Nursing Process Record_Nursing Fundamentals

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School Name Student: Student Name, SN School

Date(s) of Care: 11-09-2010

NURSING PROCESS RECORDInitials: H.L. Room: 919A Age: 95 Sex: Female Admission Date: 11-07-2010

Chief Complaint (What brought you into the hospital): I tripped on blanket at home and was unable to bear weight on left leg.

Diagnosis: Fractured Femur (Closed) Left side at surgical neck Surgery / Date: Cardiac complications delay; Pt unwilling

BACKGROUND RESEARCH

Pathophysiological Explanation of Diagnosis: A fracture is a break in bone continuity affecting mobility and sensation.

Fractures are described by extent of break: complete or incomplete; type of break: nondisplaced, compound, comminuteddisplaced, oblique, spiral, impacted, greenstick; extent of soft-tissue damage: open (compound - skin surface disruptedinto open wound), closed (simple, no open wound); type of tissue damage: Grade I (minimal skin damage), II (open, skin& muscle contusions), or III (damage to skin, muscle, nerves, & blood vessels); and cause: pathologic, fatigue, orcompression. Bone heals in 5 stages: hematoma formation, granulation tissue, callus formation, osteoblastic proliferation,and bone remodeling. Long-bone fracture patients must be monitored closely first 48 hours for fat emboli. Hip fracture(upper femur) is most common in older adults. Hip fractures have a high mortality rate as a result of multiple complicationsr/t surgery and immobility, including blood clots, pneumonia, and infection.

Etiology: Primary cause is trauma from either direct blow to bone or indirect force from muscle contractions or pulling

forces on the bone. Fractures in the elderly often result from falls. Contributing factors include sports, vigorous exercise,

and malnutrition. Some genetic factors as well as osteoporosis (particularly in older adults) and other bone diseasesincrease the risk for fractures. Fractures may be pathological (spontaneous) occurring in weakened bone after minimaltrauma or normal forces.

Signs and Symptoms: bone alignment changes manifesting as deformity, shortening of extremity or change in bone shape;

decreased range of motion; crepitus; ecchymotic skin over fracture site; hematoma; subcutaneous emphysema overfracture site; swelling over fracture site; neurovascular compromise of affected limb; moderate to severe pain at site offracture or adjacent or distal area(s)

Common Complications: hypovolemic shock, fat emoblism syndrome, venous thromboembolism, pneumonia (geriatric),

infection, ischemic necrosis, delayed union, acute compartment syndrome (rare), crush syndrome (rare)

Other Medical Problems: Idiopathic hypertrophic subaortic stenosis, atrial fibrillation, paroxysmal supraventricular

tachycardia, sick sinus syndrome, angina pectoris, hypertension, peripheral vascular disease, hyperlipidemia,hyponatremia, thrombocytopenia, osteopenia, osteoporosis, elevated liver enzymes, gastroesophageal reflux disease,recurrent urinary tract infection

Allergies: Sulfas, amiodarones

Code Status: DNR

ASSESSMENT STEP I

Physical Assessment:

Appearance on first sight: Smiling, lying in low-Fowlers position, weakly extending a greeting.

Neurological assessment: Alert & oriented to person, place, and time, PERRLA, weak bilateral grips, but no unilateral deficit.

Skin Assessment: pink, cool (T=96.9F axillary), dry and intact. Xerosis and flaking on distal upper and lower extremities.

Poor turgor, skin tenting. Petechiae on finger tips and toes. Multiple ecchymotic areas on dorsal surface of hands (Ptstates IV attempts), 15 score on Braden Scale for predicting pressure ulcer risk (17-23 no risk); no signs of erythema,tearing, or shearing. Padding of bony prominences with pillows and foam-pressure relieving devices on feet/heels.Condition of hair: Grey, clean, well kept Nails: Normal nail beds, moderate vertical ridging, clean, trimmed

Mouth: No lesions, mucosa pink and moist, no noticeable caries

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Cardiovascular assessment: S1, S2, S3, and S4 audible, AP 94 irregularly irregular, BP: 147/78 (RA, lying), cap refill 5 sec.,

pitting edema (3+) bilateral lower extremities, pedal pulses equal bilat (1+); Sequential compression devices appliedbilaterally to lower extremities Parenteral fluids: I/V right-antecubital capped; dressing clean/dry/intact; no signs of

infiltration, hematoma, or visual phlebitis

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Respiratory assessment: Lungs clear in upper lobes bilaterally; diminished in lower lobes. R-19. SpO2 92% NC 2L.

Gastrointestinal assessment: Normal bowel sounds in all quadrants. Patient anorexic, freely consuming fluids.

Diet: Cardiac Date of last BM: 11/7 in morning, prior to fall

Musculoskeletal assessment: Strict bed rest. Non-weight bearing. Fractured left femur affecting movement, but CSM intact.

Genitourinary assessment: Indwelling Foley catheter draining to gravity 150mL/16 hours clear, yellow urine physician

notified. Intake estimated at 800mL for 16 hour time period.

Assessment of sleep: States adequate sleep during hospital stay; denies need for sedative/hypnotics.

Comfort/Pain assessment: 9/10 numeric scale (0-10). Nurse notified, morphine IV push administered. Patient feels cool to

touch, turned up heat in response and provided a second blanket. Water, glasses, and hearing aids within reach.

Environment/Safety: Bed in low position, side rails up x3 (support for fractured hip); call light and phone in reach. Floor clear

and dry. Strict bedrest.

Lab Data:

DATE TEST DEFINITION NORMALS

(KOMC values)

PATIENTS

DATA

REASON

(see index

11/07/2010

11/08/2010

11/09/2010

urinalysis (UA)

hemoglobin

protein

Blood Sodium (Na+)

Blood Carbon Dioxide (CO2)

Blood glucose (non-fasting)

Brain Natriuretic Peptide (BNP)

Aspartate Aminotransferase (AST)

Alanine Aminotransferase (ALT)

Red Blood Cell Count (RBC)

Red Blood Cell Distribution Width

Platelet Distribution (PLT)

Absolute Neutrophil Count (ANC)

Lymphocytes

UA

granular casts

hemoglobin

RBC

Bacteria

hyaline castsprotein

WBC

squamous cell sediment

Serum Creatinine

BNP

Blood Phosphate (PO4-3)

Blood Magnesium (Mg2+)

Blood Urea Nitrogen (BUN)

Blood Potassium (K+)

Multiple tests on urine specimen

Amount of blood in urine

Level of protein in urine

Amount of Na+ in blood sample

Measure of CO2 in blood sample

Level of glucose in blood sample

Measure of BNP hormone in blood (cardiac func.)

Measure of AST enzyme in blood (liver function)

Measure of ALT enzyme in blood (liver function)

Amount of RBCs per microliter of blood sample

Variation in size of red blood cells sample

Amount an d size of thrombocytes in blood sample

Measure of neutrophils in blood sample

Percentage of lymphocytes of white blood cells

Amount of cellular disintegration casts in urine

Amount of red blood cells and casts in urine

Indicates presence of bacteria in urine sample

Amount of protein casts in urine sample

Amount of white blood cells and casts in urine

Amount of microscopic epithelial cells in urine

Amount of creatinine in blood sample

Measure of PO4-3 in blood sample

Measure of Mg2+ in blood sample

Measure of urea in blood sample

Measure of K+ in blood sample

negative

0-8 mg/dL

136-145 mEq/L

22-30 mEq/L


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Blood Na+ 136-145 mEq/L 135 mEq/L (3)

Reasons Index: (1) Hematuria likely related to collecting system damage in kidneys (H.L. has Stage 3 Kidney Disease). (2)

Proteinuria indicates renal disease (H.L. has Stage 3 Kidney Disease). (3) Decrease due to increased sodium loss inH.L. related to chronic renal insufficiency. (4) Decrease likely indicative of chronic renal failure in H.L. (5) Elevated levellikely indicative of chronic renal failure and/or acute stress response. (6) Elevated levels indicative of congestive heartfailure and systemic hypertension in H.L. (7) Significant elevation indicative of hepatic ischemia or other liver disease

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process. (8) Decreased levels suggest anemia which could be related to trauma to bone marrow, dietary insufficiency, oracute stress in H.L. (9) Increased RDW suggests iron-deficiency anemia. (10) Decreased platelet distribution width andgiant size are indicative of H.L.s thrombocytopenia. (11) Increased ANC is indicative of a left-shift suggesting severeinflammation (fractured femur) and/or infection (urinary tract infection). (12) Decrease lymphocytes indicative of a left-shiftsuggesting severe inflammation (fractured femur) and/or infection (urinary tract infection). (13) Presence is indicative ofrenal failure and/or muscular trauma. (14) RBCs in urine suggest glomerulonephritis related to H.L.s kidney disease. (15)Presence indicates urinary tract infection. (16) Presence is indicative of proteinuria likely caused by H.L.s renal disease.(17) Presence indicates urinary tract infection. (18) Suggestive of glomerulonephritis related to H.L.s kidney disease. (19)Elevated levels are indicative of renal disease. (20) In H.L.s case likely indicative of impaired phosphate excretion due toseverely decreased glomerular filtration rate due to severe kidney disease. (21) Decrease likely due to excessive urinaryloss related to H.L.s kidney disase. (22) H.L.s elevated BUN is indicative of her congestive heart failure, renal disease,and hepatic impairment. (23) H.Ls hyperkalemia is likely due to stress and renal tubular dysfunction.

Diagnostic Studies: Pelvis X-ray 11/7/2010: findings indicate impacted fracture of left femur at surgical neck. Chest X-ray

11/8/2010: findings indicate moderate to large pleural effusions in Right lobes and small pleural effusions in left lobe, mostlikely reflecting fluid overload, however pneumonia cannot be ruled out.

Scheduled Medications:

DRUG/DOSE/ROUTE/FREQUENCYDRUG CLASS

(therapeutic / pharmacological)

REASON

azithromycin (Zithromax) 500 mg IVPB q24h

ceftriaxone (Rocephin) 2 g IVPB q24h

docusate sodium (Colace) 250 mg PO BID

furosemide (Lasix) 40 mg IVPush once

metoprolol (Lopressor) 50 mg PO BID

nitroglycerin (Nitro-Dur) 0.6 mg/hr 1 patch

TD every day

sennosides (Senokot) 8.6 mg PO BID

simvastatin (Zocor) 80 mg PO every bedtime

Antiinfectives / Macrolides

Antiinfectives / 3rd Generation Cephalosporins

Laxatives / Stool Softeners

Diuretics / Loop Diuretics

Antianginals, Antihypertensives /-blockers

Antianginals / Nitrates

Laxatives / Stimulant Laxatives

Lipid-lowering Agents / HMG-CoA Inhibitors

Urinary tract infection (UTI)

Prevent osteomyelitis/Treat UTI

Prevent constipation

Promote urination/Reduce edema

Decrease BP; prevent angina

Prevent/Treat angina pectoris

Promote defecation/Treat const.

Treat hyperlipidemia

As Needed (PRN) Medications:

DRUG/DOSE/ROUTE/FREQUENCY

DRUG CLASS

(therapeutic / pharmacological) REASON

acetaminophen (Tylenol) 650 mg PO q4h

atropine (Ansyrl) 0.5 mg IVPush

metoclopramide (Reglan) 10 mg PO QID

morphine (Duramorph) 2-10 mg IVPush q4h

hydrocodone/acetaminophen (Norco)

5mg/325mg 1 to 2 tablets q4hr

ondanestron (Zofran) 32 mg IVPush q8h

Antipyretics, Analgesics

Antiarrhythmics / Anticholinergics

Antiemetics

Opioid Analgesics / Opioid Agonists

Opioid Analgesics / Opiod/NonOpioid Combo

Antiemetics / 5 HT3 antagonists

Mild pain (1-3/10); temp >100.4F

Bradycardia

GERD exacerbation; N/V

Moderate to severe pain

Moderate to severe pain

Nausea/vomiting

Psychosocial Assessment:

Culture and its implications for care: Caucasian female of European American ancestry. With regard to the death process,

European Americans should have accommodations made to include family to stay with person at all times. Health care

workers are expected to care for family as well. Heroics are implied so European Americans need to state their wishes inwriting to not have life-saving measures performed. European Americans expect full disclosure of health status andshould be allowed to disclose that information to their family themselves. H.L. immediately sought treatment after her fall(self-reliance). H.L. requested family presence. H.L. has been under health care for long-term management ofhypertension, multiple cardiac issues, and renal failure. H.L. is a retired homemaker.

Spiritual practices: Was raised protestant, but not currently practicing. Believes in God, The Almighty; enjoyed her

chaplain visitation. Does not pray or go to services on a regular basis. Her family is not religious.

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Developmental assessment: According to Loevinger, H.L. is in the integrated stage of development. She evidences this by 1)

her ability to transcend conflicts in her life, 2) her sense of self-awareness where she notes and is able to discussdiscrepancies between normal conventions and her own behavior, 3) her self-identity is fully worked out. H.L. discussedher life with me and her readiness to sleep forever now. She has accomplished all she wished to in her life.

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Effects of illness/hospitalization on sexuality: H.L.s husband passed many, many, many years ago. No other comments.

Body image: H.L. was not concerned with her body image. However, she verbalized wish to sleep forever.

Family structure: Widowed, 4 children, many grand and great-grand children. Lives with great-grandson; cared for by a

granddaughter who also has power of attorney.

Patients understanding of illness: Fully understands the implications that she will likely not recover. Readily accepts that

death is a close inevitability given her situation.

Ethical issues: H.L. discussed her desire for euthanasia by asking me to provide her with more morphine. I explained that it

was illegal for me to do so and that she needed to discuss her wishes with her physicians and family.

How do you feel about caring for this patient? I really enjoyed caring for this patient, although I found it to be an emotional

experience due to the implications of near death and moving a patient into comfort care through the palliative care team. Itotally respect and understand her wishes.

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NURSING

DIAGNOSIS

GOAL INTERVENTION NURSING

ORDERS

RATIONALE EVALUATION

1) Acute Pain related to

disruption in bone

continuity as evidenced

by verbalization of pain

words

Medication Response: By

11/9 1400, H.L. will report

relief of symptoms to at least

tolerable level or to complete

relief via analgesics using

numeric scale 0-10 with 1

indicating no discomfort and

10 indicating worse

discomfort imaginable.

a) Pain Management: Perform a

comprehensive assessment of pain

to include location, characteristics,

onset, duration, frequency, quality,

intensity or severity and

precipitating factors of pain.

b) Pain Management: Evaluate

effectiveness of analgesics at

regular, frequent intervals after

each administration and especiallyafter initial doses, also observing

for signs and symptoms of

untoward effects bearing in mind

geriatric implications of analgesic

administration (respiratory

depression, nausea/vomiting, dry

mouth, and constipation).

c) Pain Management: Provide H.L.

with optimal pain relief through

prescribed analgesics.

d) Analgesic Administration:

Determine analgesic selection

(opioid or nonopioid) based on

H.L.s type and severity of pain.

e) Analgesic Administration:

Implement actions to decrease

untoward analgesic effects (e.g.,

constipation) in H.L. Assess for

overall GI functioning as well as

for constipation.

a) Pain is a subjective experience

and must be described by the

client in order to plan effective

treatment

b) The analgesic dose may be

adequate to raise the clients pain

threshold or may be causing

intolerable or dangerous side

effects or both. Ongoing

evaluation will assist in making

necessary adjustments for

effective pain management.

c) Each client has a right to expect

maximum pain relief. Optimal

pain relief using analgesics

includes determining the

preferred route, drug, dosage,

and frequency for each

individual. Medications ordered

on a prn basis should be offered

to the client at the interval whenthe next dose is available.

d) Various types of pain require

different analgesic approaches.

Some types of pain respond to

nonopioid drugs alone, others to

a combination of low-dose

opioid with non-opioid, and

others to opioids only.

e) Constipation is a common side

effect of opioid narcotics, and a

treatment plan to prevent

occurrence should be instituted

at the beginning of analgesic

Goal/outcome only partially me

The client verbalizes pain and

discomfort and requests analges

at onset of pain. Client states

pain at 6 out of 10, 30 minute

after oral pain medication. Clien

then states no pain 20 minutes

after parenteral analgesic

administration. Prior to each

administration client states pai

at 9 or 10.

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therapy.

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NURSING

DIAGNOSIS


ORDERS


2) Risk for Peripheral

Neurovascular

Dysfunction R/T

disruption in bone

continuity

Tissue Perfusion: Peripheral:

By 11/9 1400, H.L. will

have usual or improved

peripheral neurovascular

function as evidenced by

palpable peripheral pulses,

capillary refill time of 5 or

less seconds, extremities

warm and usual color,

ability to flex and extendfeet and toes, usual or

improved reflexes, muscle

tone, and sensation in

extremities, and no new or

increased pain in

extremities.

a) Pain Management: Pain: Assess

severity (on a scale of 1 to 10),

quality, radiation, and relief by

medications.

b) Peripheral Sensation Management :

Pulses: Check the pulses distal to

the injury. Check the uninjured

side first to establish a baseline fora bilateral comparison.

c) Peripheral Sensation

Management : Pallor /

Poikilothermia: Check color and

temperature changes above and

below the injury site. Check

capillary refill.

d) Peripheral Sensation Management :

Paresthesia: Check sensation by

lightly touching the skin proximal

and distal to the injury. Ask if the

H.L. has any unusual sensationssuch as hypersensitivity, tingling,

prickling, decreased feeling, or

numbness.

e) Peripheral Sensation Management :

Paralysis: Ask the client to

perform appropriate range-of-

motion exercises in the unaffected

and then the affected extremity.

a) Diffuse pain that is aggravated by

passive movement and is

unrelieved by medication can be

an early symptom of fat or blood

emboli, compartment syndrome,

or limb ischemia.

b) An intact pulse generally

indicates a good blood supply to

the extremity, although fat

emboli and compartment

syndrome may be present even if

the pulse is intact.

c) If pallor is present, record the

coldness carefully. A cold, pale,

or bluish extremity indicates

arterial insufficiency or arterial

damage, and a physician should

be notified. A reddened, warm

extremity may indicate infection.

Norma capillary refill time in

elderly patients is 5 seconds or

less.

d) Changes in sensation are

indicative of nerve compression

and damage and can also indicate

compartment syndrome.

e) Paralysis is a late and ominous

symptom of compartment

syndrome or limb ischemia.

Goal/outcome only partially me

Client was able to maintain

circulation to usual level. Client

was not able to perform active o

passive range of motion.

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NURSING

DIAGNOSIS


ORDERS


3) Impaired Physical

Mobility related to

disruption in bone

continuity as evidenced

by pain and inability to

ambulate

Immobility Consequences:

Physiological: Ongoing,

daily goal, H.L. will

maintain position of

function and skin integrity

as evidenced by absence of

contractures, footdrop, or

decubitus in lower

extremities.

a) Prevention of Complications:

Perform and encourage regular

skin examination and care.

b) Prevention of Complications:

Support affected body parts and

joints using padding, positioningdevices, and pressure-relieving

mattresses.

c) Promotion of Mobility: Encourage

clients participation in self-care

activities, physical or occupational

therapies as well as diversional

and recreational activities.

d) Promotion of Mobility: Assist with

and encourage H.L. to reposition

self on a regular schedule as

dictated by inability to move

lower left limb.

e) Promotion of Wellness: Involve

client and her family in her care,

assisting them in learning ways of

managing problems of immobility,especially because impairment is

expected to be long-term.

a) Regular skin examination helps

to reduce pressure on sensitive

areas and to prevent

development of problems with

skin integrity as well as quickly

identifies early development of

skin impairment.

b) Use of pressure-relieving devises

reduces tissue pressure, prevents

stress on tissue, reduces potential

for disuse complications, and

aids in maximizing cellular

perfusion to prevent skin injury.

c) Client participation reduces

sensory deprivation, enhances

self-concept and sense of

independence, and improves

body strength and function.

d) Positional changes enhance

tissue circulation reducing risk of

tissue ischemia.

e) To maintain effective coping

mechanisms, client needs to be

able to manage immobility toreduce sensory deprivation, and

enhance self-concept and

independence. Client may need

referral for support and

community services to provide

care, supervision,

companionship, respite services,

nutritional and ADL assistance,

adaptive devices or changes to

living environment, financial

assistance, etc

Goal/outcome only met. Client

participated in skin inspection a

repositioning and verbalized

feelings of discomfort or pressu

Complete absence of contractur

footdrop, and decubitus. Palliati

discharge, surgery, and social

work care team met with client

and family to discuss long-term

outcomes and immobility.

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Bibliography:

Ackley, B. J. & Ladwig, G. B. (2008).Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care(8th ed.). St. Louis,

MO: Mosby Elsevier.

Deglin, J. H. & Vallerand, A. H. (Eds.). (2007).Daviss Drug Guide for Nurses (11th ed.). Philadelphia, PA: F. A. Davis.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010).Nursing Diagnosis Manual: Planning, Individualizing, and Documenting

Client Care (3rd ed.). Philadelphia, PA: F. A. Davis.

Eckman, M. & Labus, D. (Eds.) (2010). Fluids & Electrolytes: an Incredibly Easy Pocket Guide (2nd ed.). Philadelphia, PA: Wolters

Kluwer/Lippincot Williams & Wilkins.

Harkreader, H., Hogan, M. A., & Thobaben, M. (2007). Fundamentals of Nursing: Caring and Clinical Judgment(3rd ed.). St. Louis,

MO: Mosby Elsevier.

Ignatavicius, D. D. & Workman, M. L. (2010).Medical-Surgical Nursing: Patient-Centered Collaborative Care (6th ed.). St. Louis,

MO: Mosby Elsevier.

Myers, T. (Ed.). (2009).Mosbys Dictionary of Medicine, Nursing, & Health Professions(8th ed.). St. Louis, MO: Mosby Elsevier.

Pagana, K. D. & Pagana, T. J., (2006).Mosbys Manual of Diagnostic and Laboratory Tests (3rd ed.). St. Louis, MO: Mosby Elsevier.

Venes, D. (Ed.). (2001). Tabers Cyclopedic Medical Dictionary (20th ed.). Philadelphia, PA: F. A. Davis.

DRUG CARDS SCHEDULED MEDS

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DRUG CARDS PRN MEDS

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