the abdominal aorta and bilateral iliac arteries.

There is mild stranding seen within the posterior pelvic cul-de-sac adjacent to the distal sigmoid colon/proximal rectum.  No definite diverticulum is seen within this region and there is no evidence for bowel wall thickness. 

Multi level degenerative disk disease is seen at the lumbar spine in conjunction with osteophytic change.  In other words, nothing acute was identified to explain her abdominal pain.       

 

Other (EKG, telemetry, etc):  ECG, ordered because patients heart rate dropped to 41, O2 to 84% night of 7/18 Abnormal, sinus rhythm, abnormal, consider ischemia, anterior leads.  These results could reflect the patients chronic conditions and also be a side effect of medication.  The patients Diltiazem HCL CD was held per Dr. Noffsinger as a precaution because her heart rate had dropped in the night. 

 

Medications:

Name, Dose, Freq, Route

Action

Side Effects

Nursing Implications

Reason Patient Taking Medication

Isosorbide Mononitrate

30 mg/Oral/Once a day

Start 7/18 0900

Prevent angina, reduces oxygen demand by decreasing preload and afterload, relax vascular smooth muscle, dilate peripheral arteries/veins

Headache, dizziness, weakness, tachycardia, ankle edema, flushing, fainting, sublingual burning, nausea, vomiting, rash

For patient, do not crush, take on empty stomach.  May interact with antihypertensives (sildenafil, tadalafil, vardenafil) monitor BP, chest pain, heart rate

Patient taking to prevent chest pain, patient often feels SOA

Carvedilol (BB)

12.5 mg/Oral/Every 12 hrs

Start 7/18 0900

Antihypertensive, nonselective beta blocker with alpha blocking activity

Dizziness, fatigue, stroke, headache, fever, vertigo, edema, chest pain, diarrhea, vomiting, nausea, abdominal pain, blurred vision, cough

May enhance hypoglycemic properties, may decrease antihypertensive effects.  Monitor blood pressure.  May increase ALT, AST, BUN. Can affect heart rate.  Monitor for respiratory distress, heart rate, O2 sat.

Patient has high blood pressure, taking to treat hypertension

Dorzolamide HCL 2%

1 drop/Both eyes/Every 12 hrs

Start 7/18 2100

Carbonic anhydrase inhibitor, slows formation of bicarbonate ions with reduction in sodium and fluid transport, reduces aqueous humor secretion and elevated intraocular pressure

Asthenia, fatigue, headache, blurred vision, dryness, lacrimation, ocular allergic reaction, ocular burning, stinging, discomfort, nausea, bitter taste in mouth

Drug may be absorbed systemically, remove contact lens, monitor intraocular pressure

Patient has occluded vein in left eye, prescribed to lower intra ocular pressure in glaucoma and ocular hypertension

Aspirin

81 mg/Oral/Once a day

Start 7/19 0900

 

Inhibitor of prostaglandin synthesis and platelet aggregation

Tinnitus, hearing loss, nausea, GI bleeding, occult bleeding, renal insufficiency, bruising, angioedema, leucopenia, Reye syndrome

Avoid use with ginko biloba, may decrease antihypertensive effects, monitor BP closely.  May increase risk of bleeding, take with full glass of water

Patient prescribed to make platelets less sticky, taking to prevent heart attack because has angina

Cetirizine HCL

10 mg/Oral/Once a day

Start 7/19 0900

Human metabolite of hydroxyzine, antihistamine that selectively inhibits effect of peripheral H(1) receptors

Somnolence, fatigue, dizziness, headache, pharyngitis, dry mouth, nausea, vomiting, abdominal distress

Monitor central nervous system effects, urticaria, improvement in itching/hives, improvement in rhinitis symptoms

Prescribed to treat angioedema. Prescribed for seasonal allergies.

Diltiazem HCL CD

120 mg/Oral/Once a day

Start 7/19 0900

Antihypertensive, calcium channel blocker that inhibits calcium ion influx across cardiac and smooth muscle cells, decrease myocardial contractility and O2 demand. Also dilates coronary arteries and arterioles

Headache, dizziness, asthenia, somnolence, arrhythmias, AV block, bradycardia, heart failure, flushing, abnormal ECG, nausea, constipation, abdominal discomfort

For patient, avoid grapefruit juice, do not crush.  Monitor blood pressure and heart rate.  If systolic BP below 90 mmHg or heart rate below 60 bpm, withhold dose and notify prescriber, monitor chest pain

Held per Dr. Noffsinger b/c patient heart rate dropped night before to 41 bpm, O2 sat dropped to 84%. Patient prescribed because has high blood pressure and recent angioplasty.

Name, Dose, Freq, Route

Action

Side Effects

Nursing Implications

Reason Patient Taking Medication

Lisinopril (ACE)

2.5 mg/Oral/Once a day

Start 7/19 0900

Angiotensin-converting enzyme(ACE) inhibitor, prevents conversion of angiotensin I to angiotensin II which is potent vasoconstrictor.

Dizziness, headache, fatigue, paresthesia, hypotension, chest pain, nasal congestion, diarrhea, nausea, impaired renal function, dyspnea

Monitor blood pressure closely, may increase BUN, creatinine, potassium, monitor WBC, tell patient to rise slowly. Monitor renal function, S&S heart failure

Prescribed as part of treatment to treat high blood pressure

Multiple Vitamins/Minerals

1Tablet/Oral/Once a day

Start 7/19 0900

Multi vitamin

Nausea, gastrointestinal upset

Monitor lab values

Patient refused, prescribed to enhance nutritional status.  Patient states takes at home, but doesn’t take when away from home or in hospital

Pravastatin Sodium

40 mg/Oral/Once a day

Start 7/19 0900

Inhibits HMG-CoA reductase, an early and rate limiting step in cholesterol biosynthesis, blocks production of LDL

Dizziness, fatigue, headache, chest pain, rhinitis, nausea, abdominal pain, constipation, diarrhea, flatulence, heartburn, vomiting, myopapathy, cough, flulike symptoms

Patient should follow diet restricted in saturated fat and cholesterol. Advise patient to report muscle pain, tenderness, weakness

Prescribed to reduce risk of myocardial infarction, and reduces cholesterol

Pregabalin (Lyrica)

50 Mg/Oral/Twice a day

Start 7/18 1800

End 8/01 0901

GABA analog binds to alpha(2) delta site in CNS tissues.  Reduces calcium dependent release of neurotransmitters

Ataxia, anxiety, nystagmus, edema, blurred vision, tinnitus, dry mouth, abdominal pain, vomiting, urinary frequency or incontinence, hypoglycemia, appetite changes, dyspnea

Monitor patient closely.  May increase risk of hives/swelling. Monitor patient for dizziness and somnolence.  Monitor patient for fluid retention. Monitor pain.

Prescribed to treat neuropathic pain, part of pain management

Sodium Chloride 0.9% 1000mL

IV Rate 75 mL/hr

Start 7/17 1946

Source of water and electrolyte. Important in regulation of osmolarity, acid-base balance, and membrane potential of cells

Phlebitis, injection site extravasation, injection site reaction, hypervolemia, congestive heart failure, overhydration, respiratory distress

Monitor adequate hydration, changes in fluid balance, edema, potential worsening of clinical condition, renal function

Patient had diarrhea day before came to emergency room, was dehydrated.  Extracellular volume replacement.

Alprazolam

0.25 mg/Oral/TID PRN

Start 7/18 0100

End 8/01 0059

Potentiates effects of GABA, depresses the CNS, suppresses the spread of seizure activity

Irritability, dizziness, headache, confusion, suicide, chest pain, blurred vision, diarrhea, dry mouth, nausea, vomiting, muscle cramps, sweating, dyspnea, myalgia

Patient avoid grapefruit juice, may increase ALT, AST levels. Monitor hepatic, renal function. Assess patient anxiety before and during therapy

Patient having anxiety when came to emergency room and admitted

 

 

 

ASSESSMENT

 

History of Present Illness: The patient is an 87 year old Caucasian female patient of Dr. Hans Noffsinger.  She was recently admitted to the hospital 7/06-7/10 with the findings, at the time, of some chest pain, possibly secondary to coronary disease.  She had a heart catheterization, which demonstrated non critical stenosis.  Imdur was added to her regimen, at that time, and she was discharged home.  She did fairly well for several days but 7/16 began having some lower abdominal pain.  Pain worsened and she eventually presented to the emergency room.  There on examination, she did have some left lower quadrant tenderness.  A CT scan of the abdomen was done.  Patient felt nauseated.  Patients chief complaint was abdominal pain that started 7/16, but as of 7/18 no longer present.  Was waxing/waning pain.  Patient described as cramping located in left lower quadrant.  No radiation.  At its maximum severity, patient described as mild.  When seen in emergency department, severity described as mild.  Modifying factors-not worsened by anything.  She has had diarrhea (chronically).  No vomiting.  Patient was kept in hospital after visit to ER because close monitoring of her cardiac and respiratory conditions were recommended.  Patient was expecting to be discharged 7/19, however during the night of 7/18, patients HR dropped to 41 bpm and oxygen saturation dropped to 84%.  Dr. Noffsinger advised patient she would not be discharged 7/19 because he wanted her cardiac and respiratory conditions to be further monitored.

 

Vital Signs:                         Date:                     BP                           HR                          RR                           Temp                    O2 Sat                   Pain

                                                7/19                       146/63                  64                           20                           97.9                        96                           0/10

                                                7/20                       152/68                  78                           20                           97.1                        97                           0/10

 

Neuro/Musculoskeletal Activity (Movement, Strength, Sensation): Patient is alert and oriented X4.  Patient aware of situation and easily aroused.  Sensation of extremities found to be intact by patient confirming ability to perceive light touch with washcloth.  Patient able to slowly move and raise all extremities symmetrically with equal strength bilaterally.  Patient able to ambulate around nurses station with assist of 1.  Patient needs assistance to get to restroom but able to toilet herself.  Patient walks with unsteady gait and states uses cane when at home.  Patient said had plenty of canes around her house and in her car, but didn’t have one with her in hospital.  Said didn’t bring cane with her and denied physical therapy’s offer of getting her one to use while she was in hospital.  Physical therapy also asked if she’d like one to ambulate with in hall because they didn’t want her to use her IV pole for stability.  Patient denied and held physical therapy tech hand instead. 

 

Skin (CUSPs/ 4Ts): Patient skin warm, dry, intact.  Patient has numerous cherry angiomas on back and legs.  Patient had bruises on both lower legs and fist size bruise on right lower quadrant from recent cath.  Otherwise skin color fairly even throughout, some brown pigmentation/age spots on legs, face, and chest.  No ulcerations, no swelling, no pitting edema. Patient has small horizontal scar on right lower quadrant from previous surgery.  Patient states always has some tenderness in left lower quadrant.  Some tenting of skin, decrease skin elasticity.  No irritation on nares, face, ears from nasal cannula. Patient had cousin bring her skin cream from home because said her face was feeling dry.

 

Cardiac (Heart Sounds, Rate & Rhythm, Capillary Refill, Radial & Pedal Pulses: Heart-regular rhythm, heart rate lower, hx shows always runs a little low.  No murmur.  S1 auscultated at apex, S2 auscultated at base.  Capillary refill in less than 2 seconds.  Radial and pedal pulses palpable and equal bilaterally. 

 

Respiratory (Lung Sounds, Rate, Rhythm, Effort): Respirations not labored.  No use of accessory muscles or nasal flaring at rest.  Auscultated lungs-clear bilaterally.  Symmetrical expansion.  Mucous membranes-pink.  Patient short of air after ambulating in hall and going to restroom and back.  On 7/19 when I met patient she was on O2 via NC because HR dropped and O2 sat low in night.  Patient stated had never used or been on oxygen before.  O2 taken off 7/19 am.

 

 

GI/ Nutritional Status (Diet, Weight, Bowel Sounds, Abdomen-Flat/Distended/Soft/Firm, Last BM): Active bowel sounds in all 4 quadrants.  Patient states no current feelings of nausea.  Patient on clear liquids 7/19 until 0930, regular heart healthy diet 7/19 after 0930.  Abdomen soft, round.  Patient hasn’t had bowel movement since 7/16, had bright red blood on toilet paper after.  Abdominal tenderness in lower left quadrant.  At first, I thought nutritional status was a concern because total protein and albumin lab values were low on 7/19 am report.  But after discussion with nurse, those values most likely low because patient experienced diarrhea majority of day 7/16 before coming to ER.  After admitted patient on clear liquids.  Patient stated hadn’t taken in much because tired of red jello and chicken broth.  Once put on regular diet 7/19, patient ate at 50-75%meals.  Patient stated hospital was very accommodating regarding menu.  Stated 7/20 didn’t like any choices that she was given so she asked for bagel.  Also said requested extra cherry ice and her requests were accommodated.  Patient also stated hospital did a good job of keeping meals hot so food was more enjoyable.  Patient said does know what foods are irritating regarding her IBS, but sometimes eats foods not realizing irritants may be in them.  Patient said also some things are only irritating if she eats too much.

 

GU/ Reproductive (Urine color, clarity, amount, I&O, Menses for Women): Patient urinating clear, light yellow urine frequently. Not measured. No menses.

 

Psychosocial:  Patient was anxious about going home and disappointed after Dr. Noffsinger advised she wouldn’t be discharged 7/19 as originally planned.  She also requested Xanax and asked that the schedule be followed because the day before she didn’t receive her Xanax until very late at night.  This heightened her anxiety.  Patient stated she needed the Xanax because panics and becomes very nervous in hospital.  Patient stated had anxiety attack in ER.  Patient talking on phone with family often.  Patient said getting over recent death of cat.  Patient stated lost one of her four children, her son, when he was 37, lost her husband but always had people around her so it didn’t affect her as deeply as her cat did.  Patient states lives alone and cat was her companion for the last 6 years. Patient was prescribed Zoloft after telling doctor she was depressed about cat dying but removed because of heightened feelings of nervousness.  Patient liked having me around to speak with and often came up with things to discuss or things for me to do in order to keep me in the room.  Patient cooperative, funny, pleasant to work with. Patient states lives at home (tri level home) by herself. Uses cane all the time.  Cousin and friend come over to help PRN. 

 

Learning Needs: Continue to monitor diet, avoid irritating foods, comply with doctors orders of diet and restrictions, management of health conditions.

 

 

 

 

Date/ Time

Nurses Notes

7/19 0700

Patient hit call light to use restroom.  Patient on O2 2L/min via nasal cannula and pulse oximeter hooked up.  Both had to be detached and IV unplugged.  Patient urinated clear, light yellow urine.  Assist patient back to bed.  Connect IV, O2, pulse oximeter. CMunson SUNS---------------------------------------------------------------------------------------------------------------------------------------------------------------------------

7/19 0715

Initial assessment completed.  Active bowel sounds heard in all 4 quadrants.  Patient states always has a little tenderness in lower left quadrant.  Patient states no current feelings of nausea.  Skin warm, dry, intact.  Patient alert and oriented X4.  Patient on clear liquid diet.  Patient states tired of chicken broth and apple juice.  Auscultated lungs-clear bilaterally.  Heart- regular rhythm, rate low.  Patient states always runs a little low.  Checked history and is under 60 normally.  No murmur.  Capillary refill in less than 2 seconds.  Patient had polish on fingernails and toe nails so used tips of fingers and tips of toes.  Radial and pedal pulses palpable and equal bilaterally.  Respirations not labored but patient states feels short of air often after activity.  Patient did sometimes open her mouth to breath, however no nasal flaring or use of accessory muscles. Patient states using restroom to urinate frequently with no difficulty or pain.  Patient states hasn’t had bowel movement since before arrival on 7/17.  Patient states just prior to arrival had last bowel movement with some blood on toilet paper(bright red).  CMunson SUNS----------------------------------------------------------------------------------

7/19 0800

Provided patient complete bed bath.  Assisted patient to sink to perform self oral care.  Patient stated hadn’t had bath or brushed teeth since arrival on 7/17.  After bath assisted patient to chair to eat breakfast (chicken broth, apple juice, red jello, coffee).  While patient in chair- changed bed linens.  Nurse came in to do assessment, took patient off O2/O2 pulse oximeter because O2 sat above 95% for period of time.  Patient stated to nurse did not feel short of breath or experiencing angina  CMunson SUNS--------------------------

7/19 0840

Assisted patient to use restroom, then back in bed.  PT arrived to ambulate with patient using gait belt. CMunson SUNS--------------------

7/19 0920

Administer oral medications.  Patient refused multivitamin.  Carvedilol gave per Dr. Noffsinger, was held night before.  Diltiazem HCL CD held per Dr. Noffsinger.  Dr. Noffsinger advised patient she would need to stay at least another day.  Patient handled news well despite thinking she was going home 7/19.  Patient was disappointed and made calls to family members to let them know it would most likely be tomorrow.  Dr. also advice could be taken off clear liquid diet and placed on regular heart healthy diet. CMunson SUNS--

7/19 1000

Assisted patient to use restroom.  Patient returned to chair to read newspaper.  CMunson SUNS---------------------------------------------------

7/19 1030

Assisted patient to return to bed.  Returned couple minutes later, patient already asleep.  CMunson SUNS--------------------------------------

7/19 1130

Assisted patient to use restroom.  Patient returned to chair to eat lunch.  Patient excited to have regular diet (turkey w/gravy, mashed sweet potatoes, green beans, roll, fruit cup  iced tea) Patient ate 75% meal. CMunson SUNS---------------------------------------------------------

7/19 1215

Assisted patient back to bed after eating lunch.  Patient said was going to make few phone calls and read books.  CMunson SUNS--------

7/20 0745

Patient up in chair eating breakfast.  Said woke up at 0720 to use restroom.  CMunson SUNS--------------------------------------------------------

7/20 0800

Did initial assessment.  Patient states pain 0/10.  Pt states no tenderness today.  Skin dry, intact, warm.  Patient alert, oriented X4.  Capillary refill (end of toes/fingers) less than 2 secs. Respirations not labored.  Symmetrical expansion. Heart-normal rhythm and rate.  Bowel sounds active in all 4 quadrants.  Abdomen soft.  Frequent urination.  No bowel movement since 7/16.  Patient on regular diet.  Ate 50% breakfast. Physical therapy came to ambulate with patient around nurses station.  CMunson SUNS------------------------------------

7/20 0830

Assisted patient with oral care, bath.  Patient up in chair reading newspaper.  CMunson SUNS-------------------------------------------------------

07/20 0930

Patient wanting to get back in bed to rest.  Patient daughter in law came to visit.  CMunson SUNS--------------------------------------------------

07/20 1130

Patient easily aroused.  Assisted patient to restroom, then to chair to eat lunch.  Patient ate 50% lunch.  Dr. came in to let patient know she was going to be discharged today.  CMunson SUNS--------------------------------------------------------------------------------------------------

 

 

NANDA Diagnostic Statement:  Activity Intolerance related to exertional discomfort as evidenced by dyspnea, patient verbalizing feeling short of breath, patient needing assistance with activities of daily living, verbal report of weakness, and need for frequent breaks during activity.

 

Behavioral Outcome/ Goal (goal + timeframe + measurable parameters):  Patient will demonstrate increased tolerance to activity by discharge by showing decreased signs of dyspnea and verbalizing doesn’t feel breathlessness.  Patient will participate in physical activity with appropriate changes in heart rate, blood pressure, and respirations each day until discharge.  Patient will participate in increased self care activities to include dressing and ambulation by discharge date.

 

Nursing Interventions:

1. Assess for pain before activity.

 

 

 

2. Determine self care activities patient should assume.  Increase activities as energy allows.  Assist patient with self care activities as needed. Allow patient to determine assistance needed.

 

 

3. Encourage rest as needed between activities. 

 

 

 

4. Obtain any necessary assistive devices or equipment needed before assisting in ambulation

 

 

5. Monitor blood pressure, pulse, respiration before and after activities.

 

 

6. Provide emotional support and encouragement to the client to gradually increase activity.

 

 

Rationales with citations (APA format):

1. Pain restricts the client from achieving a maximal activity level and if often exacerbated by movement (Ackley & Ladwig, 2008, p 120).  Unwillingness to get up and participate in activities when in pain (Hur, Park, Kim, Storey, & Kim)

2. Gradually increases tolerance.  Allows patient to have some control and choice in plan of care (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

 

 

 

3. Planned rest assists in maintaining and increasing activity tolerance (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

 

 

4. Assistive devices can increase mobility by helping the client overcome limitations.” (Ackley & Ladwig, 2008, p 120)

 

 

 

5. Vital signs increase with activity and should return to baseline within 5-7 minutes after activity (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

 

6. Fear of breathlessness, pain, or falling may decrease willingness to increase activity (Ackley & Ladwig, 2008, p 120).  Reassurance, goal setting, and self assurance increase effectiveness (Greaves, et al., 2011).

 

Client Response:

1.Patient stated both days that pain was 0/10.  Patient tolerated activity well regarding pain, despite feeling short of air.  Patient stated only had pain when she was repositioning in bed or put pressure on her knee.  Patient verbalized joint pain associated with arthritis.

 

2. Patient able to get to restroom and around room to gather belongings on second day.  Patient did need assistance with bath because of awkward position in bed.  Patient states has walk in shower with seat at home.  Patient did hair on her own and walked to sink to provide oral care on own.  Patient feeds self and put robe on self second day.

 

3. Patient did need frequent rest periods during all bouts of activity.  Patient would stop, straighten back, and take deep breaths while maintaining balance by holding onto something.  Patient then could resume activity.

 

4. Patient stated used cane at home or something to stabilize when out (shopping cart).  During ambulation with PT, patient used IV pole to support self.  PT discouraged patient from doing so and offered to hold her hand instead or get her a cane.  Patient held PT tech hand while ambulating around nurses station.

 

5.  Patient vital signs did not drastically increase during or after activity.  Even when patient said felt short of air, respirations and heart rate stayed close to baseline.

 

6. Patient very cooperative and expressed gratitude while she was completing activities.  Patient stated “thanks for being patient” because she was unsteady and took time to perform some tasks.


 

Goal Evaluation (goal met, partially met, or unmet within timeframe as evidenced by…):  The goal of patient demonstrating increased tolerance to activity by discharge was met.  The patient was much more active on the 2nd day than the 1st, participating in more activity and willing to be more active.  The first day the patient complained of breathlessness numerous times, however on the 2nd day, she didn’t complain of being short of air at all.  Even after ambulating with physical therapy, patient stated felt fine. The goal of participating in activity with appropriate changes in heart rate, blood pressure, and respirations each day until discharge was met.  The patient participated in activity both days and blood pressure, respirations, and heart rate remained close to baseline data.  Patient’s heart rate typically runs a little low.

The goal of patient participating in self care activities was met.  The first day, 7/19, the patient was very resistant to performing any tasks on her own.  She wanted a complete bath, her teeth brushed, hair combed, things from the room to be retrieved for her.  The second day, also the day of discharge, the patient combed her own hair, assisted with her bath, provided her own oral care, including getting out of bed and getting to sink area on own.  The patient also moved about the room to get from bed to chair and also to retrieve personal items from around the room.  The patient also ambulated with physical therapy around the nurses station with no complaint of discomfort. 

 

Diagnosis Evaluation (Provide summary.  Include answers to the following questions: was this care plan effective in resolving, monitoring, management your patient’s diagnosis? If so, provide evidence. Is more time needed in order to evaluate effectiveness):  This care plan was effective in monitoring  and management of patient’s diagnosis because the patient was eager to go home, yet had complaints of feeling breathless after activity.  The patient was also expressed feelings of being worried about remaining in hospital and missing family coming into town.  Once patient realized it was in her best interest to remain calm and relax, activity became much more enjoyable and less strenuous.  The patient was able to ambulate the 2nd, day with no report of breathlessness, where as the first day patient said she felts short of breath after returning from restroom and ambulating with physical therapy.  Patient took more rest periods on 2nd day and paced herself when performing self care tasks to conserve energy.  By monitoring patients heart rate, respirations, and blood pressure, we were able to see any drastic changes that would indicate rest was needed.  Prior to meeting the patient, her heart rate and oxygen saturation level had gotten low in the night and she was placed on oxygen.  The first morning I met the patient, she was back to her baseline normal and taken off the oxygen. The patient was discharged on my 2nd day and very happy to be going home.  Patient said she felt well rested and was ready to return home. 



#1: Activity Intolerance related to exertional discomfort as evidenced by dyspnea, patient verbalizing feeling short of breath, patient needing assistance with activities of daily living, verbal report of weakness, and low heart rate.
Data: ECG consider ischemia
patient states SOA after going to restroom and back and after ambulating with phyical therapy
verbal report of weakness/fatigue
patient expresses need for frequent breaks when ambulating
patient demonstrates dyspnea when moving around room to retirieve items
patient displays movement induced SOA
#2: Risk for falls related to impaired balance as evidenced by patient walking with unstead gait, verbalizing need for assistance because feels off balance, and patient needing to urinate frequently.
Data:  patient is female older than 65
patient walks with unsteady gait, weakness
patient states uses assistive device (cane) at home
patient states lives alone
patient needs to urinate frequently
patient has prosthetic hip
patient takes antihypertensive medications
bed alarm in place
Current Illness: Inflammatory Colitis
Previous History: Angina, Hypertension, irritable bowel syndrome, hyperlipidemia, gastroesphageal reflux disease, cardiomyopathy, congestive heart failure, cholecystectomy, arthritis, angioplasty
Assessments: Monitor BP, vital signs often (before and after activity), pain, mobility, fluid balance, nutritional status, bowel sounds
#3: Anxiety related to unfamiliar environment and
feelings of confinement as evidenced by patient verbalizing feelings of worry because staying in hospital and being away from home.
Data:  patient stated daily wanted to go home asap
patient states is having to miss monthly hair/nail appt
patient verbalized her cousin is going to be picking her up when discharged and has been waiting around /missing work for 3 days (patient felt bad)
patient had panic attack in emergency room 7/17, prescribed xanax
patient stated daughter coming into town from xxxxxxx 7/21, worried wouldn't be released in time
#4: Acute pain related to inflammation of joints as evidenced by grimacing while repositioning and sitting in bed, verbalizing pain when pressure placed on knee
Data: patient uses protective gestures when repositioning, putting on items of clothing
patient grimaces when repositing in bed or sitting up in bed, states hip and knee cause pain
patient states 0/10 when ask about general pain patient states only feels pain when goes to lay down in bed or puts pressure on knee
patient has hx of arthritis, inflammation of joints

 

 

 

REFERENCES

 

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.

Greaves, C. J., Sheppard, K. E., Abraham, C., Hardeman, W., Roden, M., Evans, P. H., & Schwarz, P. (2011). Systematic review of reviews of intervention            components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health, 11(1), 119-130. doi:10.1186/1471-        2458-11-119.  Retrieved from EBSCO host.

Newfield, S. A., Hinz, M. D., Tilley, D. S., Sridaromont, K. L., & Maramba, P. J. (2007). Cox's Clinical Applications of Nursing Diagnosis (5th ed.). Philadelphia,             PA, USA: F.A. Davis Company.

Hur, H., Park, S., Kim, S., Storey, M., & Kim, G. (2005). Activity intolerance and impaired physical mobility in elders. International Journal Of Nursing              Terminologies & Classifications, 16(3-4), 47-53.  Retrieved from EBSCO host.

Potter, P. A., & Perry, A. G. (2009). Fundamentals of Nursing (7th ed.). St. Louis, MO, USA: Mosby Elsevier

Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Textbook of Medical-Surgical Nursing (12th ed., Vol. 1). Philadelphia, PA, USA: Wolters Kluwer Lippincott Williams & Wilkins.

 

 


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