Noticing

Demographics Age: 50 Gender: Male Code status: DNR Allergies: Sulfa drugs Family psycho-social support: estranged from his family, a friend is always visiting him every morning Language/Culture/Religion: English/ Mexican/ Catholic Activity/Mobility Activity order: ambulation as tolerated Mobility devices: walker PT/OT/Speech: PT Hygiene Oral care : independent x assist Perineal care: independent x assist Shower x bed bath Nutrition Diet order: clear liquid diet Appetite : refused-poor Ht/Wt: 55/55.26kg BMI: 20.2 (normal) Tube feeding (type & rate) none Assist with feeding: Dependent with feeding Output BRP urinal /bedpan/ x incontinent Foley: none

Student name/Date: Jeffrey B. Viernes

Medical Dx: Seizure d/o, ESRD 2 to ETOH, altered mental status, probable hepatic encephalopathy, UNSP essential HTN, Radial distal fracture, neural HEARING LOSS, UNSP infective otitis externa, cellulitis of leg (right), colitis, thrombocytopenia, ARF, DM, Anemia-Upper GI bleeding, Portal HTN gastropathy, varices-esophageal and gastric, cirrhosis of the liver Past History: PUD (6-30-2012), Never Smoke, long history of ETOH Medications Ordered/Reason 1. Lactulose 10g/15mL liq. 30 mL PO q4h (decrease ammonia) 2. Levetiracetam 1000 mg in NaCl 0.9% 100mL IV q12h (anticonvulsant) 3. Nadolol (Corgard) 20 mg (1 Tab) PO daily (mgt for HTN and esophageal varices) 4. Rifaximab Tab (Xifaxan) 550 mg (1 Tab) PO BID (antiinfective) 5. Pantoprazole inj. (Protonix) 40 mg IV daily (anti-ulcer) 6. Acetaminophen (Tylenol) 650 mg (2 Tabs) PO q4h (for fever and pain) 7. Ondansetron 2mg/mL (Zofran) 4mg (2mL) IV q4h (N/V) 8. Insulin Aspart 100units/mL (NOVOLOG) 2-9 units 0.01-0.05 mL of 100 units/mL SQ QID before meals and at bedtime 1. 81-150 (no coverage) 2. 151-200 (2 unit) 3. 201-250 3 units) 4. 251-300 (5 units) 5. 301-350 (7 units) 6. >350 (9 units)

Strict I&O q 12h. Peripheral IV 22G RFA. Glucose (PCOT) before meals and @ bedtime. SCD on. Call PCP if SBP >190, DBP >110, HR <50, T > 38.1 Fall Risk. Risk for Skin Breakdown. Blood Type: O positive Anticipated LTC placement or HOSPICE.

Review of Systems/ Physical Assessment & VS

Vital sign: Day 1 @ 0830 T (axillary) 36.7 degree Celsius, BP 109/55 (lying, left arm), P 64 (strong bilateral), RR 16 (unlabored), O2 sat 100% on room air. @1230 T(axillary) 36.5 degree Celsius, BP 112/60 (lying, left arm), P 64 (strong bilateral), RR 18 (unlabored), O2 sat 99% on room air. Day 2 @1100 T (axillary) 37.2 degree Celsius, BP 108/57 (lying, left arm), P 74 (strong bilateral), RR 16 (unlabored), O2 sat 100% on room air. Neurological: Confused when asked about name, place, DOB, and situation. Agitated at times. Unable to assess cognition. Sleepy most of the time. Unable to follow commands. PERRLA. Able to move all extremities well with limitation on the lower extremities. Does not respond to question appropriately. Uncooperative with care (bed bath) and combative. Respiratory: RR is 16, O2 sat is 100% on room air. Unlabored and spontaneous breathing noted without use of accessory muscle to breathe. No retraction or nasal flaring noted. No cough noted during shift. No adventitious sounds noted on bilateral lungs. Labs: CO2 level of 29 (WNL). Neutrophils (70) (high), Lymphs (15) (low), Monocytes (11) (high)- (07-10-2012), it can pertain to possible presence of infection such as pneumonia d/t immobilization. It can also pertain to colitis. Cardiovascular: HR 74 @ the PMI, regular S1 and S2 noted. No heart murmur or gallops noted upon auscultation. Radial pulses palpable with equal rate, rhythm, 2+ amplitude, bilaterally. Dorsalis pedis pulse weak with +1 equal rate and rhythm, bilaterally. Capillary refill <3 seconds. No signs of clubbing noted. RBC (7/11/2012) is 2.47 (low), might signify hemorrhage or anemia. Hgb (7/11/2012) is 8.9 (low) and Hct (7/11/2012) is 25.2 (low), indicative of an anemia, possible hemorrhage d/t GI bleeding and ESRD. The kidneys were damaged as a secondary complication of liver cirrhosis, Erythropoietin was suppressed thereby decreasing RBC production. It can also signify DHN (dehydration) d/t decrease fluid intake.

Skin: Skin color is appropriate to race, uniform over body. Skin temperature is warm and dry bilaterally on both upper and lower extremities. Skin turgor elastic. Mucous membrane pink and moist without notable lesions. No signs of cyanosis noted circumorally and peripherally. Eyes and skin appears jaundiced. No redness noted on the coccyx, occipital area and the heels of his foot. Fingernails are trimmed and no nail clubbing present. No ecchymosis or abrasion noted. GI/GU/Nutrition: Appears cachectic, probably d/t muscle wasting. Abdomen soft, round and non- distended. Tenderness was palpated on the RUQ probably d/t inflamed liver. No signs of ascites noted. Hypoactive bowel sounds throughout all 4 quadrants. Patient is incontinent with dark yellow colored urine and strong concentrated odor. (reported to RN). Patient is in Lactulose as scheduled order for decreasing ammonia level and causes the patient to have BM. Diet order with clear liquid and advance as tolerated. Ate 25% of his foods for breakfast and lunch. BMI is 20.2 signifying a normal weight. Strict I&O needs to be observed. Lab Values: BUN (7/9/2012) is 25 (high); Creatinine (7/11/2012) is 0.95 (normal); GFR (7/11/2012) is >60 (normal) signifying normal functioning of the kidney in filtering metabolic waste of the body. Albumin level (7/11/2012) is 2.4 (low) signifies poor nutrition. Blood glucose of 141 (hyperglycemia), maybe related to stress d/t present condition. No alcohol serum value available on his chart. Musculoskeletal: Able to move all extremities with limitation on the lower extremities. Passive ROM needed for lower extremities. No ambulation was observed during my shift. Patient is risk for fall. Able to move head from side to side without crepitus or limitation. Pain: Unable to assess for pain d/t confusion. No nonverbal cues was noted to proved for pain. Psychosocial: The patient has poor family support. Friend is available for him every day to check on him. History of alcohol abuse prior to hospital admission, no history of smoking documented in his chart. Patient belongs to Ericksons Psychosocial Developmental Stage Generativity vs. Stagnation. Sleep: Sleeps during my shift. Lines&tubes: No lines and tubes noted.

Interpreting
List and Prioritize 3 top nursing diagnoses for management of this patient. 1. Imbalanced Nutrition: Less Than Body Requirement related to continuous refusal of eating his meals as manifested by decreased level of albumin (2.4), and muscle wasting.
2. Impaired Liver Function related to alcohol abuse as manifested by increase in bilirubin (4.5), increase in ammonia level of 79, PT of 19.8, jaundiced skin and sclera of the eyes.

3. Acute Confusion related to alcohol abuse and increase level of ammonia as manifested by increased agitation and fluctuation in level of consciousness.

1. 2.

GOALS FOR CLIENT

The patient will eat at least 50-75% of his meal tray during my shift. (short term) The patient will exhibit no signs and symptoms of malnutrition by the time of discharge from treatment as evidence by albumin within normal limits, a steady weight gain will be demonstrated, and increased in energy in participation in activities by discharge. (long term)

3.

The patient will demonstrate behaviors or lifestyle changes to limit effects of condition as evidence by liver function studies within normal limits and absence of jaundice, hepatic enlargement and no alteration in mental status by discharge. (long term)
The patient will be oriented to name, date, and situation during my shift. (short term) The patient will initiate lifestyle or behavior changes to prevent or minimize recurrence of problem and will maintain usual level of mentation and reality orientation by discharge. (long term)

4. 5.

Responding
NURSING INTERVENTIONS :
1. 2. 3. 4. 5. 6. 7. 8. In collaboration with dietitian and the patient, determine number of calories required to provide adequate nutrition and realistic weight gain. Weigh client daily. Determine clients likes and dislikes, and collaboration with dietitian to provide favorite foods. Ensure that client receive small, frequent feedings, including a bedtime snack, rather three larger meals. Stay with the client during meals to assist and to offer support and encouragement.

Review results of laboratory tests and diagnostic studies such as bilirubin and ammonia. Assess for jaundice in the skin and the sclera of the eyes and altered mentation. Assist RN to prepare banana bag to support the nutritional status of the patient especially when intoxicated with alcohol. 9. Administer medication that decreases ammonia level (Lactulose). 10. Evaluate the effectiveness of the therapy by assessing the lab studies and nutritional status of the patient. 11. Observe for changes in behavior and mentation: lethargy, confusion, slowing or slurring of speech, and irritability. 12. Note development or presence of asterixis, fetor hepaticus, and seizure activity d/t increased ammonia level that can lead to encephalopathy. 13. Reorient to time, place, person, situation. 14. Maintain a pleasant and quiet environment and approach in a slow calm manner. 15. Reduce provocative stimuli and confrontation. Refrain from forcing activities.

Reflection in Action / Evaluation

1.

Client Response to Actions:

Goal was not met The patient did not eat his breakfast and lunch despite of encouragement. The patient only consumed 25% of his meal tray on both breakfast and lunch. The patient verbalized GO away, I dont need you here. Prior to breakfast I provided oral care for the patient to increase his appetite and stimulate his food intake. I positioned the patient in a fowlers position to prevent aspiration. 2. Goal was partially met. The patient still shows jaundiced in the sclera of his eyes and skin. The ammonia level is still elevated d/t discontinuation of lactulose per MD order. 3.

Adjustment of Nursing Interventions and PLAN OF CARE for Your Patient: 1. Incorporate the patients likes and food preferences to stimulate the appetite of the patient and increase consumption of food. 1. Suggest to the RN or to the physician that the patient should receive multivitamins and continue to administer Lactulose. Unfortunately the PCP discontinued all the patients medications including Lactulose that helps lower the ammonia level of the patient. 2. Administration of Lactulose is necessary for the patient to lower his ammonia level. Increased ammonia level leads to continual confusion or altered mental status. Continue to reorient the patient by writing his name and todays date on the board.

Reflection-on-Learning and Clinical Learning

WHAT DID YOU FEEL YOU DID WELL? Ive used a lot of therapeutic communication during my nursing care for my patient. I communicated a lot with my nurse regarding the status of my patient.

WHAT DO YOU FEEL YOU NEED TO IMPROVE ON? I need to continually improve my communication skill.

WHAT SIGNIFICANT KNOWLEDGE DID YOU GAIN THAT WILL MAKE A DIFFERENCE TO YOUR FUTURE PRACTICE? Communicating to a patient with altered mental state of confused is quite challenging but I appreciated the effects of therapeutic communication in establishing trust and rapport to my patient.