nurs 201-3 medical/surgical nursing practice...

Running head: NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 1

NURS 201-3 Medical/Surgical Nursing Practice Theory: Case Study and Care Plan

Trina Skinner

Stenberg College

NURS 201-3

K. Bagshaw April 28th, 2013

NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 2

NURS 201-3 Medical/Surgical Nursing Practice Theory: Case Study and Care Plan

IDENTIFYING DATA AND GENERAL DESCRIPTION

Name: A.K.D. Sex: F Race: Caucasian Culture: Canadian

Relationship Status: Married

Appearance and referral source:

Admitted from home (resides with husband). Prior to admission for CVA able to perform ADL’s

independently, able to mobilize independently (walk/transfer). Slightly underweight/

malnourished, well-adjusted, as per patient chart records. *

CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS

Reason for admission:

L side Cerebral Vascular Accident (CVA/stroke), occult hip fracture (ruled out)

Significant signs & symptoms:

Loss of sensation entire R side of body, patient verbalized she was experiencing moderate pain

in leg affected by stroke (Right leg). Unable to mobilize leg on stroke affected side, maintained

use of R arm (minimal strength upon assessment), lack of coordination, patient reports difficulty

swallowing, states she must “eat slowly” (AK.D., 2013)..

Stresses & precipitating factors:

Cardiovascular health compromised; History of Hypertension, Atrial Fibrillation, TIA’s.

History of medication compliance & treatment program:

Willingly took all prescribed medications, A.K.D. explained that during the week she would

mobilize under supervision/care of physiotherapist.

Kim Bagshaw, 05/08/13,

Make sure to cite the pts chart as per apa and to put in your reference section.


Patient was optimistic regarding discharge plan, although reluctant to mobilize with nursing staff

(or myself); A.K.D. felt comfortable mobilizing exclusively with physiotherapist. I was able to

convince patient to transfer from bed to Broda chair @ meal times.

Medications:

Medication Dose Route Time

*Metoprolol (Lopressor/Betaloc)

50 mg Lopressor25 mg. Betaloc

PO- BID 09001700

Levothyroxine (Synthoid)

50 mcg/0.05 mg PO 0900

Atrovastatin (Lipitor)

40 mg PO 0900

Felodipine ER (Plendil)

10 mg PO 0900

Tramacet 325 mg Acetaminophen/ 37.5 Tramadol

PO- TID 090017002100

Citalopram 10 mg PO 0900

Baclofen 100mg PO 1700

Ferrous fumerate (Palafer)

300 mg PO 2100

*Warfarin (Coumadin)

Pharmacist Managed1 Dose QD

PO 1600

Pantoprazole Magnesium (Tecta)

40 mg PO- BID unit stock 09002100

Risodronate (Actonel)

35 mg PO QThurs

Ergocalciferol (Ostoforte)

50 000 Int. Unit PO QThurs


PAST MEDICAL HISTORY

A.K.D. has a fairly extensive medical history, affecting all body systems. Past and current

medical conditions include: Atrial fibrillation, Transient Ischemic Attack’s (TIA’s),

Hypothyroidism, Glaucoma, Heart Disease- Class I Corotid artery disease, Osteoporosis,

Hypertension, Cerebral Vascular Accident- CVA (Right side)

SURGICAL HISTORY

A.K.D.’s surgical history includes a bowel resection, partial hysterectomy CABG (Coronary

Artery Bypass Graft surgery).

ALLERGIES

A.K.D. has been identified as having allergic reactions to both Codeine, and Sulpha drugs;

specific reaction (not available)

. DISEASE PROCESS

TEXTBOOK DESCRIPTION OF DISEASE PROCESS

CLIENTS PRESENTATION OF DISEASE PROCESS

Diagnosis: Cerebral Vascular Accident (CVA)

Physician confirmed CVA had occurred Right side

of brain (left side of body affected) post CT scan

Etiology/Pathophysiology: CVA, or stroke

(apoplexy) “is the sudden onset of weakness,

numbness, paralysis, slurred speech, aphasia,

problems with vision and other manifestations

of a sudden interruption of blood flow to a

particular area of the brain. The ischemic area

A.K.D. was admitted following a fall at her home

on the premise of a possible occult hip fracture and

CVA. Following an X-ray, the possible hip

fracture was ruled out. A CT scan revealed

evidence that a stroke had occurred

“Computerized tomography (CT) scan.


involved determines the type of focal deficit

that is seen in the patient” (ISC, 2012).

Brain imaging plays a key role in determining if

you're having a stroke and what type of stroke you

may be experiencing. A CT scan uses a series of X-

rays to create a detailed image of your brain. A CT

scan can show a brain hemorrhage, tumors, strokes

and other conditions” (MayoClinic, 2012).

Clinical Signs and Symptoms:

Trouble with walking. You may

stumble or experience sudden dizziness,

loss of balance or loss of coordination.

Trouble with speaking and

understanding. You may experience

confusion. You may slur your words or

have difficulty understanding speech.

Paralysis or numbness of the face,

arm or leg. You may develop sudden

numbness, weakness or paralysis in

your face, arm or leg, especially on one

side of your body. Try to raise both your

arms over your head at the same time. If

one arm begins to fall, you may be

having a stroke. Similarly, one side of

your mouth may droop when you try to

The patient exhibited signs and symptoms such

that included numbness and tingling on left side of

body. It was yet to be determined if permanent

hemi paralysis would ensue. The upper left

quadrant of A.K.D.’s body (including arm and

face) were unaffected by visual assessment. The

patient stated that she could not mobilize her leg

and was experiencing loss of sensation as well as

occasional sharp pains, particularly on

movement/when repositioned. This patient was

experiencing dysphagia (difficulty swallowing),

which she was aware of and explained to me that

she would require my assistance with feeding,

although she had use of both upper extremities,

A.K.D. explained that she was experiencing

systemic weakness. I assisted with feeding, and did


smile.

Trouble with seeing in one or both

eyes. You may suddenly have blurred or

blackened vision in one or both eyes, or

you may see double.

Headache. A sudden, severe headache,

which may be accompanied by

vomiting, dizziness or altered

consciousness, may indicate you're

having a stroke.

so at a very slow pace, as this patient was at high

risk for choking/aspiration. Patient was able to

squeeze my hands with minimal strength and lift

her arms slightly for only a few seconds. Patient

denied any visual disturbance/effect and

complained frequently of headaches and dizziness

(Mayoclinic, 2010)

LAB RESULTS

The following is a panel of laboratory results that outlines abnormal values in comparison to

levels that are of ‘normal range’. All lab tests were performed by laboratory technicians on site

@ Nanaimo Regional General Hospital. The following information is extracted from VIHA’s

online charting system, on operating system Cerner (VIHA Intranet).

*International Normalized Ratio

Lab Test Patient’s Value Normal Range

Neutrophils 6.59-High 2.00-6.00

Lymphocytes 0.87-Low 120-150

Monocytes 0.81-Low 0.35-0.45

*INR 5.8-High 0.9-1.1


Chloride 96 -Low 96-106

Sodium 132-Low 135-145

Urea Level 11.5-High 3.0-7.5NURSING PHYSICAL ASSESSMENT

Upon introducing myself to A.K.D., I assessed her level of orientation, she is oriented x 3 (to

person, place, and time). Upon visual assessment I noted that this patient was extremely thin with

a distinct lack of muscle tone. Her pallor was pale, her affect was congruent with her mood and

she was very pleasant to interact with. I noted her pupils were equal in diameter and reactive and

her lips were dry and chapped, which indicated that she may be dehydrated. I then assessed

A.K.D’s vitals, the first set I recorded @ 0800 hrs are as follows: BP 149/87, HR 81, Oxygen

sats. 98%, Temp. 37.0.

Upon auscultation of heart and lungs, I noted a distinct irregular heart beat. Her lungs were clear,

no adventitious sounds in all lobes. A.K.D. presented as somewhat nervous in regards to certain

aspects of her care. For instance she was concerned that Tecta be administered 30 minutes ac

breakfast to reduce symptoms of GERD. Capillary refill was good, skin was think and fragile.

Bowel sounds present in all four quadrants and A.K.D.’s abdomen was soft upon palpitation. IV

site was absent of redness, swelling, & pain. Patient stated that on a pain scale of 1-10 (1 being

no pain, and 10 being the worst pain she had experienced in her life) A.K.D. stated her pain level

was a 4. The pain she described was sharp and intermittent occurring on her entire left side. She

explained that she was thirsty and her mouth was dry, but she had difficulty swallowing and

required my assistance. Skin was dry and intact, my only concern was a reddened area on her

right heel which she said was painful when pressure applied to the area. A.K.D. also presented

with slight pedal edema bilaterally. A.K.D. was able to grip my hands with hers with a moderate


level of strength. While assessing this patient’s ROM (range of motion) it was clear that

attempting to mobilize the patient (without use of the overhead lift) would not be safe as she was

unable to raise her legs or resist the pressure of my hands against her feet. Pedal pulse was

palpable bilateral. This patient was underweight and undernourished as per clinical

manifestations noted throughout assessment phase. Patient was clean, comfortable, dry, & safe

when released from my care. well done

TREATMENT PLAN

The current treatment plan on the unit is to promote comfort, and pain management for this

patient. One goal is to decrease incidence of heartburn/nausea in order to increase adequate

nutrition, promote client ability to feed herself. The main focus/goal in this case is to have

A.K.D. mobilize and restore patient to equal or greater level of functioning prior to admission to

hospital. Patient is transferred from bed to chair pc breakfast- pc lunch. Encourage patient to

mobilize and perform ROM’s as much as possible, promote increased input to increase strength

to the point A.K.D. can return home safely. Medication education is necessary, as this patient is

on a number of medications, several *high alert cardiac meds that require compliance and

comprehension of what these medications are for. AAT (Activities as tolerated), presently

movement of muscles and joints and encouragement to gradually restore ability to perform own

personal care as much as possible. A.K.D. must be educated on the importance of mobilization

as the primary factor in her recovery. A.K.D. will also receive education upon discharge in terms

of outpatient treatment to obtain highest quality level of health and wellness. Patient will

continue to receive treatment from resident physiotherapist. Patient’s emotional state is pleasant

and she maintains an optimistic attitude regarding her current state of health and continued

recovery. The client is interested in which medications she is prescribed and the function of each


prior to administration. In terms of receptiveness with plan of care, patient is reluctant in terms of

proceeding forward with efforts to mobilize, she voices some concern about the rate at which she

is being encouraged to mobilize.

Patient also expresses some fear of further injury if she attempts to mobilize; patient’s concerns

are validated and patient education regarding the necessity of obtaining adequate nutrition and

mobilizing daily in order to be discharged was implemented.

TEACHING AND DISCHARGE PLAN

In regards to necessary patient teaching upon discharge, A.K.D. must have her medication

regime explained in a way that we are able to verify understanding. Perhaps meds can be

prepared in blister packs labeled and if the patient finds the medication regime overwhelming;

A.K.D. must also be encouraged to seek clarification and address any concerns she may have

prior to or regarding discharge. The plan is for A.K.D. to be discharged and return home with the

assistance of her husband following the ability to mobilize safely and achieve a safe level of

intake food & fluids. The patient will be discharged as per physician’s order. Whatever follow up

treatment and medication will be presented and explained with assurance that patient or next of

kin understand in order to enhance the likelihood of compliance. Outpatient treatment and

community resources will be provided upon discharge, and follow-up with GP or specialists as

per physician’s orders.

STUDENT REFLECTION UPON WRITING CASE STUDY

Over the course of the few days I worked with A.K.D. I enjoyed the interaction I shared with her.

She was consistently pleasant and maintained a very positive attitude. Upon further studying of

her past medical history, I became very humbled and touched by her sunny disposition in spite of

all the major health concerns she is faced with. Her smile is radiant, and the time that we spent


communicating throughout provision of care and whenever I had a few free minutes, I felt very

grateful for my health and all the loving support and opportunity I have in my life. Working with

A.K.D. helped remind me how crucial it is to live in the present.

I noticed I had quite an emotional response to caring for this client, as it was reminiscent of my

former work as an HCA and the patients I had developed therapeutic relationships with. After

working with more patients who have been affected by CVA than I can recall, I felt a familiar

anxiety and slight fear arise in me, as after caring for a large population of older adults who have

suffered strokes, I developed a fear of one day suffering a stroke myself. I am extremely

empathetic for patients who experience TIA’s or strokes as the thought of losing my ability to

communicate and persistent numbness/tingling, let alone full on hemi paralysis. I certainly feel

grateful that I made drastic lifestyle changes prior to the start of the RDPN program, giving up

smoking, drinking alcohol, healthy/clean eating, and regular exercise and meditation/yoga

practice. I would like to work to reduce the risks of developing cardiovascular problems as much

as possible. Following this experience, I am more committed to maintain my current, as well as

broaden my healthy lifestyle choices in the future. excellent reflection.


References

Jaap H. Buurke, Anand V. Nene, Gert Kwakkel, Victorien Erren-Wolters, Maarten J. IJzerman

& Hermie J. Hermens (2008) Recovery of Gait After Stroke: What Changes?

Neurorehabil Neural Repair. 22: 676 DOI: 10.1177/1545968308317972

Kim, T. Y., Lang, N. M., Berg, K., Weaver, C., Murphy, J., & Ela, S. (2007). Clinician adoption

patterns and patient outcome results in use of evidence-based nursing plans of care. AMIA

2007 Symposium Proceedings, 423-427.

Lewis, S.L., Heitkemper, M.M.Dirksen, S.R., Bucher, L., and O’Brien, P.G. (2010). Medical-

Surgical Nursing in Canada (Canadian 2nd Ed.). Toronto, ON: Elsevier Canada

Mayoclinic.com (2012). Stroke symptoms. Retrieved from

http://www.mayoclinic.com/health/stroke/DS00150/DSECTION=symptoms

Tourangeau, A. E., Doran, D. M., McGillis Hall, L., O’Brien Pallas, L., Pringle, D., Cranley, L.

A., & Tu, J. V. (2006). Impact of hospital nursing care on 30-day mortality for acute

medical patients. Journal of Advanced Nursing,57(1), 32-44.doi.org/10.1111/j.1365-

2648.2006.04084.x

Williams, L. (2007). The fluid and electrolyte balancing act. Nursing Homes: Long Term Care

Management, 56(12), 31-33. Retrieved from

http://web.ebscohost.com.proxy.lib.sfu.ca/ehost/detail?vid=3&sid=6163230c-aa8a-44c5-

bc5ea1cc6e749523%40sessionmgr4&hid=24&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d

%3d#db=hxh&AN=33020811

Appendix


Nursing Diagnosis

Desired Outcomes

Interventions (I)-Independent(C) - Collaborative

Rationale & APA Reference

Evaluation of Interventions

NDX: (Problem)

Impaired skin integrity

R/T: (etiology/factor):

Related to inability to mobilize or reposition self

AEB: (s/sx; defining characteristics)

1. Inability to turn from back onto either side without assistance

2. Reddened area on left heel as a result of pressure (bed rest)

3. Inability to mobilize transfer from bed

*If ‘risk for’ would exhibit:Decubitus ulcers, reddened/ open/blistered areas of skin over bony prominences, maceration of skin

NDX: Problem

Goal (Reversal of Problem)

Patient’s skin integrity is no longer compromised by when *

Client will (list measurable outcomes; reverse signs and symptoms)

1. No presence of redness over bony prominences

2. No evidence of maceration of skin prone to moisture (perineal area)

3. Increased mobility to improve circulation/systemic blood flow maintaining skin integrity by means of adequate tissue perfusion (integumentary system is nourished)

Evaluation of Outcomes (address each outcome)

1. Patient’s skin is intact

2.Healthy pallor

3. No evidence of signs related to skin breakdown

N-1 Assess skin daily for signs of irritation so that early treatment can provided (C)

N-1 Wash and dry skin thoroughly, paying special attention to areas @ higher risk for breakdown (i.e. groins/abdominal skin folds) where bacteria can accumulate(C)

N-2 Promote independence in terms of encouraging patient to wash and dry herself thoroughly as per instruction (I)

N-3 Implement patient education regarding significance of properly drying and moisturizing skin (C)

N-4 Encourage patient to perform ROM exercise/AAT in order to retain ability to reposition/mobilize self (I)

N6- Turn Q2h as preventative measure (decubitus ulcers)

N7- protect bony prominences with pillows/padding & elevate heels off the bed (no direct pressure applied)

Educate patient on risks associated with skin breakdown in order to increase likelihood patient will participate in own care RE: maintenance of skin integrity

Explain process of development of decubitus ulcers

Encourage patient to regain independence or perform as much personal care as possible; to increase likelihood of patient continuing to care for skin upon discharge; ability to perform own personal care will expedite scheduled discharge

Reposition patient frequently (Q2h) to avoid extended periods of pressure on any area of the body- which decreases circulation of vital nutrients to support/maintain healthy skin

Pillows or other protective aids will promote prevention of skin breakdown

ROM’s will help to promote healthy circulation to ensure skin is nourished

(Tourangeau, 2006)

Patient is washing and drying herself safely & effectively

Patient makes effort to reposition herself as per her ability; or requests assistance from nurse to reposition if in same side-lying or supine position for extended period of time

Patient understands the relationship between mobility and impaired skin integrity & therefore makes effort to mobilize as much as possible in order to avoid constant pressure on skin and to promote circulation

Patient summarizes knowledge obtained regarding the necessity of proper skin care in order to allow nurse to check for understanding

Kim Bagshaw, 05/08/13,

You may want to reword this as pt will experience no further skin breakdown in the next 7 days.Also it is always important to have a time frame so that you can better evaluate your interventions.


Nursing Diagnosis

Desired Outcomes




Deficient fluid volume, risk for


Related to Insufficient fluid intake, compromised cardiac health


1. Abnormal levels of sodium, chloride as evidenced in lab values

2. Presence of pedal edema, bilateral

3. Decreased intake/output related to difficulty swallowing

*If ‘risk for’ would exhibit:

Poor skin turgor

Electrolyte imbalances

Poor muscle tone

NDX: Problem


Patient will achieve sufficient fluid volume by discharge


1. Lab values RE: electrolyte balance will return to within normal range

2. Exhibit no edema

3. Establish consistent intake/output fluid volume


1. Resolution of dysphagia

2. Increased muscle tone

3. Patient records indicate adequate intake/output

N-1 Request swallowing assessment to be performed by OT (C)

N-2 If patient is unable to swallow to obtain adequate fluid/electrolyte balance; IV fluids will be ordered (physician) and administered by nursing staff (C)

N-3 Monitor intake/output as accurately as possible each shift

N-4 Elevate feet (above heart)

N-5 Patient on cardiac diet

N-6 Assess vitals QID, with special attention to HR, BP

N1- Establish schedule

R1- If patient is unable to swallow, initiative must be taken to ensure sufficient fluid volume

R2- If patient is unable to obtain fluid PO, hydration via IV may be necessary

R3- An accurate account of patient’s fluid volume intake and output will demonstrate evidence of adequate hydration/fluid-electrolyte balances

R4- Elevating feet/lower legs above heart level will function to prevent/reduce edema

R5- As the patient has significant cardiac issues, a diet that takes these comorbid disorders into account will function to increase likelihood of maintaining adequate nutrition/fluid balance

(Williams, 2007)

(Lewis, et al., 2010)

E1- Patient’s ability to swallow is regained or alternate means of nutrition is undertaken (IV, nasogastric tube, parenteral feeding) if necessary

E2- Patient will monitor fluid intake/output; notify healthcare provider if inadequate amounts/patient will identify signs of fluid deficiency as per nursing education/teaching

E-3 Patient will continue to elevate feet/lower legs at rest. Consider need for TED stockings with physician

E-4 Patient will adhere to ‘heart healthy’ diet and follow guidelines of patient teaching prior to discharge RE: nutrition

E1- Patient is able to


Nursing Diagnosis

Desired Outcomes




Mobility, impaired physical


Related to

Immobility as result of CVA


1. Patient is incapable of reposition/transferindependently

2. Patient’s lack of confidence/initiative to attempt to mobilize

3. Pain and discomfort verbalized upon reposition/transfer


Patient is rehabilitated and able to mobilize independently (mobility aides prn, i.e. walker) following discharge


1. Patient will continue to work with PT upon discharge RE: mobility

2. Patient will perform ROM’s & AAT upon discharge

3. Patient will be made aware of and establish contact with community resources RE: heart & stroke


1. Patient practices healthy lifestyle habits in relation to her co-morbid diagnoses

2. Patient maintains appropriate diet in relation to health status upon discharge

with PT to assist patient with rehabilitation (C)

N2- Encourage patient to mobilize as tolerable to restore patient to highest level of health possible (C)

N3- Teach client significance of ROM’s/ perform ROM’s daily (C)

N4- Address and validate patient’s concerns/anxiety RE: rehabilitation, regaining mobility (C)

N5- Promote independence as every opportunity, encourage patient to do as much for herself as possible in preparation for discharge

N6- Administer all patient medications as per physician’s orders

R1- Patient feels comfortable working with PT, PT specialize in rehabilitation of physical health impairment

R2- Promote restoration of mobility to highest level possible (post-CVA)

R3- ROM’s are extremely important in maintaining health in the elderly and bed ridden patient, in order to promote/maintain mobility & circulation. All body systems require movement/exercise of some sort to function adequately

R4- Patient must regain ability to provide care for herself or arrange provision of care upon discharge from hospital

R(5)- Patient’s compliance with medication regime and established enables proper management of co-morbid conditions

(Jaap, 2008)

(Lewis, et al., 2010)

mobilize independently upon discharge

E2- Mobility aides are provided and implemented with proper patient teaching if necessary

E3- Patient performs ROM’s daily and understands significance of doing such

E4- Patient maintains healthy diet that takes cardiac issues into consideration

E5- Patient is educated on signs/symptoms of CVA and is informed on when to contact health care provider

E6- Patient refrains from any risk factors associated with CVA and cardiovascular system

E7- Patient is made aware of and establishes/maintains communication with community resources i.e. heart and stroke foundation


Nursing Diagnosis

Desired Outcomes




PSY 201-3 Med/Surg TheoryCase Study and Care Plan (20%)

Mark Assigned

Mark Earned

Comments

APA Format (5%) 1 1

Structure and Scholarly Presentation (15%)Well structured paper, logically & coherently developed content

1 1

Reference list reflecting depth and breadth of reading

1 1

Spelling, punctuation and grammar 1 1

Content and Care Plans (80%)Accuracy and depth of head to toe assessment, treatment and teaching plan and other pertinent information

6 6

Demonstrated critical thinking & reflection both throughout paper and in student reflection section

2 2

Sound rationale for ideas and conclusions

2 2

Thoughts & opinions substantiated with relevant & current sources

1 2

Care plans concise, patient focused with clear diagnoses, interventions, rationales and evaluation

5 4.5 See comments.

Total 20 19.5 Well done.

nurs 201-3 medical/surgical nursing practice...

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