Student Name: Robyn Begalke 1045075

Nursing Assessment Form

Client Name: J.M. Medical Diagnosis: SEE PATHOLOGY RECORD

Client Perception of Health Needs: Assistance with ADL’s and hygiene.

Client Goals for Health: To be assisted with toileting to avoid being incontinent.

Allergies (food, medication, environmental)

No known allergies.

Medications SEE MEDICATION RECORD

Dietary considerations

- diet cut up, scheduled HS snack- refused assist table- fluids are regular (thin)- 1 person assist for set up and supervision- provide intermittent encouragement to improve consumption

Vital Signs T 36.2 P 62 R 12 BP 118/60 O2 sats 92% Pain rating 0

HEALTH ASSESSMENT DATA

Physiological Variable

Student Name: Robyn Begalke 1045075

HEALTH ASSESSMENT DATA

General Appearance/Mental State:Female, 90 years old. English speaking. Pleasant and quiet, doesn’t maintain eye contact when in conversation. Prefers to wear lipstick, have her hair combed in a specific way, likes to dress nicely and doesn’t like slippers/shoes. Lays/sits stiffly and isn’t able to reposition herself. Dry skin on legs and feet bilaterally. Oriented to person, place and time. Cooperative and enjoys attention from health care team. Speaks coherently and often. Likes to attend community activities and enjoys company. GCS of 15 but suffers from dementia and depression. Occasionally confused.

Cardiovascular System:- Has been diagnosed with congestive

heart failure, atrial fibrillation, dyslipidemia and benign hypertension

- On anticoagulant therapy to minimize risk of clot formation

- No bruising or signs of bleeding noted- BP: 118/60, P: 62 weak and irregular- Apical pulse 62, strong and irregular- S1 and S2 sounds identified on all

cardio sites with no additional sounds noted, but muffled and slow

- Popliteal, dorsalis pedis and posterior tibial pulses unpalpable bilaterally

- All extremities warm to touch- Capillary refill < 3 seconds on upper

and lower extremities bilaterally- Mild pitting edema to right foot < 2

seconds

Student Name: Robyn Begalke 1045075

HEALTH ASSESSMENT DATA

Respiratory System:- 12 respirations per minute deep and

unlaboured- SPO2 of 92% on room air- Lung sounds clear in right and left

upper lobes- Fine crackles noted in right middle

lobe and right and left lower lobes bilaterally

- Symmetrical chest expansion- Bronchial, bronchovesicular and

vesicular sounds heard- Slight labour in breathing after too

many deep breaths in a short period of time

- No cough noted

Gastrointestinal System:- Patient eats well, usually over 75% of

her meal- Patient eats better with company and

enjoys her meal mates- Appears hydrated, skin turgor < 2

seconds, no tenting noted, mucous membranes and lips moist

- Has natural teeth- Hyperactive bowel sounds in all 4

quadrants, high pitched- History of frequent constipation and

refuses suppository, but is able to go with adequate fluid intake and prune juice

- Abdomen distended but soft on palpation

- Has bowel incontinence and wears a large brief

Urinary System:- Incontinent of urination and wears

large sized brief- No distension of the bladder- Usually voids x 2 per shift- Drinks well when offered hot water- Urine is clear light yellow- Has history of UTI’s

Sensory Systems:- Wears eyeglasses on a regular basis- No hearing aid and doesn’t show any

significant signs of hearing deficit- Has no signs of peripheral neuropathy- Speech is slightly delayed but is able to

speak and comprehend well- Reports some occasional nerve pain in

the lower extremities

Student Name: Robyn Begalke 1045075

HEALTH ASSESSMENT DATA

Nervous System:- Alert and oriented to person, place and

time- GCS of 15- Pupil size approximately 2mm, equal

and reactive- No paralysis and has feeling in all

extremities- Occasionally confused due to dementia

but is more often aware of surroundings and situation

Integumentary System:- Skin pink and warm to touch- Thin, dry hair- Skin turgor of < 2 seconds and no

tenting noted- Many moles everywhere- Has a rash under breasts from moisture- Patient has a braden score of 16: mild

risk- Is often moist in her brief and can only

make small positional adjustments without assistance

Musculoskeletal System:- Limited mobility- Limited ROM- Has suffered a fracture to the right

femur and tibia with a right sided knee replacement

- Is very stiff in the mornings- Is able to sit up without much

assistance but is unable to move limbs on her own

- Unable to weight bear or walk- Requires full assistance with dressing,

toileting, and is a mechanical lift transfer

- Requires assistance in getting around in wheelchair, cannot use feet or arms to move herself

- Has history of falls- Weak against resistance

Reproductive System:- Post menopausal- Has no symptoms that would indicate

reproductive system pathology- Has two sons and a daughter- “Too many grandchildren to count”

Endocrine System:- Patient is able to regulate hormones

naturally

Client Resuscitation Status:MI: interventions appropriate excluding resuscitation and ICU care, transfer to acute care is considered if appropriate, surgery is considered with aim at symptom relief, deterioration should be discussed with family and power of attorney

Student Name: Robyn Begalke 1045075

HEALTH ASSESSMENT DATA

Spiritual Variable (Environment)- Client practices Pentecostal religion- Enjoys going to church as evidenced

by her attending services often- Taught Sunday school before

retirement

Developmental Variable (Environment)- In Erickson’s stages of development,

patient is in ego-integrity vs. despair- Hard to determine which end of the

continuum client is leaning towards, diagnosed with depression and has occasional spurts of sadness but generally seems outwardly content

- Does not seem to be afraid of her diagnoses

Sociological Variable (Environment)- Client enjoys to have company- Enjoys meal times with her table mates- Spends time watching TV alone in her

room- Likes to have her door open but

occasionally feels self conscious when neighbouring residents have visitors

- Daughter visits multiple times a week to keep her company

Psychological Variable (Environment)- Suffers from dementia and depression- Enjoys interacting with others- Has many photos of family in her room- Takes pride in her appearance and

enjoys wearing lipstick- Feels self-conscious about herself and

her dependence on health care staff

Determinants of health impacting client’s health (Environment)- Client is bed and wheelchair bound and cannot ambulate- Inability to perform daily activities without extensive assistance- At risk for falls, impaired skin integrity, emotional distress, loneliness, helplessness

Interdisciplinary Team Members- Physician- RN, LPN, SPN- HCA- Dietary- Occupational therapy- Pharmacy- Family members (offspring), husband deceased

Student Name: Robyn Begalke 1045075

HEALTH ASSESSMENT DATA

Health Priorities- To maintain fluid balance, skin integrity, adequate perfusion, blood pressure- To stimulate the client to keep her occupied- To protect the client from falls- To ensure the client maintains adequate fluid intake to avoid dehydration related

complications- To limit the risks for bleeding associated with anticoagulant therapy- To keep pain to a minimum- Avoid further decline in bladder control

Client Strengths- Has a relatively happy outgoing demeanour and likes to be actively involved in

maintenance of health- Very cooperative and trusting in health care staff- Client is able to feed independently- Is very polite to staff and other residents- Can remember her past and the life she has lived/accomplishments she is proud of- Is able to laugh and have fun in spite of her depression and dementia

Laboratory/Radiology ReportsMost recent April 16 2015

- RBC – L 97- HCT – L 3.31- Creatnine – H 117- Pottassium H 5.2- INR H 3.2

Student Name: Robyn Begalke 1045075

Pathophysiology Record

Must be written in your own words (i.e., as if teaching a patient)

Medical Diagnosis Pathophysiology Signs and Symptoms ComplicationsCongestive Heart Failure (CHF)(Primary Diagnosis)

The heart is unable to pump enough blood to sustain the body’s requirements, the blood moves through the body at a slower rate and pressure in the heart increases. The heart tries to compensate by thickening its walls to keep blood moving but it causes the heart to become weaker. This condition is usually caused by damage to the heart muscle. It is common for an individual to present with right sided or left sided failure. The symptoms and complications vary depending on which side of the heart is affected, but often failure in one side of the heart leads to failure in the other.

Left sided CHF: shortness of breath at rest and/or when laying flat, cough, crackles in the lungs, bloody sputum

Right sided CHF: pitting edema in the extremities, weakness

Left sided CHF: buildup of fluid in the lungs, decreased urine output, arrhythmias, hypertrophy of the heart and lungs

Right sided CHF: buildup of fluid in the abdomen, decreased urine output, arrhythmias and hypertrophy of the heart, weight gain

Atrial Fibrillation(Secondary Diagnosis)

A heart condition causing irregular heart beats or rhythm known as an arrhythmia that can cause a blood clot to form due to irregular blood flow or pooling in the upper chambers

Irregular fast heart rate, palpitations or thumping in the chest, chest pain, shortness of breath, fatigue, dizziness, light-headedness

Atrial fibrillation increases the risk of a stroke due to the increased risk of clot formation, can cause heart failure, and can also cause the heart muscle to become weak.

Student Name: Robyn Begalke 1045075of the heart.

Benign Hypertension(Secondary Diagnosis)

Hypertension is consistent high blood pressure of 140/90. It is usually caused by an increase in blood volume being pumped throughout the body causing the arteries to become less elastic. Benign hypertension is usually over a prolonged period of time and escalates more slowly than malignant hypertension. It is generally asymptomatic, but will likely cause similar complications as malignant hypertension and can present with the same symptoms.

Headache, blurred vision, nausea, weakness, confusion, fatigue and change in mental status

Cardiovascular disease, stroke, damage to the heart, kidneys and eyes.

Dyslipidemia(Secondary Diagnosis)

We have natural fats in our body that are essential for supplying and storing energy. These fats are called lipids, more commonly known as cholesterol levels. Dyslipidemia refers to an abnormal amount of lipids in our blood, either too high or too low. With hyperlipidemia, the lipids or fats can buildup in the arteries that may lead to a partial or full blockage that can affect blood flow to the vital organs, with hypolipidemia,

Hyperlipidemia symptoms include chest pain, cramping in one or both calves while walking, sores on the toes that do not heal, sudden stroke like symptoms including one side of the face to droop, trouble speaking, weakness of one arm or leg, and loss of balance.

Hypolipidemia symptoms are few but include thin dry hair, tooth deformity and malnutrition.

Hyperlipidemia or high cholesterol can cause a hardening of the arteries, a buildup of fats that can cause deficient blood flow and can lead to a stroke or myocardial infarction or heart attack.

Hypolipidemia can cause a deficiency in normal blood clotting, inability to absorb and use fat and vitamins, and abnormalities in hormone levels. It can also cause poor wound healing, increased risk

Student Name: Robyn Begalke 1045075low lipid levels rarely cause a problem, but can indicate the prescense of another disorder.

for infection

Student Name: Robyn Begalke 1045075Ineffective peripheral tissue perfusion related to inadequate distribution of circulating blood volume secondary to congestive heart failure as evidenced by diminished peripheral pulses and mild pitting edema in the lower extremeties.

Client goal: Client will maintain tissue perfusion to extremities.

Client outcome: Client will have no decline in peripheral perfusion and maintain mild pitting edema of 1+ to lower extremities bilaterally within the next week.

1) Ensure the client remains warm throughout the day to encourage blood flow. (Day, Paul, Williams, Smeltzer & Bare, 2010, p. 926)

2) Sit with the client during meal times to promote and encourage proper nutrition with adequate protein and vitamin intake, which is essential for arterial health. (Day et. al., 2010, p. 926)

3) Ensure that the client does not cross her feet while in bed or in her wheelchair. (Day, et. al., p. 927)

Goal ongoing, client has shown no signs of worsening perfusion including maintenance of peripheral pulses and edema.

Intervention 1) Effective, student nurse is able to ensure that the client is always warm enough by adding sweaters as needed and ensuring that she always has an extra one on her chair. Ongoing.

Intervention 2) Effective, student nurse is able to provide encouragement at meal times and has been able to promote intake of nutrients. Ongoing.

Intervention 3) Effective, student nurse is able to place a pillow between her legs when the client is in bed and redirects her if she begins to cross her feet in her chair. Ongoing.

Student Name: Robyn Begalke 1045075Risk for imbalanced fluid volume related to deficient cardiac output secondary to congestive heart failure and daily administration of diuretics.

Client goal: Client will maintain a balanced fluid volume.

Client outcome: Client will maintain urine output of > 30ml per hour and demonstrate no signs of dehydration throughout the 2 weeks in my care.

1) Ensure adequate fluid intake by client by encouraging fluids. (Potter & Perry, 2014, p. 948)

2) Assessment of hydration status including urine, mucous membranes, skin turgor, blood pressure and intake patterns. (Potter & Perry, 2014, p. 948)

3) “Obtain daily weight measurements” which may indicate extreme fluid retention or loss. (Potter & Perry, 2014, p. 954)

Goal ongoing; client has shown no signs of dehydration or fluid overload in the past week but will have to continue to monitor over the upcoming week.

Intervention 1) Effective, student nurse is able to encourage client to drink > 500ml of hot water per 8 hour shift. Ongoing.

Intervention 2) Effective, student nurse is able to assess hydration status during AM assessment and monitor vital signs. Student nurse is also able to collaborate with other health care staff to determine amount of fluid intake per shift. Ongoing.

Intervention 3) Student nurse has not been effective in this intervention thus far but will ensure to take daily weight measurements beginning next week. In progress.

Student Name: Robyn Begalke 1045075Risk for bleeding related to decreased amount of clotting factors in the blood as evidenced by anticoagulant therapy and INR lab value.

Client goal: Client will have no incidence of significant bleeding.

Client outcome: Client will have no bruising or signs of bleeding in the next week.

1) Assess skin and gums for bruising which may indicate a hematoma. (Vallerand & Sanoski, 2013, p. 1274)

2) Take all vitals before and during administration of anticoagulant including blood pressure and pulse rate and rhythm. A low BP and thready pulse could indicate blood loss. (Vallerand & Sanoski, 2013, p. 1274)

3) “Monitor stool and urine for occult blood before and periodically during therapy” (Vallerand & Sanoski, 2013, p. 1274)

Goal ongoing; client has shown no evidence of bleeding thus far but will have to remain diligent in monitoring for signs and symptoms over the next week.

Intervention 1) Effective, student nurse is able to watch for any bruising on the gums during AM oral care and assess for skin bruising during morning integumentary assessment. Ongoing.

Intervention 2) Effective, student nurse is able to monitor vitals every morning to ensure that they are within normal range for the client and that anticoagulant therapy is therapeutic. Ongoing.

Intervention 3) Effective, student nurse is able to monitor excretions during afternoon toileting. Ongoing.

Student Name: Robyn Begalke 1045075Medication Research Record

Ensure you relate the medication information to the appropriate medical diagnosis. Please use lay terms as if you were teaching a patient.

Medication/Reason for Medication Order

Dosage/Safe Dose Action as Related to Medical Diagnosis

Common Side Effects Nursing Implications

Citalopram Dose Ordered: 30 mg PO daily

Safe dose: 20 mg PO once daily initially, may be increased to 40mg PO once daily after 1 week

Citalopram delays the break down of the neurotransmitter or chemical in the brain that can affect mood, social behavior, appetite and digestion and sleep and memory. The delay in the breakdown of this chemical decreases the feelings of depression.

Confusion, drowsiness, insomnia, weakness, abdominal pain, anorexia, nausea, diarrhea, dry mouth

Monitor mood changes during therapy, monitor electrolytes, reposition slowly to minimize dizziness, provide good oral hygiene to avoid dry mouth, watch for abnormal rhythm that may lead to ventricular fibrillation and serotonin syndrome (agitation, hallucinations, tachycardia)

Metoprolol Dose Ordered: 12.5 mg POBID

Safe Dose: 25-100mg daily as a single dose initially or two divided doses, may be increased every 7 days as needed up to 450mg/day

Metoprolol decreases the heart rate and decreases the amount of oxygen needed to sustain the heart while increasing the oxygen delivery to the heart. Lowers blood pressure.

Fatigue, weakness, anxiety, depression, bradycardia, pulmonary edema, diarrhea, constipation, hypo/hyperglycemia

Take apical pulse before administering and withhold if <50bpm, administer with meals or directly after eating, reposition patient slowly to avoid orthostatic hypotension, monitor for dyspnea, bradycardia, arrhythmias and wheezing.

Student Name: Robyn Begalke 1045075(immediate release) or 400mg (extended release)

Sennosides Dose ordered: 8.6mg PO every bedtime

Safe dose: 12-50mg 1-2 times daily

Increases the accumulation of fluid and peristalsis(movement) in the large intestine resulting in increased bowel movements

Cramping, diarrhea, nausea, pink-red or black-brown discoloration of urine, electrolyte imbalance

Ensure sennosides are taken with a full glass of water, administer at bedtime, may take 6-12 hours to take effect, administer on an empty stomach to speed up onset

Spironolactone (Aldactone)

Dose ordered: 12.5 mg PO daily

Safe dose: HF: 25-50mg PO daily

Promotes the absorption of water and sodium in the kidneys to increase urination

Dizziness, headache, sedation, arrhythmias, GI irritation, hyperkalemia, hyponatremia

Monitor intake and output and weight daily, BP should be monitored prior to administration when adjunctive to hypertension therapy, assess frequently for hyperkalemia

Telmisartan (Micardis) Dose odered: 80mg PO once daily

Safe dose: CV risk reduction: 80mg PO once daily

Dilates the blood vessels causing a decrease in blood pressure

Dizziness, fatigue, headache, hypotension, hyperkalemia, abdominal pain, diarrhea, impaired renal function

Reposition slowly to avoid orthostatic hypotension, encourage fluids, monitor for signs of hyperkalemia

Acetaminophen (Tylenol)

Dose ordered: 500mg PO twice daily

Safe dose: 325-650mg PO q 6 hours or 1g 3-4 times daily

When used for analgesia, relieves pain by increasing the pain threshold and decreasing inflammation and swelling

Hepatotoxicity, renal failure, rash, constipation

Administer with full glass of water, may be taken with food or on an empty stomach, monitor frequency of bowel movements

Student Name: Robyn Begalke 1045075Furosemide (Lasix) Dose ordered: 20mg

PO once dailyIncreases the excretion of fluid and electrolytes by decreasing the reapsorption in the kidneys

Blurred vision, dizziness, headaches, vertigo, hearing loss, hypotension, constipation, anorexia, dry mouth, muscle cramps

May be administered with food or milk to reduce gastric irritation, tablets may be crushed, monitor for fall risk, monitor intake and output and blood pressure

Vitamin D Dose ordered: 1000 units daily

Safe dose: 400-1000 units daily

Promotes the absorption of calcium in the intestine

Headache, irritability, weakness, conjunctivitis, arrhythmias, hypertension, constipation, dry mouth, nausea, hypercalcemia

Assess for bone pain/weakness, observe closely for hypercalcemia, encourage dietary recommendations/orders

Warfarin Dose ordered: 3 mg PO once daily

Safe dose: 2-5mg/day for 2-4 days, then adjust to INR results

Prevents the blood from clotting

Cramps, nausea, dermal necrosis, bleeding, fever

Assess for signs of bleeding (gums, stool, nosebleed, unusual bruising, tarry black stools, blood in urine), evaluate PT/INR before administering, withhold if bleeding occurs, administer at the same time each day, avoid activities that may cause injury, soft toothbrush only

Cyanocobalamin Dose ordered: 500mcg PO daily

Improves metabolism of fats and catbohydrates to support metabolism of Vitamin B12

Headache, heart failure, diarrhea, hypokalemia, pulmonary edema

Assess patient for signs of Vitamin B12 deficiency(pallor, neuropathy, red inflamed tongue, psychosis) prior to and during administration, administer with meals to increase absorption

Student Name: Robyn Begalke 1045075Polythylene Glycol Dose ordered: 17g

PO daily

Safe dose: 17g in 8oz water may be used up to 2 weeks

Increases the absorption of water in the GI tract to promote bowel movements

Abdominal bloating, cramping, flatulence, nausea

Dissolve powder into 8oz of water prior to administration, assess for abdominal distension, presence of bowel sounds, and usual pattern of bowel movements, assess color, consistency and amount of stool excreted

Bisacodyl Dose ordered: 5mg PO every 3 days PRN

Safe dose: 5-15mg/day up to 30mg/day as a single dose

Increases fluid buildup in the colon and increases movement (peristalsis) in the intestines

Abdominal cramps, nausea, diarrhea, rectal burning, hypokalemia with chronic use, muscle weakness with chronic use

May be administered before bedtime for AM results, taking on an empty stomach will speed up onset, do not crush or chew enteric coated tablets, avoid administration within 1 hour of milk or antacid consumption, assess for bowel sounds, abdominal distension, colour, consistency and amount of stool excreted

Salbutamol (Ventolin NEB)

Dose ordered: 2.5mg(ml) via sidestream every 4 hours PRN

Safe dose: 2.5-5mg every 20 minutes for 3 doses, then 2.5-10mg every 1-4 hours PRN

Causes relaxation of smooth muscle and dilation of the airway to improve breathing pattern

Restlessness, tremor, headache, insomnia, bronchospasm, palpitations, angina, arrhythmias, hypertension, nausea, vomiting, hyperglycemia, hypokalemia

Allow 1 minute between inhalations, oxygen should be set to 6-10 LPM, assess lung sounds, pulse and BP before administration and after onset, monitor pulmonary function tests prior to and during therapy, observe for bronchospasm

Student Name: Robyn Begalke 1045075Nursing Care Plan - Summary

Describe the benefits of using the nursing process and the nursing concepts in your assessment and nursing care.

Assessment:During my assessment of my client I was really grateful for the nursing process. I was able to use

the knowledge I obtained in theory to help me make the experience more enjoyable for my client

and easier for me to gather information. I was able to use the nursing process to develop a strong

rapport and therapeutic relationship with my client, which made it easier for her to disclose

information to me and feel more comfortable in my care. During the assessment I was able to

acquire information about her emotional well-being that I may not have if I wasn’t using the

tools I learned to use through the nursing process. I was also able to determine what was

pertinent information and what was irrelevant, what was normal and what was abnormal and

what was supported by objective findings and what wasn’t. I am grateful for my knowledge in

assessments to make a difference in my client’s health and well-being. For example, during my

assessment of my client’s emotional state I learned that she served in the Air Force, and that’s

how she met her husband who passed away in 2010. Being comfortable with me as her caregiver

gives the client the confidence that I have her best interest in mind and that I am a competent and

caring practitioner. Another benefit of using the nursing process in the assessment of my client

was that I was able to recognize her abnormal findings and report to the LPN so that they can be

closely monitored. For example, during my head to toe assessment of my client I noted that she

had mild pitting edema on her right and left feet and foot drop and without my knowledge of

health assessment and the nursing process that may have gone unnoticed. Using the nursing

process during my assessment I was able to learn a lot about my client and determine my

Student Name: Robyn Begalke 1045075priorities for her care.

Nursing Care:Providing nursing care for my client and other residents at the care center has been an incredible

experience so far and I imagine it will continue to be exciting and rewarding. It is so enjoyable to

see the difference you can make in a patients day just by spending time with them or doing the

little things that they may not be able to do for themselves. I will always remember my first

client, initiating my first g-tube feed, changing my first dressing and even giving my first bed

bath. These things are not something that can be prepared for in the lab because it doesn’t

include how you’re going to feel. I have never felt so good about what I’m doing everyday and I

couldn’t imagine doing anything else. All the tedious hours spent in theory doing assignments

and writing exams and lab pretending a water bottle was a g-tube were so worth it and I cant wait

for more experience and time spent doing what I love.

Student Name: Robyn Begalke 1045075

References

Day, R. A., Paul, P., Williams, B., Smeltzer, S., & Bare, B. (2010). Brunner & Suddarth's

textbook of Canadian medical-surgical nursing (2nd Canadian ed.). Philadelphia:

Lippincott Williams & Wilkins.

Potter, P., & Perry, A. (2013). In J. Ross-Kerr, M. Wood, B. Astle, & W. Duggleby (Eds.),

Canadian fundamentals of nursing (5th ed.). Toronto, ON: Elsevier Canada.

Valerand, A. H., & Sanoski, C. A. (2013). Davis’s drug guide for nurses (13th ed.). Philadelphia,

PA: FA Davis Company.