Student Name Heather Humphrey

Priority Diagnosis: Impaired Skin Integrity

Unit 3A

Patient initials CKR Date 10/05/2012

Room 3116A

TEXAS WOMANS UNIVERSITY ADAPTED CRITICAL THINKING WIZARD

Patients Chief Complaint & History Of Present Illness CC: diverticulitis with internal abdominal abscess (left sigmoid colon junction) w/ JP drainage. 52 y.o. female pt present in ED w/ left sided lower abdominal pain. Denied in N/V, diarrhea, fever and previous history of abdominal pain. The past week (9/1609/26/12) pt had been treated for diverticulitis with antibiotics. Pt has past history of chronic steroid use for rheumatoid arthritis. Pt denies hx of smoking or alcohol use. PMH: 1. Significant rheumatoid arthritis 2. Hypertension 3. Hyperlipidemia 4. Gallbladder disease 5. Diaphragmatic hernia (right side) 6. dysphagia 7. Abdominal pain 8. Unspecified gastritis 9. migraines 10. lumbago Past surgical hx: 1. cholecystectomy 2. hysterectomy 3. tubal ligation Current meds (PO meds on hold to NPO status) 1. prednisone 2. propranolol 3. diovan AGE: 52yo female Weight: 77.73Kg (171 lb) Height: 65cm ALLERGIES: codeine/hydrocodone DNR Yes/No (full code) Drugs & Indications 1. D5W NaCl 0.45 20 MEQ KCl 1000mL; 100mL/hr q10h; hypertonic soln used to rehydrate, has free water, salt, calories with potassium supplement. 2. piperacillan/ tazobactam (Zosyn) 3.375 g/50mL NS, IVPB IV 50mL/hr IV q6h; moderate to severe infections of betalactamase producing strains causing infections, effective for resistant Staphylococcus aureus, E.coli. SE: seizures, cardiac toxicity, oliguria, proteinuria, hematuria, glomerulonephritis, renal faiure, bone marrow suppression, agranulocytosis, hemolytic anemia, exfoliative dermatitis, rash, pruritus, anemia, increased bleeding time, vertigo 3. metronidazole (flagyl); 500mg/100mL; IVPB 100ml/6hr IV q8h6; anaerobic infections SE: HA, dizziness, confusion, restlessness, ataxia, fatigue, drowsiness, seizures, blurred vision, dry mouth, metallic taste, glossitis, N/V, diarrhea, epigastric distress, abdominal cramps, pseudomembraneous colitis, darkened urine, albuminuria, dysuria, leukopenia, thrombocytopenia, neurotoxicity 3. Esomeprazole (Nexium) inj; 40mg (1 vial), bid IV. **Dilute w/ 5ml NS; inject given 5ml over 3 min**. Treat GERD, inhibit gastric acid secretion (PPI); SE: HA, dizziness, diarrhea, hepatic failure, hepatitis, rash, dry skin, heart failure, toxic epidermal necrolysis 4. NaCl 0.9% 10ml IV flush; 1, 10ml syringe, IVF q8hr. Clearance of IV catheter tubing, check for patency PRN medications 5. hydralazine (apresoline); 20mg/1ml <10mg/0.5mL); q4hr prn IVP; SBP>160; antihypertensive, vasodilates arteriolar smooth muscle by direct relaxation, reduction in BP with reflex increases in HR, SV, CO; SE: headache, tremors, dizziness, anxiety, peripheral neuritis, palpitations,

Assessment Findings for 10/04/2012, 0600 Vitals: 1. Temp: 97.5 2. BP: 120/90 3. Pulse: 106 4. RR: 20 5. Pulse Ox: 97% 6. O2 flow rate: 2 L/min I/O - 10/04/2012, 0600 Input: PO: 0, IV: 0 Output: Urine: 0 drainage (lower abd): TOTAL BALANCE: 0

NSGDX/PRIORITY PROBLEMS 1. Impaired skin integrity r/t abdominal incision and presence of drains, tubes AEB hypoalbuminemia, eleveated WBCs, elevated neutrophil counts, and depressed lymphocyte counts. 2. Imbalanced Nutrition less than body requirements r/t wound drainage, NPO status, decreased intake, acute pain

Diagnostics & Labs DIAG: 1. CXR; 10/02/2012: cardiac size large; perihilar & basal airspace disease w/ small effusions; right diaphragmatic elevation; right PICC line has tip in region of Vena Cava; assess tube placement of ultrasound guided drainage of abdominal abscess, 18gauge chiba needle advanced into fluid collection, 10 french pigtail catheter placed + secured to pts skin and connected to J/P bulb suction 2. CT Scan; 10/102/2012: RLQ + right flank w/out contrast; bilateral atelectasis; moderate size hiatal hernia present; loculated fluid collection resides just deep of muscular wall of LUQ of abdomen just above umbilicus level; just caudal to this level is 2nd fluid collection, LLQ paracolic gutter fluid collection 3. Microbiology abdominal wound specimen; 10/02/2012; gram stain: many WBCs; many gram positive cocci present pairs, chains, clusters. Organism: Viridans streptococcus spp; few in number. LABS 10/04/2012 0600 BMP: Na = 136; K = 4.1; Ca = 8.1 L; Cl =102, CO2 = 25; Anion Gap= 8; Creatinine=0.55L; BUN = 10 Glucose = 105 EXT BMP: Albumin = 2.7 L; Lipemia <20 CBCs WBC = 12.2 H; RBC = 4.04; Hbg = 12.7; Hct = 36.5; Plts = 125 L WBC Differential: Neutrophils % = 84.6 H Lymphocytes % = 8.1 L LFTs (not seen in labs): Total Bilirubin = AST = ALT Alkaline phosphatase = Albumin = 2.7 L Coagulation (not seen in labs): PT = INR =

AEB NPO status, parenteral intake D5W NaCl 0.45 20 MEQ KCl 1000mL; 100mL/hr q10h; total PO and IV input = 0 10/04/2012 at 0600.

3. Acute pain: abdominal, joint

r/t abdominal incision, presence of drains, tube and rheumatoid arthritis AEB subjective complaint of pain, expressive behavior of pain, guarded movement, & Morphine 2mg/1mL <2mg/1ml> IVP q4hr PRN

reflexive tachycardia, angina, shock, rebound HTN, orthostatic hypotension, N/V, diarrhea, anorexia, constipation, paralytic ileus, urinary retention, hematuria, leukopenia, agranulocytosis, anemia, thrombocytopenia, rash, pruritus, urticaria, nasal congestion, muscle cramps, flushing, edema, dyspnea 6. Morphine 2mg/1mL <2mg/1ml> IVP q4hr PRN; Moderate to severe pain, SE: drowsiness, dizziness, confusion, HA, sedation, insomnia, seizures, palpitations, bradycardia, changes in BP, cardiac arrest, shock, chest pain, hypo/hypertension, edema, tachycardia, blurred vision, diplopia, tinnitus, N/V, constipation, biliary tract pressure, urinary retention, thrombocytopenia, rash, urticaria, pruritus, respiratory depression, respiratory arrest, apnea

1. 2.

Support Equipment PICC R upper arm Oxygen Nasal Cannula, 2 L/min

Related Medical Problems

1. 2. 3. 4. 5. 6. 7. Significant rheumatoid arthritis Hypertension Hyperlipidemia Gallbladder disease Diaphragmatic hernia (right side) dysphagia migraines 1. 2. 3. 4. 5. 6. Treatments J/P drain in LUQ Strict I/O Transition from NPO (IV fluids) to PO full clear liquid diet O2 nasal cannula: 2L/min Fall risk assessment bid Dysphagia full liquid diet; raise HOB

Post Clinical Assessment Documentation

Focused Assessment

Focus on assessing for any changes r/t Excess Fluid Volume.

Cardiac

BP: 112/67; Pulse: 80bpm, reg, 2+; Apical pulse, reg, 80 bpm; no extra heart sounds (no S3); No thrills or heaves; Cap refill < 2sec bilaterally; Neg JVD; Neg signs of clubbing bilat; Pedal Pulses: not palpable bilaterally; Edema; generalized, non-pitting. O2 Sat 96%, RR: 22, unlabored + regular , BS clear bilaterally; no adventitious lung sounds Oxygen in use 2 l/min, patient removed @ 0800; Cough intermittent, productive with clear thick sputum. Pt given Oxygen Nasal Cannula, 2 l/min, took off approximate 0800. Did not observe her place it back on, refused placement. Patient did not receive RT Albuterol 0.83% nebulizing system (provetal) by 1300. Patient reports pain upon intermittent eructation in epigastric region. Pain described as stabbing with rate 4/10. Denies need for pain medication Pt has eructation intermittently; normoactive BS all 4 quads; Abd soft, non distended all 4 quads; tender LLQ on gentle palpation; 09/25/2012 last BM with small, hard, dry stool. Poor appetite. Refused Full Liquid Diet breakfast due to contraindicated with gastric bypass and fatigue. Ordered cream of chicken soup, ate 100% @ 120ml; drank 120ml Apple juice. Refused Lunch. 09/28/12 Total Input: 240mL Total Output: 6mL foley catheter, urinary meatus has slight redness, irritation & tenderness with no signs of encrustment. Strong urine odor. No suprapubic tenderness or guarding. Foley has no dependent loops, secured on bed frame; Urine output < 15ml over 5 hours. Urine quality in foley bag: hematuria, dark amber with visible blood, no clots. Strong urine odor. 09/28/2012 Total output = 6mL 09/25/2012 last BM with small, hard, dry stool A & O X 3, patient refused ambulation. Moves all extremities with ease; however, movement of trunk and repositioning require assistance. Independent in ADLs, All extremities exhibit grade 5 strength (Full ROM agst gravity with resistance

Pulmonary

GI

Nutrition

Elimination

Neuro

M/S

Safety

Moves all extremities with ease; however, movement of trunk and repositioning require assistance. Pt reports althralgias in hips, knees, ankles. Independent in ADLs, All extremities exhibit grade 5 strength (Full ROM against gravity with resistance). Fall risk assessment, patient A+O X3; however, fatigued. Pt. refused attempt to ambulate for shower or oral mouth care. Patient not categorized as fall risk; however, bed in lowest position, locked with 4 bedrails up

Skin -see Presby shees

Psycological

Warm, dry, smooth & firm with uniform thickness. Tugor with mobile tissue & readily returns to position when released. Edema; generalized, non-pitting. Heels Blanchable. Coccyx sacrum has some redness, non-blanchable surrounding area of sacral skin tear. Sacral skin tear located 5cm below the buttocks crease. Stage 2 Pressure Ulcer Skin tear 4cm X 0.3 cm with no tunneling, immeasurable depth. Sore, red irritated, with minimal sanguineous drainage on dressing Patient reluctant to talk about diagnosis of ARF. Mentions family history of Lupus, and is concerned about her health relative to her two aunts. Patients mood is anxious with flat affect. Spontaneous speech but with little elaboration on answers to open ended questions. Pt reports some anxiety and concern to what her health outlook, and how she will be able to make appointments for hemodialysis.
Pts sister stayed overnight 09/27 and slept throughout the morning. Family friend came and visited approximately 0900. Patient lives with boyfriend of several years. Patient denies children or taking care of other family members in her household. Several family members live in the state of Louisianna

Family

Cultural

Sociological

Spiritual

D/C needs -Communit y

No indication of aspects of cultural background influencing her current and medical treatment. Noted several cards in the room from friends/family, and 2 balloons. Pt is primary caretaker at home with live-in boyfriend. Pt is supported financially by boyfriend and has only one car as primary source of transportation. Patient indicates that he boyfriend will be taking her to doctor and dialysis appointments Patient indicated she felt hopeful that she will be able to get her health condition under control. States family and friends are helping her through the period. Noted several cards in the room from friends/family, and 2 balloons. Patient did not indicate a specific faith or religion that she is actively involved in. Patient history notes Social worker is investigating assisting patient to social security disability insurance. Patient indicates in medical history notes indicate she currently has no form of insurance or finances to pay for her continued hospitalization and future dialysis.