Nursing Case Study

Running Head: NURSING CASE STUDY. AS, is a 74 year old male. He is married and has 3 children, and a few grand children. He lives in south bend with his wife and his youngest daughter. He seemed to be a family man. His family was in and out of the hospital while he was there.

He is a very outspoken person; his family was very supportive. AS, formally worked for the city but is now retired. He is a full code with no known drug allergies. He presented to the emergency room with a fever of 100 degrees and complications from chemotherapy. Subjective symptoms upon admission were; nausea, vomiting and pain.

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Objective symptoms were a temperature of 100 degrees, and elevated blood pressure. He seemed calm, and was adjusting well with treatment and has accepted his medical condition. He has a past medical history of; Coronary artery disease (CAD), chronic renal insufficiency, myocardial infraction, and Gerd. His present medicals conditions are; uro sepsis, hypertension, urinary retention, general weakness, aplastic anemia, gastrointestinal prophylaxis, deep vein thrombosis, osteoarthritis, and was recently diagnosed with neck and head metastatic cancer of unknown cause.

Surgical history include: Coronary artery bypass graft, cholecystectomy, gastric surgery, renal artery stenosis with stenting, port placement and right neck lymph node biopsy.

Assessment Data Sheet Patient Initials: AS Code Status full code Date of Care 9/4 and 5th. | Medical Diagnosis CAD, chronic renal insufficiency, uro sepsis , hypertension,General weakness, neck and head metastatic ccancer. Osteoarthritis. Allergies NKDA| Vital SignsB/P 177/101 on the 4th 130/72 on the 5th.

Biox-98%Heart rate 74Respirations-20 (TPR, BP, & O, Sat) Pain (0-10 & describe) No pain on the first day of care.

Pain of 8 on the second day, managed with medication. (Norco)| Psychosocial| Neuro/Sensory Integumentary| 74 year oldMaleMarriedPatient has children and grand children. Supported by retirement income, and social security. Religion-Baptist. Ethnicity-African AmericanHobbies-fishing. Community involvement-churchDate of admission-9/2/12LOS- Discharged 0n 9/7/12.

Interaction with staff and othersHx of alcohol –N/AQuit smoking 20 years ago. No change on the second day. | Loc-alert, orientedx3PERRLA-yesSpeech-clearHearing-mild impairment noted. (AS was turning the TV volume up, and was using a loud tone of voice). No glassesResponded to touchTongue in midlineCalm at first, then became anxious and agitated later. Long/short term memory-intactFollows directions well but disagrees on a lot of things.

Strong on the right upper and lower extremities but weak on the right side on the first day but were both strong on the second day.

Needed one person assist on the first day but was steady the next day. No pain on the first day. Pain level of 5 on the second, managed with medication and dropped to 0| Skin color- normal for ethnicity. Turgor-elasticNo bruises or rashesNo skin ulcerationMucous membrane-pinkFinger nails and toe nails-rigidFull head of hairNo abnormal opening.

A peripheral port in place. No drainage, dressing intact and dry. 2nd day. No changes on the above assessment. | Respiratory| Cardiovascular| Gastrointestinal| Respirations- regular rate and rhythm.

Biox-98% and 100%Lung sounds clear posterior and anterior bilaterally. Cough-present, productive with moderate secretions. Tracheal-midlineSmoking- hx of smoking but quit a few years ago. No change on the second day. | B/p-177/101, then 130/72 on the 5th. Pulses-74, 72 on the 5th.

Heart tones- S1no change on second dayNo pacemaker in placeEdema-no edemaHad his ted holes. Peripheral pulses-present 2+| Abdomen- round, soft and non-tender. Bowel sounds- activex4No masses on abdomen. Bm- 9/5/12. Brown formed and soft. Passing flatus.

ContinentNo tubes/stomas.

No hemorrhoids. No changes the next day other than no BM on time of care. | GenitourinaryVoiding patterns- regular. Q 2-3 hours. Urine- clear, odorless.

No catheterNo discharge from the perineal area. LMP-N/AHx of std-n/aNo change on second day| MusculoskeletalSteady gait. Active range of motion. Weak on the right side on the first day (5th). Ambulated well from the bed to chair, to bathroom. Tolerated activities wellNo redness, edema or swelling.

Has a walker in the room but was not using it. Wife helped with most of the ADL’s. Mode of ambulation- independent.

The second day, pt had a steady gait. No more problems on his right. | NutritionHeight-6′ 2Weight-185lbDiet-cardiac dietTeeth-denturesMouth sores-noneEats 25% of his breakfast and lunch.

No tube feeding. I- 9000-780Changes for the 5thI-760O-460| The patient’s blood pressure was very unstable. It was stable upon admission (144/68). On the first day of care, BP was elevated to 177/10 in the morning. it dropped down to 159/83 by noon, then to 130/72 by 1600.

The antihypertensive drugs administered in the morning seemed to be working well with bringing the blood pressure down.

By the second day of care, his vital signs had stabilized, and patient was responding well to treatment. Nurse would assign patient a 4 in a scale of 0-10, of the wellness/illness continuum. The reason for this number is; although AS, has challenging medical diagnosis, he seems to be doing well as far as coping with his disease process, and he is stable enough to take care of most of his day to day’s responsibility; nurse noted that patient was always on the phone making arrangements with family members about how he was excited about gardening soon as he got home.

Pathophysiology Urinary retention: This is a condition that affects the genitourinary system, and the main organ of function is the kidneys. The kidneys are located on either side of the vertebral column in a depression high on the posterior wall of the abdominal cavity.

Kidneys help with eliminating substances from the blood, form urine and help certain metabolic processes. A pair of tubules known as ureters, transport urine from the kidneys to a saclike reservoir known as the bladder. Urine is then removed from the body through another tube (urethra).

The urge to urinate comes about when the bladder is filled with about 150 milliliters of urine. The internal pressure increases, and bladder wall contractions intensify. This motion causes the internal urethral sphincter to open and external to relax, then the bladder empties.

The urinary bladder, ureters, and urethra changes with age. These muscular organs may loose their elasticity or recoil with age. In older age, the bladder holds less than half of what it did in young adult age, and many retain more urine after urination. If the spinal pathways from the brain to the urinary system are destroyed (eg, after a spinal cord injury), reflex contraction of the bladder is maintained, but voluntary control over the process is lost. In both situations, the detrusor muscle can contract and expel urine, but the contractions are insufficient to empty the bladder completely, so residual urine remains”.

(Smelter, Bare, Hinkle, Cheever 2010). Acute urinary retention causes great discomfort, and even pain. The patient may feel an urgent need to urinate but you simply can’t, the lower belly is bloated.

Chronic urinary retention, by comparison, causes mild but constant discomfort. Patients have difficulty starting a stream of urine.

Once started, the flow is weak and may need to go frequently, and once finished, they still feel the need to urinate. They may dribble between trips to the toilet because their bladder is constantly full, a condition called overflow incontinence. A bladder scan is a portable ultra sound device that is used to check how much urine remains the bladder after voiding. With acute urinary retention, treatment begins with the insertion of a catheter through the urethra to drain the bladder.

This initial treatment relieves the immediate distress of a full bladder and prevents permanent bladder damage. Long-term treatment for any case of urinary retention depends on the cause.

The cause of acute urinary retention may be temporary. If the patient has retention after surgery, they mostly regain your ability to urinate after the effects of the anesthesia wear off. In such cases, they may need to have a catheter inserted once or twice with no other treatment required after they have shown the capability of voiding on their own.

If a patient has chronic urinary retention, or if acute retention appears to become chronic, further treatment will be necessary. They may continue to use the catheter until they go through further evaluation.

AS was not getting any treatment for urinary retention at the time of care. He did not seem to have any difficulties with using the bathroom, and had no signs of distress as far as voiding. Hypertension: this is an elevation in diastolic or systolic blood pressure. There are two types; primary (idiopathic), and secondary.

Idiopathic is the most common. Secondary hypertension results from renal disease or other unknown causes.

This condition mostly affects the cardiovascular system. The heart is a muscle organ located in mid thorax between the lungs and the diaphragm. The heart is divided into four main chambers, right and left atrium, and right and left ventricles. Blood that is low in oxygen and high in carbon dioxide enters the heart through the right atrium from the superior venacava. The right atrium contracts and blood enters the right ventricle.

When the right ventricular contracts, the tricuspid valve closes the atrioventicular orifice and blood moves through the pulmonary valve into the pulmonary trunk and its branches.

Blood then enters the capillaries associated with the alveoli of the lungs. Gaseous exchange occurs in the lungs, and oxygenated blood returns to the lungs through pulmonary veins into the left atrium. Atrial wall contracts and blood moves through the left atrioventicular orifice into the left ventricle. When ventricular walls contracts, blood passes to aorta and its then pumped to the rest of the body. Several mechanisms may lead to hypertension , including, changes in the arteriolar bed causing increased peripheral vascular resistance, abnormal increased tone in the sympathetic nervous system which causes increased peripheral vascular resistance, increased blood volume resulting from renal or hormonal dysfunction, arterial thickening which may lead to increased peripheral vascular resistance, and abnormal renin release, resulting in the formation of angiotensin II , which constricts the arteriole and increase blood volume”.

(Atlas of pathophysiology pg. 58).

Smoking, obesity, foods high in fat and being African American are risk factors for hypertension. Pathophysiology Hypertension generally does not show any signs and symptoms, although it can be diagnosed from a serial BP (blood pressure) reading. If a patient has prehypertension, the systolic blood pressure reading is greater than 120mm Hg but less than 140mm Hg.

Diastolic blood pressure reading is greater than 80mm Hg but less than 90mm Hg. For stage 1 hypertension, the systolic BP is greater than 139 mm Hg but less than 160mm Hg or diastolic BP greater than 89 mm Hg but less than 100mm Hg.

With stage 2 hypertension, systolic BP is usually greater than 159 mm Hg and diastolic blood pressure greater than 99mm Hg. (Smelter ‘et al’ 2010). Some other signs and symptoms of hypertension include; edema, blurry vision, dizziness, headache, confusion, and fatigue. This condition can be treated in a variety of ways.

First, patients can reduce the risk factors by changing their life style, by eating healthy foods that a low in fat and sodium, exercising for about 3 times week. Medications like; diuretics, angiotensin-converting enzyme inhibitors,

Alpha receptor blockers, Alpha-receptor agonists and blockers, beta-adrenergic blockers can all be used for treatment. The patient is taking; clonidine, which is an alpha-agonist that works by decreasing the heart rate and relaxes the blood vessels so that the blood can flow easily through the body. He is also on nifedipine, a calcium channel blocker which is a coronary vasodilator. Hydralazine is also being administered.

This medication is a vasodilator that helps with decreasing the work load of the heart hence lowering the pressure needed to pump blood.

AS did not show any reactions to the antihypertensive medications although his blood pressure was very high on the first day, but had gone down on the second. He did not show any adverse reactions from the medications. The patient was taking his medications as scheduled, and nurse monitored his apical heart rate and blood pressure before administration and through out the day as scheduled. The patient was on a cardiac diet, which is low fat and low sodium.

Nurse also advised patient to daggle his feet on the bed before standing up to avoid orthostatic hypotension. Cancer: patient was recently been diagnosed with brain and neck cancer.

This affects the head, the neck, and may spread to other cells of the body. The brain is the largest part of the central nervous system, its located within the cranial cavity of the skull. It includes the two cerebral hemispheres, the diencephalon, the brain stem, and the cerebellum.

It contains billions of neurons that communicate with each other and other neurons in the nervous system. Brain has three layers of covering; the dura mater, arachnoid mater, and pia mater. “The Dura mater if the outermost layer composed of tough, white, and dense connective tissue with many nerves and blood supply.

Arachniod mater is a thin web like membrane that lacks blood vessels; it spreads over the brain and spinal cord but does not dip into the grooves and depression on their surface. The pia mater is very thin and contains many nerves, as well as blood vessels that nourish the underlying cells of the brain and the spinal cord”. (Lewis, Butler and shier 2004 pg.

388). The normal functions of the brain are, sensation, memory, verbal linguistics, and arithmetic, control of movements, control the autonomic nervous system and body metabolic processes. Smelter ‘et al’ 2010). Pathophysiology Brain tumors are abnormal growths that develop after the cells have gone through transformation within the brain, meninges, or the cerebral vasculature. The tumors are usually either benign or malignant. Highly malignant brains tumors are aggressive tumors that grow and multiply rapidly.

Benign tumors are not aggressive, but may be harmful neurologically depending on their size and location. The cause of primary brain tumor is unknown but the strongest risk factor is exposure to ionizing radiation.

Many additional risk factors have been investigated, but only rare genetic mutations, familial tendencies, epilepsy, and seizures show strong evidence of association. ” At the level of the cell nucleus, both positive and negative regulators of growth are necessary for normal control of cell proliferation. The positive regulators have products that function as growth factors, growth factor receptors, and signaling exams. Excessive production may occur that converts proto-oncogenes into oncogenes, resulting into significant neoplastic growth”.

Negative regulators called tumor suppressor genes; inhibit cellular proliferation at the level of the nucleus. (Atlas of Pathophysiology pg. 128. ) The signs and symptoms of brain tumor are; headache, seizures, decreased motor strength and coordination, altered vital signs, nausea and vomiting, increased intracranial pressure, neurological defects, and double vision. The patient had been experiencing acute headaches in the past before he was officially diagnosed with brain and neck tumor.

He also had a seizure, while at the hospital, and Doctor ordered additional testing for brain activity.

Patient had already been going through chemotherapy for a while. Computed Tomography (CT) of the brain and neck was done, and it showed a palpable metastatic mass in the right neck. Clinician stated that the mass had decreased in size from previous CT exam. Magnetic Resonance Imaging (MRI) of the head was also ordered and completed on 9/3/12 due to suspected stroke.

Results from this test indicated an acute ischemia of the left posterior cerebral artery. Old ischemia also noted in the cerebellar hemispheres bilaterally.

The mostly often forms of treatment used for tumors are; surgery if appropriate for the patient, radiation therapy, chemotherapy, corticosteroids such as dexamethasone, anticonvulsants such as phenytoin, ranitidine and analgesics. Patient was not on chemotherapy at the time of care since he had experienced complications a few days before admission. He was stable, alert and oriented, independent on activities of daily living, but occasionally complained of back pain of an 8 on the second day of care.

Nurse administered hydrocodone acetaminophen 325mg which brought his Pain level down to a two. Arthritis. (The Musculoskeletal System)

Joints or articulation are functional junctions between bones they bind parts of the skeletal system, make it possible for bones to grow permits parts of the skeletal to change shape during child-birth and enable to move to respond to skeletal muscle contractions. Different joints have different structures and functions. The three general groups are fibrous joints, cartilaginous joints and synovial joints. The other type of classification depends on the degree of movement possible at the bony junctions under the classification, there are three groups; immovable (synarthostic) slightly movable (amphiarthrotic and freely moveable diarthrotic.

Fibrous joints lie between bones that are in close contact. There are three types of fibrous joints; 1. Syndemosis, for example the joint between tibia and fibula 2. Suture; these are only found between flat bones example the joints in the skull. 3. Gomiphosis, this is a joint formed by union by a cone-shaped bony process with above socket for example the joint between the root of a tooth and the jawbone.

Cartilaginous joints – in these types of joints, hyaline cartilage or fiber cartilage connects the bones of the cartilaginous joints. The two types are 1. Synchndrosis and symphysis synovial joints.

This group constitutes most joints of the skeletal system. The articular cartilage resists wear and minimizes friction when it is compressed as the joints mores. Synovial membrane produces synovial fluid which lubricates the joints and allows easy movement and also prevents friction as the joints contact each other.

There are different types to synovial joints for example ball and sock, hinge, pivot which allow different kinds of movement example flexion, extension, and rotation supination among others. There are different changes that occur in joints as someone gets older joints stiffens is an early sign of aging.

Changes in the collagen structure causes stiffness to increase. Range of motion may diminish. However joints actually age slowly, and exercise can lessen to forestall stiffness. Disuse hampers blood supply to the joints, which hasten stiffening.

Paradoxically this can keep from exercising when this is exactly what they should be doing (Shier, Butler, and Lewis 2007). Osteoarthritis (OA). It is slowly progressive non-inflammatory disorder of the diarthrodial (synovial) joints and vertebrae (Tabers Encyclopedia). It is then most common form of joint (articular) disease in North America (Lewis, Heitkemper and Lewis).

The disease involves the formation of new joint tissue in response to cartilage destruction. Affected cartilage gradually become softer, less elastic and unable to resist wear with heavy use.

The body is unable to repair the destroyed cartilages in the same pace as the destruction occurs. Aging continues to be the most consistently identified risk factor for disease development. With AS being 74 years old, he is at an increased risk of developing OA due to his age. Cartilage destruction may begin at an early age reaching a climax at the age of 40. The disease could either be symptomatic and asymptomatic especially to those over 65 years.

The disease affects more men than women below the age of 50 but women above the age of 50 are more affected than men.

Etiology and Pathophysiology The cause of idiopathic (formerly primary osteoarthritis) is unknown however the secondary osteoarthritis is caused by a known event or condition that directly damages cartilage or cause joint instability. Some of the secondary causes of osteoarthritis include trauma, mechanical stress where repetitive physical activities cause cartilage deterioration. AS worked for the city where he spent most of the time standing and lifting heavy equipment.

This may be the origin of the osteoarthritis and the subsequent chronic back pain that he has. Other causes include joint instability, neurologic disorders, skeletal deformities, obesity which contributes to new osteoarthritis.

Estrogen reductions in women at menopause, genetic factors are other known causes of secondary osteoarthritis. Signs and Symptoms There are no systemic manifestations such as fatigue or fever, manifestation of OA ranges from mild discomfort to significant disability. The predominant symptom of OA is joint pain which worsens with the use of the joint.

Rest relieves joint pain when the disease advance pain is felt even when the patient is resting. This may interfere with the ability to sleep because of the discomfort.

As the disease progresses, the increasing pain can cause disability and loss of function. Osteoarthritis pain may be referred to the groin, buttock, or knee, sitting down and standing up becomes a difficult. Early morning stiffness is common but generally resolves within thirty minute, crepitation – a granting sensation caused by loose particles of the cartilage in the joint and cavity can also contribute to stiffness.

In most cases OA affects joints asymmetrically; the most common involved joints are the distal and proximal interphalegeal joints of the finger, weight bearing joints (hip and knees), metatarsophalageal joint of the foot and cervical lower lumbar vertebrae. OA involved the knees and the lower lumbar vertebrae resulting to chronic back pain.

A deformity associated with OA includes Herberden’s nodes and Bonchard nodes. Although these bony enlargements do not cause significant loss of junction the patient may be distressed by the visible disfigurement (Lewis et al (2007). Diagnostic Studies

Some of the tests that may be useful in the early diagnosis of OA include bone scan, MRI and CT scan. X-rays are used to confirm the presence of the disease and also to monitor the effectiveness of the treatment. No laboratory test can indicate the presence of the disease.

Erythrocytes Sedimentation Rate (ESR) is always normal except in instance of acute synovitis when minimal elevations may be noted. To allow differentiation between OA and other forms of inflammatory arthritis, synovial fluid analysis may be used where clear a yellow fluid indicates the presence of OA.

AS has chronic back pain and an intermittent knew pain. These are common sign associated with people who have been affected by OA both at the lower vertebrae and the knees. Treatment of the Disease OA has no cure.

Collaborative care is used focusing on managing pain, preventing disability, maintaining and improving joint functions. Non-pharmacological interventions are the foundations of care and should be maintained throughout the treatment period. In the event of worsening conditions; unrelieved pain and decreased ability to perform care, surgery may be recommended.

The surgery is made either to repair the cartilage or ligament tears, or to remove bone beats or cartilage. Rest and joint protection are very important in the treatment of OA.

The affected joints should be rested in any acute period of inflammation, pins and braces may be used to maintain the joint in a functional position if necessary (Lewis 2007). Modifications of daily activities will be required to reduce the workload on the joints and allow maximum rest. Assistive devices like using a walker, wheelchair may also be used to decrease rest on the joints, heat and cold therapy may also be used to reduce complaints of stiffness and pain.

Nutritional therapy and exercise can be of great help to the patient; weight reduction will help ease the pressure on the joints. Complementary and alternative therapy such as acupuncture, massage, yoga and therapeutic touch provide relief to those who have failed to find relief through traditional medical care. Drug therapy is used on the severity of the patient’s symptoms.

Acetaminophen may provide relief to those with moderate to severe joint pain. Nonacetylated salicylates (Aspirin) may provide greater relief to those with moderate or severe pain.

These doses are started low and may be increased as patients symptoms indicate. AS is currently taking celecoxib (Celebrex) 200mg by mouth twice a day to help relieve the severe chronic back pain. He is also taking acetaminophen (Tylenol extra) 500mg as needed for pain.

Non-pharmacological therapies that are currently in use include rest and joint protection. He is advised to make sure that he gets sufficient rest and avoid straining his back. Heat therapy may also be use d to relieve his back pain. He can also do some exercise as tolerated. Laboratory Tests

Name of testNormal range| Date/patient results| Brief definition of test and overall function| Correlate results to your patient | Chemistry general and normal valuesSodium level 134-145me/qlChloride level 96-108mEq/lPotassium 3.

5-5Carbon dioxide 21-29mEq/lAnion gap 6-22 Glucose level 64-105mg/dlBUN 8-23mg/dlCreatinine 0. 70-1. 50mg/dlGFR estimated African American Calcium total 8. 2-10. 4mg/dl Alkaline phosphate 38-137IU/L ALT/SGPT 8-45IU/L AST/SGOT 0-40IU/L Bilirubin 0.

0-1. 0MG/L Albumin level 3. 5-5. 2g/dl Globulin level’ 2. 1-3. g/dl Albumin/globulin ratio 1.

3-2. 5Magnesium 1. 7-2. 2mg/dlProtein. 6. 2-8.

1g/dl| Patient results for 9/5/12(Wnl)-within normal limits. Sodium 137me/ql(wnl)Chloride level 108mEq/l(wnl)Potassium 3. 6(wnl)Carbon dioxide 18mEq/l(low)Anion gap 14 (wnl)Glucose level 110 H mg/dlBUN 22mg/dl (wnl)Creatinine 2. 2mg/dl HighGFR estimated African American 104(wnl)Calcium total 8. 8mg/dl (wnl)Alkaline phosphate 84IU/L (low)ALT/SGPT 29IU/L AST/SGOT 28IU/L (wnl)Bilirubin 0. 7MG/L Albumin level l 2.

7g/dl (wnl)Globulin level 4/dl Albumin/globulin ratio 0. 7L Magnesium L Magnesium 1. 3mg/dl(low)Protein 6. g/dl( wnl)| Na test is used to evaluate and monitor fluid and electrolyte balance and therapy. Chloride test is also used as of multiphasic testing for electrolytes. Potassium is mostly a test used for electrolytes in patients who take diuretics or heart medication.

Carbon dioxide test is used to assist in evaluating the PH status of the patient and assist in evaluation of electrolytes. Calculation of anion gap assists in the evaluation of the patient with acid-base disorders. Blood glucose test measures the level of glucose in the blood. Creatinine is used to diagnose impaired renal function.

GFR is an equation that uses the serum creatinine, age and numbers that vary depending upon sex and ethnicity to calculate the GFR with very good accuracy.

The serum calcium test is used to evaluate parathyroid function and calcium metabolism. ALP is used to detect and monitor diseases of the liver and bone. ALT is used to identify hepatocellular diseases of the liver. Bilirubin test is used to evaluate the liver function. Albumin test also measures the level of hepatic function. Magnesium test is used to identify magnesium deficiency or overload.

Magnesium test is used to identify magnesium deficiency or overload.

Evaluation of serum protein is used to test for protein deficiency. | Low carbon dioxide is usually normal in patients with chronic renal insufficiency which is the case in this patient. Low Carbon dioxide may also indicate metabolic acidosis. High glucose levels are usually associated with hyperglycemia.

Patient did not indicate any signs of hyperglycemia and has not been diagnosed with any form of diabetes. High creatine in this patient is due to insufficient clearance due to disease process of the renal system. Low alkaline phosphate may be a result of liver or kidney damage.

Patient Low albumin ratio indicates that there may be impairment in the hepatic function.

Low magnesium indicates deficiency of this mineral in the body. | Coag-routine. Pt sensitiveINRpartial thromboplastin normal 9-12 sec| Results for 9/5/12PT sensitive 14. 8sec(high)INR 1. 2| Used to check how well the anti coagulant is working to prevent embolism. | PT is high which means that the patient an increased risk for bleeding.

| Complete blood count. (CBC) WBC 4. 0-11k/ulRBC 3. 70-5. 40m/ulHGB 11. 4-15.

4HCT 35-47MVC 81-100MCH 26MCHC 30-36lPLT 130-470lRDW 12. 2-15. 2| Completed on 9/5/12Patient results. 9. x10(3)mm low3.

61×10(16) low9. 7gm/dl low27. 7% low77fl low26. 9 pg low35. 0gm/dl 211k/ul14. 7% H | CBCIt’s a common blood test that evaluates the three major types of cells in the blood: red blood cells, white blood cells, and platelets.

| All the abnormal values indicate low count of red blood cells and oxygen. Patient has aplastic anemia. RDW is an indication of the variation in RBC sizes. Variation in the width of RBC is helpful when classifying certain types of anemia. Normal length is 120 days before they are replaced AS has aplastic anemia which affects the newer RBC being replaced, causing different size and shape of RDW.

Mosby’s Pangana, 2010 Date| Test| Description of the test. | Patient result/ impression| 9/3/129/4/129/4/12| CT brain- without contrastCT of the neck without contrast due to elevated creatinine. Head MRI due to suspected head and neck carcinoma. Comparison made to CT head exam on 9/3/12| Computed tomography (also CAT or CT scan) of the brain (cerebral hemispheres, cerebellum and brain stem. )A CT brain is ordered to look at the structures of the brain and evaluate for the presence of pathology, such as mass/tumor, fluid collection (such as an abcess), ischemic processes (such as a stroke).

It is particularly good for hemorrhage, trauma or fracture to the skull and for hydrocephalus. CT (computed tomography) of the neck- a study of the neck region from the skull base (bottom of the head). Magnetic resonance imaging (MRI) is a test that uses a magnetic field and pulses of radio wave energy to take pictures of the head. | Mild atrophy with some subtle senescent white matter changes, stable in appearance relative to the preceding study. No acute intracranial abnormality. Clinical history-patient with palpable metastatic disease in the right neck said to have decreased in size.

Impression: there was an area of soft tissue mass in the level 3 jagular lymph node distribution as described which is said by referring to clinical history to represent soft tissue metastasis responding to therapyImpression: Acute ischemia in this distribution of the left posterior cerebral artery. Old ischemic insult also noted in the cerebellar hemisphere bilaterally. Old small vessel ischemic changes present in the periventricular and deep white matter. No evidence of intracranial metastasisModerate diffuse atrophy. | Scheduled medications. 1.

Trade name: magnesium oxide Generic name: magnesium salt

Therapeutic class- mineral and electrolyte replacements/supplements, laxative. Pharmacologic class- salines Usual dosage: 200-400mg/day Patient’s dosage: 400mg Drug action: replacement in deficiency states. Evacuation of the colon. Patient is taking medication as a nutritional supplement. Side effects: diarrhea, flushing and sweating. Nursing implications: nurse should assess the patient for abdominal distention, presence of bowel sounds, and usual patterns of bowel function.

Patient teaching: patient should not take this medication within 2 hours of taking other medications especially floroquinolones, nitrofurantoin and tetracyclines. . Trade name: warfarin Generic name: Coumadin Therapeutic class-anticoagulant Pharmacologic class-coumarins Usual dosage-1-10mg Patient’s dosage-5mg po daily Drug action- prevention of thromboembolic events. Patient taking medication for deep vein thrombosis. Nurse should monitor patient‘s INR.

The INR value should be between 2 and 3. Nursing implication: nurse should assess patient for signs of bleeding and hemorrhage, tarry, black stools, hematuria, and fall in hematocrit or blood pressure, guaiac-positive stools. Side effects-GI cramps, nausea, fever, bleeding. Patient teaching: patient should review foods high in vitamin k.

Patient should avoid IM injections and activities leading to injury.

3. Trade name: Nifedipine Generic name: Adalat. Therapeutic class-Antianginals, antihypertensive Pharmacologic class- calcium channel blockers. Usual dosage-10-30mg. Patient’s dosage-5mg po daily Drug action- systemic vasodilation, resulting in decreased blood pressure. Coronary vasodilation, resulting in decreased in frequency and severity of attacks of angina.

Patient taking medication for hypertension. Nursing implication: nurse should monitor blood pressure and pulse before therapy, during titration and periodically during therapy.

Monitor ECG periodically during therapy. Patient teaching: patient should know how take their blood pressure and pulse. Patient should contact health care professional if heart rate is ;lt;50. 4.

Trade name: Clonidine Generic name: Duraclon Therapeutic class-antihypertensive Pharmacologic class- adrenergic (centrally acting) Usual dosage- 200-600mcg Patient’s dosage- 0. 3 mg 1 tab Bid po Drug action-decreased blood pressure, decreased pain. Patient taking the medication for hypertension. Side effects-depression, dizziness, dry mouth, constipation. N/V.

Nursing implications: nurse should monitor intake and output ratios and daily weight, and assess for edema daily, especially at the beginning of therapy. Monitor BP and pulse frequently during initial dosage adjustment and periodically during therapy. This medication may cause a transient increase in blood glucose levels. Patient teaching: patient should avoid sudden changes in position o decrease orthostatic hypotension. 5.

Trade name: Hydralazine Generic name: Apresoline Therapeutic class- antihypertensive Pharmacologic class- vasodilators Usual dosage- 300mg/day in 4 divided doses.

Patient’s dosage- 50mg Tid po Drug action-lowering of blood pressure in hypertensive patients and decrease afterload in patients with CHF. Patient is taking it for Hypertension. Side effects-headache, tachycardia, sodium retention, hypotension. Nursing implications: Nurse should monitor CBC, electrolyte, LE cell prep and ANA titer prior to and periodically during prolonged therapy.

Patient teaching: patient should be aware that this medication may cause drowsiness. Patient should avoid driving or other activities requiring alertness until response to medication is known. 6. Trade name: Zonisamide

Generic name: Zonegran Therapeutic class- anticonvulsants. Pharmacologic class- sulfonamides. Usual dosage- 100-600mg/day.

Patient’s dosage- 100mg capsule daily. PO Taken for seizures. Drug action- raises the threshold for seizures and reduces duration of seizures probably by action on sodium and calcium channels. Side effects: drowsiness, fatigue, agitation, depression, anorexia. Nursing implications: nurse should monitor frequency, duration and characteristics of seizures. Patient teaching: patient should contact health care professional immediately if skin rash occurs or seizure worsen.

Patient should know that the medication may cause drowsiness and should avoid driving or other activities that require alertness. 7. Trade name: isosorbide mononitrate. Generic name: sorbitrate Therapeutic class- Antianginal Pharmacologic class- Nitrates Usual dosage- 40-80mg Patient’s dosage- 60mg tab daily. Patient taking medication for chest pain. Drug action- relief of angina attacks and increase in cardiac output.

Side effects-Dizziness, headache, hypotension, tachycardia, abdominal pain. Nurse implications: Nurse should assess location, duration, intensity, and precipitating factors of angina pain.

Medication may cause falsely decreased serum cholesterol determinations. Patient teaching: patient should wear protective clothing and use of sunscreen to prevent photosensitivity reactions. 8.

Trade name: Atorvastatin Generic name: Lipitor Therapeutic class- lipid lowering agent Pharmacologic class- HMG-CoA reductase inhibitor Usual dosage- 40-80mg Patient’s dosage- 80mg PO daily Drug action- lowering of total and LDL cholesterol. Increase HDL and decrease VLDL cholesterol and triglycerides. Slowing the progression of coronary artery disease with resultant decrease in MI/stroke and need for myocardial revascularization.

Side effect- headache, constipation, abdominal cramps, diarrhea, flatus and heartburn. Nursing implications: nurse should obtain a dietary history, especially with regard to fat consumption.

Nurse should evaluate serum cholesterol and triglyceride levels before initiating, and 4-6 weeks of therapy, and periodically thereafter. Patient teaching: patient should notify health care professional if unexplained muscle pain, tenderness, or weakness occurs, especially if accompanied by fever or malaise. 9. Trade name: filgrastim Generic name: Neopogen injection Therapeutic class- colony stimulating factor Pharmacologic class- none

Usual dosage- 300mcg/ml in 1 and 1. 6ml vials Patient’s dosage- 1.

6ml Patient is taking the medication as a prophylaxis while going through chemotherapy to prevent infections. Drug action: decrease incidents of infection in patients who are neutropenic from chemotherapy or other causes. Side effects- excessive leukocytosis, pain, redness at subcut site, medullary bone pain. Nursing implications-nurse should obtain CBC with differential after chemotherapy including examination for the presence of blast cells, and platelets count before chemotherapy and twice weekly during therapy to avoid leukocytosis.

Patient teaching- nurse should instruct patient on correct technique and proper disposal for home administration and disposal of needles and vials. 10.

Trade name: pantoprazole Generic name: protonix Therapeutic class- Antiulcer agent Pharmacologic class- Gastric acid pump inhibitor. Usual dosage- 40-120mg Patient’s dosage- 40mg PO daily Patient is taking the medication for GERD. Drug action: diminished accumulation of acid in the gastric lumen, with lessened acid reflux. Healing of duodenal ulcers and esophagitis. Decreased acid secretion in hyper secretory conditions.

Side effects: headache, abdominal pain, diarrhea, hyperglycemia.

Nursing implications- nurse should assess patient routinely for epigastric or abdominal pain and for frank or occult blood in stool, emesis, or gastric aspirate. Patient teaching- patient should avoid alcohol, products containing aspirin or NSAID’s, and foods that may cause an increase in GI irritation. Patient should report onset of black tarry stools, diarrhea, or abdominal pain to health care professional promptly. 11. Trade name: cholecalciferol Generic name: vitamin D3 Therapeutic class- vitamins Pharmacologic class- fat-soluble vitamins Usual dosage-400 -1000units/day Patient’s dosage- 1000 units daily.

Patient is taking medication for general weakness and as mineral supplement. Drug action: treatment and prevention of deficiency states, particularly bone manifestations. Improved calcium and phosphorous hemostasis in patients with chronic renal failure. Nursing implications- nurse should monitor serum ionized calcium concentrations weekly during initial therapy. Nurse should assess patient for bone pain and weakness prior to and during therapy. Side effects- bone pain, anorexia, headache, dizziness, malaise.

Patient teaching- patient should comply with dietary recommendations of health care professional.

Patient should eat a balanced diet that is high in vitamin D. 12. Trade name: Celecoxib Generic name: Celebrex Therapeutic class- antirheumatics, non steroidal anti-inflammatory agents. Pharmacologic class- Cox-2 inhibitors.

Usual dosage- 100-200mg bid Patient’s dosage- 200mg bid Patient is taking the medication for Arthritis. Drug action-decreased pain and inflammation caused by arthritis. Side effects: dizziness, headache, abdominal pain, insomnia, dyspepsia. Nursing implications: nurse should assess patient’s range of motion, degree of swelling, and pain I the affected joints before and periodically during therapy.

Nurse should be aware that this medication may cause elevated AST and ALT levels. Patient teaching: patient should discontinue celecoxib and notify health care professional if signs and symptoms of hepatoxicity (nausea, fatigue, lethargy, pruritus, jaundice, flu like symptoms occur.

PRN. 1. Trade name: Zolepidem Generic name: Ambien Therapeutic class- sedative/hypnotics Pharmacologic class- sedative/hypnotics Usual dosage-5-10mg Patient’s dosage- 10mg Drug action: sedation and induction of sleep. Patient is taking medication as needed as a sleep aid.

Side effects-amnesia, daytime drowsiness, dizziness, diarrhea, N/V. Nursing implications: nurse should assess patient for mental status, sleep patterns, and potential for abuse prior to administration.

Patient teaching- patient should not take more than prescribed because of the habit forming potential. This medication is not recommended for use longer than 7-10 days. 2. Trade name: Alprazolam Generic name: Xanax Therapeutic class- antianxiety agent Pharmacologic class- benzodiazepines Usual dosage-0. 25-0. 5mg 2 to 3x daily Patient’s dosage-0.

5mg TID PRN to reduce anxiety. Drug action: relief of anxiety.

Side effects- dizziness, drowsiness, lathargy , confusion, hangover, headache, depression. Nursing implications-nurse should assess degree and manifestations of anxiety and mental status prior to and periodically during therapy. Nurse should monitor CBC and liver and renal function periodically during long term therapy. May cause decrease of hematocrit and neutropenia.

Patient teaching- patient should avoid alcohol or other CNS depressants concurrently with this medication. Patient should consult health care professional before taking OTC medications or natural /herbal products concurrently with this medication. 3.

Trade name: Hydrocodone -acetaminophen Generic name: Dolacet. Therapeutic class- opiod analgesics Pharmacologic class- opiod agonist/ nonopiod analgesic combinations.

Usual dosage- hydrocodone 2. 5 to 10 mg; acetaminophen 300 to 750 mg) every 4 to 6 hours Patient’s dosage- 7. 5-325mg, for pain. Drug action: decrease in severity of moderate pain. Side effects- confusion, sedation, hypotension, constipation. Nursing implications-nurse should assess blood pressure, pulse, and respirations before and periodically during administration.

Assess type location and intensity of pain prior to and 1 hr following administration.

Patient teaching-patient should avoid using alcohol or other CNS depressants with this medication. Patient should change position slowly to avoid orthostatic hypotension. 4. Trade name: Lorazepam Generic name: Ativan Therapeutic class- anesthetic adjuncts, antianxiety agents, sedative/hypnotics. Pharmacologic class- Benzodiazepines.

Usual dosage- 1-10mg/daily Patient’s dosage-3mg tabQ4hours PRN. Drug action: management of anxiety or insomnia. Patient taking medication to decrease anxiety. Side effects: dizziness, drowsiness, lethargy, hangover, headache, mental depression and blurred vision.

Nursing implications: Nurse will assess degree and manifestation of anxiety prior to and periodically throughout therapy.

Nurse should be aware that patients on high dose therapy should receive routine evaluation of renal, hepatic, and hematologic function. Patient teaching: patient should not consume alcohol or other CNS depressants concurrently with this medication. (Nursing drug hand book 20 Nursing Diagnosis 1. Acute Pain related to treatment/therapy as evidenced by patient stating of having a pain of 8 in the scale of 0-10. Explanation: pain may affect the normal functioning of an individual.

They may not able to cope with activities due to a lot of distress. Planned outcome: patient’s pain will have decreased to a zero or a tolerable level by 1900. Interventions: A. the nurse assessed the pain level every one hour and before ambulating patient using the verbal numeric scale and will offer pain medication for any pain rating above 3 out of 10. Rationale: Patient was given pain medication after nurse had assessed him for an hour. Patient stated that he had trouble going to sleep due to pain, so nurse administered the pain medication.

Evaluation: The goal was met. After one hour, patient stated that his pain was down to a four.

B. Nurse encouraged the patient to avoid activities that cause more pain, like bending, walking or sitting on one position for long periods of time. Rationale: resting will help reduce pain by reducing tension in the muscles.

Evaluation: patient showed less distress when resting on his recliner reading the paper. C: Nurse offered destruction by turning the television to patient’s favorite show, talked to patient about something interesting to keep him from dwelling on the pain. Rationale: Television is a good distractor because it will take the entire patient’s attention, which then carries him away from the distress of pain.

Evaluation: goal was met. Patient was laughing and smiling as he watched TV.

D. Nurse encouraged the patient’s wife to give him a back rub when she was helping him with his bed bath since he wanted her to do it. Rationale: Back rubs and massage causes the relaxation of muscles. Evaluation: patient stated to the nurse; “that bed bath made me feel really good”. 1. Anxiety related to disease process as evidenced by patient getting agitated and yelling at the nurse.

Explanation: Dealing with anxiety is important because when one is anxious, it affects many function of the body for example, the BP, pulse which might worsen the disease process.

Goal: AS will shows signs of calmness and have a positive feeling about his future by 9/5/12. Interventions A. Nurse carefully listened to patient’s concern and reassured him accordingly. Rationale: By carefully listening to his concerns, showing understanding and reassuring him, patient will reduce his anxiety level Evaluation: more time needed to assess the success of the intervention B. Administer medication as ordered and PRN: He is currently taking lorezepam (Ativan) 1 tablet by mouth every 4 hours Rationale: anxiolytic will help him lower his anxiety level Evaluation: Lorazepam (Ativan) given as needed and he calmed down C.

Closely monitor AS vital signs every 4 hours Rationale: higher than normal readings of vital signs could indicate increased levels of anxiety for example sudden high pulse or respiratory readings. Evaluation: Intervention was successful; there was a rise in the BP, Pulse readings whenever he became anxious. D. Use calming techniques such as having AS listen to his favorite music read an interesting magazine or newspaper. Rationale: favorite music, reading, TV show can help calm a person Intervention was successful: AS seemed relaxed and calm after filling his favorite word puzzle on the newspaper E.

Nurse made sure that patient was in a calm and favorable environment by limiting the number situations that can cause un-necessary stimulation, for example closing the door to his room to avoid noises from outside Rationale: hostile and unfavorable environment for example noisy place, excess heat or cold in the room can cause some one become anxious Evaluation: Patient seemed more relaxed whenever his door was shut and there was less noise coming from the outside. 2. Nutritional imbalance less than body requires related to disease process as evidenced by lack of desire to eat food and decreased albumin level (2. gm/dl). Planned outcome. AS will increase calorie intake from 600 to 1000 by 9/5/12 Nursing interventions: 1 Nurse assessed patient for ability to chew noting denture fit to promote ingestion of food. Rationale: improperly fitting dentures may cause pain in the gums, which may lead to patient having difficulties with chewing. Evaluation: Nurse assessed the mouth and dentures fitted okay, patient did not have any complaint. 2. Assess factors such as underlying diseases and psychological disturbances so as to identify the contributing factor of AS’s lack of appetite.

Nurse encouraged patient to order his favorite food for breakfast and lunch. Rationale: many patients going through chemotherapy usually experience a lot of nausea and vomiting and may not want to eat for that reason. Evaluation: patient stated that he sometimes have nausea, but tried to eat about 25% of his breakfast, and 30% at lunch time. Patient showed improvement with meal consumption. 3. Provide a pleasant relaxing environment including socialization during meals to enhance food intake. Rationale: patients are more likely to eat more of their food in a place where they feel comfortable.

They may prefer to sit at the bedside chair, or have a table on their bed. Evaluation: patient started getting out of bed to sit on the chair for meals. He seemed to be having an easier time sitting on the chair and did not have to reach so much for food on the tray. 4 . Nurse encouraged the patient to choose appropriate meal for him that would increase his appetite and provide required nutrients that would improve his health status. Rationale: Patient will meet the goal by having the knowledge to order meals with his required amount of calories. Evaluation: goal was met.

Patient ordered vitamin D milk for breakfast instead of tea. 3. Risk for bleeding related to medication regimen; patient currently taking Coumadin 5mg daily. Planned outcome: patient will have no bleeding episodes by 1900. Explanation: patients on Coumadin therapy may experience bleeding since this medication is a blood thinner. Interventions: A. Nurse monitored patient’s INR before administering medication. Rationale: if the INR levels are outside the range of 2-3, the nurse will hold medication. If bleeding occurs, patient may loose a lot of blood since they have a low clotting factor.

Patient’s results were within normal limits at tie of care. Nurse also monitored patient’s skin for petechia, and stools for occult blood. Evaluation: Goal met, patient did not experience any bleeding after taking medication. B. Nurse encouraged patient to use a soft brush for teeth brushing. Rationale: soft brush will prevent injury to the gums, therefore preventing bleeding. Evaluation: Goal was met. AS took out his dentures, and nurse cleaned them. C. Nurse informed patient about vitamin K which interferes with effectiveness of Coumadin.

Rationale: if patient takes vitamin K or foods high in vitamin K, then Coumadin will not be effective. Evaluation: goal met. Patient did not order any foods high in vitamin K. AS also stated that he was well aware of that from Doctor’s knowledge, and long term use of medication. D. Nurse assessed port site for any bleeding or hematoma. Rationale: To ensure that the site is dry and dressing is intact and patient is free from bleeding. Evaluation: Goal met. Port site looked intact and dry with no hematoma. 5. Risk for fall related to age (74years old) and disease process. 6.

Risk for injury related to weakness. 7. Risk for impaired swallowing related to chemotherapy. ( patient complained of a sore throat from neck chemotherapy). Normal process of aging observed from AS are; Grey hair. He African American and according to (Tabloski 2010) its normal for older adults in this community to stay grey at an old age as compared to other communities that have all white hair by age 65. The patient skin was also beginning to be elastic, and nails were very rigid. Patient has already experienced decline in the renal system by kidneys becoming less efficient.

He also had wrinkles mostly on the face and neck. The nurse also had to use a higher tone while communicating with the patient. He also spoke very loudly and had the television on high volume. This is an indicator that his hearing is getting impaired. AS has been experiencing back pain and muscles have weakened. AS has current medical condition like hypertension that is a common condition in the older adults of the African American community. As a 74 year old patient, he is still very strong, ambulates with no adaptive equipment, and looked a lot younger than his age.

He had fewer wrinkles than expected in an older adult at that age. Patient was in great shape, body fat well distributed in the body. His sense of sight and taste are still well intact. Older adults usually have poor, or impaired sight by AS’s age. Although it’s normal for older adults to have fewer hours of sleep, (Tabloski 2010) it’s not normal for them to lack sleep due to pain. .AS was having difficulties going to sleep at all due to his back pain. Medication helped manage patient’s pain which made it easier for him to take a nap during the day. He stated that he experiences sleep apnea .

Patient has a continuous positive airway pressure mask ( CPAP) at home but finds it uncomfortable to use . AS, also has a central line implanted on the right side of his chest for therapy and other treatments. Healthy aging older adults do not require central line placement.

References. 2002 drug hand book. (2001). San Francisco: Blanchard ;amp; Loeb. Atlas of pathophysiology (3nd ed. ). (2006). Philadelphia: Lippincott Williams ;amp; Wilkins. Moyet, L. J. (2006). Nursing diagnosis: application to clinical practice (11th ed. ). Philadelphia: Lippincott Williams ;amp; Wilkins. Shier, D. (1996). Hole’s human anatomy & physiology (7th ed. ). Dubuque, IA: W. C. Brown Publishers. Smeltzer, Textbook of Medical Surgical Nursing, 12th Ed + Textbook of Medical Surgical Nursing Study Guide + Textbook of Medical Surgical Nursing Handbook + Fluids and Electrolytes Made Incredibly Easy. (2012). philadelphia: Lippincott Williams & Wilkins. Tabloski, P. A. (2006). Gerontological nursing. Upper Saddle River, N. J. : Pearson Prentice Hall. Pagana, K. , & Pagana, T. , (2006). Mosby’s manual of diagnostic and laboratory test. St. Louis: Mosby, Inc.