Major Client Data Packet
NURS 110
Data Sheet / Projected plan of care / Pathophysiology
Student Name Sam Sanderson Date(s) of Care 10/5/2009
Instructor Name Brenda Anderson Agency Skilled Nursing Room # 503
Client initials KD Age 79 Gender: FemaleAllergies NKDA
CODE STATUS Full Code
Ht 5’4” Admit wt 48 kg Current wt 47.5 kg
Mobility Needs:
Ability to Ambulate/Transfer: 1-person assist
Assistive devices: walker
Sensory Needs:
Glasses or Hearing Aids: None
Nutritional Needs: Regular, Soft
Diet/Supplements: Calcium and iron supplements
Swallowing difficulty (yes/no) No
Needs assist with feeding (yes/no) No
Self Care Needs:
Ability to toilet self: Assist to bathroom
Incontinent (yes/no) No
Bowel/bladder management: No
Ability to bath/dress/groom self : Needs assistance
r/t pain and decreased mobility / Reason Client is at Long-Term Care facility: S/P ORIF left hip 2 weeks ago. Needs rehabilitation for mobility and a dietary consult. The plan is that she will return home with her son or other living arrangements will be explored. When the patient is strong enough to be independent she will be discharged.
Pathophysiology of Medical Diagnosis : etiology, pathogenesis, clinical manifestations / signs and symptoms
· Use Lewis Medical-Surgical Nursing Text
· Add additional pages if necessary
· Choose a different condition each week
Definition: Osteoporosis is a chronic and progressive disease that causes bones to become fragile.
Etiology: Risk factors are old age, being female, early menopause or oophorectomy, family history, white or Asian race, small stature, sedentary lifestyle, history of anorexia, excessive use of caffeine, or dietary calcium deficiency. My patient is malnourished and calcium deficient. She also lives a sedentary lifestyle.
Pathogenesis: Normally bone mass is completed by the age of 20. Bone loss is a normal part of aging but the rate of loss is different for everyone depending on their risk factors. Normally bone is kept strong by equal deposition ( osteoblasts) and resorption (osteoclasts). In osteoporosis there is an imbalance where the resorption exceeds the deposition. The bone becomes increasingly porous and weakened making the patient more prone to fractures from the slightest trauma.
Clinical Manifestations: Osteoporosis is many times asymptomatic and may be called “the silent disease” (Lewis, 2007, p. 1688). Fractures may result from a jolt, bump, or fall and may be the first symptom of osteoporosis. Patient may have back pain or decreased height from loss of vertebral structure. Patients may also have kyphosis. My patient fell while getting out of the shower. It is unclear as to whether she fell and broke her hip or whether her hip broke spontaneously and caused the fall.
Source & Page #Lewis (7th ed.) p. 1686-1688
PRIORITY FOCUSED ASSESSMENT
(INCLUDE RATIONALE) / PROJECTED PRIORITY NURSING DIAGNOSIS
(INCLUDE RATIONALE) / PROJECTED NURSING INTERVENTIONS
(minimum 3)
(only 1 r/t assessment or monitoring
Musculoskeletal
Muscle strength/equality
Capillary refill/pulses
edema
Pain
Gait / ND: Impaired Physical Mobility
Related to: musculoskeletal impairment (secondary to recent fracture of left hip)
Defining characteristics: decreased movement, range of motion, and strength of left lower extremity. / -Assess pain, gait, muscle strength, and fatigue during ambulation (1-person assist and walker)
-Encourage patient to make decisions about her daily schedule as much as possible, i.e. ADLs, activities to participate in, times for ambulation.
-Increase distance of ambulation daily per PT recommendations; pre-medicate for pain as needed (currently ambulating 200 ft. / PT visit)
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NURS 110 Fall 09
Major Data Packet, revised 9.24.09
Medications - Scheduled
(Highlight any medications that were discontinued prior to giving)
Generic & Trade Name / Dose / Route / Time / Classification· Client’s reason for taking drug
· Therapeutic class
· Pharmacologic class / Nursing Implications
What do you need to know or do to give this medication safely?
(nursing assessments and, implementation) / Evaluation of Medication Effects
· What would you assess to know it was working?
· What was your finding?
calcium salts
calcium citrate
Citrical
iron supplement
ferrous sulfate
SlowFe
docusate sodium
Colace / 2 tabs
325 mg.
100 mg. / po
po
po / bid
TID
Daily / ●“I have brittle bones”
Osteoporosis
●Therapeutic –
mineral/electrolyte
replacement/supplement
● none
● “It helps me with my
weakness”
Anemia
●Antianemic
●Iron Supplement
● “Prevent constipation”
●Laxative
●Stool softener / Assessment:
Assess for hypocalcemia: parasthesias, muscle twitching, Trousseau’s or Chvostek’s sign, colic, laryngospasm, cardiac dysryhthmias.
Assess for hypercalcemia: n/v, anorexia, thirst, paralytic ileus, severe constipation, & bradycardia.
Implementation:
Do not take within 2 hours of other medications or high-fiber foods (VCE – med room).
Take on an empty stomach with a full glass of H20.
Assessment:
Assess for n/v/d, fever, stomach pain, constipation.
May make stools dark green or black and cause constipation.
Implementation:
Give one hour before or 2 hours after meals w/ a full glass of H20 or juice. Absorbed better in an acidic environment – better if given with orange juice.
May cause a false decrease in calcium.
Assessment:
Assess abdomen for distention, pain, bowel tones. Assess bowel pattern.
Implementation:
Give with a full glass of H20 or juice. For more rapid results give on an empty stomach.
Should not be given within 2 hours of other laxatives d/t increased absorption. / Assess serum calcium levels
Results: (Fill out during clinical)
Assess RBCs/Hgb, serum iron levels, energy level, pallor
Results:
Assess bowel pattern
Results:
Medications - Scheduled
(Highlight any medications that were discontinued prior to giving)
Generic & Trade Name / Dose / Route / Time / Classification· Client’s reason for taking drug
· Therapeutic class
· Pharmacologic class / Nursing Implications
What do you need to know or do to give this medication safely?
(nursing assessments and, implementation) / Evaluation of Medication Effects
· What would you assess to know it was working?
· What was your finding?
ibuprofen
Motrin/Advil
oxycodone w/ acetaminophen
Percocet / 600 mg.
2.5mg/325mg
1-2 tabs / po
po / tid
Every 4-6 hours / ● “Pain”
●Pain & inflammation
●Antipyretic,
antirheumatic, nonopioid
analgesic, NSAID
●Non-opioid analgesic
“Pain”
Opioid analgesics
Opioid agonist/nonopioid
Analgesic combination / Assessment:
Assess pain & fever. Monitor for GI bleeding (black tarry stools, abdominal pain).
Implementation:
Give with meals or milk to decrease GI upset.
Administering with opioid analgesics may increase analgesic effects and decrease need for opioids doses.
Assessment:
Assess for pain, LOC, & respiratory status.
Implementation:
Check other ordered medications for contents including acetaminophen. Avoid overdosing w/ acetaminophen.
Give with milk or food to decrease GI upset.
May cause drowsiness, dizziness, and may affect judgment.
Patient should change positions slowly. / Assess pain and surgical incision condition
Results:
Assess pain before and after medication.
Results:
Medications – PRN
(List only those given in the last 24 hours)
Generic & Trade Name / Dose / Route / Time / Classification· Client’s reason for taking drug
· Therapeutic class
· Pharmacologic class / Nursing Implications
What do you need to know or do to give this medication safely?
(nursing assessments and, implementation) / Evaluation of Medication Effects
· What would you assess to know it was working?
· What was your finding?
1
NURS 110 Fall 09
Major Data Packet, revised 9.24.09
Physical Assessment
(HIGHLIGHT ABNORMAL DATA or defining characteristics for problems)
Date 10/5/2009General Survey
Lying on back in bed. Abductor splint in place. Eyes open. No safety hazards noted.
Psychological
Awake, alert, oriented x4. Flat affect; seems emotionless and disinterested. c/o feeling tired and states she is unable to get up. Able to make needs known and is cooperative with care. / Date ______
General Survey
Psychological
Changes From Day 1
Vital Signs Time 10/5/2009 Time_0755
B/P 113/79 HR 106 RR 20 T- 102 O2 Sat 94%
Pain: Rating 2/10 Description “sharp”
Pain: Rating Description
Pulse Oximetry 94% Oxygen None / Vital Signs Time ______Time ______
Pain: Rating Description
Pain: Rating Description
Pulse Oximetry Oxygen
EEN/ Mouth
Eyes clear; sclera white; no drainage
Ear and nasal skin intact; no drainage
Oral membranes intact, pink, and dry. c/o discomfort and difficulty with chewing r/t poor fitting dentures. / EEN/ Mouth
Cardiovascular
Heart tones regular S1 and S2. HR tachycardic. / Cardiovascular
Respiratory
Respirations regular, unlabored, w/ symmetrical chest wall movement. Lung sounds clear on left; crackles in middle and lower lobes on right. No cough observed. Denies SOB at rest and with activity. / Respiratory
Gastrointestinal/GU
Abdomen flat, soft, non-distended; bowel tones present x4 quadrants. Denies pain with light palpation. States last BM was at 0600; stool was brown, soft, and formed.
Voiding small amounts of clear, dark amber urine; c/o stress incontinence. / Gastrointestinal/GU
Upper/Lower Extremities
Left hip incision well approximated at 8cm, clean, dry and intact without redness, heat, or swelling.
Capillary refill 3 seconds all extremities; radial and pedal pulses +2 equal. No edema or calf pain. Grips strong and equal.
Neuro-Muscular
Slow, slightly unsteady gait with walker. Decreased movement, strength, and range of motion in left leg. Abductor splint in place Easily fatigued with activity. / Upper/Lower Extremities
Neuro-Muscular
Skin Skin warm, dry, pale and intact. No redness over pressure points. Diminished skin turgor. / Skin
Functional Health Patterns (Gordon’s)
(HIGHLIGHT ABNORMAL DATA or /defining characteristics for problems)
Health Perception-Health Maintenance PatternPatient rarely experience illness such as colds and flu. Patient feels that her health was good until she fell. Now she states that her health is “pathetic”. She feels that she can’t take care of herself. This worries her and she is unsure as to whether or not her son will be able to give her the care she needs. She maintains her health by having regular doctor visits and trying to eat healthy, but states "my appetite just isn't what it used to be." / Cognitive – Perceptual Pattern
Alert and oriented x4. Processes information well; appropriate in conversation. Processes written material and reads with understanding. Good short and long-term memory.
Activity – Exercise Pattern
Does not exercise; watches TV. She has little social interaction because her son does not let her drive so she is at home unless her son or girlfriend takes her out. Tires easily. / Coping – Stress Tolerance
Demonstrates stress over her helplessness and loss of her past roles as a mother, wife, and independent adult. Fearful that her son will put her in a nursing home permanently. Coping mechanism – regression and/or dissociation.
Nutrition– Metabolic Pattern
% of diet eaten: ______
Fluid intake ______ml
Has lost 5# in the last 4 months and a total of 15# since husband’s death. Poor appetite that is worse since her fall. Meals at home are irregular. Is not allowed to cook and son/girlfriend does all the shopping for food. Does not feel like she gets enough food. Poor fitting dentures make it painful to chew. Prefers soft foods. / Self Perception – Self Concept Pattern
Respect may be important to this patient – wants to be called “Mrs. ______”. Son makes all decisions for the patient. She feels like she is a helpless, old woman. Feels like she is a burden; does not feel needed.
Elimination Pattern
Normally has a BM daily or every other day. Stool is usually brown, soft, and formed. Does have some problems with constipation and occasionally takes Biscodyl.
Urinates several times a day. Patient states urine is yellow. No dysuria, hematuria, frequency, or nocturia. Does have some stress incontinence; wears a pantiliner. / Role – Relationship Pattern
No longer independent in many areas of her life.
No siblings; Widow – husband died 2 years ago. Mother of one son.
Sold home to live with her son and his girlfriend and her teenage son. Is not happy living there.
Has to depend on son for supplying medications and most everything else. Feels like she does not have a role anymore.
Sleep – Rest Pattern
Normally gets 8-10 hours of good quality sleep and naps during in the afternoon. Usually watches the evening news before bed.
Not sleeping well since surgery; naps off and on all day. / Value – Belief Pattern
Religion – Non-denominational. Does not attend any specific church. Practices Christian values.
Keep in mind that you will be collecting data as you care for the patient and some information may be gathered from the chart or family. To obtain this data you do not sit and interview the patient. You can use the interview process to fill in gaps. What is the patient’s baseline and what is their functioning level now?
Nursing Documentation
Narrative Head to Toe Assessment
Date/Hour
10/5/2009 / Lying flat in bed; abductor splint in place. Awake, alert, oriented x4. Flat affect; seems emotionlessdisinterested. c/o feeling tired and states she is unable to get up. Eyes, ears, & nasal
intact; no drainage. Oral membranes intact, pink, & dry. c/o difficulty and discomfort
while chewing due to poor fitting dentures. Skin warm, dry, pale, and intact. No redness over
pressure points. Skin turgor diminished. Heart tones regular S1 & S2; tachycardic.
Respirations regular, unlabored, with symmetrical chest wall movement. Left lung sounds
clear; crackles in middle & lower lobes on right. No cough. Abdomen flat, soft, & non-
distended; bowel tones x4 quadrants. Denies pain with light palpation. States last BM was
at 0600 this am; stool brown, soft & formed. Voiding small amounts of clear, dark amber
urine; c/o stress incontinence. Left hip incision dry & intact without redness or swelling.
capillary refill 3 seconds; radial and pedal pulses +2 & equal. No edema or calf pain. Grips
strong and equal. Slow, slight unsteady gait with walker. Decreased movement, strength, &
range of motion in left leg. Easily fatigued with activity. ------S. Sanderson, SN
Instructor Feedback
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NURS 110 Fall 09
Major Data Packet, revised 9.24.09
Nursing Plan of Care
Points Achieved ______
Nursing Diagnosis/Expected Outcome / Nursing Interventions ( 1.5 points)3 required / Rationale (1.5 points)
Provide one for each intervention
Nursing Diagnosis
(Highlight one of the following diagnosis from the client’s chart)
Altered Nutrition Risk for Infection
Altered Elimination, urinary Activity Intolerance
Constipation or diarrhea Impaired Mobility
Self Care Deficit Chronic Pain
Risk for Injury Social Isolation
Other: Impaired Physical Mobility
Etiology “Related to” ((1 point):
Musculoskeletal impairment (secondary to left hip fracture)
Defining Characteristics related to Nursing Diagnosis: (2 points)
(as HIGHLIGHTED from client data sheet, physical or functional assessment sheets)
Decreased range of motion, movement, and strength of left lower extremity.
Expected Outcome (1 point) :
· Measureable with timeframe
Patient will ambulate to the dining room for all 3 meals during my care on 10/5.
Evaluation of Expected Outcome (1 point) :
· Was the goal met? Any changes needed?
Goal was not met. Patient refused to ambulate to dining room this shift; continue with pain control & emotional encouragement; discuss with PT. / -Assess pain, gait, muscle strength, and fatigue during ambulation (1-person assist and walker)
-Encourage patient to make decisions about her daily schedule as much as possible, i.e. ADLs, activities to participate in, times for ambulation.
-Increase distance of ambulation daily per PT recommendations; pre-medicate for pain as needed (currently ambulating 200 ft. / PT visit) / Helps the nurse and the patient understand the baseline of the patient’s mobility and set realistic goals that will encourage and increase mobility.
Increases patient’s feelings of competency and independence. Increases patient’s self-worth. Encourages a nurse-patient helping relationship and partnership.
Gradual increase in activities prevents fatigue and discouragement; ambulation may be decreased if patient in pain.
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