FORMAL CARE PLAN MEPN 556

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Nov 2, 2013 (3 years and 9 months ago)

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FORMAL CARE PLAN

MEPN 55
6



By: Alberto Amezquita


Spring 2010

University of San Diego


Medic慬
-
Sur杩c慬 F潲m慬 C慲e Pl慮



MEPN 556


Student Name: Alberto Amezquita









Date of Care:


2/11/10






Health Care Setting: Scripps

Green Hospital, 4 North Medical
-
Surgery



Demographic Data:

Initials of client: J.R. Age: 46 Sex: Male


Admitting Medical Diagnoses:

Hepatic Encephalopathy


History of Present Illness
:
J.R. is a 46 year old man who is on the liver transplant list. He has
end
-
stage liver disease secondary to alcoholic cirrhosis
with complications of his cirrhosis including hepatic encephalopathy (liver failure causing coma, altered LOC, and confusion)
, spontaneous bacterial
peritonitis (with recent admission for extended
-
sp
ectrum beta
-
lactamase E. Coli peritonitis), diuretic refractory ascites (ascites not mobilized by sodium
prevention and maximum diuretic use), non
-
bleeding esophageal varices, hyponatremia (plasma sodium level less than 135 mEq/L), partial portal vein
thro
mbosis with a history of acute kidney injury, and his last admission required hemodialysis temporarily with subsequent normal
ization of his renal
function.



The patient was at a rehab facility in Las Vegas, became encephalopathic and was transferred to a local hospital where he was

treated with Neomycin 1
g PO Q6 in addition to Lactulose 40 g PO TID. He was given diuretics as well and developed acute renal fai
lure with his creatinine in the mid 3’s.
During his stay he slowly improved. On transfer J.R. said that he feels well. He doesn’t have any complaints and denies abdom
inal pain and confusion.
He is A&O x3. He does not have any asterixis (tremor of the wrist

during dorsiflexion). He denies at fever or chills, shortness of breath, chest pain,
cough, abdominal pain, hematemesis, BRBPR, or melena (black, tarry feces). J.R. denies nausea and vomiting. He has had many b
owel movements, at
least 5 per day. He notes
a decrease in lower extremity edema, but possibly some increase in abdominal girth.


Past Medical History
:

1.

End
-
stage liver disease secondary to alcoholic cirrhosis with complications as stated in the client’s history.

2.

Anemia of chronic disease


anemia as a result of chronic disease like liver failure.

3.

Hyponatremia that has possibly caused his history of seizures.

4.

Listed for transplant with type O blood, latest MELD score of 29
-

Model for end
-
stage liver disease. A s
core of 29 translates into an approximately
76% chance of mortality within 3 months unless a liver transplant is carried out.

5.

History of acute kidney injury in the past requiring dialysis with subsequent normalization in creatinine levels


Reflects GFR,
with higher than
normal levels showing impaired kidney function and damage.

6.

Hypothyroidism


insufficient production of thyroid hormones by the thyroid gland.

7.

Hypertension

8.

DM 2

9.

MDS


Myelodysplastic syndrome. A bone marrow disorder characterized by the u
nderproduction of one or more types of blood cells due to
dysfunction of the marrow.

10.

Osteoporosis

11.

History of ESBL E. Coli spontaneous bacterial peritonitis treated with ertapenem in the past. This is a strain of E. Coli tha
t is resistant to beta
-
lactam an
tibiotics, making many (or all) of the penicillins and cephalosporins ineffective as therapy. Ertapenem is a carbapenem antib
iotic used for
gram negative bacteria like E. Coli.

12.

Hernia.


Vital Signs 0730: T

37.2


HR

102


RR

20


BP

81/55


Ox sat: 97% on

2 L NC, Accucheck


178. Dawn (RN) notified about slight
tachycardia, low systolic BP, and blood glucose at 150
-
199 (meds delivered).


Vital Signs 1100: T

37.5


HR

111


RR

18


BP


83/55


Ox sat: 97% on 2 L NC, Accucheck
-

100



Noon
HTN meds withheld due to low BP (systolic BP<90 mmHg).


Oxygen needs
: 2 LPM NC that needs to be weaned off if the client is consistently saturating at 92% or more.

Diet:
1.5L Q24 fluid restriction, low sodium ADA diet. Carbohydrate controlled diabetic di
et. Low sodium and fluid restriction to help reduce ascites.

Activity:
Bed rest. Body position alternation at 0800, 1030, and 1230 to prevent further skin breakdown (buttocks wound with developing

pressure
wound). Scrotal elevation to prevent edema and chance of pressure wound. J.R. may ambulate as tolerated, but the only amb
ulation that was carried out
during my shift was to and from the bathroom with assistance from his wife. He was very frail and weak.

Last BM:
2/11/10, 1000

Hygiene needs:
Full assist. Morning care carried out by his wife.

ROM:
Decreased due to anorexia, w
eakness, and ascites.

Code status:
Full.

Last weight:
55kg

Allergies:
Neomycin

IV site:
PICC

line: R upper arm, 22 gauge IV:
L upper arm.

IV fluids:
None

Precautions:
Reverse contact precautions (to prevent infection from visitors and staff). Patient wa
s on fall and aspiration precautions given history of
encephalopathy (1/14/10) but both were discontinued before my arrival.


Risk for Altered Body Temperature: No, due to controlled room temperature and appropriate bedding. R/T:

23 degrees C

Biophysical
Dimension

Pain/Altered Comfort

Lab/Diagnostic Data


Pt’s physical state (anorexia, muscle wasting, jaundice, and ascites) suggests
considerable pain and discomfort, but the client did not report any AM or PM
pain. There were no scheduled pain medications
at 0900 or 1200, and J.R. never
requested pain meds during my shift.




0700: Pt does not report
any pain. Visual pain
scale is at 2/10, but it is
hard to gauge; this patient
smiles occasionally and
shows high spirits with
family present.




Neurologic

La
b/Diagnostic Data


Client J.R. was awake and talkative when I arrived in his room. He was
accompanied by his wife and her brother. He is a native Spanish speaker but is
able to understand and say short sentences using English. There are no obvious
auditory, mechanical, or visual disturbances. Because of improvement, J.R. does
not display symptoms associated with hepatic encephalopathy (confusion, altered
LOC, coma).


Non absorbable antibiotics (rifaximin) and lactulose help suppress the production
o
f toxic substances in the intestines which may become systemic and cause hepatic
encephalopathy. Lactulose helps improve the generation of inabsorbable
ammonium and increase the transit of bowel content through the gut. An antibiotic
helps because ammonia
and other toxins are generated by intestinal bacteria, and
killing them can help reduce waste products that will be absorbed by the intestines.
D/C of rifaximin may have been done to promote normal intestional levels of
symbiotic bacteria that aid with dig
estion and nutrient/vitamin creation and
absorption.


Asterixis is a tremor of the wrist when the wrist is dorsiflexed. It is a sign of
hepatic encephalopathy: the liver is unable to metabolize ammonia to urea at the
rate and volume needed to prevent toxic
ity. Brain cells are easily damaged by high
levels of ammonia. This condition is seen in patients with decreased LOC and
increased stupor, secondary to liver cirrhosis or acute hepatic failure.




A&Ox4, Pupils equal,
round, reactive to light.
Oroph
arynx is clear and
mucous membranes are
jaundiced but still pink
and dry. Bilateral grip
strong. Bilateral pedal pull
and push is strong. No
asterixis. Currently taking
lactulose but rifaximin has
been D/C.








Cardiac

Lab/Diagnostic Data


Pt denies any
chest pain, and was tachycardic during entire shift (100
-
110 BPM).
Tachycardia can be attributed to low blood pressure, low fluid volume, poor
nutrition, low total protein, high creatinine, hyponatremia, hypochloremia,
borderline hypocalcemia, high alkalin
e phosphatase, and high thyroid stimulating
hormone (although this pt has a history of hypothyroidism). This patient also has a
high WBC count indicating infection, and low HGB, HCT, and RBC, indicating
anemia (
myelodysplastic syndrome)
. There may be other

factors stemming from
ascites, liver cirrhosis, kidney injury, diabetes, and history of hypertension that
affect J.R.’s cardiac state.















Tachycardic, normal S1,
and S2, no murmurs, rubs,
or gallops. Capillary refill
2
-
3 seconds on RUE,
RLE,
LUE, LLE
phalanges. Carotid, radial,
and pedal pulses present at
medium strength
bilaterally. No cyanosis or
clubbing present on upper
or lower phalanges.


Respiratory

Lab/Diagnostic Data


No difficulty in breathing seen. No signs of fremitus or crepitus

noted.
Diaphragmatic excursion is not present. MD order stated that oxygen was to be
weaned off of this patient if the oxygen saturation was consistently over 92%. I
questioned nurse Dawn about this since he was saturating well at 2 L/min, but she
recomm
ended not taking any action. Oxygen was removed during trips to the
bathroom and for morning hygiene without any change in J.R.’s alertness.


Clear to auscultation
bilaterally. No wheezes,
crackles, or rhonchi.
Accessory muscle use not
seen. Occasional cou
gh.

Oxygen at 2 L/min NC.
AM Ox sat was 97, and
Noon Ox sat was 100.

Gastrointestinal/Nutrition

Lab/Diagnostic Data


This client was NPO due to aspiration risk related to his history of
encephalopathy, but this was discontinued before my arrival. J.R. is

on an ADA
diet and a 1.5 L fluid restriction. He was able to consume about 50% of his
breakfast and 50% of his lunch. He was given Lactulose not to aid with digestion,
but to promote ammonia excretion in the colon (liver cirrhosis reduces ammonia
clearanc
e and conversion in the body, leading to toxic levels). He was also given
Saccharomyces boulardii caplets as a probiotic, since the systemic anti
-
infectives
he takes wipe out much of the bacteria living symbiotically in the intestines.
Ascites is the accu
mulation of fluid in the peritoneal cavity caused by liver
cirrhosis. Cirrhosis can cause portal vein hypertension, causing fluids to diffuse
out into the peritoneum. Esophageal varices are also a consequence of portal
hypertension secondary to liver cirrh
osis. Parecentesis is a procedure involving
needle drainage of fluid from the peritoneal cavity in the abdomen to relieve
pressure from ascites. End stage liver failure is secondary to alcoholic cirrhosis.
MELD score of 29 indicated J.R. has a 76% chance o
f mortality within the next 3
months unless he is able to receive a liver transplant.








Pt does not report any
nausea or abdominal pain.
No diarrhea. Abdomen is
soft and distended with
dullness to percussion
consistent with ascites.
Bowel sounds are
soft but
normal sounding. Last
BM was today at 1000,
when pt’s wife assisted
him to the toilet.
Esophageal varices.
Paracentesis was
performed on 1/8/10. End
stage liver failure, MELD
score of 29.

Genitourinary/Gynecologic/Reproductive

Lab/Diagnostic Dat
a


Pt has no dysuria or hematuria. He has a past history of hyponatremia (low blood
sodium), and acute kidney injury requiring dialysis, which could be related to
diuretic use and a prerenal azotemia (abnormally high level of nitrogenic wastes in
the
blood caused by inadequate blood supply to the kidneys), in addition to
neomycin, which can be nephrotoxic when used in conjunction with diuretics like
Lasix (which was d/c before I assumed care). Urine pH is within normal limits of
4.5 to 8. Trace ketone
s are seen in patients who have poor nutrition or have
diabetes. Ketones are the body’s response to a shortage of blood glucose, and are
the result of fat metabolism. His urobilinogen level is slightly low, resulting from
enzymatic jaundice (hyperbilirubin
emia syndrome) or drugs that make urine
acidic. His urine was acidic, at the lowest normal value on the scale (5
-
8).

























Bladder is non distended
and non
-
painful to
palpation. Pt urinated 3
times during my shift,
using the toilet with
assistance from his wife.
UA on 2/10/10 showed a
pH of 5.0, trace ketones,
and urobilinogen of 0.2.
All other tests came up
negative.


Integument

Lab/Diagnostic Data


Pt’s skin is brown (yellowed from jaundice), warm, and dry from core to all
extremities
. Jaundice is caused by hyperbilirubinemia, which causes biliruben to
pool in the extracellular space. The concentration of biliruben in the blood must
exceed 1.5 mg/dL for discoloration to occur (usual value is about 0.5 mg/dL). This
client had a level of

3.2 mg/dL, which is a little over 6 times the normal amount in
the blood. Cirrhotic liver is unable to metabolize and excrete biliruben leading to a
buildup in the blood. The wound on his right buttock was dressed with nurse
Dawn and the client was shifte
d to his right side and left side during my shift.
Microguard powder was applied to all reddened areas suspected of having a fungal
infection. Lowered skin turgor may be due to dehydration (low blood pressure and
tachycardia). Pt is on fluid restriction du
e to ascites, thus complicating his
hydration.

Developing pressure wound is a stage 1 pressure ulcer.






Pt has jaundice (TBILX
3.2 mg/dL) and ascites.
Skin, mucous membranes,
and sclera (icteric sclera)
are yellowed. No edema is
present on extremities.

Pt
has a small wound on his
R buttock and a
developing pressure
wound on his L buttock.
Wound was dressed and
the client was moved Q2
hours. Skin is warm and
dry. Fungal infection of
perineal area, abdominal
and lateral abdominal skin
folds, and arm pits.

Skin
was reddened in these
areas. Skin turgor is less
than normal on
extremities. Pt has very
little fat.













Musculoskeletal

Lab/Diagnostic Data


Pt has decreased muscle mass for his height (anorexia), secondary to chronic
disease, and
previous poor PO nutrition. He has low total protein levels (normal
range 6
-
8 g/dL), and when levels are low the body will metabolize skeletal muscle
and fat stores for energy use. A sign of skeletal muscle breakdown is high levels of
BUN and creatinine,
both of which are evident in J.R. Although J.R. is weak he
still has the ability to move on his own and make it to the bathroom with some
assistance.





Pt has muscle atrophy. TP
5.4 g/dL. Creatinine 1.6
mg/dL (0.7
-
1.3 N), BUN
61 mg/dL (7
-
21 N). Pt
was tu
rned during shift
and ambulated to and
from the bathroom. Pt is a
fall risk because of his
previous hepatic
encephalopathy.

Renal/Metabolic

Lab/Diagnostic Data


High blood urea nitrogen occurs when the kidneys do not clear urea efficiently,
secondary to
nephritic impairment and lowered GFR. J.R’s value of 61 indicates
moderate to severe level of renal failure, caused by chronic disease of the kidneys
secondary to increased levels of serum toxins secondary to end stage liver failure.
Because this patient’s

BUN:Creat ratio is greater than 20, he is said to have
prerenal azotemia, another sign that pathologic process is unlikely due to intrinsic
kidney damage.


Pt’s blood glucose was high at 0530, and high at 0730. The sliding scale
recommended 2 units of ins
ulin for a value 150
-
199, so rapid acting Novalog was
delivered.


Low TCO2 applies to all forms of carbon dioxide in the blood, including
bicarbonate and carbonic acid. Bicarbonate accounts for 95% of the CO2 in the
blood, so measuring TCO2 is a good esti
mate. Normal levels are 23 to 30 mEq/L,
indicating J.R. has some form of alkalosis.


Total protein and biliruben have been discussed. J.R’s GFR is less than 60
mL/min/1.72m2, indicating chronic kidney disease. GFR is calculated from serum
creatinine values

using the Modification of Diet in Renal disease (MCRD) Study
equation. Low GFR indicates glomerular damage, and a lowered ability to pull
metabolites and toxins from the blood stream.


High creatinine levels are indicative of nephritic damage. In J.R’s ca
se it is also
due to increased skeletal muscle breakdown so that the body may use protein for
energy.


J.R. is hyponatremic and hypochloremic, indicating that his nephrons aren’t

Pt urinated 3 times during
my shift, producing clear
yellow urine. Pt did not
feel any
pain on his lower
abdominal area, and
reported no pain upon
urination.

Labs from 0530 draw on
2/11/10

Clear, specific gravity
1.020.

BUN (H: 61), glucose (H:
222), TCO2 (L: 20), TP
(L: 5.4), TBILX (H: 3.2),
GFR (50), CREAT (H:
1.6), NA (L: 127), CL (L:
94)
, Ca+ (L: 8.4), ALK
(H: 249).

2/11/10 Urinalysis view:

pH (5.0) acidic, ketones
(trace), urobilinogen (0.2).

DM:
AM blood glucose
of 178 (2 U insulin
delivered), Noon blood
glucose of 100.

Other:

Pt had a blood draw
pulling these ions back into the blood stream efficiently, and he needs IV fl
uids to
replace them.


Pt’s calcium level is at the lowest value within the normal range, 8.4. About half
the Ca+ in the blood is bound to serum proteins (which are low), and the other half
are unbound. If a pt has abnormal blood protein levels the plasma
Ca+ assay may
be inaccurate. Low ionic Ca+ can be a result of alkaline blood (indicated by low
TCO2) and low PTH (not tested in this pt).


Alkaline phosphatase is high, indicating a blockage of flow in biliary tracts or a
build
-
up of pressure in the liver.

It is also indicative of kidney damage.


PICC line occluded because of blood becoming stagnant during the blood draw.
HCL and Alteplase were administered to dissolve the clot, with lidocaine being
administered before to reduce any pain. Physical vacuum
and pressure were given
using a 10 ml NS flush at the port, and eventually the clot was sucked into the NS
flush. More blood was drawn to remove further clots, and the port was closed
using the SASH method. Port #2 was used for the blood draw, and closed u
sing
the SASH method.


MELD score on 2/11/10 based on lab values: 18. 90 day mortality rate of 0.19, or
19%. This is much different than the MELD score of 29 (90 day mortality rate of
76%) that was given upon his hospital admission

on 1/14/10. Because of h
is
improvement his score has changed. Due to MELD score and UNOS transplant
policy, his position on the waiting list for a liver transplant will not change.












scheduled at 1000 from
his PICC line, bu
t the line
clotted. Blood draw was
delivered at 1100 when
the line was cleared.










Immune/Hematopoietic

Lab/Diagnostic Data


Pt is immunocompromised, showing a lymphocyte level of 2.7. This level can be
attributed to poor PO nutrition, a history of thrombocytopenia, and infection
(ESBL E.Coli peritonitis). Pt does not have a history of hypersensitivity or allergic
reactions, oth
er than a drug allergy to Neomycin. Pt has bone marrow suppression
secondary to acute infection and chronic
myelodysplastic syndrome
.
Hematopoesis has been decreased, demonstrated by a RBC count of 2.56, HGB
count of 9.5 and HCT count of 27.3. PLT level is

71 indicating thrombocytopenia.
Neutrophils are high, indicating infection. RDW is increased, showing that size
and shape of RBCs being produced are inconsistent with mean size values. This
can also be attributed to chronic disease,
myelodysplastic syndro
me
, and bacterial
infection altering normal erythropoiesis. Absolute neutrophil and monocyte count
are both high, which are indicative of an acute infection. PTT/PT/INR are
indicative of thrombocytopenia and increased clotting time. Thyroid stimulating
hor
mone is high secondary to hypothyroidism. Troponin levels are increased
during infections and severe kidney disease, both of which are evident in this pt.


Labs:

PTT (H: 38.3), PT (H:
13.7), INR (H: 1.3), WBC
(H: 13.5), HGB (L: 9.5),
MCV (H: 107.0), PLT (L
:
71), LYM (L: 2.7), NEU
(H: 11.4), MONO (H:
1.6), RBC (L: 2.56), HCT
(L: 27.3), MCH (H: 37.1),
RDW (H: 16.5), NEU (H:
84.9), LYM (L: 0.4), TSH
(3.3), Cortisol Random
(14.2), Troponin
-
I (0.17)










Behavioral Dimension

Activity/Rest & Sleep


Pt J.R. stated that he has not been sleeping well, and got around 4
-
6 hours of sleep last night. He stated that it
was mostly due to being woken up by hospital staff coming in and out of the room, and taking laboratory
samples for various tests. Recently h
e has started walking to and from the bathroom with little assistance, but he
did not have enough energy to go for a lap around 4N. Although it seems as if he is very weak (atrophy and
anorexia), he is able to give a very firm handshake, and show strength
with his pedal push and pull. He knows
that he still has strength in these areas and was happy to try and squeeze my hand as hard as he possibly could.
He is a former carpenter and has yielded a hammer for many years.
During the AM shift he was able to nap

for
about 2 hours.
I tri
ed to coordinate my assessment
with the pt’s nurse and MD assessment time so that the
patient had longer intervals of rest between interrup
tions.
Leisure activities are comprised of reading and
watching TV, as well as time spent wi
th family members.



Consumption Patterns


Patient was NPO because of hepatic encephalopathy, but is now on an ADA diet. He ate half of his breakfast
and lunch. Pt consumed alcohol heavily and smoked heavily from his teenage years up until 2004. Pt
rarely
consumes beverages with caffeine
.

Sexuality


Pt is sexually active with his wife, but has not had any recent activity due to his medical condition.


Safety


Because of his previous encephalopathy this patient is a fall
and aspiration
risk. He ambulates with assistance.
He does not use any safety belts or assistive devices.
Pt does not use a hearing aid
or corrective lenses.
He has
his side rails up, bed locked, and assistance light and phone within reach. Also, he has a lot of family a
round
which can help alert staff in the event of an emergency.











Psychological Dimension

Self
-
Concept/Self
-
Perception
/Self
-
Esteem/Body Image


J.R. has been strong throughout his treatments but his level of confi
dence is questionable. I believe

that he
under
stands that he has a 76% chance of mortality
in the next 3 months
based on his
MELD score, and
he
may
be
depressed because of this. Also, he may be depressed over his odds of getting a liver transplant. Because of
his renal complications, and

the fact that his liver became cirrhotic because of chronic drinking, his priority on
the liver transplant list is low. Other than this, he seems happy to have his family around and is grateful for care
that is delivered to him. He is even forgiving towar
ds me, since it was largely my fault that his PICC line
became occluded while I was trying to take a blood sample to be sent to the lab. Having to watch
nurses

un
-
clot
his PICC line for half an hour is an a
nnoyance. Because of his weakened

state he is not
able to carry out all of
his ADLs.
Pt stated that he felt fine, but

it was evident that he was not happy with the look of his body:
atrophied, jaundiced, anorexic, and ascitic. His wife seemed like she was very sad inside, but put on her game
face to assis
t her husband and get through the day. It is possible that J.R. was a lot more accepting of his medical
condition than his wife.



Emotional Mood/
Stress/Coping

J.R’s stress stems from the many variables associated with his current state of health
. The probable cause of any
depression that he faces is the knowledge of his
eminent
mortalit
y without a liver transplant
. He is glad to not be
experiencing encephalopathy anymore. J.R. and his wife did not indicate any other stressors
.







Socio
-
cultural Dimension

Role/
Interpersonal
Relationships
/Communication


J.R. and his wife are the parents of two children who live in Las Vegas, Nevada. He was in a rehab facility in
Las Vegas when he became encephalopathic, and was transferred to a nearby
hospital for treatment.


The majority of J.R’s family lives in Mexico, and much of his wife’s family lives in Mexico and Las Vegas.
J.R’s brother in law was also in attendance, but didn’t carry out any hands on care. He did supply a lot of moral
support an
d talked to J.R. about family things going on in Las Vegas.


J.R. has experienced some financial loss because he is no longer able to work as a carpenter. J.R. is
ha
ppy about
his

personal relationships and closeness to
his wife. His non
-
verbal behavior sho
ws that he

is appreciative of his
wife’s efforts.


Pt does communicate with healthcare staff and

family, but he is fatigued due to lack of sleep. He wants time to
relax.


Pt did not discuss any history of

psychiatric illness or physical and emotional abuse
.


Pt’ main source of income was
through
carpentry. His

main source

of emotional support is his wife, followed by
family members living in Mexico.


Values/Beliefs
/Education/Income/Cultural Affiliation


Pt is Roman Catholic.
He has a high school education

from Mexico
, and is no longer able to work as a carpenter.
He did not indicate any emergencies stemming from medical costs or being out of work.

Physical /Environmental Dimension

Living Arrangements/Pets


J.R. lives with his wife and family in Las Vegas, Nevada.
He did not state if he has any pets.



Health System Dimension

Health Perception
-

Health Management Pattern


Primary

health providers for J.R’s hepatic encephalopathy are Dr. Hillebrand MD and Dr. Singh MDF.
Pt

had
his last physical examination on 2/10/10. Pt was not sure about when his last visit to the dentist occurred. His
oral hygiene was average
.
Pt
did not state t
he type
of insura
nce that he has, but he did not

indicate

any di
fficulty

in obtaining healthcare services.
Pt is a blue collar worker and in his past he chronically subjected his body to
chemical stre
ssors like alcohol and cigarette

toxins.


Code Status:
FULL

Does patient have allergies to meds, foods, and la
tex? Explain: Patient is allergic to Neomycin.
Patient is not allergic to
latex or any foods.





























Diet & Routine/PRN Treatments

(Please state specific planned interventions)


Diet:
Patient is

no longer NPO as of AM shift, and was started on an ADA diet

this morning.


Hygiene:
Routine morning care consisted

of oral
hygiene and a shower. His shower was given with assistance of
his wife and CNA Xiomara.


Topics to teach:

Education in Spanish should be done regarding his MELD score, current placement on the liver
transplant list (and why he is not at the top of the list), the importance of adequate nutrition, and importa
nce of
ambulation and activity (especially in regards

to skin breakdown).


From a religious point of view, he would benefit from talking to a representative from the Catholic church about
the accep
tance of his medical condition. Also, this person can help him teach him ways to
maintain his self
concept while possibly going through the final months of his life.
I can t
ell that this patient would want to enjoy
his final months if his end is actually near.



Risk for Injury: (yes/no) R/T:
Yes. Although this patient has improved h
e is still
very
weak. Thus, he is still a fall
and
aspiration
risk.













Patient Learning Needs

(During days of care)



Areas of Knowledge deficit:




MELD score education

and p
lacement on liver transplant list given his alcoholic liver cirrhosis



Importance of nutrition
and DM management
for improvement of condition.



Import
ance of ambulation and activity (perfusion and skin breakdown).



Coping strategies for self and friends/family.


Preferred ways to learn:
Visual and audio

education.
Pictures
and interactive video and/or simple computer
based modules in both English and Spanish

(for understanding in both languages)
.
This patient

benefits from
the delivery of all important news and education in Spanish. He also benefits from short, simple, to
-
th
e
-
point
statements in English that don’t include jargon.


Barriers to learning:
His encephalopathy has gone away so he is not experiencing any delirium. This patient is
fatigued and may be in some pain (although he may not admit to it), both of which may
make it hard for him to
focus and absorb information. The main barrier to his education at Scripps is that he may not understand
complex words and concepts in English.


Spec
ial adaptations for learning:
A
certified medical
translator who will not cause an
y words or concepts to
be lost in the translation.




Client’s Discharge Planning Needs:

When discharged, the patient will be
attending a skilled nursing facility in Las Vegas.


Appropriate Referrals Needed To Other Members Of The Health Care Team:


MD


Patient has had consistently low blood pressure, and should not have to take medicine for HTN if his s
ystolic pressure is under 90 at all times.

Updated MELD score on chart.


Nutritionist


If this patient cannot take in enough calor
ies, and nutrients
(fats, carbohydrates
, protein) in the correct ratio
, then other methods of
nutrition delivery needs to be considered. Options are frequent high calorie snacks, NG tube feeding, or TPN.
He was just started on the ADA diet so it
is not surprising that he onl
y ate about half of the food given to him today.


Wound care


Stage pressure ulcer on his left buttock, and assess wound on his right buttock.


Client Teaching For Discharge:
(include Health Maintenance and Health Promotion and consider health literacy

issues)

In English and Spanish:



MELD score
education


The number

is
not set in stone, and improvement in co
ndition may decrease the score, just like deterioration may increase
the score.
Week to week change in score does not change position on the UNOS l
iver recipient list.



Importance of nutrition and DM management for improvement of condition


The correct diet that should be followed at home, and how this diet
will lead to progress

and prevention of
decline
.



Importance of ambulation and activity


Why

and how physical activity helps, and which daily activities are suitable for J.R. given his
current
ability.



Education on how to discuss current and future state of health and mortality with friends, family, and loved ones who have qu
estions.
For education
in this area a Catholic priest or other spiritual/religious figure may be beneficial.


1.

Client Care Plan: Problem One

Date:

2/11
/
10

Pt. Initials:

J.R.

Student Name:

Alberto Amezquita

Nursing Diagnosis

Expected Outcome

Nursing Intervention

Evaluation

Patient is at risk for imbalanced
nutrition: less than body
requirements, related to

chronic

disease (
myelodysplastic
syndrome, bacterial infection,
diabetes, end stage liver failure)
and poor PO nutrition,
as
evidenced by
low blood protein
and nutrients, skeletal muscle
wasting, and low body weight/mass
vs. height.

Patient will hav
e a level of PO
nutrition that meets his daily
caloric requirement, with factors
such as chronic disease and body
muscle/fat losses included in
this
calculation. If caloric intake cannot
be met PO, tube feeding or TPN
feeding will be considered.

Daily weight.

This pt is malnutritioned, on fluid
restriction, slightly dehydrated, and
being treated to reduce ascites. He
is at risk for fluid loss or

gain, and
needs to be monitored daily for
weight fluctuation. A goal is weight
gain while staying properly
hydrated and eliminating fluid from
the peritoneal cavity.



Monitor food intake; record
percentages of served food that is
eaten; consult with di
etician for
actual calorie count.


PO nutrition will either be met or
unmet after monitoring intake of
diet proposed by the dietician. If it
is met, current regimen will
continue. If unmet, other nutrition
options will be considered to meet
daily caloric
intake.



Observe the client’s relationship to
f潯o⸠Attem灴 t漠oe灡rate 灨ysical
fr潭 灳ych潬潧ocal causes fr潭
eating 摩ffic畬ty⸠


There is a⁰潳si扩lity that this
灡tient may 扥⁲efusi湧 t漠oat
en潵gh cal潲ies at⁥ach meal
扥cause it may 扥⁴he 潮ly
w
ay he
can ex灲ess s潭e c潮tr潬⸠
Als漬o
given his 歮潷le摧e 潦 his jbia
sc潲e E㜶T⁣hance 潦 m潲tality in ㌠
m潮ths 潲essF his 灯pr⁤ et may 扥
linked to depression/hopelessness.
If not any of these issues, it may be
as simple as adjustment to new
ADA diet
, different foods options,
and recent D/C of NPO status.




Offer small quantities of energy
-
dense and protein
-
rich food, served
in an appetizing fashion, at
frequent intervals (between meal
snacks).

Fortified foods that taste good and
are served in sma
ll portions may be
more acceptable to this client.
Added intake will result in
increased levels of blood protein,
fat, and vitamins.




This client may lack endurance, so
rest periods before meals, open
packages, and cut up food will
assist with eating.


This patient is lucky to have his
wife and family assisting him
throughout the day. When they go
on break (which is highly
important) the nurse’s assistance
will help conserve the client’s
energy for eating.



Discussion of Pathophysiology & Rationale
for the Problem:


Due to patient’s current medical state (
myelodysplastic syndrome
, anemia,

renal impairment
,
electrolyte imbalances,
poor n
utrition, current
medications, bacterial infection of the peritoneum, and end stage liver failure
) the patient is
experiencing a nutrition imbalance.
It is highly likely that
each of the patient’s health problems h
as had an additive affect on his ability to hold weight. When a patient is malnutritioned he or she will start to
use glycogen stores in the liver as energy
. When this is exhausted the body will first break down cardiac and skeletal muscle so that it may convert
protein into usable energy. As malnutrition continues the body’s ability to metabolize fatty acids catches up, and fat stores

are used over skeletal
muscle (cardiac atrophy slows drastically). When fat stores are near depletion the body will begin to metabolize skeletal mus
cle at a higher rate again,
as well as proteins found in other organs and tissues.
If this patient can take in
the required
calorie
s via PO route then the necessary steps need to be
taken to prevent further wasting. If this patient cannot obtain the necessary amount of calories orally
,
other nutrition options need to be taken into
consideration. Some appropriate methods are NG tube fe
eding, TPN, or gastrostomy tube feeding.


Client Care Plan: Problem Two

Date:

2/11
/
10

Pt. Initials:

J.R.

Student Name:

Alberto Amezquita

Nursing Diagnosis

Expected Outcome

Nursing Intervention

Evaluation

Patient is at
risk for ineffective
tissue perfusion/deficient fluid
volume resulting from
hypotension, as evidenced by low
systolic and diastolic blood
Cardiac pump effectiveness,
circulation status, f
luid balance,
hydration, tissue perfusion: cardiac,
cerebral, peripheral, urinary
elimination.

Check all pulses bilaterally. If
unable to find them, a Doppler
stethoscope will be used. MD will
be notified if new onset of pulses
aren’t present.

Diminished

or absent peripheral
pulses indicate arterial insufficiency
with resultant ischemia.

pressure, tachycardia, and impaired
tissue perfusion at extremities.



Encourage client to walk with
compression stockings on and
perform toe
-
up and point
-
flex
exercises.

Exercise helps increase venous
return, builds up collateral
circu
lation, and strengthens the calf
muscle pumps.



Note skin texture and the presence
of hair, any additional ulcers, or
gangrenous areas on the legs or
feet.

Thin, shiny, dry skin with hair loss,
brittle nails, and gangrene or
ulcerations on toes and ant
erior
surfaces of the feet are seen in
clients with ineffective tissue
perfusion.



Fluid restriction of 1.5 L per day
will be met (but not exceeded) via
PO and IV fluids.

Proper hydration will decrease
tachycardia, increase blood
pressure, and improve
tissue
perfusion at extremities.



Client educ
ation


recognizing the
signs a
n
d symptoms that should be
reported to a physician (change in
skin temp, color, sensation,
presence of new ulcers anywhere
on the body).

Question the patient to see if they
understand or require more
education. Prevention of further
complications is more efficient vs.
trying to fix problems that have
already occurred.

Discussion of Pathophysiology & Rationale for the Problem:


This patien
t has low vascular fluid volume resulting in hypotension. To compensate, the heart is beating faster (tachycardia) to keep up

with cardiac,
cerebral, peripheral, digestion, and urinary oxygen demand. Unfortunately this patient has impaired oxygenation abil
ity secondary to
myelodysplastic
syndrome, anemia, bacterial infection, diabetes, end stage liver failure, and poor venous return secondary to bed rest. Ascit
es management and renal
impairment prevents the administration of IV fluid bolus to help raise vas
cular fluid volume and diminish hypotension. Interventions will be targeted
at improving the transport of oxygen throughout the body, especially in tissues which are at risk of ischemia.

Client Care Plan: Problem Three

Date:

2/11
/
10

Pt. Initials:

J.R.

Student Name:

Alberto Amezquita

Nursing Diagnosis

Expected Outcome

Nursing Intervention

Evaluation

Patient is at
risk for
further
impairment of skin integrity
resulting from mechanical factors,
medications, bed
-
rest, jaundice,
fluid retention, emaciation,
impaired metabolic state,
immunological deficit, diabetes
mellitus, and impaired sensation, as
evidenced by
a small wound on his
R buttock and a developing
pressure wound on his L buttock.



Tissue integrity: skin

intactness
will improve as evidenced by
the following factors: skin
intactness/integrity not
becoming

further
compromised, and tissue
perfusion
and temperature
be
ing

indicative of conditions
optimal for healing.



Client will regain integrity of
skin surfa
ce, report any altered
sensation or pain at his sites of
skin impairment, demonstrate
understanding of plan to heal
skin and prevent further injury,
and describe measures to
protect and heal the skin and
care for any lesion.

Determine that skin impairment

involves skin damage only (partial
thickness wound, stage 1 or stage 2
pressure ulcer).

Developing pressure wound on L
buttock is a stage 1 pressure ulcer
because of the following indicators:
warmth, firm tissue consistency,
redness, and lack of sens
ati
on in the
area. Also, there is no partial
-
thickness skin loss involving the
epidermis or dermis. It does not
appear as an abrasion, blister, or
shallow crater.




Ensuring that client is not
positioned on the site of skin
impairment. Turn and position
every 2 hours. Transfer client with
care to protect against the adverse
effects of external mechanical
forces like pressure, friction, and
shear.

Client was turned ev
ery two hours,
and was repositioned on his right or
left side with pillow use. Pt was
ambulated to and from the
bathroom with assistance.
Client
was educated as to why he had to be
repositioned; he preferred to lay on
his back while under bed rest.



Ass
ess the client’s nutritional
status. Refer for a nutritional
consult and/or institute dietary
supplements as necessary.

Optimizing nutritional intake,
including calories, fats, protein,
vitamins, is needed to promote
wound healing. A nutritional
assessmen
t and treatment plan has
been done, and this patient is on a
2200 calorie per day ADA diet.
This client’s nutrition has been
discussed, but it is one of the most
important factors in his overall
healing process, not just skin
integrity.



Identify the cl
ient’s phase of
wound healing (inflammation,
proliferation, maturation) and stage
of injury.

Accurate
understanding of tissue
status combined with knowledge of
underlying diagnosis provides

a
basis for determining appropriate
treatment objectives. No sing
le
wound dressing is appropriate for
all phases of wound healing. Nurse
Dawn determined that this patient’s
R buttock wound was due to tear,
and was healing. The client’s L
buttock stage 1 pressure ulcer was
not healing, and thus a potential
problem.



I
nitiate a consultation for a
case
assignment with a wound care
nurse to establish a comprehensive
plan for

J.R’s impaired skin
integrity.

The wound care nurse was
scheduled to have a consult with
this client and assess his two
buttock wounds, but she did
not
visit him during my shift. The
wound care nurse can properly
stage his pressure ulcer, a
ssess and
dress his buttock tear
, and educate
the client about skin care in the
hospital and at home.


Discussion of Pathophysiology & Rationale for the Problem:


Pressure ulcers are caused

by a decreased blood supply paired with

reperfusion injury when blood flows back into ischemic tissue. Ischemia can lead
to tissue damage and cell death, which can happen faster in patients with a long list of risk factors (like

J.R.). J.R’s stage 1 ulcer is reddened but not
painful, most likely due to diabetic neuropathy. Neuropathy is the deadening of peripheral sensory nervous

tissue secondary to metabolic, chemical,
and glucose imbalance.
Many patients cannot actually feel th
e development of their ulcer. If left untreated, this ulcer will eventually develop into a
stage two or worse.


This client has a long list of problems as mentioned before, and each concern increases the risk of skin breakdown and furthe
r complications (l
ike
i
nfection).

Although there is much to blame for his impaired skin integrity, it was ultimately mechanical factors that caused J.R’s skin
to tear
on one
buttock,
and develop a pressure ulcer

on the other
. If this client had changed position every two ho
urs, spent some time in his chair, and ambulated a
little more it is possible that he would not have developed skin breakdown. Because he didn’
t, friction and pressure forces caused mild damage.




Client Teaching Care Plan

Knowledge Deficit 1:

NDx

-

Knowledge deficiency: MELD score as evidenced by the following indicators: inaccurate interpretation and
understanding of the MELD score and UNOS liver transplant waiting list. Related factors are unfamiliarity with how the MELD s
core is
calculated,
low kn
owledge base of how UNOS ranks transplant patients, and all previous and current education about MELD and UNOS
delivered in English

ins
tead of Spanish (using proper medical terminology).

Date:

2/11/10

Pt. Initials:

J.R.

Student Name:

Alberto Amezquita


Topics to teach

Expected Outcomes

Bilingual
Teaching Methods

Translator Present

Evaluation

1. What is the MELD score?



Pt understands purpose of
MELD score.



Pt understands MELD score
range.



Pt understands lab values used
in the MELD calculation.



Pt understands how waiting
time is calculated using MELD
score.



Pt knows his own MELD score.



Verbal education in both English
and Spanish, with emphasis on
Spanish translation at the
bedside.



Image of MELD score bar or
graph, in both English and
Spanish. Visual can be computer
based, on a poster, or in a binder.



Lab values
verbally
described in
simple terms

using images
showing what organs are
targeted.
Biliruben


measures


Pt will explain what the
MELD score is in his own
words.



Pt will state where he falls in
the MELD score range.



Pt will state the 3 lab values
used to determine MELD
score (INR, TBILX, CREAT),
and give a description of each
in his own wor
ds.



Pt will calculate a MELD
score using computer software
how effectively the

liver excretes
bile. INR (prothrombin time)
-

measures the liver’s ability to
make blood clotting factors.
Creatinine


measures kidney
function. Impaired kidney
function is often associated with
liver disease.



Chart showing four MELD
levels, and what ea
ch level
means.

and provided lab values.

2. How does the liver transplant
waiting list work?



Pt understands where and how
donor organs are offered to
patients.



Pt understands factors which
determine organ dono
r
matching.



Pt understands how individual
priority is determined on the
UNOS (United Network for
Organ Sharing) waiting list.



Verba
l explanation and graphic
showing

where a potential liver
may come from.



Poster or computer based visual
showing
and explaining
the
factors that

determine recipient
match

(blood type, Rhesus
factor)
.



Verba
l explanation and graphic
showing

how UNOS uses these
same factors to determine
placement on waiting list.



Pt will state where a donor
or
gan may come from in San
Diego C
ounty,

and how
someone would receive a liver
from out of state.



Pt will be able to state some of
the main factors that
determine how a liver is
matched with a patient.



Pt will be able to stat
e how
UNOS makes their liver
transplant priority list.

3. Are there any special
exceptions?



Pt understands exceptions that
assign a higher MELD score
vs. what is determined by
laboratory results.



A v
isual showing and explaining
special case exceptions that merit
a higher MELD score

(dialysis,
alcohol cirrhosis, multiple organ
failure)
, and verbal explanation.
Also, exceptions that are no
longer allowed will be discussed.



Pt will be able to state some of
the exceptions that cause the
MELD score to be higher, and
some of the exceptio
ns that are
no longer used.

4. What is the average MELD
score for a patient who is receiving
a transplant?



Pt knows national average
MELD score for transplants.



Pt knows average wait time for
a liver transplant, and
exceptions to this number.



Verbal and visual explanation
using a poster, images in a
binder, or using computer
software for the following
:

o

Average MELD score for


Pt will be able to state his
MELD score and compare it to
the national averag
e, state the
main factors that determine
wait time, and state what his


Pt unders
tands what determines
overall wait time.



Pt understands UNOS policy
about informing patients about
their position on the liver
transplant list.

a patient receiving a
transplant.

o

Average wait time and
exceptions to this wait
time.

o

Review of the factors that
determine wait time.

o

Why healthcare
professionals cannot
accurately predict when a
donor liver will become
available.

o

Why patients cannot be
informed about their
placement on the UNOS
waiting list.

estimated wait time is.



Pt will be able to explain why
his healthcare staff (MDs,
RNs) cannot place a prediction
time on when a liver transplant
will become available.



Pt will state w
hy patients
aren’t told their position on the
UNOS waiting list.

5. What if I still have more
questions about MELD score and
liver transplant?



Pt knows where he can get
additional details about MELD
policy: UNOS MELD
calculator, Organ Procurement
& Trans
plant Network, United
Network for Organ Sharing,
and contact information for
healthcare professionals
for
whom J.R. is a patient of.



Pamphlet written in Spanish
and English covering all key
topics discussed.



Discussion about all additional
details regarding MELD policy.



Following along with the patient,
a review of the pamphlet
contents containing UNOS
MELD calculator and web
address (to calculate online),
UNOS, Organ Procurement &
Transplant Network.



Person
al contact information and
document containing contact
information for other healthcare
professionals involved with
J.R.’s care.



Pt will state how he will get in
contact with healthcare staff
involved in his treatment (via
phone or internet) if he has
any

questions or concerns.



Pt will retain pamphlet for
further reference.

Discussion of Adaptation of teaching for this particular patient
:


Because this patient’s primary language is Spanish and his highest level of education is high school in Mexico, his education

needs to be delivered
differently than it would be to someone who is an English speaker that attended high school in the US. This
patient is an intermediate level for English
comprehension and communication, but an expert at his native Spanish language. Thus, for his education to have the biggest im
pact, he needs to have
it delivered in Spanish language primarily, with visuals and pa
tient
-
educator activities created for native Spanish speakers. This does not mean that
English should not be used, because leaving it out will make it difficult to communicate with English only healthcare staff,
and
when personally
translating what he has
learned back to English.


This patient is bright and interested in future as an end
-
stage liver patient. I believe that he may not necessarily look forward to some of the education
involving MELD score (due to its effect on his self image and esteem), but

he will actively participate and put forth effort.












Hepatology.

2001 Feb;33(2):464
-
70.

A model to predict survival in patients with end
-
stage

liver disease.

Kamath PS
,
Wiesner RH
,
Malinchoc M
,
Kremers W
,
Therneau TM
,
Kosberg CL
,
D'Amico G
,
Dickson ER
,
Kim WR
.

Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, Rochester, MN 55905, USA.



Knowledge Deficit
2
:
NDx
-

Knowledge deficiency: ADA diet as evidenced by the following indicators: inaccurate interpretation of ADA
diet, verbalization of confusion about diet, and apa
thetic behavior about ADA diet. Related factors are
unfamiliarity with ADA
diet, and low
knowledg
e base of ADA diet secondary to previous
and current
diet education delivery

in English

instead of Spanish

(using proper medical
terminology).


Date:

2/11/10

Pt. Initials:

J.R.

Student Name:

Alberto Amezquita


Topics to teach

Expected Outcomes

Bilingual
Teaching Methods

Translator Present

Evaluation

1. What is the ADA diet?



Pt will be able to describe what
the ADA diet is, and how it is
different than other
diabetic/non
-
diabetic diets that
are popular today.



Verbal and visual education
using computer so
ftware, a
pamphlet, or a poster.



Graphic showing the difference
between the ADA diet and
other popular diets such as
Atkins, high
-
protein, low
-
fat,
South Beach, and more.



Pt will verbally describe what
the ADA (American Diabetic
Association) diet is in his own
words.



Pt will describe how this diet
plan differs from other popular
diet plans that are advertised in
the media.

2.
What type of patient is placed on
an ADA
diet?



Pt will be able to state which
patients are good candidates for
the ADA diet, and which
patients may benefit from a
different type of nutrition plan.



Graphic showing
patient
characteristics and health
concerns which would make
them prime candidates
for the
ADA diet.



Verbal education and
explanation of this graphic.



Pt will be able to state the
following in his own words: the
ADA diet is an eating plan set
forth by the ADA that is
considered best suited for
diabetics needing to control
their glucose

levels.



Pt will state that this diet does
not follow a strict regimen, but
does limit unhealthy foods.



Pt will state that the most
important part of the ADA diet
is how
it regulates the amount of
carbohydrates
, fats, and foods
high in processed sugars.

3.
How will being on the ADA diet
help me improve?



Pt will be able to verbalize the
reason that he is on an ADA
diet, and how being on this diet
will positively influence all
factors associated with the


Pt will follow along while the
educator states the reasons why
the ADA diet is suitable for
him.



Educator will use a visual while


Pt will state that the ADA di
et
will help regulate his blood
glucose, and keep him from
becoming dangerously hyper or
hypoglycemic.

improvement of his health.

verbally explaining the health
benefits that J.R. will attain
should he stick to his ADA
diet.



Pt will state in his own words:
regulating blood sugar while
attaining the correct levels of
carbohydrates, fats, proteins,
vitamins, and fiber will giv
e his
body the components needed
actively heal itself and prevent
further complications.

4.
What type of ADA diet am I on?



Pt will be able to state the type
of ADA diet he is on, which
includes the number of daily
calories allowed, the
breakdown of food
-
groups
allowed during meals and
snacks, and which foods can
have positive or negative
effects on the success of the
diet plan.



Pt and educator will review the
personalized ADA diet that has
been created by the dietician.



Images of food groups, possible
m
eals, and caloric breakdown
will be reviewed. Pt will be
asked what foods he is fami
liar
with that may fit into each

category.



Graphic showing negative food
choices will be verbally
reviewed

and pt will be asked
about what food choices he
would personally

place into this
category.



Pt will be able to state that he is
on a 2200 calorie ADA diet.



Pt will be able to state foods that
he is familiar with from the
following groups: starches and
grains, high
-
fiber vegetables,
fruits, dairy, proteins like meat
or meat substitutes, and fats.



Pt will state the foods that he is
familiar with that fall into

the
fried, fatty, and sweet junk food
group.



Pt will state why alcohol is not
allowed in his customized ADA
diet.

5.
What if I still have more
questions about the ADA diet and
my personal nutrition?



Pt will be given bilingual
material with detailed ima
ges
regarding his specific ADA
diet.



Pt will meet with nutritional
staff and obtain their contact
information so that he may
address them with concerns and
questions should they arise.



Overview of take
-
home
material will be reviewed with
the patient.



Be
fore discharge the pt will
meet with nutritional staff and
obtain contact information.



Pt will state how he can find
answers to his questions in the
take
-
home materials given to
him, and how he can get in
contact with nutritional staff and
other healthcar
e providers (MD,
RN) should he have any other
questions or concerns.

Discussion of Adaptation of teaching for this particular patient:


Because this patient’s primary language is Spanish and his highest level of education is high school in Mexico, his education

needs to be delivered
differently than it would be to someone who is an English speaker that attended high school in the US. This
patient is an intermediate level for English
comprehension and communication, but an expert at his native Spanish language. Thus, for his education to have the biggest im
pact, he needs to have
it delivered in Spanish language primarily, with visuals and pa
tient
-
educator activities created for native Spanish speakers. This does not mean that
English should not be used, because leaving it out will make it difficult
for him
to communicate with English only healthcare staff, and when
personally translating what

he has learned back to English.


This patient is bright and interested in
his
future as an end
-
stage li
ver patient

who may receive a transplant
. I believe that as his PO intake begins to
improve
he will actively particip
ate and stick

to his ADA diet.




Diabetes Care.

2000 Aug;23(8):1108
-
12.

The 1997 American Diabetes Association and 1999 World Health Organization criteria for hyperglycemia in the diagnosis
and
prediction of diabetes.

Gabir MM
,
Hanson RL
,
Dabelea D
,
Imperatore G
,
Roumain J
,

Bennett PH
,
Knowler WC
.

National Institute of Diabetes and Digestive and Kidney
Diseases, National Institutes of Health, Phoenix, Arizona 85014, USA.







PowerPoint slide Illustrating the teaching steps for one of the above identified knowledge deficits








CURRENT MEDICATIONS (ROUTINE AND P.R.N.) AS OF AM SHIFT



Generic
name/Trade name:

Novalog
/Insulin Glulisine


Lantus/Insulin Glargine

PRN


Microguard powder

Classification:

Rapid acting antidiabetic,
pancreatic hormone


Long acting antidiabetic,
pancreatic hormone



Topical antifungal

Dosage/route/frequency ordered:

2
-
10 units/SQ/ PRN within 15 min
before or 20 min after starting a
meal (breakfast, lunch, dinner)


35 units/SQ/0800 daily

Applied liberally topically to
skin suspected of having a
fungal infection.

Why is this client receiving this
medication?

DM 2

DM
2

Suspected fungal infection of
perineal area and in anterior
and lateral skin folds.

How does this medication work?




Decreases blood glucose; by
transport of glucose into cells and
the conversion of glucose to
glycogen, indirectly increases
blood pyruvate and lactate,
decreases phosphate and
potassium; insulin may be human.


Decreases blood glucose; by
transport of gluc
ose into cells and
the conversion of glucose to
glycogen, indirectly increases
blood pyruvate and lactate,
decreases phosphate and
potassium; insulin may be human.

Interferes with fungal cell

membrane permeability.

What side effects are most likely
to oc
cur secondary to this
medication?



Blurred vision, dry mouth,
flushing, rash, urticaria,
lipodystrophy, hypoglycemia, and
anaphylaxis.


Blurred vision, dry mouth,
flushing, rash, urticaria,
lipodystrophy, hypoglycemia, and
anaphylaxis.

Burning, stinging
, dryness,
itching, local irritation.

What actions do I as a nurse need
to take specific to this
medication?

(Including adverse reactions I
need to be aware of and labs to be
monitored)



Measure blood glucose level
before a meal to determine if this
med
icine needs to be
administered

and if so, number of units to be
given for insulin correction.
Fasting blood glucose, 2 hr PP
(80
-
150 mg/dl) normal fasting
level).


Measure blood glucose level
before 0800/breakfast to
determine if the ordered 35 units
of insulin needs to be adjusted or
withheld until blood glucose level
deems necessary. Onset 5 hr, no
peak identified, duration > 24
hours.

Massage into surrounding are
a
daily or BID, continue for 7
-
14
days, not to exceed 4 weeks.

Assess skin for fungal
infections; peeling, dryness,
itching before and throughout
treatment. Also assess for
continuing infection; increased
size, number of lesions.


Evaluate therapeutic res
ponse,
decrease in size, and number
of lesions.

Contraindications include
hypersensitivity
to this drug.

Precautions include pregnancy
(B), breastfeeding, and
children.

What do I as a nurse need to teach
the client about this medication?



Blurred visi
on may occur; not to
change corrective lens until vision
is stabilized 1
-
2 mo. Keep insulin,
equipment ready at all times.
Product does not cure diabetes but
controls symptoms. Recognize
hypoglycemia reaction: headache,
tremors, fatigue, and weakness.
Reco
gnize hyperglycemia
reaction: frequent urination, thirst,
fatigue, and hunger. Symptoms of
ketoacidosis: nausea; thirst;
Polyuria; dry mouth, decreased
B/P, dry, flushed skin; acetone
breath; drowsiness, Kussmaul
respirations. Avoid all OTC
products unless

directed by
prescriber.


Blurred vision may occur; not to
change corrective lens until vision
is stabilized 1
-
2 mo. Keep insulin,
equipment ready at all times.
Product does not cure diabetes but
controls symptoms. Recognize
hypoglycemia reaction: headach
e,
tremors, fatigue, and weakness.
Recognize hyperglycemia
reaction: frequent urination, thirst,
fatigue, and hunger. Symptoms of
ketoacidosis: nausea; thirst;
Polyuria; dry mouth, decreased
B/P, dry, flushed skin; acetone
breath; drowsiness, Kussmaul
resp
irations. Avoid all OTC
products unless directed by
prescriber.



Apply with a glove to
prevent further infection;
not to cover with occlusive
dressings.



2 weeks to 6 months to
clear infection depending
on fungus. Compliance is
needed even after feeling
better.



Proper hygiene like hand
washing, nail care, use of
concomitant topical agents
if prescribed.



Avoid the use of OTC
creams, ointments, lotions
unle
ss directed by
physician.



Hand wash before each
application.



Report to the physician if
infection persists or recurs;
if blisters, burning, oozing,
swelling occur.



Avoid alcohol because
nausea, vomiting, HTN
may occur.



Use sunscreen or avoid
direct sun
light to prevent
photosensitivity.



Notify the physician of
sore throat, fever, skin
rash, which may indicate
overgrowth of organisms.

What other medications is the
client taking that may interact
with/alter the action of this
medication?


Long acting In
sulin Glargine
(Lantus) may add to an overall
hypoglycemic affect when
Glulisine is used concurrently.


Short acting Insulin Glulisine
may add to an overall
hypoglycemic affect when Lantus
is used concurrently.



NA



CURRENT MEDICATIONS (ROUTINE AND
P.R.N.) AS OF AM SHIFT



Generic name/Trade name:

Fluconazole tablet

Protonix/Pantoprazole


Lactulose

Classification:

Systemic antifungal

Proton pump inhibitor,
benzimidazole.


Laxative; ammonia
detoxicant.

Dosage/route/frequency ordered:

100 mg/day

40mg/IV push reconstituted with
10ml NS delivered over 2
minutes/BID

10 g/day. 10 g per 15 ml
solution.

Why is this client receiving this
medication?

Surface fungal infections of the
perineal area and anterior/lateral
abdomen. Also, to rule out

a
fungal infection as a contributing
cause of his encephalopathy.

Patient is NPO, and excessive
stomach acid production can be
uncomfortable for a patient who is
not stomach digesting food.
Stomach acid can cause GERD,
duodenal/gastric ulcers in NPO
pati
ents, so used as prophylaxis.


Ammonia detoxification due
to renal and hepatic
insufficiency. Lactulose
increases ammonia clearance
in the stool,
and
decreases the
amount which may become
systemic.
Portal
-
systemic
encephalopathy in patients
with hepatic d
isease.

How does this medication work?

Inhibits ergosterol biosynthesis,
causes direct damage to fungal
membrane phospholipids.

Suppresses gastric secretion by
inhibiting hydrogen/potassium
ATPase enzyme in gastric parietal

Prevents the absorption of
ammonia in the colon, and
increases water in the stool.




cell; characterized as gastric acid
pump inhibitor, since it blocks the
final step of acid production.



What side effects are most likely
to occur secondary to this
medication?



Headache, nausea, vomiting,
diarrhea, cramping, flatus,
increased ALT/AST,
hepatotoxicity, Stevens
-
Johnson
syndrome.


Headache, diarrhea, abdominal
pain, rash.






Nausea, vomiting, anorexia,
abdominal cramps, diarrhea,
flatulence, distent
ion,
belching. Product should be
D/C if cramping, rectal
bleeding, nausea, vomiting
occur.

What actions do I as a nurse need
to take specific to this
medication?

(Including adverse reactions I
need to be aware of and labs to be
monitored)




Assess for i
nfection: clearing of
CSF and other culture during
treatment,
obtain C&S baseline
and throughout, product can be
started as soon as culture is taken.
Assess for hepatotoxicity.

Evaluate therapeutic response:
decreasing oral candidiasis, fever,
malaise, rash, negative C&S for
infection of organism.

Increases pantoprazole serum
levels, as well as diazepam,
phenytion, flurazepam, triazolam,
clarithromycin. Increases bleeding
from w
arfarin use. Decreases
absorption of sucralfate, calcium
carbonate, and vita B12.

GI must be assessed: bowel sounds
Q8hr, abdomen for pain, swelling,
and anorexia. Hepatic studies:
AST, ALT, alk phos during
treatment.

Check for therapeutic response:
abse
nce of epigastric pain
swelling, fullness.


Assess:



Stool: amount, color,
consistency.



Blood ammonia level.



Blood, urine electrolytes of
this product is used often;
may cause diarrhea,
hypokalemia,
hyponatremia.



I&O ratio to ID fluid loss.



Clearing of

confusion,
lethargy, restlessness,
irritability if portal
-
systemic encephalopathy.

What do I as a nurse need to teach
the client about this medication?







Long term therapy may be
needed to clear infection.



Medication may be taken with
food to reduce GI effects.



Notify prescriber of nausea,
vomiting, diarrhea, jaundice,
anorexia, clay
-
colored stools,
Report diarrhea. Hyperglyce
mia
may occur in diabetic patient.
Hazardous activities should be
avoided because dizziness may
occur. GI irritation can occur if
alcohol, salicyclates, or ibuprofen


Do not use this product
long ter
m.



Dilute with water or juice
to counteract sweet taste.



Store in cool environment.



Take on an empty stomach
for rapid action.

dark urine.



Use alternative methods of
contraception while taking this
product.

is used.

Do not breastfeed if patient
becomes pregnant.



Report diarrhea since it
may indicate OD.

What other medications is the
client taking that may interact
with/alter the
action of this
medication?


Hypersensitivity to this product or
azoles.

Precautions: pregnancy class C,
renal/hepatic disease,
breastfeeding.

Increases effects of:
hypoglycemia
-

oral antidiabetics,
anticoagulation


warfarin,
[plasma]


cyclosporine,
ph
enytoin ,theophylline, rifabutin,
tacrolimus, effect of zidovudine,
nephrotoxicity


gossypol.

Decreases effect of oral
contraceptives.

Patient is DM 2 and on insulin, so
accuchecks are important for
monitoring blood glucose levels.
Elimination rate decr
eases in older
patients and half
-
life increases.


Do not use with other
laxatives.

Decreases effect of this
product: neomycin, oral
antiinfectives.

Flax, senna increases the effect
of Lactulose.

Contraindications:
Hypersensitivity, low
galactose diet.

Pregnancy class (B),
breastfeeding, DM, geriatric
patients, debilitated patients.




CURRENT MEDICATIONS (ROUTINE AND P.R.N.)



Generic name/Trade name:

Norfloxacin tablet


Pregabalin

Propranalol

Classification:

Urinary antiinfective,
fluoroquinolone
.


Anticonvulsant


Antihypertensive, antianginal,
antidysrhythmic (class 2).
Beta
-
Adrenergic blocker
.

Dosage/route/frequency ordered:

PO 400 mg BID

75 mg QD


40 mg BID

Why is this client receiving this
medication?

Impaired renal function, acute
kidney injury, ESBL E. coli
spontaneous bacterial peritonitis.

Seizures related to encephalopathy
and hyponatremia.

HTN

How does this

medication work?

Interferes with conversion of
intermediate DNA fragments into
high
-
molecular
-
weight DNA in

Binds to high
-
voltage
-
gated Ca++
channels in CNS tissues; this may
lead to anticonvulsant action,
Nonselective beta
-
blocker with
negative inotropic,
chronotropic, dromotropic
bacteria, inhibits DNA gyrase.

similar to the inhibitory
neurotransmitter GABA,
anxiolytic analgesics, and
antiepileptic properties.



properties.

What side effects are most likely
to occur secondary to this

medication?



Headache, dizziness, QT
prolongation, nausea, hepatic
necrosis, pseudomembranous
colitis, agranulocytosis, Stevens
-
Johnson syndrome, angioedema.


Dizziness, fatigue, confusion,
vertigo, ataxia, dry mouth, blurred
vision, nystagmus, constipa
tion,
flatulence, abdominal pain, weight
gain, ecchymosis, back pain,
pruritus, dyspnea.



Fatigue, bradycardia, CHF,
pulmonary edema,
dysrhythmias, laryngospasm,
agranulocytosis,
thrombocytopenia,
bronchospasm.

What actions do I as a nurse need
to take

specific to this
medication?

(Including adverse reactions I
need to be aware of and labs to be
monitored)



Assess: renal and hepatic studies,
I&O ratio, tendon pain, CNS
symptoms, allergic reactions.

Administer after clean catch urine
for C&S.

Evaluate

therapeutic response:
decreased pain, frequency,
urgency, C&S, absence of
infection.


Assess: seizures, pain, renal
studies, mental status.

Administer: uncrushed caps,
without regards to meals,
gradually withdraw over 7 days
because abrupt withdrawal ma
y
precipitate seizures.

Perform/provide: storage at room
temp, hard candy, frequent rinsing
of mouth, gum for dry mouth,
assist with ambulation
, seizure
precautions, increase fluids and
bulk in diet for constipation.




Contraindications:
hypersensitivity
to this
product, cardiac failure,
cardiogenic shock, 2
nd
-
3
rd

degree heart block;
bronchoaspastic disease,
sinus bradycardia, CHF.



Pregnancy class (C),
breastfeeding, DM,
hyperthyroidism, COPD,
renal/hepatic disease,
children, myasthenia
gravis, periphera
l vascular
disease, hypotension, CHF.



Asses vitals, weight, I&Os,
chem panel, angina pain,
deliver PO with food,
water, juice.



Protect pt from light and
evaluate the therapeutic
response: decreased B/P,
dysrhythmias.

What do I as a nurse need to teach
the client about this medication?





If dizziness occurs, to walk
and perform activities with
assistance.



Complete full course of
product therapy, and take at
the same time each day.



Contact physician if adverse
reactions occur.



Take 1 hr before bed or 2 hr
after meals. Don’t take with
antacids, with or within 2 hr of
this product; sip water or use
hard candy for dry mouth.



Carry emergency ID stating
patient’s name, products
taken, condition, prescriber’s
name, and phone number.



Avoid activities that require
alertness.



Taper D/C of med over 1
week to prevent seizure.



Notify physician of pregnancy
is planned or suspected, and
avoid breastfeeding.



Report muscle pain and
weakness with accompanied
by fever, malaise.



Avoid alcohol
.



Do not D/C this med
abruptly because life
threatening dysrhythmias
may develop. Also it may
exacerbate angina, MI.



Take this med at the same
time each day, and
decrease dosage over 2
weeks to prevent cardiac
damage.



Avoid OTC products
unless approved
by
prescriber; avoid alcohol.



Avoid hazardous activities
if dizzy.



Monitor blood glucose.



Make position changes
slowly to prevent fainting.



Sensitivity to cold may
occur.

What other medications is the
client taking that may interact
with/alter the
action of this
medication?


Contraindications:
hypersensitivity to quinolones.

Precautions: Pregnancy class (C),
breastfeeding, children, renal
disease, seizure disorders.

Increases: toxicity of theophylline
and caffeine, serum concentrations
of cyclospo
rine,
anticoagulation of
warfarin.



For OD: lavage, VS,
hemodialysis.



Avoid use with
thiazolidinedione.



CNS depression is increased
with anxiolyti
cs, sedatives,
hypnotics, barbiturates,
general anesthetics, opiate
agonists, phenothiazines,
sedating H1 blockers,
thiazolidinediones, tricyclics.



Increases creatine kinase in


Increases the effect of: Ca+
blocker
s, neuromuscular
blockers, negative inotropic
effects ,beta
-
blocking
effect, hypotension.



Decreases: effect of
barbiturates, and smoking
decreases effect of this
drug.



These products increase the
antihypertensive effect of
this drug: barberry, betony,
Decreases effects of Norfloxacin:
nitrofurantoin, antacids, iron
products, sucralfate: give 2 hours
apart.

lab tests, and decreases
platelet count.

black catechu, black
cohosh, bloodroot, broom,
burdock, cat’s claw,
dandelion, goldenseal, Irish
moss, Jamaican dogwood,
kelp, khella, mistletoe,
parsley.



Antihypertensive effect:
coltsfoot, guarana, khat,
licorice.



Can decrease blood
glucose.


AM IV
fluids:


None delivered.


AM Meds Delivered:

1.

Pantoprazole Sodium IV



Protonix


Proton
-
pump inhibitor. Used to stop acid production in the stomach by stopping H+/k+ ATPase
enzyme in parietal cells. For this patient it is used for GERD prophylaxis since
she has a history of chronic GERD.

2.

Microguard powder


Used to treat fungal infections of the skin. Was used on client’s perineal area due to redness and inflammation
caused by fungal infection.

3.

Fluconazole tablet


systemic antifungal used against candi
diasis. Used for integumentary fungal infection and for prevention of septic
fungal disease.

4.

Lactulose PO


used for ammonia detoxification in patients who have end stage liver failure.

5.

Norfloxacin tablet


Fluoroquinolone


used for UTI or kidney infect
ions as an anti
-
infective for infections caused by E.Coli and more.
This patient has ESBL E. Coli peritonitis and renal impairment, so this drug is being used to prevent a urinary infection.

6.

Pregabalin tablet


GABA analog


used for neuropathic pain
associated with diabetic peripheral neuropathy, and seizures caused by
hyponatremia.

7.

Novolog



rapid acting insulin glulisine


antidiabetic. Decrease high blood glucose by transporting glucose into liver and muscle cells.


Vitamins
and supplements d
elive
red:

8.

Folic acid tablet

Vita

B. Used in patients who are anemic to help increase eurythro and hemopoiesis.

9.

Multi
-
vitamin tab


Broad spectrum vitamin tablet.

10.

Phytonadione ampule
-
Vita K


Needed for adequate blood clotting factors. This patient has increased clotting time and
thrombocytopenia, so vita K is being given to help decrease clotting time and decrease bleeding.

11.

Thiamine HCl tablet


Vita B1


Used fo
r polyneuritis, metabolic disorders, alcoholism, and to aid with carbohydrate and pyruvate
metabolism (Krebs Cycle).

12.

Sacchoromyces boulardii tablet


Probiotic used to help re
-
establish normal colony of symbiotic intestinal bacteria.


Noon Meds:

Propran
olol


Not delivered due to low BP (withhold if systolic BP<90 mmHg).
antihypertensive, antianginal, beta
-
1 blocker. Lowers BP by
reducing elevated rennin plasma levels, blocks beta
-
2 adrenergic receptors in bronchial smooth muscle, negative chronotropic e
ffect. Used to
treat HTN, acute MI, angina, class 2 and 3 heart failure.


References:


1. Mosby’s Drug Guide for Nurses


2. Fundamentals of Nursing by Potter & Perry, 7
th

Ed.


3. Medical
-
Surgical Nursing by
Lewis, 7
th

Ed.


4. Nursing Diagnosis Handbook
by Ackley & Ladwig, 9
th

Ed.








MEPN 556P: Medical
-
Surgical Rotation


Formal Care Plan Grading Criteria


Names: __________________________________________________ Date: ______________


Directions
: Submit the following elements of the Formal Care Plan: Assessment data, complete list of problem statements (written as nur
sing
diagnoses), Teaching Plans (covering two client problems), medication sheets, and reference page.
Attach this grading sheet

a
nd submit to
the instructor on the assigned date.


Points

Earned

Criteria for Evaluation

Points
Possible


1.

Provides comprehensive assessment data based on the

following:

3


a.

Includes assessment data of all body systems for



one shift.



b.

Includes
appropriate lab and diagnostic data.



c.

Includes medication sheets for all medications,



with information tailored to specific
client.



2.

Lists in order of priority,
all client problems

using
complete


problem statements. Attach this list of problems
to the
FCP.

2


a.

Includes appropriate actual and potential
problems.



b.

Includes problem statements that are
individualized



to client and supported with assessment
data.



c.

Lists problem statements in order of importance.



3.

Selects two areas of
knowledge deficit and lists all the
topics to teach related to each of these areas including
expected outcomes, methods, and evaluation

2






a.


Discussion of Adaptation of teaching for
this particular patient



4.

Specifies realistic
and measurable expected outcomes
based


on manifestations of the problem.

3


a.

Writes expected outcomes in positive, measurable
terms.



b.

Includes appropriate, realistic time frames for



completion.



c.

Addresses all manifestations.



5.

Develops
a minimum
of 5

appropriate, comprehensive,
and


realistic nursing topics for teaching related to identified
area of knowledge deficit.

3


a.

Includes appropriate frequencies.



b.

Covers all aspects of the problem.



c.

Writes topics in appropriate format.



Points

Earned

Criteria for Evaluation

Points
Possible


6.

Documents methods for
teaching topic
utilizing current


Best practice and evidenced based nursing references.

3


a.

Rationale and methods facilitate achievement



of the outcome statements.




b. Utilizes at least
two different current references

for
the methods section.



7.

Describes client’s progress toward achieving each of the


ex灥cte搠潵tc潭esK

2


a.

Evaluation section clearly addresses the client’s



灲潧ress t潷ar摳 achievi湧 the
潵tc潭esK



b.


Evaluation section addresses whether each

outcome was “met”, “partially met”, or “unmet”.



8. Includes
one or more revisions

for each unmet outcome.

2




a. Includes revisions that are based on evaluation



data.



b.

Includes revisions that are related to a specific step



in the nursing process.



c.

Discusses continuation of the teaching plan if all
outcomes are met.



9. Explains how the teaching
plan is adapted specifically for this
patient

3


10.


Grammar, spelling, appropriate use of medical
terminology,


reference page and APA format.

2


11. Classroom presentation of teaching plan

5


Sub
-
Total

30


Deductions
: One point will be
deducted from student’s total
course points for each day late.



Total Points