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NURSING 111 CARE PREPARATION

Student Name:

Rachelle Johnson

Unit/Room Number: MCU 472


Age: 93
Gender: Male
Eriksons Developmental Level: Integrity vs
Despair

Date of Care: 2-10-15


Date of Admission: 2-7-15
Ethnic/Cultural Preferences: White /
Catholic
Allergies: PCN, Sulfa
Code Status: Full Code

Primary Diagnosis:
Sepsis from UTI
Co-morbidities:
C-Diff, Hypokalemia, Acute renal failure, PCM Severe, Chronic kidney disease stage 4, AFib, UTI
Hypertension, BPH with urinary retention, Candiduria, nephrolithiasis, osteoarthritis,
failure to thrive, restless leg syndrome, onychomycosis
Discharge Plan (add day of clinical):
Home with hospice when C-Diff subsides
Integrated Pathophysiology (what is going on with your patient at the cellular level for the health
condition, no more than three pages in length, including reference page)

My patient is a ninety-three year old male presenting to MCU for sepsis related to a UTI. His wife
brought him to the ED with progressively worse weakness. He was admitted for sepsis due to a UTI. Sepsis is a
condition that cannot occur on its own it must start with some kind of infection such as a UTI like my patient
had. It is an infection that begins with bacteria, a virus or fungi. It occurs when bacteria enters the bloodstream
and produces bacteremia. The bacteria can stimulate the inflammatory response or release toxins into the
bloodstream.
Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any
assessment/elaboration should be made on the assessment sheet):
Diet (Type): Regular
IV (Fluid type, rate, access type):

I&O (MD order/Nursing Order/Frequency): Nursing


order q6
Fall Risk/Safety Precautions (Yes/No): Yes
Wound Care (Yes/No): No
Drains (Yes/No, Type): No
Other Tubes: No

Central line

Right femoral SL
CBG (Yes/No, frequency): No
Activity (What is ordered): 1-2 assist with PT
Oxygen (Yes/No, Delivery method, how much):
Standing order 1-4L NC to keep 02 about
93%
Last BM: 2-9-15

ASSESSMENTS
(Include Subjective & Objective Data)

Integumentary:
Weeping skin all over body weeping
edema? Skin moist? Diaphoretic?
Abrasion L upper arm
Abrasion R upper back covered- Clean, dry,
intact dressing
Ecchymosis spread all over body
Amputated L third finger
No tenting
Nails-Thick
Skin temp?
Texture?
Turgor?
Ear/Nose/Throat:
Ear- No drainage, HOH
Nose- Bloody drainage, dry mucous
membranes
Throat & Mouth- Dry, own teeth, missing
back teeth
No difficulty swallowing
Eyes?
Cardiac:
Cap refill less than 3 seconds where?
S1 & S2 heard regular? Irregular?
No JVD
No murmur, gallop
A-Fib how do you know?
+2 bilat radial & pedal pulses regular?
Irregular?
Edema 1+ hands, no lower extremity
edema
Genitourinary:
Tea colored urine
Incontinent & Continent
Voided 150mL
No odor, pain or burning
UTI hx
Neurological:
A&O x 2 not oriented to time
No facial droop
Clear speech
PERRLA
Face symmetrical

Head and Neck:


Neck supple & symmetrical
No palpable thyroid
Trachea straight & intact
Full ROM of neck
Balding

Thorax/Lungs:
Diminished LLQ & RLQ lungsanterior?
Posterior?
Clear upper & middle quadrants lungs have
lobes not quadrants
No cough
SOB upon turning & activity
Respirations labored 16 breaths per minute
Respiratory effort?
Chest expansion?
Musculoskeletal:
Generalized weakness muscle strength
___/5
1-2 assist with PT
Full ROM where?
Turns self in bed
Did not get up for me

Gastrointestinal:
Normoactive bowel sounds where?
Last BM 2-9-15
Distended non tender
Incontinent of bowel?
Soft- no palpable masses
C-Diff
Other (Include vital signs, weight):
BP: 129/66
P: 85
R: 16
O2: 97%
T: 97.4

Demeanor?

Weight- 66.7kg
Height 67.99 Inches

CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)
Generic &
Trade Name

Dose/Route
/
Rate if IV

Clasiisficatio
n

Onset/Peak

Chest Heparin
Flush

30 Unit=3mL
IV PRN

Anticoagulants

O: Immediate
P: 5-10 min
D: 2-6 hr

Chest Saline
Flush (Sodium
Chloride Flush)

10 ML IV
PRN

Bifantis
(Align)

4mg 1 Cap PO
Daily

Mineral
Electrolyte
Replacement
Isotonic
Probiotic
Herbal
supplement

Chlorhexidin
e 0.12% oral
rinse
(Peridex
0.12%)

15mL BID
Swish and
Spit

Chlorhexidin
e 4%
(hibiclens
4%)
Flagyl
(Metronidazole)
Mupirocin 2%
Ointment Nasal
(Bactroban)
Pantoprazole IV
(Protonix IV
Push)

Prednisone

Intended
Action/Therapeutic
use. Why is this
client taking med?
Anticoagulant to prevent
clots

Adverse reactions
(1 major side
effect)

Nursing Implications for this client. (No


more than one)

Bleeding

Assess for signs of bleeding and hemorrhage


(diarrhea, pale skin, headache, poor appetite,
vomiting, weakness, rapid pulse)

O: Unk
P: Unk
D: Unk

Used to Flush IV

Redness

Assess skin at IV site

O: Unk
P: Unk
D: Unk

Restoration of intestinal
flora

Bloating

Assess for effectiveness. Assess for bowel tones.

Anti-septic
AntiMicrobial

O: Unk
P: Unk
D: Unk

Gingivitis

Mouth Irritation

Assess inside mouth for redness. Have pt


report any signs of burning. Educate pt
on rinsing & spitting and not to swallow

1
application
topical
daily

Anti-septic
AntiMicrobial

O: Unk
P: Unk
D: Unk

Prevent skin infection

Skin Irritation

Assess skin for redness.

500mg/NS
100mLQ8

AntiTrichomonal
Amebicide

HL: 25-75h
O: rapid
P: 1-3h

Fungal infection

Vertigo

Educate pt on importance of calling before getting


up

Anti-infective

O: unk
P: unk
D: 12 hr

Skin infection

Burning, stinging

Assess lesions before and daily during therapy.

2% Ointment
Nasal 1g =
1g nasal BID
40mg = 10mL
IV push daily

Antiulcer
agents/
Gastric proton
pump inhibitor /
Anti-secretory

O: 2.5 hr
P: unk
D: 1 wk

GERD

Diarrhea

Monitor for s/s angioedema or severe skin reaction.


Last BM 2-9-15

10mg a day,
1tab

Adrenal
corticosteroid

Peak 1-2h
Half life 3.5h

Has an anti-inflammatory
and immunosuppressant
property.

Hypoglycemia

Establish baseline and continuing data regarding


BP, I&O ratio and pattern, weight, fasting blood
glucose level, and sleep pattern.

Vancomycin
(Vancocin Oral)

125mg = 1
cap PO Q6H

Antibiotic;
glycopeptide

Acetaminophen
(Tylenol)

650mg = 2
tabs PO Q4H
PRN headache

Pain Reliever/
Antipyretic

Peak 30min
: 4-8h

Active against many


gram-positive organisms.

Hypotension
accompanied by
flushing and
erythematous rash on
face and upper body

O: w/in 1H P:0.52H

Pain reliever

Elevation of
ALT/AST

Monitor BP and heart rate continuously through


period of drug administration.

ANTIDOTE: Acetylcysteine (NAC)


Monitor for therapeutic effects (pain relief)
Monitor temperature to ensure relief of fever.

Ondansetron
Injection
(Zofran
Injection)

4mg = 2mL
IV Q4H prn
nausea/
vomiting

Antiemetic

O: rapid
P: 15-30m
HL:3.5-5.5h

Prevents nausea &


vomiting

dizziness, drowsiness,
constipation, diarrhea

Assess for GI problems, increased liver enzymes,


extrapyramidal, reactions assess for extrapyramidal
effects (involuntary movements, facial grimacing,
rigidity, trembling hands). Administer over at least
30 sec and preferably over 2-5 minutes.

DIAGNOSTIC TESTING

Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [Xrays, CT, MRI, U/S, etc.]

NOTE: Adult values indicated. If client is newborn or elder, normal value


range may be different.
Interpretation as related to
Pathophysiology cite reference & pg
#

Date

Lab Test
Normal
Values

Patient Values/
Date of care

2-915

Sodium
135 145 mEq/L
Potassium
3.5 5.0 mEq/L

139

NA

5.3

Chloride
97-107 mEq/L

119

Was hypokalemic upon admission, been receiving


potassium supplement IV for 2 days. Which raised
his potassium.
`An increase in chloride can be d/t renal failure and
the kidneys unable to excrete chloride properly. My
patient has kidney disease as well as renal failure.
Laboratory Tests and Diagnostic Procedures pg 122
Decreased Co2 is caused by increase of hydrogen,
potassium and chloride ions, this could be caused
by the potassium they have been giving him.
Laboratory Tests and Diagnostic Procedures pg 140
Could be an indicator of diabetes, diabetes 2 can be
caused by age as well as decreased physical
activity; which applies to my patient d/t his inability
to be mobile without pain and discomfort.

Co2
23-29 mEq/L
Glucose
75 110 mg/dL

16
134

Laboratory Tests and Diagnostic Procedures pg


182
BUN
8-21 mg/dL

62

Increased BUN can be d/t diseased or damaged


kidneys, because they can not get rid of the waste
as easily causing an elevated BUN. Laboratory Tests
and Diagnostic Procedures pg. 83
Increased creatinine is d/t renal impairment.
Creatininie is increased when of the nephrons are
nonfunctioning. Laboratory Tests and Diagnostic
Procedures pg 89

Creatinine
0.5 1.2 mg/dL

2.07

Uric Acid Plasma


4.4-7.6 mg/dL
Calcium
8.2-10.2 mg/dL

NA

NA

8.0

Hypocalcemia is seen with renal failure, which my


patient has because acid phosphates is impaired.
Laboratory Tests and Diagnostic Procedures pg 164

NA

NA

1.6

Liver dysfunction causes high elevations of BU. The


liver is not able to conjugate the free bilirubin that
circulates in the bloodstream. Laboratory Tests and
Diagnostic Procedures pg 261
Liver dysfunction causes decreased protein levels
as well as a loss through renal dysfunction.
Laboratory Tests and Diagnostic Procedures pg 233
Albumin is synthesized in the liver so liver
dysfunction causes decreased albumin levels as
well as a loss through renal dysfunction. Laboratory
Tests and Diagnostic Procedures pg 233

Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
0.3-1.2 mg/dL
Total Protein
6.0-8.0 gm/dL

5.0

Albumin
3.4-4.8gm/dL

2.4

Cholesterol
<200-240 mg/dL
Alk Phos
25-142 IU/L
SGOT or AST

NA

NA

42

NA

35

NA

10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
WBC
4.5 11.0
RBC
male: 4.7-5.14 x
10
female: 4.2-4.87 x
10

HGB
male: 12.6-17.4
g/dL
female: 11.7-16.1
g/dL

HCT
male: 43-49%
female: 38-44%
MCV
85-95 fL

MCH
28 32 Pg
MCHC
33-35 g/dL
RDW
11.6-14.8%
Platelet
150-450

NA

NA

NA

NA

10.8

NA

3.02

Low RBC is anemia, can be d/t loss or


destruction of erythrocytes. Laboratory Tests
and Diagnostic Procedures pg 27

8.7

Its a component of RBCs so if there is a


decrease in RBSs it also causes a low HGB
level. Laboratory Tests and Diagnostic
Procedures pg 32
D/t a decrease in number of RBCs, this could
be d/t a blood loss; such as, my patients
surgery she experienced. Laboratory Tests and
Diagnostic Procedures pg 28
MCV is an indicator of size of the RBCs this
can be caused by anemia, which my pt has
been currently bleeding & required blood
products. Laboratory Tests and Diagnostic
Procedures pg 34

25.5

85

28.9

NA

34.3

NA

14.8

NA

157

NA

DIAGNOSTIC TESTING
Date

UA

2-715

Color/Appearan
ce
pH
Spec Gravity
Protein

Normal
Range

5-8
1.0051.030
Neg

Results

Interpretation as related to
Pathophysiology cite
reference & pg #

Red

Due to blood in urine, can be caused


by UTI.

7
1.005

NA
NA

3+

Protein in the urine can be d/t


decreased renal function, which is
appropriate to my pt because they
have a hx of renal disease. .

Laboratory Tests and Diagnostic


Procedures pg 68

Glucose
Ketones

Neg
Neg

Neg
Trace

NA
Ketones in the urine indicate fat
being used as a main source of
energy. This can be d/t starvation or
fasting, my pt has not been

consuming much food and has a hx


of failure to thrive. . Laboratory

Tests and Diagnostic Procedures pg


71

Blood
Date

Other

Date
2-9-15

4+

Normal
Range

Results

INR

0.9-1.1

1.4

NA
NA
NA
NA
NA
NA
NA

NA
NA
NA
NA
NA
NA
NA

NA
NA
NA
NA
NA
NA
NA

(PT, PTT, INR,


ABGs, Cultures,
etc)

2-915

NegTrace

Radiology
ABDOMEN
(KUB)

Scans
EKG-12 lead
Telemetry

Results

Blood in the urine can be d/t a UTI.

Interpretation as related to
Pathophysiology cite
reference & pg #

NA
NA
NA
NA
NA
NA
NA
Interpretation as related to
Pathophysiology cite
reference & pg #

No evidence of
obstruction, no gross
ascites, mult calcifications
in the pelvis consistent
with phleboliths.

NA

NA
NA
NA

NA
NA
NA

DAR NURSING PROGRESS NOTE


Include the same note that was written in the client record for the priority
nursing diagnostic statement. Include the date/time/signature.

2-10-15 1735- Pt reporting no pain, VS- 97.4, 129/66, P: 85, R: 16, O2: 97%,
normoactive bowel sounds where?. Administered vancomycin, educated pt
on side effects & to take it with food. Pt shook head in understanding,
swallowed pill with out difficulty, set up tray for dinner, call light & fluids with
in reach.

PATIENT CARE PLAN


Patient Information: 93 y.o pt presenting to MCU for sepsis d/t UTI day #3. Actively
having diarrhea, tested positive for C-Diff, receiving antibiotics. Incontinent of stool and
urine. Pt ambulates with 1-2 assist; however, has not been up today. Has a good
appetite. Reporting no pain.

Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as
evidenced by (AEB).

Problem #1 Fluid volume deficit r/t active fluid volume loss AEB diarrhea what other
evidence supports thisuse more than 1
Desired Outcome: Maintain adequate fluid intake AEB moist mucous membranes & with
vital signs remaining: Pulse between 60-100, BP between 90-119/60-79)what is
adequate? 1 cup? 64 oz?
Nursing Interventions
Client Response to Intervention
1. Provide 100mL of fluid every hour
1. Pt enjoyed fluids & gladly took
drinks when offered
2. Assess VS & Mucous membranes every 4
2. Pt was cooperative with frequent
hours
checks
3. Assess pts preference on different fluid
choices at beginning of shift

3. Pt verbalized enjoying juice

Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):
Pt was cooperative; he enjoyed drinking & was always accepting of any fluids I offered
him. His vitals remained between designated ranges; however, his mucous membranes
remained dry. He was not hooked up to any IV fluids and appeared to be dehydrated.
Problem #2 Impaired urinary elimination r/t weak sphincter AEB urinary incontinence &
urgency
Desired Outcome: Demonstrate urinary elimination twice during shift

Nursing Interventions
1. Assess pts ability to sense ability to urinate
every 2 hours

Client Response to Intervention


1. Pt able to sense urine urgency
occasionally but not always

2. Ambulate pt to bathroom every 2 hours

2. Pt not willing to ambulated, used


urinal instead
3. Pt cried out when needed to go,
didnt use call light

3. Instruct pt to call immediately with first


feeling of urgency

Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed) :
Pt used urinal often with small amounts of urine; however, also was incontinent at times
when not able to get gowned up quick enough. Never used call light but would call out at
first sign of urgency. Educated pt on call light use; however, pt was forgetful so could not
properly use it. Instead I sat outside his door so I could hear when he woke up. Do you
think his dehydration played a role in his voiding pattern
Problem #3 Impaired skin integrity r/t moisture AEB incontinence
Desired Outcome: Keep skin clean, dry, & intact without redness
Nursing Interventions
Client Response to Intervention
1. Change pt promptly after elimination &
1. Checked pt every 2 hours & changed
perform peri care
brief & did pericare each time
incontinent. Pt cooperative & willing to
let me help.
2. Reposition pt every 2 hours
2. Pt was self moving
3. Apply barrier skin to patients bottom every
time changed

3. Pt agreed to barrier cream.

Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed) :
Kept pt clean & dry throughout shift with frequent hourly checks. Pt was able to self-turn
& reposition himself. Cooperative with pericare as well as barrier protection.

Use more than 1 supportive data for your care


plan.

Sepsis related to UTI Pathophysiology

My patient is a ninety-three year old male presenting to MCU for sepsis related to a UTI.
His wife brought him to the ED with progressively worse weakness. He was admitted for sepsis
due to a UTI. Sepsis is a condition that cannot occur on its own it must start with some kind of
infection such as a UTI like my patient had. It is an infection that begins with bacteria, a virus or
fungi. It occurs when bacteria enters the bloodstream and produces bacteremia. The bacteria can
stimulate the inflammatory response or release toxins into the bloodstream.
A urinary tract infection is an infection caused by bacteria in the urinary epithelium. The
most common site for a UTI is in the bladder, also known as acute cystitis. With advanced
inflammation in the bladder, blood is common; my patient has been experiencing blood in his
urine, which could be due to this reason from the UTI. The most common types of bacteria
associated with urinary tract infections include, Escherichia coli and Staphylococcus
saprophyticus. The retrograde movement of gram- negative bacilli in the urethra and balder and
then the ureter and kidney is how the normally sterile urine is contaminated with the bacteria
(Huether & McCane 2012). The elderly have the highest risk factor to UTI, my patient fits in to

this category. The elderly often times show confusion along with aggression and can be the only
symptom that they show. Recurrent UTIs affect my patient and can increase his risk of mortality.
A urinary tract infection interferes with my patients life, he is experiencing incontinence
most like due to the UTI as well as incontinence of stool due to his diagnosis of c-diff. This can
put him at a severe risk for skin integrity from constant moisture and irritation on his buttock and
perennial area. My patient is on vancomycin to help treat his infections and help with his sepsis
and prevent septic shock. It is important to educate my patient on continuing his antibiotics for
the entire course they are ordered and taking them the same time every day to prevent antibiotic
resistance.

References:
Huether, S., & McCance, K. (2012). Understanding pathophysiology (5th ed.). St. Louis, Mo.:
Mosby/Elsevier.