ncp osteomyelytis

HEALTH ASSESSMENT SUMMARY

Student's Name Lacy Rodriguez Patient's Initials J. L.

Date of Assessment 01-31-12 Date of Admission 01-21-12

Location of Patient 7A134Primary Language English

Summarize or briefly state what caused the patient to come to the hospital (chief complaint) (include age, sex, race): 48 yo Hispanic M, admitted to the ER on 1-21-12 for c/o (L) ankle pain and swelling x 2 days, referred from Good Samaritan Hospital for increased swelling and decreased ROM. Pt stated he was in “severe 10/10, throbbing pain that doesn’t stop” and unable to bear any weight on injured leg. Pain radiates to lower back, and pt. sustains no relief from elevation or Motrin. Presents with red, edematous RLE and no ROM, () N/V/D.

List all prior health problems including surgeries with approximate dates: Glaucoma x 10 years, L eye enucleation x 2 yearsGERD x 5 yearsSpinal fusion and L ankle ORIF x 5 years, post-MVAORSA-nares, diagnosed 1 year agoHep C and OM x 5 yearsIVDA x 25 yearsSmoker x 30 yearsSeizure disorder x 25 years, last szr 11 mos ago

Social Hx: Unemployed x 15 years, homeless x 15 years, incarcerated “several times”.

List medications patient was taking prior to this hospitalization and patient’s reason for taking medication (including prescriptions, herbs, over-the-counter).Neurontin for szr disorderMotrin for general pain or HA

List significant family health history: Father: 84, emphysemaMother: Deceased x 20 years, MI.

Allergies: No Yes X Dilantin and Tegretol-Rash Ht. 5’7 Wt 160 lbsSubstance Use/Abuse:

Alcohol No X Yes Type Beer Amount consumed/day Last use: 1 year agoDrugs No Yes X Type Heroin Amount consumed/day “None now” Last use: 11 mos agoSmoking No Yes X Packs per day 1/2 ppd Caffeine No Yes X Cups per day 2-3

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Admitting Diagnosis (discuss briefly):Osteomyelitis: An inflammation of the bone caused by an infecting organism. May be related to vascular insufficiency related to IVDA. This is a local bone infection, which causes progressive destruction of the bone (Lewis, 2011).

Current Diagnosis (including pathophysiology):Septic Arthritis: Develops when bacteria or fungi spread through the bloodstream to a joint, and into the normally aseptic synovial fluid. Septic arthritis is a joint infection and resulting inflammatory process, causing destruction of the synovial membrane. Results in cartilage damage and causes it to become yellow, dull and granular. Continued hanges in collagen structure may lead to fissures & erosion. The most common sites for this type of infection are the knee and hip. Most cases of acute septic arthritis are caused by bacteria such as staphylococcus or streptococcus. (Lewis, 2011).

Labs: Increased WBCs (shift to the left, ESR and CRP. Decreased H & H. Positive BC. (Lewis, 2011).

Risk Factors: IVDA, nutritional deficiency, joint implants, immunosuppressants, chronic illness, recent injury or trauma. More common in men before 45 yo. (Lewis, 2011).

Signs and Symptoms: Tachycardia, fever, joint warmth, redness, swelling, stiffness, pain, fatigue, decreased ROM, irritability, fatigue, HA, decreased appetite, purulent drainage, nausea and vomiting. (Lewis, 2011)

Summarize what has happened to this patient since being admitted to the hospital (include all diagnostic tests):Since being admitted to the hospital the pt has undergone an X ray to eval LLE that suggested infection and inflammation. He is on a regular diet after being NPO prior to I & D surgery, and eats 75%-95% of his meals, depending on his level of pain. The patient underwent surgery to remove old hardware from the L ankle, and drainage of purulent fluid from the joint. Dr. ordered PT after surgery, pt refused PT 3 times after surgery due to pain. Patient has been given several pain medications since being admitted, and requests pain medication about every 2 hours. He voids spontaneously and freely and has regular BMs. He is continuing to receive IV vanco via PICC to the LUE. He is awaiting placement through Social Services. All medications are as follows: Vanco for infection, Benadryl for itching/insomnia, Tylenol for fever, Vicodin for pain, Norco, Morphine and MS Contin for pain, Keppra and Neurontin for szr disorder, Fragmin to prevent thrombosis, MOM, Dulcolax and Colace to prevent and treat constipation. Multi-vitamin, zinc and Vitamin C for wound healing, Iron Sulfate to treat anemia. Zofran for treatment and prevention of nausea and vomiting. Protonix for GERD.

DR ORDERS:

02-01-12-AM labs: CBC c diff, BMP, The labs are drawn to monitor the patient.

01-31-12-Morphine sulfate 2mg IV q 4 hrs PRN for pain x 72 hours, Morphine/morphine H.P/ IV/ 4-10mg q 3-4hr/opiod/ severe pain, Morphine is ordered every 72 hours.

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01-30-12-PFS for Medi-cal, The patient is to meet with financial services -SW for placement, social work for placement and insurance.

01-29-12-Vancomycin, Vancomycin/vancocin/IV/500mg q6hr or 1g q 12 hr/anti-infective/tx of potentially life-threatening sepsis-Discontinue Foley, pt can get OOB to BR

1-27-12-Discontinue IVF, discontinue NPO status, change to reg diet, pt no longer NPO-AM labs: CBC c diff, BMP, The labs are drawn for monitoring purposes.-Add AM labs: prealbumin and CRP, The labs are drawn for monitoring purposes (inflammation process).-I&D Surgery ordered for incision and drainage with hardware removal of L ankle to assist in infection prevention and healing (EBL: 20ml)-SCD to RLE ordered post-surgery to prevent thrombosis and decubitis-PT, ordered for gait training and to promote increased L foot ROM and perform ADL’s.-AM labs c diff, CMP, The labs are drawn to monitor the patient-Morphine sulfate 2mg IV q 4 hrs PRN pain x 72 hrs, Morphine/morphine H.P/ IV/ 4-10mg q 3-4hr/opiod/ severe pain, The morphine is to be ordered every 72 hours.

01-26-12-Hold vanco trough 23.4, The vanco level is high and too much for the kidneys. It should be held until it returns to the therapeutic range.-Please reposition pt q 2 hrs, The orders for repositioning are due to the patients decubitis ulcers-AML: CBC c diff, BMP, Mg, Phos, PT/PTT/INR-X Ray to LLE, to check results of surgery, healing process.-Renew MS Contin 30mg PO q 12 hours x 72 hours, Opioid to treat pain

01-25-12-AML: CBC-d, BMP, Mg, Phos, Ca, The labs are necessary to monitor the patient’s blood, electrolyte and fluid levels.

01-24-12-Change diet to NPO except meds for I & D and surgery for removal of hardware in LLE.

--Pre-Op check list-Start D5NS @100cc per hour, used for maintenance of body fluid and electrolyte balance or fluid therapy before surgery.-Protonix

01-23-12-MVI 1 tab PO q day-Vitamin C 500mg PO BID, Ascorbic acid/Mega-C,vitamin c/500 mg q day for at least 14days/vitamins/tx and prevention of vitamin deficiency. Promotes collagen synthesis-Zinc sulfate 220mg PO Q day, Zinc sulfate/zincate, zinc 220/PO/15-19mgday/mineral and electrolyte replacement/replacement and supplementation therapy.-Foley Catheter Placement: Ordered due to pt unable to ambulate, impending surgery, and to check for a ruptured bladder.-Fragmin 5000 units SubQ Daily, Anticoagulant to prevent DVT.-Zofran Inj 4mg q 8hrs, give 2 ml prn for nausea and vomiting-Morphine Sulfate 2mg IV qhs, Opioid to treat pain-MS Contin 30mg PO q 12 hours x 72 hours, Opioid to treat pain

1-22-12:-Xray CXR eval, The x-ray is performed for evaluation purposes, specifically TB, which was ruled out-AML: BMP, which is given to determine complete Ca+, Cl, Na+, CO2 levels, body electrolytes (K+), blood sugar, kidney/liver function (BUN/Cr) and hydration status, usually in patients with acute or chronic htn, DM, Vanco tx, and kidney dysfunction. CBC w/diff ordered to determine if anemia, infection, and blood loss are present. The blood CBC is standard, PT and APTT is to determine clot time.-Urinalysis and U-tox given to r/o hematuria, determine bacterial count, pH and SG. Opioids, benzos and cocaine found in pt’s system

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-X ray for eval of LLE, rule out fx-EKG, to r/o MI or other heart-related issues, & to determine sinus rhythm. Also a pre-op requirement to r/o cardiopulmonary dysfunction, no abnormality-Type & Screen, needed to cross-match blood products prior to surgery, in case of excessive blood loss during surgery, O-.-Neurontin 300mg PO tid Anti-convulsant for tx of szr disorder.-Keppra 500mg PO q 12 hours to prevent szrs.-Colace 100mg PO prn, to prevent straining and constipation-MOM 30ml PO q 8 hrs prn, to treat and prevent constipation-Norco 10mg-325mg q 6hrs for BTP, 2 tabs-NWB LLE

1-21-12-Vitals=PR-Activity= strict bed rest-Diet= Reg-Strict I&O per protocol-+indwelling Foley-Contact precautions, ORSA-nares-Szr precautions-Start labs: CBC c diff, CMP, PT/PTT/INR, BC, CRP, ESR-Urine culture, to detect bacteria in the urine-Urine tox, to detect drugs or alcohol in the body-Vanco 1 gm IV q 12h, Vancomycin/vancocin/IV/500mg q6hr or 1g q 12 hr/anti-infectives/tx of potentially life-threatening infection-Check Peak & Trough q 3rd dose, to prevent vanco toxicity-Protonix 40mg IV q 24 hr, Pantoprazole/protonix/IV?/ 40mg once daily for 7-10 days/proton pump for GERDinhibitors/erosive esophagitis associated w gerd-Tylenol 650mg PO q 6hr PRN pain, temp >100.4, Acetaminophen/tylenol/PO/ 325-650mg q 4-6 hr/antipyretics,non opiod analgesic/ mild pain or fever-Benedryl 25mg PO or IV q 6hrs prn for itching or insomnia

Other pertinent patient information:

a. Predominant stressor: (intra-, inter, extrapersonal)Intrapersonal:

Worried about eventually losing his foot and future ROM. Anxiety r/t future surgery, and scared of more pain. Current continuous pain, not relieved by narcotic pain medication. Pain level was never below 6 during my care for him. Possibly drug-seeking behavior evidenced by IVDA hx, constant complaints of pain that does not match the severity of injury and

asking for pain meds every time I entered his room.

Interpersonal: Expressed worry and fear regarding future job prospects if his “foot doesn’t work”, and questions, “who will take care of me”. Worried about who will change his foot dressing after he gets discharged from the hospital. Expressed fear with regard to whom will administer IV anti-biotic and take care of his PICC line post-discharge. States he has a grown daughter, but only speaks with her “every couple of years. I don’t really want to talk about that.” IVDA, ETOH hx, smoker.

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Extrapersonal: Lives “on the street” or in a hotel “sometimes, when I have enough money.” Expressed worry about stability, how long he will be in the hospital and where he will go upon discharge, as Rancho Los Amigos denied acceptance of him because he did not qualify. Verbalized fear of leaving the hospital without a wheelchair, as he “can’t afford one.”

b. Variables: (physiological, psychological, spiritual, Sociocultural, developmental)

Physiological Gait: Unsteady and slow d/t long leg splint and administered pain medication. Able to get OOB to wheelchair without assistance. Range of motion: active in RUE-5/5, except for LLE ROM 1/5, with limited movement. Muscle tone: Symmetrical. BLE hand grasps are strong, pulses 2+, strong and equal on all extremities, except L foot-unable to palpate d/t cast. (-) paralysis, (-) parasthesia, (-) pressure, and positive adequate perfusion, except L foot, pt states he feels moderate pressure, and some numbness. Able to wiggle fingers and toes bilaterally.

Psychological: Patient is feeling groggy and in pain today d/t ATC opioid pain medication intake (as per MD), and “Kept getting woken up” and as a result, he got very little sleep. Expressed worry over at-home anti-biotic IV therapy, and who will help with his foot dressing changes after hospital d/c.

Spiritual: Patient stated he was brought up Catholic and he sees the Chaplain often, satisfying his spiritual needs.

Sociocultural: Patient smokes ½ ppd, and claims he quit drinking in 2008. Stated that his diet is unpredictable because he is homeless, and sometimes doesn’t know when or where he will eat. Divorced since 2000, he is unemployed and supports himself with social assistance checks. Lives on the street and/or in a hotel since his divorce.

Developmental: Client is 48 years old and in Middle Adulthood according to Erikson’s developmental stages. In this stage the individual is in the stage of Generativity vs. Stagnation. If an individual has too little of Generativity (e.g. contributing to family or society) they risk stagnation. The client has been NPO intermittently, and in the hospital for 10 days, with no family contact. According to Erikson the client is most likely feeling isolated and unfulfilled, therefore leaning toward stagnation. He feels unable to be “productive or feel as if he can contribute to my own well-being with my foot the way it is.” A person that is more in the Stagnation stage has a tendency to become bored, and have a feeling of purposelessness. I have observed the patient undergoing a daily routine of showering independently, combing his hair, and brushing his teeth, which seems to bring a bit of self worth. I also observed Mr. Lopez getting himself getting to his wheelchair from bed and socializing with staff and other patients, perhaps helping him cope with isolation and establishing a sense of independence. I encouraged him to practice with his ROM exercises, showering, and fixing his hair to make him feel more purposeful. I also encouraged him to participate fully in PT to increase his chances of gaining back full ROM in his foot. I suggested he may want to practice his own dressing changes if he has a problem finding someone to do it for him, and educated him that the MD, RN and I would fully educate him prior to d/c about his anti-biotic IV therapy, and he expressed relief.

Source: Lewis, Dirksen, Heitkemper, Bucher, Camera. (2011). Inflammation and wound healing. Medical-Surgical Nursing: Assessment and management of clinical problems, Volume 6 (pp. 187-203). St Louis, MO: Elsevier.

Kee, J.L. (2009). Laboratory and diagnostic tests with nursing implications, Volume 6 (pp 27-400). Saddle River, NJ: Pearson.

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Medications

Med, Dose, Rte, Freq, Time Class Indication Action O, P, D Pt Teaching Labs Side Effects

Fragmin5000 units SQ, give 0.2ml Daily

1000Antidote: Protamine Sulfate

LMW Heparin/Anti-coag

DVT prophylaxis

Enhances inhibition of factor Xa & thrombin by anti-thrombin. Reduces risk of DVT.

Onset unk, Peak: 4 hrs Watch for S/S of bleeding, & avoid NSAIDsBBW: Spinal hematoma & neuroaxial dysfunction.

>AST & ALT, < Plt

Bleeding-epistaxis, ecchymosis, petechiae, bleeding gums, thrombocyopenia, rash, & fever. BBW:Paralysis, spinal hematoma

Keppra/Levetiracetam500mg Q 12 hrs Over 60 Mins

0600/1800

Anti-Convulsant

Szr, epilepsy, neuropathy

Slows abnormal impulses in the brain

15-30 mins, 1.5 hrs, 7 hrs 3000 mg max daily, report suicidal thoughts

>BUN/Cr, <H & H

HA, infection, pain,Anxiety, depression,Amnesia, increase In szrs, cough, Rhinitis, cough

Protonix40mg IV Daily

1000

PPI, gastric acid suppressant

GERD Suppresses gastric acid secretion by inhibiting PP activity at the gastric parietal cells

Onset: 15-30 mins, Peak: unk, Dur: 24hrs

St John’s Wart increases risk of sunburn, don’t take with food. Report signs of bleeding

>glucose HA, insomnia, dizziness, flu-like sndrome, gastroenteritis, vomiting, UTI & arthralgia.

Morphine Sulfate2mg IV qhs

2200

Antidote: Narcan

Opioid, analgesic

Severe pain

Binds with opioid receptors in CNS, altering perception of pain.

Onset: < 5 mins, Peak: 20 mins, Dur: 4-5 hrs

Report continued pain and constipation. Withhold if <12 BPM

<Plts Szrs, sedation, euphoria, hypotension, bradycardia, shick, constipation, ileus, thrombocytopenia, resp depression.

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Gabapentin300mg PO tid

1000/1400/1800

Synthetic inhibitory CNS transmitter/Anti-convulsant

Epilepsy and neuralgia

Prevents & treats szrs (unk)

Onset: Unk, Peak: 2-4 hrs, Dur: Unk

Stop gradually due to risk of szr, morphine may increase levels

<WBCs Dizziness, ataxia, tremor, amnesia, impotence, LEUKOPENIA, vasodilation

MS Contin30mg PO q12hrs x 72 hrs

2200

Opioid analgesic

Moderate to severe pain

Binds with opioid receptors in CNS , altering response to pain via unk mechanism

Onset: 10-15 mins, Peak: <1 hr, Dur: 3-6 hrs

Do not crush, take with food

>Amylase and lipase

Resp depression, hypotension, sedation, urinary retention, vomiting.

Vancomycin30mg PO q12hrs x 72 hrs

2200

Glycopeptide Antibiotic

Severe Staph & Strep infections

Hinders bacterial cell wall synthesis, damaging the plasma membrane, killing susceptible bacteria.

Onset: Unk, Peak: Immediately, Dur: Unk

Chk peak & trough, teach signs of infection

>BUN & Cr, <WBCs

Red man syndrome, hypotension, superinfection, ototoxicity, nephrotoxicity, leukopenia, & thrombophlebitis

Zofran Inj4mg Q 8 hrs, give 2 ml PRN

Anti-emetic/Selective serotonin Inhibitor

Prevents N/V

Blocks action at CNS chemoreceptor trigger zone & PNS

Unk Report HA >AST/ALT Hypotension, HA, arrhythmias, rash, diarrhea

Colace100 mg PO PRN for Constipation

Surfactant/Emoll-ient laxative

Prevents bowel strain

Reduces surface tension of liquid contents in the bowel. The incorporation of additional liquid into

Duration of 24 to 72 hrs Teach about dietary bulk including bran, fuits & veggies. D/C if sever cramping occurs. Monitor I & O.

None Reported

Fainting, throat irritation, bitter taste, abd cramping, & diarrhea.

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stool, forming a softer mass.

MOM30ml PO q 8hrs prn for constipation

Stimulant Laxative

Treats and prevents con-stipation

Stimulates peristalsis

Onset: 15-30 mins, Peak: 2-3 hrs, Dur: 4-6 hrs

Monitor I & O for BM & urinary retention, Monitor VS Q 2 hours

<K, < H & H, > Mg

Norco 2 tabs Q6 hrs prn for BTP

Opiate/Analgesic

Prevents N/V

Blocks action at CNS chemoreceptor trigger zone & PNS

Onset: 10-20 mins, Dur: 3-6 hrs

Monitor RR before & after administration, monitor pain level, St. John’s Wart increases sedation, take with food

>AST/ALT Bradychypnia

Benedryl 225mg PO or IV q 6 hrs Prn insomnia

Anti-histamine, sedative

Insomnia, itching

H1 blocker, prevents histamine related responses. Prevents transmission of nerve impulses. Relieves allergy symptoms, moton sickness & promotes sleep.

Onset: 15 mins, Peak: 1-4 hrs, Dur: 6-8 hrs

Avoid alcohol, use sunblock, increase fluids to relieve dry mouth.

< H & H, Plts Drowsiness, HA, insomnia, tachycardia, hypotension, THROMBOCYTOPENIA, AGRANULOCYTOSIS, anemia, dry mouth, N/V, dysuria, SZR, tremor, vertigo, sedation, epigastric pain & rash

Tylenol/Analgesic, Anti-pyretic 650 mg PO p

Analgesic Anti-pyretic

Fever NSAID

No alcohol, monitor skin signs Q2 hours, monitor I & O.

<BUN, >WBCs, monitor skin signs Q2 hours, monitor I & O.

Hepatic failure/toxicity, renal failure, neutropenia, leukopenia, rash, uticaria. Normal Dose: 4g daily.

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Date: 1-31-12Vital Signs T: 98.0 BP:126/68 HR: 88 RR: 18 SPO2: 97%-

RAPain: 10/10

Height: 5’7 Weight: 160 lbs I&O: Strict BRP

Lab Values:Date:1-22-12 Date:1-31-12

Lab Test Normal ValuesAdmission

LabsCurrent Results

Significance of Findings Specific to Patient

Na 135-145 mmo/L 139 141

WNL, though trending higher, possibly due to continuous IV NS administration, and intermittent NPO status. Monitor for S/S of hypernatremia including polydipsia, edema, tachycardia, confusion, restlessness, dehydration, rough tongue, sticky mucous membranes, N/V/D,& flushed skin. Monitor I&O and daily weights x 1 and prn

Cl 100-110 mmo/L 102 100

Trending low. Risk for low, may be r/t low vomiting. Monitor for S/S of hypochloremia including hyperreflexia, tetany, slow/shallow breathing & hypotension. Monitor I&O and daily weights x 1 & prn.

CO2 20-30 mmo/L 30 34 HHigh, monitor for S/S of alkalosis including shallow respirations, apnea, cyanosis, N/V/D, irritability & muscle weakness x 1 & prn. May be caused by cocaine and heroin intake.

K 3.5-5.1 mmo/L 3.4 L 4.5

Low upon admission, though now WNL. Indicates adequate dietary intake and kidney tissue function. At risk for high d/t, IVDA, Hep C hx. Monitor for S/S of hyperkalemia including oliguria, anuria, metabolic acidosis, N/V/D, & anorexia. Monitor K+ intake, I&O, blood sugar, & pH. Assess VS, I&O, K intake, plts, and daily weights x 1 & prn.

Glu 65-99 mg/dL 122 H 85High upon admission, which correlates with pt’s szr disorder & hospital-Related stress. Now WNL, Monitor for S/S of hyperglycemia including polydipsia, polyuria, polyphagia, weight-loss & Kussmaul’s breathing x 1 & prn.

BUN 7-20 mg/dL 32 H 18High, trending lower, risk for high due to Keppra & vanco intake. Test used to determine renal function & hydration status. Monitor I & O x1 & prn.

Lactate 0.5-2.2 mmo/L 1.1Not tested

againWNL, test used to determine if pt has lactic acidosis.

LD 90-220 U/L Not Tested

Creatinine 0.5-1.4 mg/dL 0.80 0.81

WNL, indicating adequate nephron glomular function, & muscle mass. Monitor for decreased urinary output, monitor elevation in BUN/Cr labs for increase, as HCV can cause proteinuria. Also, risk for increase due to abx & Keppra intake.

Amylase 30-130 U/L 99 95WNL, suggesting adequate pancreatic and kidney function, though monitor for increase due to high AST and BUN upon admission and IVDA hx.

Lipase 7-60 U/L 44 42WNL, suggesting adequate pancreatic fand kidney function, though monitor for increase due to high AST and BUN upon admission and IVDA hx.

Hgb 11.8-14.7 g/dL 11.8 L 11.2 LLow, indicating low O2 in RBCs, possibly r/t Hep C, Keppra intake, low B12 intake, low flic acid & low Fe. Monitor for S/S of anemia inclusing dizziness, weakness, dyspnea, & tachycardia

Hct 36-44% 35.0 L 32.9 LLow, may be related to infection and wound surgery or antibiotics.Monitor for fatigue, pallor, tachycardia, decreased BP, and blood loss in every orifice-petecchiae, ecchymosis, hematoma, and erythema.

RBC 3.7-5.2 m/cumm 3.2 3.62 Test monitors RBC count, which is low due to anemia.

Protime 12.2-14.1 secLow coagulation time and indicates high blood viscosity & potential for clotting. Monitor for S/S of thrombosis.

INR 0.92-1.1 1.22 1.18 High upon admission, though trending down to WNL. Test

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measures blood coagulation time. Elevation may be r/t anemia, inflammatory process, and antibiotic therapy. Monitor for bleeding gums, bruising, epistaxis, and hematuria

APTT 24-36 42 40

High upon admission, though trending down to WNL. Test measures blood coagulation time. Elevation may be r/t anemia, cirrhosis dx, and antibiotic therapy. Monitor for bleeding gums, bruising, epistaxis, and hematuria

Mg 1.7-2.3 1.8 2.0 WNL, at risk for low due to Dulcolax intake.

Anion Gap 10-17mEq/L 9 L 14Low upon admission, possibly d/t electrolyte increase or low protein. S/S of decreased AG Levels are the same as alkalosis-cyanosis, N/V/D,tachycardia, <BP & confusion x 1 & prn.

Ca 8.5-10.3 mg/dL 9.0 9.5WNL, at risk for low due to diagnosis, and high Phos. S/S of hypercalcemia including lethargy, HA, weakness, muscle flaccidity, N/V/D & anorexia x 1 & prn.

Phos 2.5-4.5 3.2 3.9WNL, though rising, which occurs with normal bone healing. Monitor for S/S of hyperphosphatemia, including tetany, decreased UOP, assess for low calcium x 1 & prn.

Total Protein 6-8 g/DL 5 6Low, possibly d/t prolonged immobilization, decreased protein intake& ASA intake. S/S of low albumin include peripheral edema & ascites.

Albumin 3.5-5.0 g/dL 3.7 3.8 WNL, though moni

AST/ALT10-40 U/L & 10-55 U/L

45 H/30 23/17Test measures liver enzymes. An elevation can indicate liver damage. AST increase may have been high d/t Hep C or Fragmin & abx intake per MD order.

WBC 3.7-10.3 k/cumm 13.2 H 6.9 High upon admission due to infection, now WNL with abx therapy. Monitor for S/S of infection-fever, tachycardia, increased RR, & leukocytosis).

Plt 145-340 k/cumm 267 287WNL, risk for low related to Fragmin intake. S/S of thrombocytopenia Including bleeding x 1 & prn.

Vanco 5-15 20.6 HP 22.5 HP High Panic, monitor peak & trough levels q 3rd dose to avoid toxicity.

CRP >10 24

Not tested again

High, test detects inflammatory process, due to septic arthritis.

Urinalysis

pH5.5-7.5 6.0 6.2

WNL- Adequate Metabolic acid base balance. Monitor for electrolyte imbalance, loss or gain of acid or base, dyspnea, and decreased kidney function.

Spec. Gravity1.005-1.035 1.051 N/A

WNL, indicates adequate hydration and renal function, though monitor as pt is post-surgery, which nay increase urinary retention, resulting in increased SG. Monitor I&O for dysuria & anuria.

Clarity Clear Indicates pt is well-hydrated

Blood Neg. NegWNL- No blood in urine. Monitor for hematuria, dysuria, labs for blood loss, abd distension/ascities, and urine discoloration.

Keytone Neg. Neg WNL, indicating adequate blood sugar levels and acid-base.

ProteinNeg. Neg

WNL, indicates good kidney function. Monitor for S/S of proteinutriaIncluding edema and foamy urine output.

Bacteria Neg. WNL, indicating no bacteria in the urine.

ABG

10

pO2 N/A

O2 Sat (pulse ox)

100%

pH 6.0

pCO2 N/A

HCO3 N/A

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LAC School of Nursing N233L – Intermediate Medical Surgical & Psychiatric Nursing Clinical

N233L - ASSESSMENT

Pt. Initials: J.L. Date of Assessment: 1-31-12Vital Signs: BP 126/63 T 98.0 P 88 R 18_______Pain Level 10/10__O2 Sat 97% Neurological: Alert and oriented X 4. PRRLA. Speech status: clear and appropriate. Head: (-) lumps, (-) nodules, (-) lesions, (-) tenderness. Facial features: symmetrical, (-) facial drooping or sagging. Nose: Symmetrical. Ear assessment: auricles without deformity or tenderness, lumps or lesions, no cerumen. Eye assessment: L eye enucleation present with mild ptosis. White sclera, conjunctiva is pink/moist/intact, (-) excessive tearing, (-) swelling, (-) pain (+) prescription lenses: nearsighted. Neck/Throat: Symmetrical and has no difficulty swallowing and denies pain when swallowing, (-) palpable neck lymph nodes, no JVD. No tremors or dizziness.

Cardiovascular: Skin: Warm and dry to the touch. (-) Homan’s Sign to RLE. Sensations intact, MAE except LLE. Pulse rate is 2+ in all extremities except LLE-unable to palpate due to splint. Capillary refill is less than 3 seconds on all extremities. 2+ edema noted on LLE phalanges. Apical pulse is 88 and regular, S1 and S2 heard. PICC is patent and saline-locked to L upper extremity-no drainage, redness, or swelling-PICC clean, dressing dry and intact.

Respiratory: O2 Sat: 97%-room air, RR: 18-unlabored regular. Breath sounds are clear bilaterally/AP upon auscultation. Symmetrical bilateral chest expansion. Nose: Nares bilaterally patent (+)ORSA. Mucosa pink and moist, external structure without deformity, and pt can identify the smell of coffee. Oral assessment: Pink, moist and tongue is midline, no cyanosis present. (-) cough, (-) sinus tenderness. (-) Cough, sputum is clear.

Gastrointestinal: Absence of N/V/D/C. Abdomen: soft with absence of tenderness or pain in all 4 abd quadrants. BS normoactive in all 4 quadrants. Reg diet: consumes between 75-100% of his meals, depending on his pain level. No chewing or swallowing problems. No masses or nodules felt, no abd distension. All teeth are present, white and healthy looking. Last BM: yesterday (1/31/12), “normal”, brown, hard consistency.

Genitourinary: Voiding: Urinates spontaneously and regularly, without difficulty or pain. Into urinal. Urine is yellow in color and clear, with no odor. No pain or burning with voiding. (-) bladder distention. (-) penile discharge, per patient.

Integumentary: Double lumen PICC to LUE, site and dsg clean, dry and intact, no redness, no tenderness. Nail shape WNL and smooth texture, (-) clubbing. Hair distribution: appropriate, hair pattern normal, little hair loss. Mucous membranes intact, moist and pink. Skin turgor: <2 seconds on clavicle. Skin is warm, dry, and intact all over, except. L lower anterior/posterior leg ecchymosis present and mild swelling noted on the toes. Multiple tattoos present throughout the body, (-) rash. Thick, peeling skin to dorsal bilateral feet present. Several small circular scars present throughout arms and legs. 10 incision scar present along the spine. 2 inch scar present to posterior L FA.

Musculoskeletal: Gait: Unsteady and slow d/t long leg splint and administered pain medication. Able to get OOB to wheelchair without assistance. Range of motion: active in RUE-5/5, except for LLE ROM 1/5, with limited movement. Muscle tone: Symmetrical. L Bilateral hand grasps are strong, pulses 2+, strong and equal on all extremities, except L foot-unable to palpate d/t cast. (-) paralysis, (-) paresthesia, (-) pressure, with adequate perfusion, except L foot, pt states he feels moderate pressure, and some numbness. Able to wiggle fingers and toes bilaterally.

Behavioral: Calm, interactive, cooperative, though mildly anxious in relation to pain and future surgery. Exhibits fear and anxiety related to where he will go upon discharge and who will take care of him. Main language is English, but speaks Spanish as well.

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NURSING 233L

List ALL nursing diagnosis for your patient (PRS format), and collaborative problems.Rank in order the priority problems identified.

Nursing Diagnoses:

1. Ineffective bone tissue perfusion r/t the inflammation & destruction of tissue, and continuation of infectious process/delayed wound healing as manifested by Pt having elevated WBCs, tenderness & pain, 2/2 septic arthritis.

2. Risk for Peripheral neurovascular dysfunction r/t vascular insufficiency evidenced by decreased ROM and LLE edema

3. Impaired mobility r/t pain and weakness evidenced by verbal complaints of pain (when moving) and NWB status

4. Fear r/t homelessness and isolation evidenced by verbalizing “I have no where to go when I get out of here and don’t know who will take care of me.”

5. Impaired comfort r/t decreased mobility evidenced by complaints of 10/10 pain

Potential Complications:-Hemorrhage and hypovolemia

-Shock and CVA

-Sepsis

-MRSA

-Cellulitis

-Compartment Syndrome

-Kidney failure

-Falls and injury

-Hemorrhage and hypovolemia

-Avascular necrosis

-Amputation

-Loss of joint function

-Neuropathy

-Joint deformity

-Chronic pain

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ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATIONSubjective:

*Patient complains of pain in LLE, “The pain is 10/10, throbbing, and I can’t move my toes”.*Referred from Good Sam Hospital on 1/21/12 for increased swelling and decreased ROM.*Patient has consistent complaints of pain from ranging from 4/10 to 9/10 pain.*S/P L ankle joint implant hardware and ORIF x 5 years ago.*Hx of IVDA, states, “I quit drinking in 2008.”Objective:

*Displays decreased ROM and weight-bearing status*Asks for Morphine before the scheduled time.*Skin on L foot appears red, with 1 + edema, ROM: 1/5*Smoker, delayed wound healing & vasoconstrictionRelated Labs 01/31/12:--Glu: 122 H--Hct: 32.9 L--Hgb: 12.2 L--WBCs: 6.7 N--CRP: 24

-VS on 01/31/12

BP: 126/68HR: 88O2 Sat: 97 % room air

P: Risk for Peripheral neurovascular dysfunction

R: R/t vascular insufficiency

S:

Goal: Pt will verbalize the 6 P’s of neurovascular dysfunction during my shift on 2-01-12.Interventions:*Assess patient’s knowledge about neurovascular status and S/S of skin irritation. Rationale: Evaluation of pt knowledge determines what to teach.

*Instruct pt to and move his toes, check his skin temp & pulse to his L foot tid.Rationale: To determine patient’s level of ROM, improve tissue perfusion & circulation, and prevent increased dysfunction.

*Teach patient 6 P’s (Pain, pallor, paresthesia, pulselessness, pressure, paralysis) related to neuro dysfunction.Rationale: Patient needs to know how to prevent and identify neurovascular dysfunction.

*Document assessment, teachings and interventions Chart Assessment in Affinity in the computer.Rationale: This is done to ensure communication with other healthcare providers, informing them of interventions, to assist in further care of patient. Also, done in compliance with hospital protocol and state law.

*Assessed pt’s knowledge regarding neurovascular dysfunction to LLE, which were WNL, except for pain and pressure.

*Performed head to toe assessment. Bathed pt, & changed linens. ROM of LLE is 1/5 S/P I&D surgery.

* Evaluated patient’s level of knowledge r/t his type of disease process, pain management, infection, and possible complications.

*Taught pt the 6 P’s of neurovascular dysfunction with flash cards, he verbalized them back.

*Documented Assessments, teachings and interventions into Affinity.

Goal: Met. Pt experienced no new neurovascular dysfunction and verbalized the 6 P’s.


ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

SUBJECTIVE:

*Pt stated “I have no where to go when I get out of here and don’t know who will take care of me.”

OBJECTIVE: *Absence of love ones at bedside

*Displays facial grimacing intermittently

*Homeless, divorced and unemployed

*Denied placement from Rancho

*Goes off ward to smoke

P: Fear

R: R/t homelessness and isolation

S: Evidenced by verbalizing “I have no where to go when I get out of here and don’t know who will take care of me.”

Goal:Patient will identify & demonstrate 1 guided imagery technique (visualization with other sensory attributes) by 1500 on 8/22/12.INTERVENTION:*Assess level of knowledge regarding guided imagery & Identify current coping behaviors.Rationale: To establish a baseline and level of care needed.* Rationale: To learn how to better manage stress and fear. Also enhances personal confidence.* Teach adaptive coping mechanism-guided imagery.Rationale: To promote self-control and independence *Provide a safe, calm, quiet environment, keep lights low. Restrict caffeine.Rationale: To reduce anxiety.* Document assessments, teachings and interventions into Chart Assessment inAffinity .Rationale: To ensure communication with other healthcare providers, informing them of further care of patient.

*Assessed level of anxiety (8 out of 10) and provided reassurance that the social worker would do her best to find placement for him.Pt Response: Stated that he was relieved.

*Identified current coping behaviors (smoking and diversionary), gave him a smoking cessation pamphlet and taught adaptive coping mechanism-guided imagery.Pt Response: Has smoked for over 30 years, ahs tried to quit twice “cold turkey”, but eventually started again.

*Taught pt to shut his eyes, breathe deeply and practiced guided imagery techniquesPt Response: Pt imagined he was lying on the beach and breathing deeply while he imagined waves. He stated that it was calming, but he didn’t know if it was enough to make him not want to smoke, but it did help with the anxiety he was feeling

*Provided a safe, calm, quiet environment, with low lighting and a soft voice. Restrict caffeine. Fall and szr precautions were enforced.

*Documented assessments, teachings and interventions Chart Assessment in Affinity R: This is done to ensure communication with other healthcare providers, informing

Goal: Met. Patient verbalized reduced anxiety, and practiced guided imagery, via “walking on the beach” during an episode of anxiety. Outcome met.

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them of interventions, to assist in further care of patient. Also, done in compliance with hospital protocol and state law

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Objective:*Osteomyelitis and IVDA hx

*Smoker half ppd

*Male in his 40’s

*Status post L ankle ORIF with hardware x 5 yrs ago

*Increased WBCs upon admission

*Increased CRP @ 24

*HR: 88

Subjective:*”I came in because I was in pain and swollen”

*”I’ve had Osteomyelitis before”

PC : Septicemia r/t infection in the left foot

Goal:Will monitor, along with other healthcare providers, the S/S of septicemia.

Intervention with rationale* Assess knowledge of signs and symptoms of Septicemia (fever, chills rapid heart rate, malaise, altered mental status), and determine pt’s preferred learning style.Rationale: So I will know what to teach regarding septicemia and teach in pt’s preferred learning style so he may better learn.

* Educate the patient the S/S of Sepsis and express the importance of early identification and intervention. Rationale: Pt will be able to quickly identify the early S/S and report them to prevent this complication.

* Educate on infection prevention techniques including proper hand-washing, & keeping dsg clean and dry @ all times.

*Teach to use pain scale and to call for pain meds before pain reaches 4/10, as ordered. Taught S/S of infection, and encouraged using PT for long-term pain reduction & increased ROM. Pt verbalized signs of infection.

Including patient response* Pt Response: “I just know about the bone infection, and that if it gets worse, they might cut off my foot”, “I just have pain and pressure.” “I learn best with pictures or reading.”

*Pt Response: Verbalized that septicemia was “an infection that spreads to the blood” and stated that s/s are fever chills and confusion.

* Pt Response: “I will sing the Happy Birthday song twice when I wash my hands.”

* Pt Response: “I will call you when my pain is more than 4 out of 10.”

Goal:Met. The patient was able to correctly verbalize greater understanding of sepsis and more that two S/S.

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* Document teachings into AffinityRationale: To ensure communication with other healthcare providers.

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ncp osteomyelytis

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