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Medical Diagnoses: Excess fluid volume related to compromised regulatory mechanisms, Activity intolerance, and Impaired physical mobility




University

School of Nursing

NUR-360 Clinical Assessment Worksheet

Student                            Date of Care 8/24      Worksheet # 18

 

Demographic Information

Health History

Care Prescriptions

Age: 75

Chronic Health Conditions & Previous Health Problems: Type 1 DM, end stage renal disease,

Diet: Heart healthy, Renal

Gender: Male

Race: Caucasian

Hypertension, hyperlipidemia, dementia, ataxia, Parkinson’s disease, obstructive sleep apnea,

Activity: up to chair with assist of 2/3

 

Code Status:        DNR                      

Weight: 207.4 bed scale

Height:

175.2 cm

Congestive heart failure, chronic obstructive pulmonary disorder, cor pulmonale

IV Access:     saline lock               continuous

Reason for Admission [patients own words]:

Patient stated was short of breath during dialysis,

 

     Solution:

Patient had 10 lbs fluid removed after dialysis and became lethargic and short of air

 

     Rate:

 

 

Previous surgeries:                    [type & year]

I & O:  voiding   Foley catheter   NG tube 

        

Medical Diagnosis [medical terms]:

Weakness, anemia, shortness of breath

 

Wound Care:

 

 

drains (Type, Location, Drainage from]

 

 

 

Pulmonary care:

Date of admission:  8/20  2203

 

Medical Complications: Dyspnea, recent femur    

Fracture, MRSA blood/cath tip 7/16/12

 

    X O2   2  L/min  via   X N/C     mask   

Surgery:                                                 Date:

 

 

    IS q ___ hrs.     MDI   HHN         

 

 

 

Nursing Diagnoses (3 - prioritized)

1.Excess fluid volume r/t compromised regulatory mechanisms aeb dyspnea, orthopnea, abnormal breath sounds, edema, and decreased hemoglobin and hematocrit lab values.  

    Med. albuterol atrovent 

            other _____________

Allergies:  Tape, cod liver oil, codeine, hydrocodone, morphine sulfate, sulfa drugs

2. Activity intolerance r/t imbalance between oxygen supply and demand and immobility aeb exertional discomfort, exertional dyspnea, verbal report of fatigue and weakness, oxygen saturation dropping  

Glucometer:      X ac & hs

 

When not laying still.

                       X sliding scale insulin

 

3. Imparied physical mobility r/t intolerance to activity and decreased

Other:

Discharge Plan Needs: Education r/t fluid retention,

Strength and endurance aeb by patient unable to bear weight, get out of

 

Management of health conditions, med s/e

Bed, limited ability to move lower extremeties, movement induced shortness of breath and drop in O2 sat, and unable to turn to side in bed without assistance.

 

Describe pathophysiology of primary illnesses (acute and chronic) 

 

         Type 1 diabetes mellitus is characterized by destruction of the pancreatic beta cells.  Combined genetic, immunologic, and possibly environmental factors are thought to contribute to beta cell destruction.  Destruction of beta cells results in decreased insulin production, unchecked glucose production by the liver and fasting hyperglycemia.  Glucose derived from food cannot be stored in the liver but instead remains in the bloodstream and continues to postprandial hyperglycemia.  Glucose appears in the urine when the concentration of glucose in the blood exceeds the renal threshold for glucose.  When excess glucose is excreted in the urine, so is excessive loss of fluids and electrolytes.  Fat breakdown occurs, resulting in increased production of ketone bodies, byproducts of fat breakdown.

         Renal disease causes end products of protein metabolism to accumulate in the blood.  The rate of decline in renal function is related to the underlying disorder, urinary excretion of protein, and the presence of hypertension.  My patient was being treated for hypertension.  Some clinical manifestations of renal disease are cardiovascular disease, peripheral neuropathy, severe pain, and restless leg syndrome.  End stage renal disease, which my patient has been diagnosed with, is when a patient has sustained enough kidney damage to require renal replacement therapy on a permanent basis.  My patient is receiving dialysis 3 times per week to removed excess fluid. 

         Dementia eventually destroys a person’s ability to function.  Neuropathologic and biochemical changes including neurofibrillary tangles and senile or neuritic plaques occur in the cerebral cortex and decrease brain size.  Cells that use the neurotransmitter acetylcholine are affected and memory processing is decreased.

         Parkinson’s disease is associated with decreased levels of dopamine resulting from destruction of pigmented neuronal cells in the substantaia nigra in the basal ganglia region of the brain.  The loss of dopamine stores result in more excitatory neurotransmitters than inhibitory neurotransmitters, leading to an imbalance that affects voluntary movement.  Cellular degeneration impairs the extrapyramidal tracts that control semiautomatic functions and coordinated movements.  Cardinal signs of Parkinson’s disease are tremors, rigidity, bradykinesia, and postural instability.  My patient was unable to bear any weight or walk and had very slow movements.  I didn’t notice any tremors; probably because my client was taking medication to control tremors.

         Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking, talking, and performing self-care activities.  Mutations of genes cause damage to pathways in the brain.  My patient did have some impaired coordination of movement.  He was able to feed himself but often spilled things and needed to be cleaned up afterward.  He was unable to walk and unable to perform any part of his bath. 

         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 has fluid overload and it is possible that the main cause of his hypertension is decreased vasodilatation of the arterioles related to dysfunction of the vascular endothelium.

         Hyperlipidemia is decreased clearance of triglyceride rich lipoproteins due to inhibition of lipoprotein lipase and triglyceride lipase.  Peripheral insulin resistance and hyperthyroidism also contribute to lipid abnormalities.  My patient is hypertensive and type 1 diabetic. 

         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 is often short of breath and is often fatigued at rest. 

         Cor pulmonale is right side heart failure triggered by long term hypertension in the pulmonary arteries. The right side of the heart pumps blood to the lungs and has to work much harder when there is high blood pressure in the arteries. COPD and obstructive sleep apnea also contribute to cor pulmonale; both of which my patient have. Shortness of breath and light headedness is often a first symptom.  My patient is often short of breath and has been becoming lethargic during dialysis.  Later signs are swelling of the feet and ankles.  My patient had 2+ pitting edema in his ankles and top of feet.

         Chronic obstructive pulmonary disorder is a disease state characterized by airflow limitation that is not fully reversible.  In COPD, airflow limitation is both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.  Because of the chronic inflammation and the body’s attempts to repair it, changes and narrowing occur in the airways.  Alveolar wall destruction leads to loss of alveolar attachments and decrease in elastic recoil.  Chronic inflammatory process affects the pulmonary vasculature and causes thickening of the lining of the vessel and hypertrophy of smooth muscle. My patient’s medical record showed a history of smoking, however it said unknown as to how long or when he stopped.  He did cough often, however no sputum.  He was often short of air and was using his belly to breath.

         Obstructive sleep apnea is a disorder characterized by recurrent episodes of upper airway obstruction and reduction in ventilation.  It is defined as cessation of breathing during sleep usually caused by repetitive upper airway obstruction.  It interferes with a person’s ability to obtain adequate rest, thus affecting memory, learning, and decision making.  Risk factors are obesity, male gender, and advanced age.  My patient was overweight, male, and 75 years old.  The tone of muscles of the upper airway is reduced during sleep.  Small amounts of negative pressure are generated during inspiration, and with sleep related changes predispose upper airway collapse.  People with obstructive sleep apnea have a high prevalence of hypertension and an increased risk of myocardial infarction and stroke.  My patient was being treated for hypertension.  It is important my patient be treated because people with obstructive sleep apnea and heart failure are at risk for death.  Obstructive sleep apnea in the absence of identifiable cardiovascular disease can increase insulin resistance and other metabolic changes that can increase the risk of vascular disease.  Repetitive apneic events result in hypoxia and hypercapnia.  This is another reason why my patient was on continuous pulse oximeter.

(Smeltzer, Bare, Hinkle, & Cheever, 2010).

          



Medications

Name

Action

Major Side Effects

Nursing Implications

Amlodipine

5mg/oral/once a day

Start 8/21 0645

 

Antihypertensive, calcium channel blocker, inhibits calcium ion influx across cardiac/smooth muscle cells, dilates coronary arteries, decreases BP

Headache, somnolence, fatigue, dizziness, light-headedness, asthenia, paresthesia, edema, flushing, palpitations, dyspepsia, nausea, abdominal pain, sexual difficulties, muscle cramps, dyspnea, rash, pruritis

Monitor patient carefully, monitor BP, monitor for swelling of hands or feet, monitor for shortness of breath.  Assess BP/angina before therapy and during

Aspirin Enteric Coated

81mg/oral/once a day

Start 8/21 0647

 

Inhibitor of prostaglandin synthesis and platelet aggregation, NSAID, makes platelets less sticky

Tinnitus, hearing loss, nausea, dyspepsia, GI distress, occult bleeding, renal insufficiency, prolonged bleeding time, rash, bruising, urticaria

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

Bumetanide

1mg/oral/2x day

Start 8/21 0645

 

Diuretic, Loop diuretic

Dizziness, headache, vertigo, orthostatic hypotension, oliguria, volume depletion and dehydration, hypokalemia, hyphochloremic alkalosis, hypomagnesemia, rash, pruritus, asymptomatic hyperuricemia

Monitor glucose level, monitor potassium and digoxin level, asses for signs and symptoms of excessive diuretic response,

Buspirone

10mg/oral/2x day

Start 8/21 0650

 

Anxiolytic, may inhibit neuronal firing and reduce serotonin turnover in cortical, amygdaloid, and septohippocampal tissue

Dizziness, drowsiness, headache, nervousness, insomnia, light-headedness, fatigue, numbness, excitement, confusion, depression, anger, tachycardia, chest, blurred vision, dry mouth, diarrhea

Monitor patient closely for adverse CNS reactions, don’t give drug with grapefruit juice, give drug at same times each day

Carbidopa + Levodopa 25mg-100mg ERT

2 tablets/ oral/4x day

Start 8/21 0650

 

Antiparkinsonian, decarboxylase inhibitor and dopamine precursor, relieves parkinsonian symptoms by being converted to dopamine in the brain

Syncope, dizziness, headache, cardiac irregularities, hypertension, hypotension, palpitations, constipation, dry mouth, GI bleeding, taste alterations, vomiting, muscle cramps, shoulder pain, nausea, dyspnea, sweating

Monitor blood pressure, may increase ALT, AST, alkaline phosphates, LDH, bilirubin levels.  My decrease hemoglobin level and hematocrit. Monitor vital signs, use cautiously in patients with severe CV, renal, hepatic, endocrine, or pulmonary disorders

Docusate

100mg/oral/2x day

Start 8/21 0652

 

Laxative, surfactant, stool softener

Bitter taste, mild abdominal cramping, diarrhea, laxative dependence with long term use

Monitor abdominal pain/discomfort, bowel movement

Donepezil

5mg/oral/once a day

Start 8/21 0652

 

Anti-Alzheimer, acetylcholinesterase inhibitor

Headache, insomnia, dizziness, fatigue, chest pain, bradycardia, nausea, diarrhea, vomiting, GI bleeding, weight loss, dehydration, muscle cramps, bone fracture, dyspnea

Monitor vital signs, improvement in signs of Alzheimer type dementia, occult GI bleeding

Furosemide

80mg/oral/once a day

Start 8/21 0645

 

Loop diuretic, antihypertensive, inhibits sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle

Vertigo, dizziness, weakness, tinnitus, abdominal pain, vomiting, constipation, anemia, volume depletion and dehydration, impaired glucose tolerance, hypocalcemia, muscle spasm, gout

May increase cholesterol, glucose, BUN, creatinine, uric acid levels.  May decrease calcium, hemoglobin, magnesium, potassium and sodium levels.  May decrease granulocyte, platelet, and WBC counts.  Monitor weight, BP, pulse rate.  Monitor fluid intake and output, glucose level, potassium level.

Hydralazine

50mg/oral/3x day

Start 8/21 0646

 

Antihypertensive, peripheral dilator

Headache, peripheral neuritis, dizziness, angina pectoris, palpitations, tachycardia, orthostatic hypotension, edema, flushing, nausea, vomiting, diarrhea, anorexia, nasal congestion, thrombocytopenia

Monitor BP, may cause severe hypotension

Hydroxychloroquine

200mg/oral/once a day

Start 0656

 

Antimalarial, aminoquinoline, also for autoimmune problems

Seizures, irritability, ataxia, vertigo, dizziness, cardiomyopathy, difficulty focusing eyes, diarrhea, vomiting, muscle weakness, anemia, alopecia

Monitor drug levels, may increase digoxin level, may decrease GI absorption

Insulin lispro

10  units/ SubQ/3x day

Before meal

Start 8/21 0735

 

Humalog, antidiabetic, pancreatic hormone

Blurred vision, dry mouth, hyperglycemia, hypomagnesemia, swelling, redness, stinging at injection site, dyspnea, anaphylaxis

Monitor glucose level, monitor patients diet

Isosorbide mononitrate Ext Release

30mg/oral/once a day

Start 8/21 0930

 

Antianginal, nitrate, thought to reduce cardiac oxygen demand by decreasing preload and afterload. Drug also may increase blood flow through the collateral coronary vessels.

Headache, dizziness, weakness, orthostatic hypotension, tachycardia, palpitation, ankle edema, flushing, nausea, vomiting, cutaneous vasodilation, rash

Use cautiously in patients with blood volume depletion, monitor BP and heart rate

Magnesium Oxide

800mg/oral/2x day

Start 8/21 0656

 

Antacid, magnesium salt

Diarrhea, abdominal pain, nausea, hypermagnesemia

Monitor lab values, bowel movement

Metoprolol succinate 24Hr Ext Release

25mg/oral/2x day

Start 8/21 0645

 

Antihypertensive, beta blocker, blocks beta 1 receptors, decreases cardiac output, peripheral resistance

Fatigue, dizziness, depression, hypotension, bradycardia heart failure, AV block, edema, nausea, diarrhea, constipation, heartburn, dyspnea, wheezing, rash

Use cautiously in patient with heart failure and diabetes.  Check patients apical pulse rate before giving drug.  If slower that 60 bpm withhold drug and call prescriber.  In diabetic patients, monitor glucose levels.  Monitor BP.

Multivitamin, Therapeutic

1 tablet/oral/daily

Start 8/21 0745

 

Multi vitamin, supplement

Nausea, gastrointestinal upset

Monitor lab values

Ofloxacin Opthalmic

2 drops/3x a day

Right day

Start 8/21 0809

 

Antibiotic, fluoroquinolone

Dizziness, vertigo, transient ocular burning or discomfort, eye dryness, eye pain, itching, lacrimation, periocular or facial edema, eye redness, earache, taste perversion

Monitor fever, symptomatic improvement.  Take with fluids

Omeprazole

40mg/oral/2x day

Start 08/21 0652

 

Antiulcer, proton pump inhibitor, inhibits proton pump activity by binding to hydrogen potassium edemosine triphosphatase located at secretory surface of gastric parietal cells, to suppress gastric acid secretion

Asthenia, dizziness, headache, abdominal pain, constipation, diarrhea, flatulence, nausea, vomiting, back pain, cough, upper respiratory tract infection, rash

Monitor magnesium level and signs and symptoms of low magnesium including abnormal heart rate or rhythm, palpitations, muscle spasms, tremors, or seizures

Ropinirole

3mg/oral/4x day

Start 8/21 2059

 

Antiparkinson, nonergot dopamine agonist, stimulates dopamine (D2) receptors

Cough, muscle cramps, dry mouth, dyspnea, falls, dizziness, fatigue, headache, hypotension, tremor, pain, sweating, anemia

Use cautiously in patients with severe renal impairment

Rosuvastatin

10mg/oral/once a day

Start 08/21 0655

 

Antilipemic, HMG-CoA reductase inhibitor

Anxiety, asthenia, depression, dizziness, headache, pain, vertigo, chest pain, peripheral edema, vasodilation, constipation, diarrhea, nausea, DM, back pain, asthma dyspnea, cough, pneumonia

Monitor lipid panel, liver function

Ursodiol

500mg/oral/2x day

Start 08/21 0652

 

Concentrated in bile, decreases biliary cholesterol saturation by suppressing hepatic synthesis and secretion of cholesterol, and by inhibiting its intestinal absorption.  Reduced cholesterol saturation permits the gradual solubilization of cholesterol from gallstones, resulting in their eventual dissolution.  Increases bile flow.

Rash, constipation, diarrhea, indigestion, nausea, vomiting, backache, dizziness, bronchitis, cough, pharyngitis, upper respiratory infection

Take with food

LAB VALUES/TEST RESULTS

 

a.   Important lab tests to monitor              Why? (Consider diagnosis, pre-existing conditions,  medications, complications, etc)                                          

Hgb

Carbidopa + Levodopa and Lasix lowers Hgb, anemia, O2, Dialysis patients are often chronically anemic

Hct

Carbidopa + Levodopa lowers Hct, anemia, O2

BUN

Hydration status, patient on Lasix and has renal disease

Glucose

Patient is type 1 diabetic

Cr

Patient end stage renal disease

 

 

 

b.      Hematology        Normal values             Patient’s Values (include serial labs)                                         Significance for this patient                                                                               

 

 

Date 8/22/12

Date 8/23/12

Date 8/24/12

 

WBC

4.8-10.8

9.3

8.6

9.0

Carbidopa + Levodopa may lower WBC count

         Bands

 

 

 

 

 

         Segs

 

 

 

 

 

Plt

130-450

139

165

171

 

Hgb

14.0-18.0

8.7

9.0

9.2

Carbidopa + Levodopa and Lasix lowers Hgb, anemia, O2

Hct

42.0-52.0

26.0

26.7

27.8

Carbidopa + Levodopa lowers Hct, anemia, O2

RBC

4.7-6.10

2.83

2.95

3.04

Hgb, Hct level, anemia, kidney failure, CHF

 

c.      Chemistry          Normal values             Patient’s Values (include serial labs)                                          Significance for this patient

K+

3.5-5.0

3.0

3.3

4.1

May be dilutional due to excess fluid

Na+

135-145

134

133

132

Lasix can lower sodium levels, May be dilutional due to excess fluid

Cl-

98-111

100

99

98

May be dilutional due to excess fluid

CO2

21-31

29

31

29

 

BUN

6-20

13

21

14

Lasix can increase BUN, May be dilutional due to excess fluid

Cr

0.5-1.2

1.8

2.5

1.9

Assess kidney function

Glucose

70-100

147

206

173

Patient is Type 1 DM, Lasix can increase glucose levels

Albumin

 

 

 

 

 

 

 

 

 

 

 

 

d.      Coagulation       Normal values             Patient’s Values (include serial labs)                                          Significance for this patient

PT

 

 

 

 

 

INR

 

 

 

 

 

PTT

 

 

 

 

 


e.      Urine                     Normal values             Patient’s Values (include serial labs)                                      Significance for this patient

Color

 

 

 

 

 

Appearance

 

 

 

 

 

Spec. gravity

 

 

 

 

 

PH

 

 

 

 

 

Glucose

 

 

 

 

 

Ketones

 

 

 

 

 

Nitrates

 

 

 

 

 

RBCs

 

 

 

 

 

WBCs

 

 

 

 

 

Casts

 

 

 

 

 

Protein

 

 

 

 

 

 

 

f.       ABGs                     Normal values              Patient’s Values (include serial labs)             Significance for this patient

pH

 

 

 

 

 

PaCO2

 

 

 

 

 

HCO3

 

 

 

 

 

PaO2

 

 

 

 

 

SaO2

 

 

 

 

 

 

g.      Other                      Normal values              Patient’s Values (include serial labs)             Significance for this patient

Ca+

8.4-10.2

7.9

8.1

8.0

Lasix can decrease calcium.  Patient recently had femur fracture.  Bone health

 

 

h. Pertinent x-rays or radiological studies 8/20/12 1. Interval placement of tunneled right internal jugular dialysis catheter with tip of the catheter overlying the junction of the right atrium and the superior vena cava with no pneumothorax. 2. Cardiomegaly 3. Mild congestive heart failure

8/23/12 XRay chest 2 views.  Cardiomegaly is unchanged, right IJ Shiley catheter is also unchanged.  Bibasilar opacities with perihilar haze.  Findings are overall unchanged compared to the prior exam.  No change in findings of pulmonary edema and likely congestive heart failure.

 

i. Other (e.g. EKG / telemetry) 8/20/12 Electrocardiogram; Prolonged QT, Vent. Rate 67 bpm, PR interval 136ms, QRS duration 94ms, QT/QTc 446-471ms, P-R-T axes 21 61 49



You’re Assessment of the Patient

 

History of present illness: The patient is a 75 year old male who was recently discharged from the hospital.  The patient was at hemodialysis when he was found to be increasingly lethargic and fatigued and with shortness of breath.  For that reason, he was sent to the emergency department and was found to have some pulmonary congestion, and also some anemia, and was admitted.  Patient has been having increased fluid overload and they have been trying to get increased fluid off.  Because of this, the patient has been getting more lethargic at hemodialysis , and at this time patient needs to get some transfusion so they can more aggressively remove fluids.  For that reason, the patient was admitted to the hospital.

         Pulmonary:  This is a nice 75 year old gentleman who has a history of end stage renal disease, obstructive sleep apnea, chronic obstructive pulmonary disease, cor pulmonale, who was presented to the hospital because he has been having some difficulty breathing and possible volume overload.  The patient had hemodialysis yesterday, but today continued to have significant shortness of breath, using accessory muscles.  He has been coughing, but no sputum.  No fever, no chills.  No loss of consciousness.  No dysphagia or odynophagia.  No signs of aspiration.  No reports of any abdominal pain.  Normal bowel movement.  No dysuria, hematuria or urgency.  No significant leg swelling.

         Renal 8/20: The patient is a 75 year old man with advanced chronic kidney disease now on dialysis, dementia, and diabetes, admitted with shortness of breath and weakness.  The patient has noted on dialysis yesterday to have significant shortness of breath.  He has been having shortness of breath since Friday.  An x-ray done Friday did show some mild congestive heart failure and aggressive fluid removal was attempted during dialysis yesterday.  However, the patients breathing did not significantly improve; he was feeling weak and not feeling well overall.  The patient now reports feeling slightly better.  His hemoglobin upon admission was found to be 7.4 and he relieved blood transfusions.

 

Vital Signs:    Time 0500            Temp 100.1         HR 71             BP 130/60            RR 34            O2 sat 100

                     Time 1000            Temp 97.9           HR 89             BP 149/67            RR 30            O2 sat 99         

                     Time 1300            Temp 97.6           HR   71           BP 126/71            RR 32            O2 sat 99

 

Neuro / Musculoskeletal Activity (Movement, Strength, Sensation):  Patient is alert, easily aroused, and oriented X2 to person and place.  Sensation of extremities found to be intact by patient confirming when he felt touch.  Patient unable to feel very light touch.  Patient identified areas of pain (knee and shoulder).  Patient able to move upper extremities on own symmetrically with equal strength.  Patient unable to freely move legs.  Can help to move legs in bed when being assisted.  Patient able to get from bed to chair with assist of at least 2 people.  Patient stated could not walk or bear any weight on lower extremities.  Patient in bed and chair at all times.

 

Skin (CUSPS/4Ts):  Patients skin warm, dry, intact for most part.  Peri area was moist with some chaffing, redness and bleeding.  Patient had fungus on nails and toenails.  Skin color even throughout.  No ulcerations.  No scarring.  Some swelling in lower extremities. 2+ pitting edema bilateral ankles.  Patient stated left knee felt sore after moving back into bed from chair.  Patient also stated right should was hurting.  No tenting of skin.  Some irritation on neck from nasal cannula.  No clubbing.  No cyanosis.  Patient appeared pale but also was fair skinned.  

 

Cardiac (Heart Sounds, Rate & Rhythm, Capillary Refill, Radial & Pedal Pulses):  Heart regular rhythm, rate high at times.  No murmur.  S1 auscultated at apex, S2 auscultated at base.  Capillary refill in less than 5 seconds.  Used tips of fingers and tips of middle toes because nails were dark brown and brittle because of fungus.  Radial and pedal pulses palpable and equal bilaterally. 

 

Pulmonary (Lung sounds, Rate, Rhythm, Effort):  Auscultated lungs, clear bilaterally.  Symmetrical chest movement.  Mucous membranes pink.  Patient often feels short of air.  Labored breathing at all times.  Using belly and accessory muscles to breathe.  Nasal flaring while breathing.  Can hear patient breathing.  O2 sat dropped upon any type of exertion or moving in bed.  Patient on O2 2 L/min via nasal cannula. 

 

GI / Nutritional Status (Diet, Weight, Bowel Sounds, Abdomen-Flat/Distended & Soft/Firm, Last BM):  Active bowel sounds in all 4 quadrants.  Patient states no feelings of nausea.  Patient being weighed using bed scale.  Patient on heart healthy, renal diet.  Abdomen soft and non tender.  Abdomen distended due to excess fluid.  Patient ate 100% breakfast.  Patient did not like lunch on 8/24.  Requested peanut butter and jelly sandwich.  Nurse approved jelly sandwich only.  Last bowel movement 8/24.  Soft, brown stool.  No masses.

 

GU/Reproductive (Urine Color and Amount, Menses for Women):  Patient urine not measured, using brief.  Yellow. 

 

Psychosocial:  Patient had some anxiety related to shortness of breath.  Patient also saw booklet titled ‘heart failure’ on his tray table that the doctor had left him with his name on it.  Patient asked ‘do I have a bad heart?’  He seemed a bit upset and unaware of his medical history and diagnosis.  Patient widowed.  No family came to visit.  Lives at Clark Nursing and Rehabilitation Center.  Patient cooperative and pleasant to work with.  Patient is hard of hearing so have to get very close to him for him to understand you.  Once he hears you, his responses are appropriate.  Patient enjoys watching tv.  Doesn’t enjoy reading because says he can’t get his eyes to focus.

 

Learning Needs:  Continue to monitor diet,  comply with doctors orders of diet and restrictions, continue to monitor blood glucose levels, management of health conditions.

 

 


Date/Time

Nurses Notes

08/24 0645

Night shift nurse states physical therapy and occupational therapy working with patient.  States patient dialysis MWF.  Patient in contact isolation, hard of hearing.  High risk for falls, DNR.  -------------------------------------------------------------------------------------------

8/24 0700

Entered patient room.  Patient asleep.  Patient on O2 2 L/min via nasal cannula and continuous pulse oximiter.  ---------------------

8/24 0730

Initial assessment completed.  Active bowel sounds in all 4 quadrants.  Patient states no current feelings of nausea and pain 0/10.  Skin warm, dry, intact with exception of groin area.  Moist and chaffed.  Patient easily aroused and alert.  Patient oriented X2 to person and place.  Patient on heart healthy renal diet.  Auscultated lungs-clear bilaterally.  Heart regular rhythm and rate.  No murmur.  Capillary refill in less than 5 seconds.  Used tips of fingers and toes because fingernails and toenails had fungal infection. Radial and pedal pulses palpable and equal bilaterally.  Respirations very labored.  Patient using accessory muscles and belly to breath.  Nasal flaring and wheezing when inhales on occasion.  Patient states feels short of air often.  Patient sacrum red.  Scrotum extremely swollen and red.  Patient had bowel movement this am.  -----------------

8/24 0830

Complete bed bath provided.  Patient’s O2 sat decreased and HR increased during bath especially at times when patient had to hold onto side rail to try and support himself while turned to the side.  After bath assisted with help of clinical instructor and aide to move patient to chair to eat breakfast.  Patient had English muffin with egg and cheese, oatmeal, coffee, milk, apple juice.  Ate 100% and drank 100%.  Patient did request sugar.  Accucheck before breakfast 143.  Administered 11 units Humalog.  10 units before meal ordered. 1 unit sliding scale.  While patient in chair eating breakfast, changed bed linens.  -------------------------------------------------------------------------------------------------------

8/24 0900

Administed oral medication and eye drops to right eye.  Hydralazine not in med cart.  Sent note to pharmacy.  Patient tolerated well.  Swallowed all pills at once with water.  Patient ordered by nurse to stay in chair for at least 2 hours before was able to return to bed.  Reclined patient with pillows for support, covered with blanket and moved close to tv.  ----------------------------------------------------------------------------

8/24 1100

Patient was administed insulin before lunch.  Blood glucose 207.  Patient to receive 13 units of Humalog.  10 units before meal.  3 units sliding scale.  Patient remained in chair for lunch.  Break for lunch.  ----------------------------------------------------------------------------------

8/24 1240

Upon returning to floor, patient in bed.  Assessed meal tray.  95% untouched.  Patient had salad spilled in bed.  Cleaned bed and patient up.  Asked why he hadn’t eaten.  Said did not like the meal.  Requested peanut butter and jelly sandwich.  Nurse approved jelly sandwich only.  Patient ate jelly sandwich and pears.  Patient resting in bed watching tv.  -------------------------------------------------------------------

8/24 1330

Administered oral medications.  Patient took all pills at once with water.  Administed eye drops to right eye.  Patient tolerated well.  ------------------------------------------------------------------------------------------------------------------------------------------------------------------------

08/24 1400

Afternoon assessment complete.  Patient stated after moving from chair to bed shoulder and knee felt sore.  Requested pain med.  Doctor said she would put in order.  Patient alert, oriented X2.  Lungs clear.  Radial and pedal pulses felt bilaterally.  Active bowel sounds in all 4 quadrants. Patient breathing labored. Patient turned.  --------------------------------------------------------------------------------------------------------



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