WW is a 54 y/o AA male. Pt. presented to the due to suspected C4 fx, dialysis catheter infection, and possible UTI. He has a PMH of poorly controlled DM2 s/p R BKA and L AKA, ESRD, and recurring UTIs. Used to smoke 2/3 ppd but quit years ago, and used to drink a pint of ETOH per day, but quit after a stroke (unknown date – data gap). Post stroke hx of heroin and cocaine abuse. Pt has a brother and sister who help him, but lives in a nursing home for the past few years. His mother recently died of a heart attack and father’s health is unknown. Brothers also have DM2. Currently on disability, used to work as a mason water operator.
I. Subjective and Objective Data and Analysis of Data
Subjective Data Objective Data Analysis of Data
Date Time Temp HR Resp BP Sa02
03/28 1500 36.5 77 16 129/59 92%
03/29 0400 37.0 88 18 156/71 100%
03/29 1400 36.0 76 12 144/66 98%
03/30 0540 36.0 78 18 145/67 98%
WW’s oral temperature consistently falls within normal limits (36.1 – 37.8 ° C), despite increased WBC count and infection. Often times with severe infection patients will experience fever, though this is not the case for WW, though many older patients may have a decreased core body temperature as their baseline (Mattson Porth, 2004).
Neuro & Sensory
Patient is A & O x 3. Pt. verbal and follows commands with encouragement. PERRLA. No sz or agitation, apparent discomfort.
Dry, warm. Mucus membranes moist. Good skin mobility and turgor. Edema in left hand due to IV infiltration. Assessing the level of consciousness (LOC) continuously can give you insight into the acuity of an infection, because often the first sign of worsening infection is an alteration in LOC (Smeltzer, Bare, Hinkle, & Cheever, 2008). It is important to continually monitor WW’s LOC due to his risk of worsening infection.
Furthermore, pain medication can alter LOC, so it is important to assess baseline before medication administration (Aschenbrenner & Venable, 2009). WW is currently taking 1-2 mg of Dilaudid every 3 hours PRN and 650 mg of Percocet every 6 hours PRN for pain, so it is important to assess LOC before and after medication administration.
Examining a patient’s skin for edema can be important in assessing protein deficiency (Jarvis, 2007). WW has low levels of albumin, which can lead to edema and ascites.
Other labs/ Blood chemistry
Complete Blood Count (CBC)
WBC 14.78 H 12.59 H
RBC 3.42 L 3.38 L
Hgb 8.9 L 8.8 L
Hct 27.1 L 26.9 L
Lymph .89 L .89 L
Normal values for CBC (per JHH chart)
Hemoglobin: 13.9-16.3 g/dl
WBC: 4.5-11.0/ L
Lymphocyte: 1.1-4.8/ L
Increased white blood cells count is an indication of infection. WW had an elevated WBC level on admission on 3/30. This level has decreased dramatically since that time and is now elevated but within normal limits, most likely due to antibiotic administration.
Low levels of lymphocytes are often seen in patients with an infection, and frequently resolve on their own (Smeltzer et al, 2008). WW is recovering from infection, so depressed lymphocyte counts are to be expected. This should be checked again if signs of infection do not clear.
Decreased red blood cells, hemoglobin and hematocrit signal anemia (Smeltzer et al, 2008). WW’s levels are significantly decreased, probably due to his end stage renal disease. It is essential that you treat anemia in patient’s in order to maximize their healing potential (Smeltzer, 2008).
RP’s values 3/30
Sodium: 137 mEq/ L
Potassium: 3.2 mEq/ L (low)
Chloride: 97 mEq/ L
Calcium: 9.2 mEq/ dL
CO2: 26 mEq/ L
BUN: 18 mEq/ dL
Creatinine: 2.9 mEq/ dL (high)
RP’s values 3/29
Sodium: 130 mEq/ L (low)
Potassium: 3.5 mEq/ L
Chloride: 94 mEq/ L (low)
Calcium: 8.9 mEq/ dL
CO2: 27 mEq/ L (low)
BUN: 19 mEq/ dL
Creatinine: 2.8 mEq/ dL
Normal range (per JHH pt chart)
WW’s creatinine is high, but that is expected in a patient with ESRD. High creatinine levels can indicate chronic or acute kidney damage (Mattson Porth, 2008). Normally, however, you would expect someone with ESRD to have high potassium, but WW has low potassium, which seems idiosyncratic to his diagnoses.
Pt’s sister came to visit on 3/30, concerned that she had not been called by the hospital and the nursing home had only just told her that he was at the hospital after he had been there for several days. The pt’s brother is a surgeon and was coming to visit him the next day. Health promotion is most optimal when the hospitalized patients family is included (Mattson Porth, 2008). WW seemed more relaxed once his sister was there, comfortable knowing that she was there to help with his care. She seemed interested in being involved with his care and receptive to teaching about his fracture.
Pt. reports neck pain 10/10, after administration of Dilaudid 9/10, ask for more pain medicine almost immediately after administration. Pain Medication
Dilaudid: 1-2 mg hydromorphone q3hrs
650 mg acetaminophen – 1 or 2 tablets PO q6h PRN
15 mg q6hrs
Dilaudid is a semi-synthetic opioid analgesic used to relieve moderate to severe acute pain (Aschenbrenner & Venable, 2009). It is important to treat pain in order to promote rest and healing of infections (Carpenito-Moyet, 2008). This is important for WW as he is recovering from a C4 fracture. To maintain optimal comfort, vital signs and pain assessment should continue to be done q4hr. Other measures to improve comfort may include repositioning, heat, and noise and light reduction, and distraction (Craven & Hirnle, 2009).
Morphine is an opioid analgesic used to treat severe pain. This drug is important in helping to treat the acute pain WW is feeling r/t his C4 fx.
Pt. is receiving IV Cefepime antibiotic. Cefepime is a cephalosporin antibiotic used to treat bacterial infections including catheter infections. Usual dose is 1-2 g IV q12h (Aschenbrenner & Venable, 2009). Adverse effects include anemia, diarrhea and pseudomembranous colitis. It is important to monitor this condition in WW, as he already has signs of anemia.
10mg PO Q day
Escitalopram oxalate (Lexapro)
20 mg PO Q day
75mg PO Q day
Polyethylene glycol (Miralax)
Sevelamer carbonate (Renleva)
800mg tid (with meals)
Amlodipine is a calcium channel blocker used to treat hypertension. Renal dose is 10mg qd for chronic therapy. This drug is important to controlling WW’s hypertension, keeping the stress off his other organs, most importantly, his kidneys because of his ESRD.
Escitalopram is a selective serotonin reuptake inhibitor used to treat depression or anxiety. Optimizing WW’s mental health is important to the rest of his healing while he is at the hospital.
Metoprolol is a beta blocker used to treat hypertension. This drug is also important in controlling WW’s hypertension, used synergistically with amlodipine.
Miralax is an osmotic laxative used to treat constipation. As many patients taking morphine develop constipation, it is important to give Miralax to prevent constipation to prevent WW from having a bowel impaction.
Sevelamer carbonate is a phosphate binder and I used to prevent hyperphosphatemia. Since WW has ESRD it is essential that he his serum levels of electrolyte stay WNL.
Before you write down the care plan in a care plan format, answer the following questions:
1. Write down a complete list of medical problems this patient have that is derived from medical diagnosis, chart, patient history, physical examination, and/or multidisciplinary documents.
2. Correctly formulates 3 nursing diagnoses. You have to use your book to give the interventions. Please, give the name of the book with page numbers you used to formulate these diagnoses.
3. Identify and correctly formulates the highest priority nursing diagnosis.
4. Write down the data relevant and appropriate that are related to your priority nursing diagnosis.
5. Write down the diagnostic study results that are related to your priority nursing.
6. Write down the medications that are related to your priority nursing.
7. Compare the pathophysiology, clinical presentation, laboratory, and diagnostic tests of this patient with the description that your textbook gives for the same medical diagnosis this patient presents.
8. Write down 1 nursing goal for each nursing diagnosis.
9. Write down 3 nursing interventions appropriate for each goal of each nursing diagnosis. The interventions are comprehensive and patient-specific.
10. Give a complete and accurate rationale for each intervention. You have to use your book to give the interventions. Please, give the name of the book with page numbers.