Patient R.R. at 8S on 04/25, day 17 of hospitalization. 76 year old male, DNR, NKA, dysphagia di...

1. PAST MEDICAL HISTORY – Patient is admitted on 04/08 after being found on the ground for 4 days. Patient has history of frequent falling. Right trochanter wound excision surgery on 4/18. History of pacemaker, coronary artery disease, gout, Parkinson, HTN, MI, osteopenia, peripheral vascular disease with stent in lower extremities.

2. RESPIRATORY – lungs clear, diminished, no abnormal breath sounds heard in all 5 lobes. There is no cough present and patient denies history of chronic cough, asthma or bronchitis. No extra effort during respiration, no auxiliary muscles used for inspiration. Shallow depth of respiration and symmetric chest wall expansion. No dyspnea noted, patient shows regular respiratory rate and rhythm at rest with the patient lying in a supine position.

3. VITALS Time: 1617 T: 37.2 ℃ P: 66 R: 18 BP: 125/60 Spo2: 97% on RA. Time: 1935 T: 36.8 ℃ P: 67 R: 18 BP: 120/73 Spo2: 97% on RA.

4. LAB RESULTS - WBC ↑12.0 k/µL (4-11 K/µL)- skin infection. RBC ↓2.66 M/µL (3.8 – 5.2 M/µL)- iron deficient anemia. Hgb ↓8.2 gm/dL (11.6 – 15.5 gm/dL) - iron deficient anemia. Hct ↓24.9% (35-46%)- iron deficient anemia. RDW ↑20.3% (11-14.5%) - anemia. Calcium ↓7.2 mg/dL (8.5-10.5 mg/dL) - can decrease in Rhabdomyolysis. Albumin↓ 1.9 gm/dL (3.3-4.8 gm/dL)- decrease in muscle wasting. Total Protein ↓4.2gm/dL (6.3-8.0 gm/dL) - decrease in muscle wasting. Alk Phos ↑205 U/L (31-98 IU/L)- Colchicine can increase ALP. AST ↑41 U/L (5-40 U/L)- can increase with musculoskeletal disease (Rhabdomyolysis) CPK ↑393 U/L (55-170 U/L)- increases with skeletal muscle disease (Rhabdomyolysis), improving scenario from 7,139 on admission 04/08.

5. INTEGUMENTARY– IV ½ NS on left hand. No signs of infection or extravasation of IV site. Multiple stage II, III and IV pressure wounds on ankles, wrists, buttocks, hip, back of the head and chest. Right buttock wound was infected and unstageable. Presence of wound vac on right buttock that was surgically excised. Braden Score 9: Very high risk. Patient is on Clinitron mattress. Lidocaine topical 5% topical film daily for pain. Mepilex on most wounds except for wounds on lateral of feet that were advised to air dry by the recommendation of wound nurse.

5.1. NURSING DIAGNOSIS 1 – acute pain r/t skin and tissue damage AMB patient reports pain 6 in a 1-10 scale. Goals: Patient will have pain at 3 or less on a 0-10 pain scale within thirty minutes after medication administration. Interventions: Evaluate effectiveness of pain control measures. Assess pain level every 2 hours and administer pain medication as needed. Rationale: “Self-report is considered the most reliable indicator of pain presence and intensity” (NANDA, 2014, pg.580), “Analgesics are administers around the clock for continuous pain.” (NANDA, 2014, pg.580) Evaluation: Goal met: Patient stated that pain was a 3 after 30 minutes of Tylenol administration. Goal not met: Continue interventions.

5.2. NURSING DIAGNOSIS 2 - Impaired tissue integrity r/t impaired physical mobility AMB multiple areas of stage III and IV pressure ulcers. Goals: Patient will be free of signs of infection by the end of shift. Wound will decrease in size and has increased granulation tissue in one week. Interventions: Monitor the status the sites of impaired tissue integrity at least once daily for color changes, redness, swelling or other sign of infection. Do not position the patient on the site of impaired tissue integrity. Maintain wet to dry dressings daily as ordered. Rationales: “Systematic inspection can identify impending problems early” (NANDA 2014, page 808), “Reposition the client based on level of tissue tolerance to avoid adverse effects of external mechanical forces” (NANDA 2014, page 809), “Choose dressings that provide a moist healing environment, keep periwound skin dry and control exudate and eliminate dead space”( NANDA 2014, page 809) Evaluation: Goal met: Patient was free of signs of infection by the end of shift. Goal not met: Continue interventions and reassess daily for signs of granulation and improvement.

5.3. Risk for infection r/t multiple wounds.

6. PSYCHOSOCIAL – nonsmoker, nondrinker, lives alone. Was found down on floor for 4 days at home by neighbor. Patient is calm and cooperative but at times can get irritated with too many interventions. Agrees with plan to transfer to SNIF. Patient states: “Look at this mess”

6.1. Anxiety r/t health status AMB patient demonstrates signs of irritability.

7. NEUROLOGICAL –Patient has Parkinson’s. Patient is alert and oriented x4. Pupils are round, reactive to light and accommodate. Cranial nerves 2, 4, 5, 7, 9, 10 and 12 were tested and no abnormality was found. Patient has sensation on lower and upper extremities. Patient does not wear glasses. Patient has hearing impediment and no hearing aids - can hear by increasing volume of speech. Patient knows limits. Carbidopa-Levodopa 25mg-100 mg tab PO TID for Parkinson’s disease.. Pramipexole 1mg tab PO TID for Parkinson’s disease.

8. CARDIOVASCULAR – Murmur heard during auscultation. Patient has pacemaker. No edema on lower extremities. Capillary refill 2 seconds on all extremities. Peripheral pulses +2 on all extremities bilaterally. Skin is warm and color is adequate for ethnicity. No cyanosis or pallor noted. No hair present on lower limbs. Aspirin 81 mg EC tab PO daily for thromboprophylaxis. Simvastatin 40 mg tab PO QPM for high cholesterol.

9. GU/RENAL – Patient is continent and requires an urinal. Urine is light yellow and clear, no pain, urgency, straining, retention, frequency or hesitancy when urinating. No signs of hematuria or sediments in urine. Patient denies postvoid fullness. Fluid intake the past 24h was 1,110 ml with an output of 720 ml. Fluid intake this shift was 560 ml and output was 300ml.

10. MUSCULOSKELETAL –. Patient is nonambulatory. All extremities are +2 and very limited range of motion. Colchicine 0.6 mg tab PO BID for gout. Ascorbic Acid 250 mg tab PO daily for muscle depletion. Acetaminophen 1,000 mg PO tab Q8H for pain. Ampicillin-Sulbactam 3gm IVPB Q6H for skin infection.

10.1. PATHOPHYSIOLOGY Rhabdomyolysis is the wasting of skeletal muscles that results in releasing muscle cell constituents into the circulation which big accumulation in the kidneys can cause renal failure. Common causes are blunt trauma, temperature extremes, extensive burns, prolonged immobilization, extreme exercise and certain medications such as Statins. Clinical manifestations include myalgia, weakness, nausea, vomiting and dark urine. Very high creatine Kinase (CK) levels (around 100 times higher than normal) are the the most indicative of rhabdomyolysis. Urinalysis typically shows RBCs and protein due to renal impairment.Treatment is aggressive hydration to flush the kidneys. Diuretics may be used to help with the flushing. Bicarbonate can help correct acidosis caused by the acids released by the broken down myoglobin. Grau, J. M., & Poch, E. (2016). Pathophysiology and management of rhabdomyolysis. Oxford Textbook of Critical Care, 1695-1700. doi:10.1093/med/9780199600830.003.0355

10.2. NURSING DIAGNOSIS 4 – Impaired swallowing r/t decreased strength of muscles involved in mastication AMB abnormality in oral phase of swallow study. Goals: Patient will be free from aspiration by the end of shift. Interventions: Observe swallowing guidelines recommended by speech language pathologist, such as positioning client upright at a 90-degree angle with the head flexed forward at a 45-degree angle . Watch for swallowing difficulties and assess for signs of aspiration of secretions or fluids such as uncoordinated swallowing, coughing immediately after ingesting, wet sounding voice, delay of more than 1 second in swallowing, change in respiratory patterns. Rationale: “This position forces the trachea to close and esophagus to open, which makes swallowing easier and reduces the risk of aspiration.”, “These are signs of impaired swallowing and possible aspiration” (NANDA 2014, page 792) Evaluation: Goal met. Patient was free from aspirations during the shift by following upright position and observing for signs of swallowing difficulties.

10.3. Risk for aspiration r/t impaired swallowing

10.4. Risk for falls r/t muscle weakness.

10.5. NURSING DIAGNOSIS 3 – impaired physical mobility r/t insufficient muscle strength AMB all extremities at +1 or +2 strength, inability to perform gross motor skills. Goals: Patient will not develop additional complications of immobility in the next 24 hours. Patient will maintain or increase strength of upper and lower limbs by discharge. Interventions: Position in proper alignment and reposition Q2H. Perform passive ROM exercises at least twice a day. Rationale: “Physical rehabilitation interventions were found to be safe, reduced disability and resulted in few adverse events”. (NANDA 2014, page 538) “These exercises help reverse weakening and atrophy of muscles” (NANDA 2014, page 539) Evaluation: Goal met: Patient was repositioned q2h to prevent complications of immobility. Goat partially met: Patient performed passive ROM exercise on evening shift, needs to be reavaluated after the end of next shift

11. GI – 1:1 feeder, dysphasia diet, thin liquids only (Ensure). 1 BM formed last shift. Severe malnutrition. Bifidobacterium-Lactobacillus oral powder, 1pkt PO BID for resolving diarrhea. Multivitamins with minerals 1 tab PO daily for malnutrition. Ferrous gluconate 324 mg tab PO daily and Ferrous sulfate 325 mg EC tablet PO daily for iron deficient anemia.

11.1. Imbalanced nutrition: less than body requirements r/t malnutrition AMB lab values suggestion anemia.