Case Study

Case Study Assignment: Nursing Care Plan Rene Tan PRNR 162: Nursing Theory III Rosanne Arcuri July 19, 2011

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Part A: Assessment and Problem Identification a. Lack of Social Support

Upon interview with the patient, she is anxious and continually asking where her husband is and who is looking after him. She is the primary caregiver of her husband who has Alzheimer's disease. Whenever she moves, she grimaces and moan. Though she denies any pain, however her outward expression denotes otherwise. She avoids any question related to her current situation and insist on seeing her husband. It is very apparent that she is anxious for her husbands well being. It is a priority for her to know that he is taken care of. He is her priority and as her nurse that makes it my priority as well.

Anxiety can lead to stress. Not knowing who is looking after her husband is very stressful for the patient, hence it is affecting her cooperation to the assessment and upcoming procedure. By addressing this need and letting her know that a social worker will be arranged, the patients worried face subsided and she has since calmed down allowing me to proceed with my assessment.

b.

Circulation

Patients blood pressure is elevating. From the chart at 1630 it shows a BP of 186/30. At 1645 her BP has gone up to 192/86. An electrocardiogram showed Atrial fibrillation. Although this is related to patients underlying disease process, any changes may become critical. Therefore maintaining adequate perfusion is essential to avoid complications that poses a threat to vital organs. This also include reviewing lab values. As her nurse, this becomes my next priority. It is essential to monitor vital signs hourly particularly blood pressure before subjecting the patient to sedation or any type of anesthesia which may lead to circulatory challenges and adversely affect the patient (Watson.2011. pg 144).

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Nutrition Hydration is a huge part in patients nutritional status. Maintaining good nutrition helps the body heals and fight infection. Therefore this comes as my next priority since malnutrition is predictive of increased risk for postoperative infection. (watson. 2011.pg 165). Upon review of clients lab results I have noted a low albumin level which is indicative of dehydration and malnutrition. As her nurse, it is important to ensure client receives normal saline at 75 ml/hour and normal saline bolus 250 ml as soon as possible as per doctors order. At the same time checking the IV site for infiltration, redness and swelling.

Preoperative Assessment including both subjective and objective data of the 3 issues or problems stated above. A preoperative assessment is useful to identify the factors associated with patients problems or issues to avoid increased risk for complications and be able to create a nursing care plan to minimize risk. These assessments include patients personal data and medical history, physical examination, special test results, review of lab results and assessment of the surgical risk involved. Patients personal data: Client is Mrs. A. B, 82 year old married female. She looks after her 89 year old husband, who has Alzheimers disease, at home. She has two children, a son who has schizophrenia and lives in a group home, and a daughter who lives overseas. Medical History as per chart: Clients history includes breast cancer 14 years ago, treated with a left mastectomy and chemotherapy, with no recurrence; hypertension; atrial fibrillation; osteoarthritis; depression; lifelong non-smoker; drinks 2 glasses of wine per week. Physical Examination: During pre operative assessment the following data was gathered: Objective:

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Large hematoma on left forehead. Fractured left femoral neck Dysrhythmia

Subjective: Drowsy Shaky Verbalizes feeling of thirst. Anxious continually asking where her husband is and who is looking after him.

Head to Toe Assessment: Vital signs at 1645 are: blood pressure 192/86, temperature 35.8, pulse 98, respirations 12, oxygen saturation 92% on a 3 litres per minute oxygen per nasal prongs. CNS: Client is grimacing and moans upon movement. Anxious, continually asking where her husband is and who is looking after him. Orientated to name and place. Clear speech, follows commands. Pupils are equal and reactive to light at 3mm. Hand grasp equal and strong bilaterally. Dorsi plantar flexion on right foot strong, on left foot weak. Pain: States no but grimaces and moans upon movement. Integument: Skin pink and warm to touch. Hematoma on left forehead 2x1. Left arm bruising, purple 2x2 on anterior are distal to elbows. No edema, lesions and rashes noted. RESP: Thoracic, effortless breather, no accessory muscle used. No shortness of breath. No cough, sputum and non-smoker. No circumoral cyanosis noted. Bronchial, broncovesicular and vesicular breath sounds audible on auscultation. No adventitious sounds heard. CVS: Skin is pink and warm to touch with no cyanosis. Capillary refill less than 3 seconds. No edema to hands or feet bilaterally. Radial pulse equal and strong. Dorsalis pedis and posterior tibial faint on palpation. No jugular vein distention noted. S1 and S2 irregular. S3 present. GI&GU: Skin turgor rapid recoil. Oral mucosa moist and pink. Abdomen convex and symmetrical. Bowel sound normactive in all four quadrants. No

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pain on light palpation. Normal saline at 75 ml per hour. Last oral intake 8 and a half hours ago. States I feel very thirsty right now. Foley catheter in situ 140 mls. Client can not recall last bowel movement. MSK: Unsteady gait. Drowsy and Shaky. Full range of motion to elbow joint bilaterally. Muscle strength unable to assess. Sleeps: Sleep 7 hours per night. No use of sleeping aids. An interview was conducted and the following information was gathered: It is important to ask specific questions that may assist the client in recalling past experiences that may have triggered an allergic reaction (Watson.2011. pg 290). 1. Do you have any family history of Anesthetic Problems? Client replies: No 2. Do you have any allergies? Client replies: No 3. Do you experience skin irritation when using adhesive bandages or tape? Client replies: No 4. Do you ever have problems blowing up a balloon? Client replies: No Laboratory results as per chart: Upon review of the lab values. It is noted that client has low level of Albumin at 22 grams/L. Since albumin is the most abundant protein component of blood and helps transport durgs and other substances by way of the bloodstream, the client needs to be monitored for signs of edema. Also low levels of albumin indicates malnutrition and dehydration. Magnesium levels is a little low at .55 mmol/L. This mineral is important for proper functioning of the nerves and muscles. It helps maintains steady heart rate and normal blood sugar. Therefore low levels may present sign and symptoms of muscle cramps, involuntary jerky movements eye, irritability, disorientation, confusion. Keeping in mind that low magnesium levels can be caused by high blood pressure and abnormal heart beats. (http://www.buzzle.com/articles/low-magnesium-levels.html) Calcium is low at 1.8 mmol/L. A low calcium level is typical for the elderly however it is essential to monitor calcium levels as this could be indicative of

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malnutrition, renal failure, hypoparthyroidism, decreased level of vitamin D. Also another common cause of low calcium is low protein levels specially albumin. (http://labtestsonline.org/understanding/analytes/calcium/tab/test) Creatinine level is high at 125u mmol/L. High levels of creatine warns for possible malfunction of the kidneys. The most common cause are high blood pressure and diabetes mellitus. (http://www.medicinenet.com/creatinine_blood_test/page2.htm) INR high at 4.1 which puts the patient at a higher risk for bleeding. Special test results: A computerized topography scan (CTC) of the head was done revealing no abnormalities; An electrocardiogram showed Atrial fibrillation; X-rays were performed, revealing a fractured left femoral neck. Pre OP Medications Given: Fentanyl 25 micrograms intravenous x 4 doses # 20 gauge intravenous catheter in the right arm with normal saline running at 75 millilitres per hour intravenous bolus of normal saline running at 250 millilitres Foley catheter in situ which has drained 140 milliltres over the last 4 hours received 2 units of frozen fresh plasma

Identification and prioritization of postoperative patient problems a. Airway, Breathing and Circulation Vital signs shows blood pressure 84/64 (sitting), temperature 36.6, pulse 114, respiration 26, oxygen saturation 90% on room air. Client is experiencing hypotension, shortness of breath and low oxygen level. Any alteration in function could be indicative of patients status deteriorating. Complications include inadequate tissue perfusion and hypoxia. It is essential to monitor for signs and symptoms as early detection can be life saving for the patient. b. Nutrition Nutrition provides the essential minerals needed for client to fight infection and promote healing. Clients lab values post-op shows low levels of

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hemoglobin, hematocrit and platet count. This lab result coupled with clients irregular pulse, shortness breath and low oxygen level are sign and symptoms of infection. Therefore as her nurse, this is my second priority. c. Ambulation Early ambulation prevents blood clots and promotes healing. As the nurse, this is my next priority since patient cannot ambulate if she is presenting any airway, breathing and circulation issues. A pain assessment will be performed prior to any exercise. Post operative Assessment: Head to Toe: Vital Signs are shows blood pressure 84/64 (sitting), temperature 36.6, pulse 114, respiration 26, oxygen saturation 90% on room air. Assessment of wound

Part B: Nursing Diagnosis and Nursing Process 1. Nursing Diagnosis : Physical Ineffective Peripheral Tissue Perfusion related to decreased cardiac output and +2 edema on left foot as evidence by absent pedal pulse, low blood pressure 84/64 and rapid respirations of 26 breaths per minute. Goal: Adequate circulation with palpable pedal pulses and decreased pitting edema from + 2 to +1 grading by end of shift. Intervention:

Elevate the leg with a pillow periodically every two hours. Since patient has minimal activity due to recent surgery, she is at risk for venous insufficiency due to prolong immobility which leads to pooling of blood and increased pressure in the veins resulting to edema of the legs. Therefore, by elevating the leg this will encourage venous return to the heart. (medicinenet. 2011)

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http://www.medicinenet.com/edema/page7.htm Monitor input and output every 8 hours. An accurate record of intake and output is essential to determine whether the patients intake is equal to outputs. This is helpful in determining if there is fluid retention. (linton. 2010 pg. 14) Talk to doctor about findings and recommend antiembolism stockings. This will increase velocity of the blood flow and improve venous function and promotes venous return to the heart. (Lynn. 2008. Pg 356) Evaluation: Elevating the leg intervention is partly met. Was able to palpate pedal pulse without use of a doppler, however edema has not decreased. Continue to elevate the leg to promote venous return. Monitoring input and output helped in assessing client has lesser output than amount of input. As a result the doctor was consulted for a diuretic medication. Recommendation for antiembolism stocking intervention was met. Doctor agreed and a written order was placed. Encourage client to use stocking to promote circulation. 2. Nursing Diagnosis: psychosocial needs Ineffective coping related to personal vulnerability due to recent surgery and lack of social support as evidenced by verbalization of inability to cope, inability to meet role expectations and lack of goal directed behavior.
Client will identify personal strengths as measured by the verbalization of two characteristics that aid in problem solving by 15:00

Complete a more in depth family assessment with the client before end of shift. This includes asking if there is someone she can rely on basic activities such as picking up groceries, dropping of mail or trips to the clinic. Is there any other relatives other than her children that she has contact with once a month. Does she have anybody she can call on for help on a short notice? These specific questions will enable to identify clients social support, hence decreasing anxiety knowing she has someone to call on for help. (Austin & Boyd. 2011.pg 746) Assist the client to set realistic goals and identify personal skills and knowledge. Helping client assess her personal skills and knowledge, as well

Case Study as guiding her to set realistic goals will encourage autonomy, enhance a sense of control, personal achievement and improve self worth (Austin & Boyd. 2011.pg 746). Gather information and teach client available community resources by the end such as seniors centers, transportation and other federally or provincially funded community resources. Accessing resources may provide opportunities for additional social support. (Austin & Boyd. 2011.pg 746). Evaluation

A complete in depth family assessment helped identify clients lack of social support. Goal is met. A social worker was contacted as a result of this assessment. Client was able to identify personal skills and knowledge however unable to set realistic goals, therefore intervention is partly met. Continue to guide client in setting realistic goals related to current situation. Client is aware of the available community resources by noting down the suggested resources in her journal. Goal is met. Continue to encourage client to utilize these resources and offer information when requested.

3. Nursing Diagnosis: discharge planning Impaired physical mobility related to anxiety and acute pain secondary to open reduction fixation surgery as evidenced by range of motion limitation, grimacing upon movement and client verbalizing It hurts too much, and I get dizzy. Client to maintain mobility as evidenced by independence in activities of daily living and absence of secondary complication. Perform pain assessment half an hour prior to activity in order to identify if pain medication per doctors order is needed. This will allow sufficient time for analgesic to attain its full effect. Pain and discomfort increases anxiety thus discourages client to participate. Once pain is manageable, client will be more inclined to participate in daily activities. (Lynn.2011.pg 501) Encourage regular movement as permitted while protecting the fracture. Regular movement help prevent complications of immobility caused poor circulation. (linton.2012.pg 973) Promote independence in self care activities as permitted while protecting the fracture. This helps the client to relearn the skills to perform for basic activities of daily living. (Linton.2012.pg 335)

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Evaluation. Pain assessment helped client identify need for analgesic to relieve pain and discomfort during activity. Client verbalizes the analgesic decreased her anxiety to perform the activity. Goal met. Regular movement helped client regain her strength and endurance hence she was able to independently walk from bed to the closet to get her clothes for the day. Client states I feel I am getting close to being my old self. Goal is met. Client is encouraged to continue intervention. Client is ready for discharge.