Ccalcei.yolasite.com

Running head: ADULTS NURSING PROCESS PAPER Client Profile
My patient, E.S, is a ninety-seven year old woman who came into the healthcare facility with pain, redness and warmth to the left forearm. She was diagnosed with cellulitis of the left forearm plus MRSA a few weeks ago and was given Bactrim by her personal care physician. After using the Bactrim for two weeks, the problem did not dissipate and she was brought into the healthcare facility from her assisted living home. Researchers are trying to develop a method in categorizing different levels of cellulitis and treatment regimens to co-inside with the severity of the infection (Campbell, MacLeod, Howlett, 2009). A pilot study done in Nova Scotia suggested that these guidelines for rating cellulitis was safe for patients, liked by physicians, and was associated with lower treatment costs (Campbell, MacLeod, Howlett, 2009). E.S. lives at Canton Christian Assisted Living. E.S is a non-drinker and non-smoker and denies any recreational drug use. E.S has a fairly heavy past medical history; including, gout, hypertension, diabetes, pulmonary embolism and DVT, high cholesterol, arthritis, dementia, and a rotator cuff tear. “Gout is a metabolic bone disorder in which purine metabolism is altered and the by-product, uric acid accumulates.” (Black & Hawks, 2009, p.496). Below explains E.S.’s past medical and surgical history and how they affect the body. In the past, E.S. has only had two surgeries according to her chart. The first is a hysterectomy, which is a removal of the pelvic organs including the uterus, fallopian tubes, ovaries and vagina (Black & Hawks, 2009, p. 928/929). The second surgery was a hernia repair, “performed using a small incision directly over the weakened area. The intestine is then returned to the perineal cavity, the hernia sac is excised, and the muscle is closed tightly over the area.” (Black & Hawks, 2009, p. 711). Most hernia repairs are done with a spinal or local anesthesia. E.S. has a much longer and detailed medical history than she does surgical. We will start with hypertension, which is high blood pressure. There was also a history of a pulmonary embolism and DVT. A pulmonary embolism is a life-threatening condition in which a free- flowing blood clot becomes lodged within the pulmonary vasculature (Black & Hawks, 2009, p. 1332). E.S. also had a DVT, which is a blood clot in the deeper veins. DVT’s most commonly occurs in the lower extremities and was most likely the reason E.S. developed her pulmonary embolism (Black & Hawks, 2009, p. 1331). Diabetes, gout and high cholesterol are also on E.S.’s list of past medical issues. Diabetes is when there is a discrepancy between the amount of insulin required by the body and the amount available (Craven & Hirnle, 2009, p. 963). There is not enough insulin produced by the body and the blood glucose level increases resulting in rather unpleasant and possibly dangerous side effects. Synthetic insulin is given to patient as ordered to bring blood glucose back down to a normal level. Gout is a kind of arthritis that occurs when uric acid builds up in the blood and causes joint inflammation. The exact cause of gout is unknown, but it’s thought to run in families and it is more common in men and women after menopause (Black & Hawks, 2009, p. 497). Cholesterol is the building block of your body’s cells. However, when the body gets too much cholesterol from diet or other sources, it starts to build up in the arteries, clogging them up and making it much more likely to develop further health issues. The last three things in E.S.’s past medical history are arthritis, dementia and a rotator cuff tear. Arthritis is inflammation of the joints in the body (Black & Hawks, 2009, p. 496). Arthritis was not originally thought to be genetically linked, but now evidence is suggesting the existence of an autosomal-recessive trait with gene defects contributing to the early onset of cartilage destruction (Black & Hawks, 2009, p. 470). Dementia is a clinical syndrome involving progressive impairment of intellectual function and memory (Craven & Hirnle, 2009, p. 1246). Dementia doesn’t interfere with a person’s level of consciousness, but it does affect their social and occupational functioning. E.S.’s last medical issue I gathered information on was a rotator cuff tear. A rotator cuff tear is a painful shoulder injury in which it is unable to perform abduction and external rotation. Activity at the glenohumeral joint is also painfully impaired (Black & Hawks, 2009, p. 539). According to E.S’s past history, she never had any surgery done Concept Map
Assessment Data
A & O x 3 (history of dementia) Weight 184 lbs Temperature - 97.5 Heart Rate – 57 Pulse Oximetry – 95% on room air Blood Pressure – 130/70 E.S.’s skin was dry and fragile but a normal color. Her upper and lower extremities were ecchymotic due to multiple different sources; easily bruising and needle pokes from blood draws and IV insertion sites. E.S. stated no numbness or tingling anywhere and had sensation in all extremities. Her mucous membranes were moist and pink, and E.S. also wears dentures. Her pupils were equal, round and reactive to a size 3mm. At the time of my clinical, E.S. was not wearing glasses, but she does use them on a regular basis. I gave E.S. a 19/23 on the Braden Scale because she does need some assistance ambulating and her memory is impaired due to her Dementia. The patient has a #22 gauge IV in the right forearm dated from the 26th of September, 2011. This IV site went bad and a new one was placed in her left hand on the 28th of September, a #22 gauge needle to hang an IV piggyback antibiotic. E.S. had slow and even breaths and clear anterior and posterior lung sounds. She had no signs or symptoms of respiratory distress or labored breathing. Her chest was symmetrical and normal and trachea was midline with no JVD. E.S. had no signs of a cough, but was still thoroughly encouraged to cough and deep breathe. The patient had a soft, round, and non-tender abdomen with bowel sounds present times four. During my clinical, E.S. was continent with both her bowel movements and urination. E.S. had one bowel movement while I was there and it was a normal brown color, formed and a normal odor. She urinated quite a few times and was able to get to the bathroom with her walker and an assist of just one person to make sure she did not fall. There was no nausea or vomiting and she ate both her breakfast and lunch at least 75 percent. E.S. was able to move all extremities. Hand grasps were slightly weak but equal, and foot pushes and pulls were strong and equal. Radial pulses were strong, equal and a +2 bilaterally. Tibial pulses were a +1 and equal on both legs. Pedal pulses were a +1 and equal on both feet. Capillary refills were less than three seconds on both hands and feet. The patient’s gait was mostly steady, but she was still asked to call for the nurse if she needed to get up for any reason. This was mostly due to her impaired memory and cognitive function. She needed minimal to no assist using her walker to get up and to the restroom. E.S. was ordered to walk at least three times during the day. During my clinical she only walked to the bathroom and back. The patient’s back looked clean, dry and intact. There were no open areas on the back or buttocks. The skin was slightly dry and fragile due to age but no wounds or sores were present. E.S. stated a 0/10 for when asking her during the morning assessment. The only time she complained of any pain is when she needed to have another IV placed. She did not like the needle poke. Other than that, E.S. was rather in a good position for a 97 year old woman. Lab information & Diagnostic Tests
Normal range
Interpretation
Complete Blood Count (CBC) Results: Normal Range
Interpretation
There was no other testing done on E.S. upon this admission. The majority of her blood work results were normal and the ones that were not directly related with either a medication E.S. was taking or a disorder she has. This information was found in E.S.’s chart and Meditech Medication information
Below is a list of medications assigned to E.S. All medication information such as: purpose, classification and side effects were retrieved from Davis’s Drug Guide for Nurses, 12th Edition. Analysis (NANDA)
Diagnosis
Short Term Goal with
Long Term Goal with
Interventions
Interventions
1. Impaired skin integrity Goal #1- the patient will 2. Knowledge deficit R/T Goal #1 – patient will be able proper equipment and knowledge to heal infection Evaluation of Patient Goals
Diagnoses
Short Term Outcomes
Long Term Outcomes
1. Impaired skin integrity Goal #1 – Goal met. Patient 2. Knowledge deficit R/T Goal #1 – Goal not met. Due References
Black, J.M., & Hawks, J.H. (2009). Medical-surgical nursing: Clinical management for positive outcomes. 8th edition. St. Louis, MO: Saunders Elsvier Campbell, S.G., Burton-MacLeod, R., Howlett, T. (2009). A cellulitis guideline at a community hospital – we can reduce our costs by standardizing care. Journal of Emergency Primary Health Care. Vol. 7. Issue 1. Retrieved from https://emergencycare.nhmrc.gov.au/gateway/forum/files/A%20cellulitis%20guideline% Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing: Human health and function 6th edition. Philadelphia, PA: Lippincott Williams & Wilkins. Deglin, J. H., Vallerand, A. H., Sanoski, C. A. (2011). Davis’s drug guide for nurses 12th edition.

Source: http://ccalcei.yolasite.com/resources/ADULTS%20PROCESS%20PAPER%20pdf.pdf