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Running head: BRADLEY GERONTOLOGY PROCESS PAPER 1

Gerontology Process Paper

Erin Bradley

Kent State University at Stark


Client Profile

DH, a 93-year-old Caucasian female, was admitted to the facility with right lower

leg cellulitis. Her secondary diagnoses include atrial fibrillation, hypothyroidism, osteoporosis,

and glaucoma. DH is 62 inches tall and states that she weighs 108 pounds, or 49.09 kilograms.

DH was previously employed by a printing company in Canton where she worked as an

accountant for over 50 years. DH states that her husband had passed away several years ago and

she had been living independently until only recently. Prior to entering the facility, she was

abiding with her daughter’s family who lives near the Canton area. DH states that she is

Protestant. She is allergic to aspirin and Dilaudid. DH is a Do Not Resuscitate-Comfort Care

Arrest patient.

Past Medical & Surgical History

DH has a history of osteoporosis, which ultimately led to the pathologic fracture of the

neck of her right femur and a total right hip arthroplasty in 2011. DH states that her fracture was

the reason she began living with her daughter after she was discharged from the rehabilitation

facility. DH has a history of hypothyroidism that she states is well maintained by her current

regimen of thyroid hormones. She also stated that she was diagnosed with glaucoma in 2008 and

is on a strict regimen of ophthalmic medication to alleviate symptoms. Lastly, DH has a history

of paroxysmal atrial fibrillation that occurs randomly without any known cause.

Medical Diagnoses

Cellulitis

Definition: “A skin infection that extends into the deeper dermis and subcutaneous tissues and causes deep, red erythema without sharp borders and that spreads widely through tissue spaces” (Black & Hawks, 2009, p. 1225).Pathophysiology: Streptococcus pyogenes is usually the cause of this infection. Older patients may be at more risk for cellulitis with the presence of wounds or ulcers, malnutrition, steroid therapy, or a history of diabetes (Black and Hawks, 2009).


Signs and Symptoms: Skin may appear edematous, erythematous, nodular, and tender. Sometimes they organism that causes the skin infection can cause other manifestations, such as high fever, confusion, tachycardia, and hypotension (Black and Hawks, 2009).Diagnosis: Wound specimen for culture and sensitivity testing is performed to determine the cause of infection and proper antibiotics treatment (Black and Hawks, 2009).Treatment: IV and/or oral antibiotics that are effective against streptococci and S. aureus. Soaks can be used to reduce inflammation and edema (Black and Hawks, 2009).

Osteoporosis

Definition: A systemic skeletal disorder that leads to compromised bone strength and increased risk for skeletal fracture (Black and Hawks, 2009). Pathophysiology: Fractures related to osteoporosis occur when the bone encounters weight greater than what it can sustain. Post-menopausal Caucasian women are at a higher risk for osteoporosis, but other factors such as medication us (corticosteroids, thyroid hormones, anticonvulsants, and furosemides) and underlying medical conditions, like anorexia nervosa, Cushing’s syndrome, and hyperparathyroidism, place patients at risk (Black and Hawks, 2009). Signs and Symptoms: Shortened stature, kyphosis, and bone loss in the mandible leading to loss of teeth or poorly fitting dentures (Black and Hawks, 2009). Diagnosis: Diagnosis of osteoporosis is generally made after a fracture has occurred. Bone mineral density (BMD), a value of bone density that is expected for a person’s age and gender, can be measured using full-table dual-energy x-ray absorptiometry (DXA) (Black and Hawks, 2009).Treatment: Osteoporosis is preventable. Increasing calcium and Vitamin D intake as early as age 10 for females can help prevent osteoporosis. 1200 milligrams of calcium per day is recommended for patients above the age of 70. Weight-bearing exercise is also a good way to increase bone mass. (Black and Hawks, 2009).

Hypertension

Definition: “Persistent elevation of the systolic blood pressure (SBP) at a level of 140mm Hg or higher and diastolic blood pressure (DBP) at a level of 90mm Hg or higher” (Black & Hawks, 2009, p. 1290). Pathophysiology: Because the cause of primary hypertension is not well known, hypertension without a cause is labeled accordingly (Tabloski, 2010). Secondary hypertension is related to problems that affect the kidneys, interfering with “sodium excretion, renal perfusion, or the renin-angiotensin-aldosterone mechanism, leading to an elevation in blood pressure over time” (Black & Hawks, 2009, p. 1293). Signs and Symptoms: When left untreated, hypertension may cause headache, dizziness, fatigue, flushing, palpitations, visual changes, and nosebleed (Black and Hawks, 2009). Diagnosis: A diagnosis of hypertension is made by taking two blood pressure readings while the patient is seated and at least two minutes apart. This must be completed after at least five


minutes of rest (Black & Hawks, 2009). These readings must have an average of 140/90 or higher in order for hypertension to be diagnosed. Specific studies to diagnose hypertension include: complete blood count (CBC), urinalysis, chest x-ray, fasting blood glucose, serum levels of potassium and sodium, serum cholesterol, blood urea nitrogen (BUN), serum creatinine, and electrocardiogram (EKG) (Black & Hawks, 2009).Treatment: Antihypertensive medications include ACE-inhibitors, diuretics, beta blockers, calcium channel blockers, vasodilators, and angiotensin receptor blockers. Lifestyle modifications such as weight reduction, sodium restrictions, dietary fat modification, exercise, alcohol restriction, caffeine restriction, relaxation techniques, smoking cessation, potassium supplementation, and pharmacologic interventions are stressed as well. (Black and Hawks, 2009).

Paroxysmal Atrial Fibrillation

Definition: Atrial fibrillation, or A Fib, is a supraventricular dysrhythmia that is characterized by rapid depolarization of the atria from a re-entrant pathway (Black & Hawks, 2009).Pathophysiology: Impulses of 350 to 600 beats per minute may occur at random, not allowing the atrium to fully recover from one depolarization to the next. These chaotic impulses lead to ineffective atrial contraction, which in turn lead to a decrease in cardiac output by as much as 30% (Black & Hawks, 2009).Signs and Symptoms: As cardiac output continues to decline, dyspnea, angina pectoris, heart failure, and shock may result (Black & Hawks, 2009).Diagnosis: A pulse deficit between apical and radial pulses may be palpated. An electrocardiogram is preferred diagnostic test to reveal A Fib. Examination of the test reveals unidentifiable P waves and irregular ventricular rhythm (Black & Hawks, 2009). Treatment: Anticoagulation, i.e. heparin or oral warfarin are started to reduce the risk of thromboembolism. Aspirin may be started for those patients who have a fall risk or a history of hemorrhage or gastrointestinal bleeding. Converting A Fib. Back to normal sinus rhythm can be achieved by cardioversion or medications. Diltiazem, verapamil, beta-blockers, or digoxin will control heart rate (Black & Hawks, 2009).

Glaucoma

Definition: “Glaucoma comprises a group of ocular disorders characterized by increased intraocular pressure, optic nerve atrophy, and visual field loss” (Black & Hawks, 2009, p. 1699). Pathophysiology: Intraocular pressure is determined by the amount of humor production in the ciliary body and the resistance to outflow of aqueous humor from the eye. An increase in intraocular pressure can occur from an obstruction of the flow of aqueous humor or a hyperproduction of aqueous humor. As the pressure increases, blood supply to the optic nerve and retina are inhibited and tissues within the eye become ischemic (Black & Hawks, 2009).Signs and Symptoms: Severe eye pain, vision loss and blurred vision, rainbow colored halos around lights, nausea and vomiting may occur (Black & Hawks, 2009). Diagnosis: Ophthalmoscope examination may show atrophy or cupping of the optic nerve.


Visual field examination is tested to discover the amount of vision loss (Black & Hawks, 2009).Treatment: Increasing the aqueous humor flow can reduce intraocular pressure. This can be achieved by constricting the pupils using epinephrine or topical miotics. Topical beta-blockers or alpha-adrenergic agents will reduce the production or humor (Black & Hawks, 2009).

Concept Care Map

See Concept Care Map.


Medications

Acetaminophen OTC Tab 325 mg (2 tabs) PO q 6h PRN pain 0-5

Amiodarone Tab: 200 mg PO qam-0800

Cosopt (dorzolamide-timolol) Drops: 2-0.5% 1 drop: ophthalmic 1 gtt to both eyes bid 0800, 2000

Lyrica (pregabalin) Schedule V, capsule: 50mg 1 cap PO q am, 0800

Miralax OTC Powder-Powder for reconstitution , 17gm oral 0800

Surfak (docusate sodium) OTC Capsule 240 mg oral once a day 0800

Synthroid (levothyroxine) Tab 75 mcg qam 0600

Vicodin (hydrocodone-acetaminophen Schedule III Tab 500mg 1 tab PO qid 0000, 0600, 1200, 1800

IV Sites/Fluids/Rates

None

Conceptual Care Map

Student Name __Erin Bradley________ Client Initials __DH_____ Date _2/7/12_

Age _93____ Gender __F___ Room # __205-1___ Admit Date _1/10/12_______

CODE Status _DNR-CCA__ Allergies _Aspirin & Dilaudid__ Braden Score __18/23___

Lab Values/Diagnostic Test Results

CBC w/o Diff (1/16/12):

WBC: 16.4 (H)

RBC: 3.88 (L)

Hgb: 11.9 (L)

Hct: 36.2

Platelets: 285

T4 Total: 8.31

TSH: 7.05 (H)

1/6/12:

Venous duplex of right lower leg extremity: no echogenic filling was seen in vessels evaluated; swelling, redness noted in calf. Impression: no acute osseous abnormality,


Assessment Data

Patient Assessment

General survey.

On at 1600 on February 7, 2012, the following assessment was taken for DH. DH had a

pulse of 68 beats per minute, a respiratory rate of 16 breaths per minute, a blood pressure of

143/78 mmHg, a temperature of 97.5° Fahrenheit, and an oxygen saturation rate of 95% on room

air. DH reported a pain level of 2, using a numeric scale of 1-10. She stated that she had some

slight discomfort in her right lower extremity, particularly her knee, but she declined any

medication for it. DH stated that she did not have a history of tobacco or alcohol use. DH also

stated that she felt her health, although not perfect, was under control. DH is currently

recovering from right lower extremity cellulitis. She explained that she needed to use the

restroom, so one of the aids wheeled her into the restroom and turned the wheelchair around to

get her on to the toilet when her right lower leg and knee became pinned between the toilet and

the wheelchair. She stated that it was just bruised at first, but then it became painful to bear

weight on the extremity. She then noticed it began to swell and became very red and tender to

the touch. She was then taken to the Emergency Room at a local hospital where they tended to

admitted her for treatment.

Cardiovascular assessment.

DH had an unlabored work of breathing. Her respirations were even and deep at 16

breaths per minute. Her oxygen saturation was 95% on room air. Upon auscultation, DH’s lung

sounds were clear bilaterally. She denied the presence of cough or sputum and shortness of

breath.


DH’s skin turgor was good with no tenting noted. Her nail beds were pink and her

capillary refill was less than three seconds. Her radial pulses were +2 bilaterally and her pedal

pulses were +1 bilaterally. DH’s skin was warm and dry to the touch. No jugular vein distention

was noted in DH’s assessment. Her carotid pulse was strong bilaterally. Her apical heart rate

was strong and 72 beats per minute.

Abdominal assessment.

DH had active bowel sounds in all four quadrants. Her abdomen was soft and non-

distended. Her last bowel movement was on February 5, 2012. She was continent of bowel and

bladder. She denied any pain in her abdomen or upon defecation or urination.

Skin assessment.

DH’s skin was warm, pink, and dry to the touch. Her skin turgor was good and no

tenting was noted. DH’s oral mucosa was pink and moist. She stated that she wore dentures.

Her throat was pink and moist. Some skin wounds were noted during the assessment, including

a right and left arm skin tear that the patient stated were from prior procedures where adhesive

bandages had been applied, a right knee wound from the accident in the nursing home, a left leg

hematoma, also from the accident, and bruising on her right and left elbow that the patient stated

she was not sure of where they came from. The right knee wound extended to her lower lateral

and anterior leg and considerable swelling was noted. The affected skin was red and warmer to

the touch than the surrounding areas. The skin surrounding the area was within normal limits.

The left leg hematoma and the right knee and calf wounds were cleansed with normal saline and

a moistened gauze pad was applied to affected areas and secured with Kerlix. DH had a Braden

Scale score of 18/23.


Neurological assessment.

DH was alert and oriented to person, place, time, and situation (Alert and Oriented x 4).

Her level of consciousness was alert and her speech was clear. DH scored a 15/15 on the

Glasgow Coma Scale. DH communicated appropriately and was cooperative throughout each

assessment. DH denied using glasses or assistive devices for hearing. DH’s pupils were equal

and reactive to light and accommodation (PERRLA). She had notable bilateral weakness in her

upper and lower extremities, including her hand grasps. DH is able to stand on her own for short

periods of time and can walk to the bathroom with assistance. DH scored a 10 on the Geriatric

Depression Scale, indicating a mild risk for depression.

Diet and activity.

DH was up with assistance of at least one person. DH scored a three out of six on the

Katz Index of Independence in Activities of Daily Living. She needs assistance bathing,

transferring to the toilet, and dressing. She is able to get from the bed to the chair without

assistance, eat her meals on her own, and she is continent of bowel and bladder. She is on a

regular diet. She states she generally eats about 75-100% of her meals. DH enjoys being

involved in group activities offered in the facility; however, she also likes to have some privacy

in her room during the day to rest and relax.


Gordon’s Function Assessment

AREA OF HEALTH SUBJECTIVE DATA

OBJECTIVE DATA

INDIRECT DATA

*Identify source of indirect data

INTERPRETATION(effective patterns or barriers/potential barriers)

HEALTH/PERCEPTION HEALTH MANAGEMENTGeneral Survey, perceived health& well-being, self-managementstrategies, utilization of preventative health behaviors and/or services.

D.H. stated that she is tired but she is having a good day today.

Patient states pain is 2/10 on vascular scale.

Vital Signs: Respirations 16 and unlabored, pulse 68, temp 97.5°F, pulse ox 95% on room air, BP 143/78.Patient demonstrates personal hygiene with grooming and is dressed in clothes from home.Patient actively participates in self-care but needs assistance x 1 when becomes tired. Patient enjoys spending time doing group activities but also enjoys private time in her room.Patient seems to be well oriented to facility and is cooperative with staff

Patient being treated for right lower leg cellulitis (chart).

Patient has orders for wound treatments every 12 hours (chart).

Patient has PRN medications for pain, i.e. acetaminophen and hydrocodone (chart).

Patient is up with assistance x 1(chart).

Patient seems to get upset that she is not as independent as she was before she entered the facility. Although patient enjoys company, she needs her privacy at times as well.


members.

NUTRITIONAL/METABOLICPatterns of food and fluid consumption,Weight, skin turgor. (Skin, Hair, Nails; Head & Neck; Mouth, Nose, Sinus; swallowing, Ht., Wt)

Patient states that she will eat between 75-100 percent of her meals, depending on what is offered.Patient states that she drinks all of the beverages offered with the meals, as well as a cup of coffee in the morning and water throughout the day.

During shift pt. ate 75% of dinner.Skin turgor was less than three seconds, and no tenting present.Skin was dry and warm with good color. Oral cavity was moist and pink.DH stated that she wore dentures.DD is 62 inches tall, 108 lbs.

DD is partially able to perform own self care.

Patient is given polyethylene glycol once a day.

Patient is given docusate sodium once a day.

Regular diet (chart) Patient seems to

have adequate nutritional intake for dietary needs, but may need additional protein and carbohydrates for wound healing.

ELIMINATIONPatterns of excretory function &Elimination of waste; relevant labs, Medications,

Patient states “I have no pain or urgency when I need to go to the bathroom”.

Abdomen soft symmetrical and non-distended.Bowel sounds present in all

Patient may have bowel elimination problems related to opioid analgesic therapy PRN.


impacting, etc.(Abdominal - bowel and bladder)

Patient states, “My last bowel movement was on 2/5/12”.

four quadrants. Pt. denies pain with palpitation.Patient is given 17gm of polyethylene glycol once per day.Patient is given 240 mg of docusate sodium once per day.

Patient may take 500mg of hydrocodone q 6h as needed for pain.

ACTIVITY/EXERCISEPatterns of exercise & daily living,self-care activities include majorbody systems involved.(Thoracic & Lung; Cardiac; Peripheral vascular; Musculoskeletal,vital signs)

DH denies any shortness of breath or presence of cough. DH states that she tries to do as much as she can on her own, but needs assistance when she becomes tired during self-care activities.DH states that she enjoys participating in activities during the day but enjoys her private time as well.

Heart sounds were regular.Lung sounds were clear. Patient was breathing at 16 respirations per minute.Katz ADL score was 3 out of 6.Patient had a Braden score of 18/23.Patient had a Fall Risk score of 6.Patient is taking Cordarone 200 mg daily.

Patient is up with assist (chart).Patient is encouraged to change position in bed q 2 hours (chart).DH had an assessment for PT ordered (chart). There were no results indicated in her chart.

Patient’s Braden score indicates a risk for developing a pressure ulcer.

Patient is cooperative and willing to try to perform self-care activities unless becomes too tired to do so.

Due to lack of mobility, patient is at a greater risk of developing infection or DVT.


Patient is taking levothyroxine 75 mcg daily.

Patient is taking pregabalin 50mg once daily.

Patient is ordered 700 mg of acetaminophen or 500mg of hydrocodone for pain PRN.

SEXUALITY/ REPRODUCTIONSatisfaction with present level of Interaction with sexual partners(Breast; Testes; Abdominal- Genitourinary-reproductive)

Patient stated that her husband passed away several years ago.

Patient stated that she has had no significant others since the death of her husband.

Patient’s current medications do not have an effect on sexuality or reproduction.

Found no information regarding sexuality from chart.

It was clear that speaking about her husband was a difficult subject for DH

SLEEP/RESTPatterns of sleep, rest, relaxation,fatigue(Appearance, behavior)

Patient stated that she sleeps about eight hours every night.Patient stated that she normally takes a nap around 1400 for about two

Patient was in physical therapy upon arrival and was did not nap that day.

Patient was pleasant and engaging in

Hydrocodone administration may lead to drowsiness (chart)

DH appears obtain a good amount of rest during the day and night.

DH seems to have a good amount of energy to complete daily activities.


hours. activities with others during shift.

COGNITIVE/ PERCEPTUALPatterns of thinking & ways ofPerceiving environment, orientationMentation, neuron status, glasses, Hearing aids, etc.

DH was able to state her name, birthdate, where she was and her situation very descriptively.

DH stated that she was admitted to the facility in January after she was released from a local hospital.

A and O x4 person place time situationPERRLADoes not use hearing aid.

Nurse and physician notes indicate patient has regularly been alert and oriented (chart).

DH did not appear to have a cognitive impairment during shift.

ROLE/RELATIONSHIPPatterns of engagement with others,Ability to form & maintain meaningfulRelationships, assumed roles; Family communication, response,Visitation, occupation, communityinvolvement

Patient states that she used to be an accountant for a printing company in Canton.

Patient states she lived independently up until this past year.

Patient states she was residing with her daughter’s family just before she was admitted into the hospital.

Patient had several pictures of family members in her room.

Patient’s daughter visited during shift.

Nothing indicated on chart about relationships with family or within community.

Although patient preferred to live independently, she seemed to have a positive relationship with her daughter and appreciated her help.

SELF-PERCEPTION/

Patient states that when she is

DH was calm and

Patient is a DNR-CCA (chart).

DH seems to miss her independence.


SELF-CONCEPTPatterns of viewing & valuingSelf; body image & psychologicalstate

at home, she relies on her daughter to take her places.DH states that she misses her independence since being admitted into the facility.Patient states that she is not afraid to die and she has lived a good life.Patient states that her level of anxiety is a 3 on a scale of 1-10.Patient says that she usually has a positive view of self.Patient feels that his level of control in his current situation is a 5 on a scale of 1 to 10.Patient feels that his normal level of assertiveness is a 6 on a scale of 1 to 10.

cooperative during assessment. DH asked questions about assessment findings throughout assessment.DH provided information about past employment history.

DH seems to have an altered self-image due to her admission into the facility.

COPING/STRESS TOLERANCEStress tolerance, behaviors, patternsof coping with stressful events &level of effectiveness, depression,anxiety.

Patient states that she would love to go back to living independently.Patient states that she does not often feel very

Patient scored a 10 on the Geriatric Depression Scale, which is indicative of a slight risk of depression.

Patient is not currently ordered any medications for anxiety (chart).

Patient seems to handle stress of facility and health issues well, but it is clear that she misses her independence.


stressed.

VALUE/BELIEFPatterns of belief, values, Perception of meaning of life thatguide choices or decision; includesbut is not limited to religious beliefs

DH states that she is Protestant and has enjoyed the services in the facility.

DH keeps a bible in her room.

DH has a cross in her room.

Patient is of Protestant faith (chart).

DH is DNR-CCA patient (chart).

DH did not indicate that she would like any religious measures taken in the event of her sudden illness or passing.

She seems to have a strong Christian faith and is actively involved in Christian activities in the facility.

Laboratory Information

See Table 1.

Table 1

Tests Normal Values Patient Results AnalysisWBC 4.8-10.8 16.4 Increased; a result of infection

from right lower extremity cellulitis

RBC 4.0-5.5 3.88 Decreased; may be due to medication use or indicative of

hemodilution from cellulitis

Hgb 12-16 11.9 Decreased; may be a result of hemodilution from cellulitis

Hct 36-48 36.2 Within Normal LimitsPlatelets 150-450 285 Within Normal Limits


T4 Total 4.87-11.72 8.31 Within Normal LimitsTSH 3-4L 0.35-4.94 7.05 Increased; Primary hypothyroidism

leads to high levels of TSH (thyroid stimulating hormone) because of normal feedback

mechanismsNormal Values from:

Nurse’s manual of laboratory and diagnostic tests (4th ed).

Medications

See Table 2.

Table 2

Medication Name(Generic/Trade)

Drug Action/Purpose

Normal Dose Range

Major Side Effects

Nursing Considerations

Acetaminophen/Tylenol 325 mg (2 tabs) PO q 6 hr PRN for pain 0-5

Antipyretic, non-opioid analgesic.

Inhibits synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS.

PO:325-650mg q 4-6hr or 1 gm 3-4 times daily or 1300 mg q 8 hr (not to exceed 4g or 2.5g/24hr in patients with hepatic/renal impairment.

Hepatic failure, hepatotoxicity, renal failure, neutropenia, pancytopenia, leucopenia, rash, urticaria

Assess type of pain, location, and intensity prior to and 30-60 minutes following administration.

Assess fever, note presence of associated signs, i.e. malaise, tachycardia, diaphoresis

Evaluate hepatic, hematologic, and renal function during prolonged therapy.

May alter results of blood glucose monitoring by falsely lowering values when measured with glucose oxidase/peroxidase method.


Amiodarone (Cordarone) 200 mg PO q am

Antiarryhthmics (class III)

Prolongs action potential and refractory period, slows the sinus rate, increases PR and QT intervals, and decreases peripheral vascular resistance (vasodilation).

800-1600mg/day in 1-2 doses for 1-3 weeks, then 600-800 mg/day in 1-2 doses for 1 month, then 400 mg/day maint. Dose

Dizziness, fatigue, malaise, corneal microdeposits, adult resp. distress syndrome, pulmonary fibrosis, pulmonary toxicity, chf, worsening of arrhythmias, bradycardia, hypotension, anorexia, constipation, nausea, vomiting, toxic epidermal necrolysis (rare), photosensitivity, hypothyroidism, ataxia, involuntary movement, paresthesia, peripheral neuropathy, poor coordination, tremor

Monitor ECG continuously during initial oral therapy. Monitor heart rate and rhythm throughout therapy.

Assess for signs of pulmonary toxicity (rales/crackles, decreased breath sounds, pleuritic friction rub, fatigue, dyspnea, cough, wheezing, pleuritic pain, hypoxia, hemoptysis).

Assess for neurotoxicity (tremors, tingling or numbness in fingers or toes, muscle weakness).

Ophthalmic exams should be performed before and regularly during therapy.

Assess for signs of thyroid dysfunction.

2% dozolamide + 0.5% timolol (Cosopt Opthalmic Solution)

Beta-blocker; management of chronic open-angle glaucoma and other

1 drop of 0.25-0.5% solution 1-2 times per day.

Conjunctivitis, visual acuity, ocular burning, rash

Last up to 24 hours


1 drop in both eyes BID

forms of ocular hypertension; decreases the formation of aqueous humor

Pregabalin (Lyrica)50 mg Capsule PO q am

Analgesics, anticonvulsants

Binds calcium channels in CNS tissues which regulate neurotransmitter release. Does not bind to opioid receptors.

50-75mg 2-3 times daily initially, may be increased within one week based on tolerability

Suicidal thoughts, dizziness, drowsiness, edema, dry mouth, decreased platelet counts

Monitor closely for changes in behavior indicative of suicide.

Assess location, intensity, and characteristics of pain before and periodically during therapy.

May cause increase creatine kinase levels and decrease in platelet counts

Polyethylene glycol (Miralax) OTC powder

Laxatives, osmotic

Polyethylene glycol in solution acts as an osmotic agent, drawing water into the lumen of the GI tract.

PO 17 g (heaping tablespoon) in 8 oz of water; may be used for up to 2 weeks.

Abdominal bloating, cramping, flatulence, nausea.

Assess patient for abdominal distention, presence of bowel sounds, and usual pattern of bowel function.

Assess color, consistency, and amount of stool produced.

Docusate sodium (Surfak) OTC 240 mg capsule PO once a day

Laxatives, Stool softeners

Promotes incorporation of water into stool, resulting in softer fecal mass.

50-400 mg in 1-4 divided doses.

Throat irritation, mild cramps, diarrhea, rashes.

Assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel function.


May also promote electrolyte and water secretion into the colon.

Assess color, consistency, and amount of stool produced.

Levothyroxine (Synthroid) 75 mcg tab q am

Hormones, thyroid preparations

Replacement of supplementation to endogenous thyroid hormones.

50 mcg as a single dose initially, may be increased q 2-3 weeks by 25/mcg/day. Usually maintenance dose is 75-125 mcg/day

Insomnia, irritability, angina pectoris, arrhythmias, tachycardia, abdominal cramps, diarrhea, vomiting, sweating, hyperthyroidism, menstrual irregularities, heat intolerance, weight loss

Assess apical pulse and blood pressure prior to and periodically during therapy.

Assess for tachycardia and chest pain.

Monitor thyroid function studies before and during therapy.

Overdose is manifested as hyperthyroidism (tachycardia, chest pain, nervousness, tremors, weight loss)

Hydrocodone-acetaminophen (Vicodin) 500 mg PO QID

Antitussive, opioid analgesics/nonopioid analgesic combinations

Bind to opiate receptors in the CNS. Alter the perception and response to painful stimuli while producing generalized CNS depression.

2.5-10 mg q 3-6 hr; acetaminophen dosage should not exceed 4g/day and should not exceed 5 tablets per day of ibuprofen-containing products.

Confusion, dizziness, sedation, hypotension, constipation, dyspepsia, nausea, respiratory depression, urinary retention.

Assess blood pressure, pulse, and respirations before and periodically during administration. If respirations are less than 10 per minute, assess level of sedation.

Assess bowel function routinely.

Assess type, location, and


intensity of pain prior to and one hour after administration.

Prolonged use may lead to physical and psychological dependence.

Medication references used:

Davis’ Drug Guide (12th ed).

Analysis

Nursing Diagnosis #1

The primary nursing diagnosis that I chose for DH was Impaired Skin Integrity

related to right lower extremity cellulitis as evidenced by edema, erythema, increased white

blood cells (16.4), and pain rating of two out of ten (Carpenito-Moyet, 2010). The patient was

admitted to the facility in January of 2012 after she was treated for the cellulitis and discharged

from the local hospital.

According to Carpenito-Moyet (201), impaired skin integrity is a state in which the

patient’s epidermis and/or dermis is at risk for or is compromised. In DH’s case, the lower

extremity cellulitis has spread throughout her epidermis and deeper dermis into her subcutaneous

tissue and caused and promoted infection. Therefore; DH’s skin and underlying tissue has been

damaged and inevitably altered. Adequate nutrition and proper wound care is essential for

achieving timely wound healing. Eaton-Bancroft (2005) states that increased intake of

carbohydrates, fats, protein, zinc, selenium, Vitamin K, A, and C are critical to establish tissue

maintenance and repair. Additionally, the author also emphasizes the need for apposite

interventions and documentation during the duration of care at any facility to ensure the

progression of wound healing. Using the appropriate anatomical terms and precise measurement


of the wound will aid in the evaluation and charting standards for wound care (Eaton-Bancroft,

2005).


The secondary nursing diagnosis I chose for DH was Risk for Infection related to right

lower extremity cellulitis as evidenced by edema, erythema, and increased white blood cell count

(16.4) (Carpenito-Moyet, 2010). Carpenito-Moyet (2010) describes a Risk for Infection as “the

state in which an individual is at risk to be invaded by an opportunistic or pathogenic agent

(virus, fungus, bacterium, protozoan, or other parasite) from endogenous or exogenous sources”.

The author goes on to state that Risk for Infection explains that the patient’s defenses are

compromised, making them more susceptible to environmental pathogens. The older adult is at

increased vulnerability to infection not only because of their health conditions, but also because

they have a decreased immune response and their decline in mobility status (Carpenito-Moyet,

2010). DH’s wound healing has been a slow progression and the continuation of the cellulitis

prolongs her risk for active infection. Nursing interventions for DH should focus on increasing

resistance to infection by improving her nutritional status and minimizing the introduction of

organisms through aseptic techniques and proper wound care (Carpenito-Moyet, 2010).


My final nursing diagnosis that I chose for DH is Impaired Physical Mobility related to

right lower extremity cellulitis, as evidenced by muscle weakness, pain of two out of ten in right

lower extremity, altered sensory perception due to opioid analgesics, and infection (Carpenito-

Moyet, 2010). Risk for Infection is defined as a state in which an individual experiences

restrictions of physical movement, but is not totally immobile. DH currently has limited use of

her right lower leg and weakness in all extremities due to infection and medication use. Nursing


interventions should focus on improving strength, preventing further deterioration and restoring

function (Carpenito-Moyet, 2010).

Nursing Diagnoses, Plans, Interventions, and Evaluation

See Tables 3, 4, and 5.

Table 3

Primary Nursing Diagnosis:

Impaired Skin Integrity related to right lower extremity cellulitis as evidenced by edema, erythema, WBC (16.4), and pain of two out of ten(Carpenito-Moyet, 2010).

Patient Goal: Patient will exhibit wound healing within 30 days.

Interventions: 1. Maintain strict skin hygiene, using mild, non detergent soap, drying gently and thoroughly, and lubricating with lotion or emollient (Doenges, Moorhouse, & Murr, 2010).

Rationale: A daily bath may create dry skin problems. Use of lubricants keep skin soft and pliable, and help to keep susceptible skin from breaking down (Doenges et al., 2010).

2. Assess nutritional status and initiate corrective measures by providing a balanced diet with adequate protein, vitamins, and minerals (Doenges et al., 2010).

Rationale: A positive nitrogen balance and improved nutritional state can help prevent skin breakdown and promote healing (Doenges et al., 2010).

3. Assist with topical applications, such as hydrogel dressings, skin barrier dressing, collagenase therapy, absorbable gelatin sponges, and aerosol sprays (Doenges et al., 2010).

Rationale: Although there are differing opinions about the use of these agents, individual or combination use may enhance healing (Doenges et al., 2010).

Evaluation: Unable to assess patient goal because of limited time at facility. In order to promote wound healing, I would discuss the importance of proper diet with the patient, enforce proper hygiene and continue the


application of wound treatments throughout my shift.

Table 4

Secondary Nursing Diagnosis:

Risk for Infection related to right lower extremity cellulitis as evidenced by WBC (16.4), edema, erythema, pain of two out of ten, and altered immune function related to normal aging process (Carpenito-Moyet, 2010).

Patient Goal: Patient will report risk factors associated with infection and precautions that can be taken to prevent infection by the end of shift.

Interventions: 1. Explain the importance of adequate nutrition. Encourage DH to develop intake goals for snacks and meals (Doenges et al., 2010).

Rationale: Helps to improve general resistance to disease and reduces risk of infection from static secretions (Doenges et al., 2010).

2. Provide meticulous, clean, or aseptic care; maintain good hand washing techniques (Doenges et al., 2010).

Rationale: Helps eliminate and defend against health care facility acquired infection (Doenges et al., 2010).

3. Observe for clinical manifestations of infection including fever, cloudy urine, confusion, and drainage (Carpenito-Moyet, 2010).

Rationale: The usual signs of infection may not always be present in geriatric patients. Patient must also be educated to observe for changes (Carpenito-Moyet, 2010).

Evaluation: Short term goal met. DH verbalized her understanding of risk factors for infection. She also verbalized her understanding of proper diet and increased protein, vitamins, and minerals. DH also demonstrated proper hygiene during shift.

Table 5

Tertiary Nursing Diagnosis:

Impaired Physical Mobility related to right lower extremity cellulitis as evidenced by muscle weakness, pain of two out of ten in right lower extremity, altered sensory perception due to opioid analgesics, and infection (Carpenito-Moyet, 2010).

Patient Goal: The patient will report an increase in strength and endurance in limbs within 30 days.


Interventions: 1. Determine DH’s functional ability using a scale of 0 to 4 and reasons for impairment (Doenges et al., 2010).

Rationale: Identifies need for and degree of intervention required (Doenges et al., 2010).

2. Plan activities and visits with adequate rest periods as necessary. (Doenges et al., 2010).

Rationale: Can limit or prevent fatigue; conserve energy for continued participation (Doenges et al., 2010).

3. Encourage participation in self-care, occupational, and recreational activities (Doenges et al., 2010).

Rationale: Promotes independence and self-esteem; may enhance willingness to participate (Doenges et al., 2010).

4. Assist with transfers and ambulation; show DH ways to move safely (Doenges et al., 2010).

Rationale: Prevents accidental falls and injury (Doenges et al., 2010).

Evaluation: Unable to measure goal because of limited time at facility. Assisted with transfers and ambulation and planned activities together to provide adequate rest periods during shift. DH actively participated in self-care activities during shift and verbalized her functional abilities and limits.

Conclusion

At the end of the shift, I felt that DH had done well throughout the day in which I

cared for her. Her physical status remained constant throughout the shift. DH was pleasant and

cooperative during the course of the day and willing to be actively involved in the care that I

provided for her. DH was receptive to education and suggestions that I had for her and

verbalized and demonstrated skills that were discussed. DH was open to discussing her past

physical, emotional and social history with me as we built up our rapport together. At the end of

my shift, DH verbalized her willingness and desire to improve her health condition by continuing


with physical therapy and active participation in self-care activities, as well as monitoring her

infection and maintaining good hygiene to promote wound healing.


References

Black, J. M. & Hawks, J. H. (2009). Medical surgical nursing: clinical management for positive

outcomes (8th ed.). Saint Louis, Missouri: Saunders Elsevier.

Cavanaugh, B. (2009). Nurse’s manual of laboratory and diagnostic tests (4th ed.). Philadelphia,

Pennsylvania: F. A. Davis Co.

Carpenito-Moyet, L. J. (2010). Handbook of nursing diagnosis (13th ed.). Philadelphia,

Pennsylvania: Lippincott, Williams, & Wilkins.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing care plans: guidelines for

individualizing client care across the life span (8th ed.). Philadelphia, Pennsylvania: F. A.

Davis Co.

Eaton-Bancroft, I. (2005). Teaming up for wound care. Nursing2005, 35(4), p32hn1-32hn3.

Hopfer, J., Vallerand, A., & Sanoski, V. (2010). Davis’s drug guide for nurses (12th ed.).

Philadelphia, Pennsylvania: F. A. Davis Co.






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