IMPLEMENTING nNURSING CARE.

 EVALUATION.

 

IMPLEMENTATION

 

Implementation, the fourth step in the nnursing process, involves the execution of the nursing plan of care derived nduring the planning phase of the nursing process. It involves completion of nursing nactivities to accomplish predetermined goals and to make progress toward nachievement of specific outcomes. The execution of the implementation phase of nthe nursing process, as with the other phases of the process, requires a broad nbase of clinical knowledge, careful planning, critical thinking and analysis, nand judgment on the part of the nurse.

Discusses the purposes of implementation, the specific skills associated nwith effectively implementing the nursing plan of care, and the activities ninvolved in this process. Although identified as nthe fourth step of the nursing process, the implementation phase begins with nassessment and continually interacts with the other steps in the process to nreflect the changing needs of the client and the response of the nurse to those nneeds.

 

REQUIREMENTS FOR EFFECTIVE IMPLEMENTATION

The implementation phase of the nursing process requires cognitive n(intellectual), psychomotor (technical), and interpersonal skills. These skills nserve as competencies through which effective nursing care can be delivered and nare used either in conjunction with each other or individually as required by nthe client and the specific needs of the situation.

Cognitive skills enable nurses to make appropriate observations, nunderstand the rationale for the activities performed, and appreciate the ndifferences among individuals and how they influence nursing care. Critical nthinking is an important element within the cognitive domain because it helps nnurses to analyze data, organize observations, and apply prior knowledge and nexperiences to current client situations.

Proficiency with psychomotor skills is necessary to safely and neffectively perform nursing activities. Nurses must be able to handle medical nequipment with a high  ndegree of competency and to perform skills such as administering nmedications and assisting clients with mobility needs (e.g., positioning and nambulating).

The nuse of interpersonal skills involves communication with clients and families as nwell as with other health care professionals. The nurse-client relationship is nestablished through the use of therapeutic communication that helps ensure a nbeneficial outcome for the client’s health status. Interaction between members nof the health care team promotes collaboration and enhances holistic care of nthe client.

 

IMPLEMENTATION ACTIVITIES

Nursing nimplementation activities include:

• nOngoing assessment

• nEstablishment of priorities

• nAllocation of resources

• nInitiation of nursing interventions

• nDocumentation of interventions and client nresponse.

These nactivities are interactive and each is discussed in further detail.

 

ONGOING ASSESSMENT

The nursing plan of care is based on the initial assessment data ncollected by the nurse and the nursing diagnoses derived from those data. nBecause a client’s condition can change rapidly, or new data may become navailable through interaction with the client, ongoing assessment is necessary nto validate the relevance of proposed interventions. Goals, expected outcomes, nand interventions may need to be altered as new data are collected or progress ntoward outcomes is evaluated.

Although a focused assessment should be completed during the initial ninteraction with the client, continuous observations during the implementatioprocess allow for adaptations to be made to better individualize care.

It nis not unusual for nursing diagnoses to change or to be resolved in a short nperiod of time. For example, the nursing care plan for Mrs. Cline, a npreoperative client, might include an intervention to teach her about the use nof a patient-controlled analgesia (PCA) pump. As the use of this equipment is nbeing demonstrated, the nurse observes that Mrs. Cline is unable to depress the nbutton easily with the fingers of her right hand. Mrs. Cline informs the nurse nthat she forgot to mention that her joints swell occasionally and she has very nlittle strength in her hand during these times. This information is essential nfor both developing a nursing diagnosis concerning Mrs. Cline’s impaired physical nmobility and determining appropriate teaching methods for use of the PCA pump.

Ongoing nassessment demands attention to verbal and nonverbal cues from the client and nrequires knowledge of expected responses to specific interventions. If nurses nobserve that responses are different from those expected, this assessment data ncan lead to a change in expected outcomes and accompanying interventions.

Ongoing nassessment is of equal importance in home health care or extended care settings nwhen contact with skilled health care providers might occur less frequently and nthe length of time that the care is required varies (see the accompanying ndisplay). The nurse’s assessment and clinical judgment often determine whether nthe client needs continued care or referral to other health care providers.

ESTABLISHMENT OF PRIORITIES

Following ongoing assessment and review of the problem list, priorities nare determined for implementation of care. Priorities are based on:

• nWhich problems are deemed most important by nthe nurse, the client, and family or significant others.

• nActivities previously scheduled by other ndepartments (e.g., surgery, diagnostic testing)

• nAvailable resources

The change-of-shift report can also be a valuable tool in determining npriorities. A client’s condition and variables in the clinical setting cachange quickly and frequently—especially in acute care settings—requiring that nthe nurse exercise strong clinical judgment and maintain flexibility iorganizing care. For example, the nursing care plan for Mr. Jenkins, who had nhip replacement surgery, might reflect a priority nursing diagnosis of Impaired nPhysical Mobility with interventions focused toward learning to ambulate. nWhen the nurse listens to Mr. Jenkins’ breath sounds on a particular morning, nit is noted that his breathing is more labored and crackles can be auscultated nin the lung bases. This assessment is noted on the change-of-shift report, and nthe priorities of interventions change to focus on this new development.

Time management is important whether nthe nurse is caring for one client or a group of clients. It is helpful to make na list of tasks that need to be accomplished throughout the day and to create a nworksheet outlining a target time for these activities. Those activities with nspecified times for completion should be scheduled first. For example, nmedications usually allow a narrow time frame for administration and must be nscheduled at specific times on the worksheet. An example of a nworksheet.

The time allotted for activities depends on the complexity of the task nand the amount of assistance required by the client.

 

ALLOCATION OF RESOURCES

Before implementing the nursing plan of care, the nurse reviews proposed ninterventions to determine the level of knowledge and the types of skills nrequired for safe and effective implementation. The assessment provides data nfor determining if an activity can be performed independently by the client, ncan be completed with assistance from family, or requires assistance of health ncare personnel.

Delegation of Tasks

The registered nurse is legally responsible for all nursing care given. nWhereas some interventions are complex and require the knowledge and skills of na registered nurse, other interventions are relatively simple and can be ndelegated to assistive personnel.

Delegation is the process of transferring na selected nursing task in a situation to an individual who is competent to nperform that specific task. It must be remembered that, although some nactivities can be assigned to other health care personnel, the registered nurse nremains accountable for appropriate delegation and supervision of care provided nby these individuals. In general, registered nurses are authorized by law to nboth provide nursing care to clients directly and supervise and instruct others nto deliver this care. Further, the registered nurse is empowered to delegate nselected tasks to either licensed or unlicensed nursing personnel

Decisions about delegation are guided by the needs of the client, the nnumber and type of available personnel, and the nursing management system of nthe unit or agency. In performing delegated tasks, nursing students must either ndetermine if the intervention is one that they have performed with supervisioand can safely accomplish independently or is one for which assistance is nneeded.

The first consideration in determining the most appropriate nursing npersonnel to administer care is client safety. Nurse practice acts dictate to nsome extent which tasks can be legally delegated. For example, administratioof blood or blood products is not an act that can be nlegally delegated to licensed practical nurses or unlicensed assistive npersonnel in most states.

Other nactivities, such as assisting clients with activities of daily living (ADL, nthose activities performed by a person usually on a daily basis), ordering nsupplies, or transcribing orders, can often be safely delegated to other npersonnel.

If delegatioof a particular activity is legally allowed, the nurse should validate the nknowledge and skill level of personnel before delegation. If uncertain about nthe level of competence of an individual to perform an activity, the nurse nshould not delegate the task even though it might be legally performed by that nlevel of personnel.

The nregistered nurse is held accountable to delegate only such care that can safely nbe done by the other individual and would be performed with the same level of ncompetency and respect for state laws and regulations as would be evident ithe nurse’s performance of this care.

Types of Management Systems

Wise use of resources dictates that tasks be nassigned to the most cost-effective level of personnel who can safely and nproficiently perform the activity. The nursing management system oftedetermines the numbers and types of personnel available. Changes in health care ndelivery in recent years have resulted in an increasing emphasis on cost ncontainment and have subsequently created several unique management models. The nredesign of the workplace in many health care agencies has included ncross-training of employees, with nurses frequently assuming responsibilities nformerly assigned to other health care providers. For example, nurses might ndraw blood for laboratory tests, perform electrocardiograms, or administer nrespiratory treatments, as care is focused around the client rather than the nvarious departments in the agency. Nurses in community health settings have ntraditionally exercised a variety of roles in their practice.

As health care delivery continues to evolve in this country, a variety nof innovative approaches will emerge to better meet the needs of clients. The nmost common management systems currently used include functional nursing, team nnursing, primary nursing, total client care, modular nursing, and case nmanagement.

FUNCTIONAL NURSING

The functional nursing approach divides care into tasks to be completed nand uses various levels of personnel depending on the complexity of the nassignment. Each member of the staff performs his or her assigned task for each nclient. For example, one nurse may assess each client and document findings and nanother may give all medications and treatments. Another nurse may be assigned nto complete client teaching or discharge planning (process that enables nthe client to resume self-care activities before leaving the health care nenvironment).

One nursing assistant might serve all trays and collect intake and noutput records for each client while another is responsible for giving baths or nmaking beds. The advantage of this system is that a large number of clients cabe cared for by a relatively small number of personnel. In addition, it allows nthe use of less skilled (and less expensive) personnel for some tasks and nallows personnel to be used in areas for which they have special knowledge or nskill. However, this system can also result in fragmented and depersonalized ncare and may invite omissions in care because no one person is nresponsible for the total care of the client.

TEAM nNURSING

The team nursing approach uses a variety of personnel (professional, ntechnical, and unlicensed assistants) in the delivery of nursing care. The nregistered nurse is leader of the team and is responsible for supervision of nthe team, as well as planning and evaluating the results of caregiving nactivities. This management system uses professional nurses for skilled nobservations and interventions and provision of direct care to acutely ill nclients, while licensed practical nurses care for less acutely ill clients, and nnursing assistants are responsible for serving trays, making beds, and assisting nthe nurses with other tasks. This management system is frequently used because nit is cost-effective and provides more individualized care than the functional napproach.

 

PRIMARY NURSING

In the primary nursing management system, the professional nurse assumes nfull responsibility for total client care for a small number of clients. nAlthough care may be delegated to nurse associates for shifts when the primary nnurse is not in attendance, the primary nurse maintains responsibility for ntotal client care 24 hours a day.

The primary nurse sets health care goals with the client and plans care nto meet those goals. The principal advantage of this approach is the continuity nof care inherent in the system. Primary nursing is most effective with a total nstaff of registered nurses, which makes this system expensive to maintain.

 

TOTAL CLIENT CARE AND MODULAR NURSING

Total client care and modular nursing are variations of primary nursing. nAlthough these systems imply that one nurse is responsible for all the care nadministered to a client, responsibility for the client actually changes from nshift to shift with the assigned caregiver. This system uses both registered nnurses and licensed practical nurses; the registered nurses are assigned to nmore complex client situations. A unit manager or charge nurse typically ncoordinates activities on the unit. Modular nursing attempts to assigcaregivers to a small segment or “module” of a nursing unit, ensuring that nclients are cared for by the same personnel on a regular basis.

CASE MANAGEMENT

In the case management system, the nurse assumes responsibility for nplanning, implementing, coordinating, and evaluating care for a given client, nregardless of the client’s location at any given time. This approach is ofteused when care is complex and a number of health care team members are involved nin providing care. Generally, a case management plan, or critical pathway, is ndeveloped (based on the norm or typical course of the condition), and the nurse nevaluates the progress of the client in relation to what is expected, ninvestigating and following up on any variance in the time required or the namount of improvement noted. Although the case load for the individual nurse nmight be smaller (thus making this approach expensive), continuity of care and ncollaboration are enhanced.

NURSING INTERVENTIONS

After reviewing the client’s current condition, verifying priorities, nand examining resources, the nurse should be ready to initiate nursing ninterventions. A nursing intervention is an action performed by the nnurse that help the client to achieve the results specified by the goals and nexpected outcomes. All interventions must conform to standards of care.

Nurses nshould understand the reason for any intervention, the expected effect, and any npotential problems that may result. Understanding the reason for a nursing nintervention is the hallmark of a professional nurse, in that the nurse is nusing logic and/or scientific reasoning as the basis of practice.

Nursing ninterventions are a blend of science (rational acts) and art (intuitive nactions). It is important for novice nurses to identify the rationale (the nfundamental principle) of all interventions in order to implement theory-based npractice.

Prior to implementation, it is necessary to determine exactly:

• nWhat is to be done

• nHow it is to be done

• nWhen it should be done

• nWho will do it

• nHow long it should be done

Interventions are determined by and directed toward the cause of the nproblem or factors contributing to the nursing diagnosis and may vary for nclients with similar nursing diagnoses depending on realistic expected outcomes nfor the individual. Consideration should be given to client preferences, the developmental nlevel of the client, and availability of resources. In addition, the health ncare practitioner’s orders often have an impact oursing interventions by nimposing restrictions on factors such as diet or activity.

TYPES OF NURSING INTERVENTIONS

Nursing ninterventions are written as orders in the care plan and may be nnurse-initiated, health care practitioner-initiated, or derived from ncollaboration with other health care professionals. These interventions can also nbe categorized as independent, dependent, or interdependent, depending on the nauthority required for initiation of the activity.

Interventions can be implemented on the basis of standing orders or nprotocols. A standing order is a standardized intervention written, napproved, and signed by a health care practitioner that is kept on file withihealth care agencies to be used in predictable situations or in circumstances nrequiring immediate attention. Nurses can implement standing orders in these nsituations after they have assessed the client and identified the primary or nemerging problem. For example, nurses in an ambulatory clinic or home health ncare agency may have standing orders for administering certain medications or nordering laboratory tests when indicated, or a health care practitioner may nestablish standing orders on an inpatient unit that specify certain medications nthat can be administered for common complaints such as headache.

A protocol is a series of standing orders or procedures that nshould be followed under certain specific conditions.

They ndefine what interventions are permissible and under what circumstances the nurse nis allowed to implement the measures. Health care agencies or individual health ncare practitioners frequently have standing orders or protocols for client npreparation for diagnostic tests or for immediate interventions ilife-threatening circumstances.

These protocols prevent needless nduplication of writing the same orders repeatedly for different clients and noften save valuable time in critical situations.

 NURSING INTERVENTIONS CLASSIFICATION

The Iowa Intervention Project has developed a taxonomy of nursing ninterventions that includes both direct and indirect activities directed toward nhealth promotion and illness management (Iowa Intervention Project, 1993). This ntaxonomy, the Nursing Interventions Classification (NIC), is a standardized nlanguage system that describes nursing interventions performed in all practice nsettings.

“NIC noffers a standardized language that communicates the nature and worth of the nwork we do. Without it, nursing will remain in jeopardy” n(Eganhouse, ComiMcCloskey, & Bulecheck, 1996). NIC is a method for nlinking nursing interventions to diagnoses and client outcomes (McCloskey, nBulechek, & Eoyang, 1999).

The nformat for each intervention is as follows: label name, definition, a list of nactivities that a nurse performs to carry out the intervention, and a list of nbackground readings (McCloskey & Bulechek, 1996)

NIC offers standardized language for research oursing interventions nand is a promising tool for determining reimbursement for nursing services.

NURSING INTERVENTION ACTIVITIES

Nursing ninterventions include:

• nAssisting with ADL

• nDelivering skilled therapeutic ninterventions

• nMonitoring and surveillance of response to ncare

• nTeaching

• nDischarge planning

• nSupervising and coordinating nursing npersonnel

Implementing nursing interventions requires that consideration be giveto client rights, nursing ethics, and the legal implications associated with nproviding care.

Clients nhave the right to refuse any intervention. However, the nurse must explain the nrationale for the intervention and possible consequences associated with nrefusing treatment. If the intervention refused was health care npractitioner-initiated, the health care practitioner should be informed of the nrefusal of care. Ethical standards require that clients be afforded privacy and nconfidentiality. Matters related to a client’s condition and care should be ndiscussed only with individuals directly involved with the client’s care, and nany discussion should be held in a location where information cannot be noverheard by visitors or bystanders. From a legal standpoint, the nurse must nensure that the authority for prescribing any intervention has been satisfied nand that applicable standards of care are maintained during implementation of nall nursing interventions.

ACTIVITIES OF DAILY LIVING

Clients frequently need assistance with ADL such as bathing, grooming, nambulating, eating, and eliminating.

The ngoal for most clients is to return to self-care or to regain as much autonomy nas possible. The nurse’s role is to determine the extent of assi stance needed nand to provide support for ADL while at the same time fostering independence. nOngoing assessment is important for determining the appropriate balance betweeensuring safety and promoting independence. For example, maintaining personal ngrooming is important for purposes of hygiene and comfort as well as for npromoting self-esteem.

The nurse must always provide privacy when assisting clients with npersonal hygiene. If these tasks are assigned to other personnel, adequate nsupervision is imperative to ensure compliance with these principles.

THERAPEUTIC INTERVENTIONS

Therapeutic nursing interventions are those measures directed toward nresolution of a current problem and include activities such as administratioof medications and treatments, performing skilled procedures, and providing nphysical and psychological comfort. Written orders must be verified before nimplementing interventions requiring prescriptive authority. Reassessment of nthe client is also needed to determine if the intervention remains appropriate. nIn addition, a nurse must also understand the rationale, expected effects, and npossible complications that could result from any intervention.

MONITORING AND SURVEILLANCE

Observation of the client’s response to treatment is an integral part of nimplementation of any intervention. Monitoring and surveillance of the client’s nprogress or lack of progress are essential in determining the effectiveness of nthe plan of care and for detection of potential complications. Specific ninterventions require specific monitoring activities; however, typical nmonitoring activities include observations such as vital signs measurement, ncardiac monitoring, and recording of intake and output.

TEACHING

A key element in health promotion and illness management is the ncounseling of clients to help them modify their behaviors in response to npotential health risks and actual health alterations. As part of this teaching nprocess, nurses must also discuss the rationales for the interventions that are nincluded in the nursing plan of care.

Numerous opportunities arise every day for informal teaching related to nclient care. For example, teaching clients about the medications they are ntaking and possible side effects should occur routinely as medications are nadministered. Similarly, as nurses perform assessment activities, the sharing nof observations with the client can be informative in terms of what ncharacteristics are desirable and what observations are sources of concern.

This knowledge can be valuable to a client when self-monitoring.

Effective teaching requires insight into the client’s knowledge base and nreadiness to learn. Realistic teaching goals and learning outcomes should be nset on the basis of these factors. It is also desirable to include the family nor significant others in teaching plans. A suitable learning environment should nbe created that is nonthreatening and allows active participation by the nclient. Nurses should be careful to use terminology easily understood by the nclient. It is important that learning outcomes are validated to be sure that nclients can safely and effectively care for themselves on discharge.

DISCHARGE PLANNING

Preparation for discharge begins at the time of admission to a health ncare facility. As the average length of stay in acute ncare settings continues to decrease, early discharge planning becomes nimperative. Expected outcomes dictate the type of planning required and the ninterventions necessary to attain the desired outcomes.

Interventions ndirected toward discharge planning include activities such as teaching and nconsultation with other agencies (e.g., home health, rehabilitation facilities, nnursing homes, social services) concerning followup care. Teaching related to nany changes in diet, medications, or lifestyle must be implemented; any nbarriers or problems in the home environment must be resolved before discharge. nSome agencies employ personnel with the primary responsibility of teaching or ndischarge planning for groups of clients; however, the nurse who is caring for the individual client is also responsible for ensuring nthat all appropriate interventionshave been implemented before discharge.

SUPERVISION AND COORDINATION OF PERSONNEL

The management style and type of facility, as well as the needs of the nclient, determine the scope of interventions associated with supervision and ncoordination of client care. In a health care facility in which nurses are nassigned clients within a total client care management system, responsibilities nfor supervision might be minimal, whereas facilities that use a variety of nancillary personnel for certain client activities might require a large npercentage of time devoted to supervision of care. In home health care, for nexample, the primary role of the professional nurse might be supervision of npersonnel who provide assistance with ADL. Although a nurse might delegate ncertain tasks to other personnel, it is still the nurse’s responsibility to nensure that the task was completed according to standards of care and to note nthe response of the client in order to evaluate progress toward expected noutcomes.

Regardless of management style or type of facility, coordination of nclient activities among various health care providers remains the nurse’s nresponsibility. For example, in acute care settings, the nurse needs to ncoordinate client activities around the schedule of diagnostic tests or nphysical therapy. Scheduling of procedures, therapy, treatments, and medications nfor a number of clients often requires considerable organizational skills, ncreativity, and resourcefulness.

EVALUATING INTERVENTIONS

An important step to assure the delivery of quality care is evaluatioof nursing interventions. One approach to determining the efficacy of nursing ninterventions is by evaluating clients’ achievement of expected outcomes.

The Nursing Intervention Classification (NIC), previously described ithis chapter, provides a systematic method for linking nursing activities to nclient outcomes. When treatment can be shown to directly improve client noutcomes, both nursing and health care consumers benefit. Another ntaxonomy, the Nursing Outcomes

Classification (NOC) has been specifically designed to evaluate nursing ninterventions. NOC provides a common language for measuring client responses to nnursing interventions.

DOCUMENTATION OF INTERVENTIONS

Communication concerning implementation of interventions must be nprovided through written documentation and should also be verbally conveyed nwhen responsibility of the client’s care is transferred to another nurse.

The nurse is legally required to record all interventions and nobservations related to the client’s response to treatment.

This not only provides a legal record but also allows valuable ncommunication with other health care team members for continuity of care and nfor evaluating progress toward expected outcomes. In addition, writtedocumentation provides data necessary for reimbursement for services and ntracking of indicators for continuous quality improvement.

The recording of information can be in the form of either nchecklists, flow sheets, or narrative summaries. A complete descriptiomust be provided if there are any deviations from the norm or if any changes nhave occurred.

Verbal interaction among health care providers is also essential for ncommunicating current information about clients. Nurses who delegate the ndelivery of client care to assistive personnel must be careful to elicit their nfeedback related to activities completed and the client’s response to any ninterventions. In addition, assistive personnel should be alerted as to what nadditional data are meaningful, and these data should be conveyed to the nurse nresponsible for the client’s care. For example, if a nursing assistant observes nthat Mrs. Robbins, hospitalized with a deep vein thrombosis of the left leg, is nhaving difficulty swallowing and has eaten very little, this information should nbe reported to the nurse. This is especially important if the behavior is a new noccurrence and not a part of the established problem list, because the nurse nmight not otherwise seek this information.

Communication betweeurses generally occurs at the change of shift, nwhen the responsibility for care changes from one nurse to another.

Nursing students must communicate relevant information to the nurse nresponsible for their clients when they leave the unit. Information that should nbe shared in the verbal report includes:

• nActivities completed and those remaining to nbe completed

• nStatus of current relevant problems

• nAny abnormalities or changes in assessment

• nResults of treatments (i.e., client nresponse)

• nDiagnostic tests scheduled or completed n(and results)

All communication—written and/or verbal—must be objective, descriptive, and  complete. The ncommunication includes observations rather than opinions and is stated or nwritten so that an accurate picture of the client is conveyed. For example, if nit is noted that a client is less alert today than yesterday, the behavior that nled to that conclusion should be documented. This observation can be nobjectively and descriptively communicated by the statement: “Does not respond nunless firmly touched; quickly returns to sleep.” This description results in a nmore complete picture of the client than simply stating:

“Less nalert today.” Thorough and detailed communication of implementation activities nis fundamental to ensuring that client care and progress toward goals can be nadequately evaluated.

KEY CONCEPTS

• The implementation step of the nursing process is directed toward nmeeting client needs and results in health promotion, prevention of illness, nillness management, or health restoration and also involves delegation of nnursing care activities to assistive personnel and documentation of the nimplementation activities performed.

• Implementation requires cognitive, psychomotor, and intellectual skills nto accomplish goals and make progress toward expected outcomes.

• Implementation activities include ongoing assessment, establishment of npriorities, allocation of resources, initiation of specific nursing ninterventions, and documentation of interventions and client responses.

• Ongoing assessment is necessary for determining effectiveness of ninterventions and for detection of new problems.

• Changing variables in clients and the environment demand clinical njudgment and flexibility in organizing care.

• Time management skills are essential in implementing client care.

• The nurse maintains responsibility for care delegated to other health ncare personnel.

• The most common management systems currently used include functional nnursing, team nursing, primary nursing, total client care, modular nursing, and ncase management.

• Interventions can be nurse-initiated, health care npractitioner-initiated, or collaborative in origin, and thus are considered ndependent, independent, or interdependent.

• Nursing Interventions Classification (NIC) is a system for sorting, nlabeling, and describing nursing interventions.

• Nursing interventions include assisting with activities of daily living, nskilled therapeutic interventions, monitoring and surveillance of response to ncare, teaching, discharge planning, and supervision and coordination of nursing npersonnel.

• Communication concerning interventions should be provided nverbally and in writing.

 

CRITICAL THINKING ACTIVITIES

1. Label each of the following nursing interventions as dependent (dep.), nindependent (ind.), or interdependent (int.).

_____ a. nApplying a heating pad to a shoulder for 20 minutes

_____ b. nAdministering a pain medication as needed following surgery

_____ c. nTurning a client with impaired mobility every 2 hours

_____ d. nTeaching a client about side effects of a medication

_____ e. nAssisting a client with oral care

_____ f. nSending an order for a diagnostic laboratory test

_____ g. nReviewing and conveying abnormal lab test results

_____ h. nStarting intravenous fluids

2. List five implementation activities and give an example of each.

3. List two reasons for documentation of client care.

4. Situation: Mary Long, age 42, has ncome to the clinic because of recurrent chest pains (although symptom free at nthis time). Although there is a strong family history of heart disease, she has nno personal history of heart problems. She is approximately 60 lb overweight and you ndetermine that her lifestyle is rather sedentary and her diet high in fat ncontent.

She lives at home with her husband. nHer childreo longer live at home. Although she works part-time as a nreceptionist, her favorite activity is cooking.

Her health care practitioner mentions ndiet, exercise, and weight control as long-term activities, orders a series of ntests to be done as an outpatient, and gives her a prescription for nnitroglycerin tablets for chest pain.

What interventions do you think will nbe necessary and appropriate for Mrs. Long? How would you organize priorities nfor Mrs. Long?

5. Consider your most recent clinical experience. How could you have norganized your time more effectively? Apply these same time management nprinciples to your study time. How could you arrange your time more nefficiently?

6. The next time you are in a clinical agency, examine your client’s record nfor the previous 8 hours. Does it provide a vivid and accurate description of the nclient? How could the written documentation be improved?

7. Ask a nurse what activities occupy most of his or her time. What nactivities does the nurse most enjoy? What does the nurse least enjoy? Compare nthis nurse’s perceptions with your own ideas.

8. How does the Nurse Practice Act in your state address delegation? Does nthe definition specifically address the registered nurse’s role in supervising nother nursing personnel? Licensed practical nurse’s role? nDelegation of nursing care to others? Has the Board of nNursing in your state established rules on delegation? If so, what do these nrules allow? If not, how is the issue of delegation of nursing care addressed?

9. You are caring for Mr. Sims, who has had a stroke. The care plaincludes the following activities and interventions:

• Up in chair at bedside 3 times a day for at least 30 minutes

• Assist bed bath/assist with eating

• CT of head at 10:00 am

• Strengthening exercises per physical therapy at 9:00 am

• Routine medications at 9:00 am and 1:00 pm You nare responsible for total client care for Mr. Sims. Write a plan of your nactivities with Mr. Sims.

EVALUATION.

Evaluation is the fifth step in the nursing process and involves determining whether nthe client goals have been met, have been partially met, or have not been met. nEven though it is the final phase of the nursing process, evaluation is aongoing part of daily nursing activities that determines the effectiveness of nthose activities in helping clients achieve expected outcomes.

Evaluation is not only a part of the nnursing process, but it is also an integral process in determining the quality nof health care delivered. In addition to discussing evaluation as part of the nnursing process, this chapter also describes the role of evaluation idelivering quality care.

This lecture discusses the purposes, ncomponents, and methods of evaluation. The relationship between evaluation and nquality of care is described.

EVALUATION OF CLIENT nCARE

Evaluation is the measurement of the ndegree to which objectives are achieved. Therefore, evaluating the care nprovided to clients is an essential part of professional nursing. “Evaluatiois a planned, systematic process compares the client’s health status with the ndesired expected outcomes” (Kenney, 1995, p. 195).

The American Nurses Associatio(1998), in its Standards of Clinical Nursing Practice, designates nevaluation as a fundamental component of the nursing process (see the naccompanying display).

The purposes of evaluation include:

• To determine the client’s progress or lack nof progress toward achievement of expected outcomes

• To determine the effectiveness of nursing ncare in helping clients achieve the expected outcomes

• To determine the overall quality of care nprovided

• To promote nursing accountability n(discussed later in this chapter)

 

Evaluation is done primarily to ndetermine whether a client is progressing—that is, experiencing an improvement nin health status. Evaluation is not an end to the nursing process, but rather nan ongoing mechanism that assures quality interventions. Effective evaluatiois done periodically, not just prior to termination of care. Evaluation is nclosely related to each of the other stages of the nursing process. The plan of ncare may be modified during any phase of the nursing process when the need to ndo so is determined through evaluation. Client goals and expected outcomes nprovide the criteria for evaluation of care.

 

COMPONENTS OF nEVALUATION

Evaluation is a fluid process that is ndependent on all the other components of the nursing process.

Ongoing evaluation is essential if nthe nursing process is to be implemented appropriately. As Alfaro- LeFevre n(1998) states:

When we evaluate early, checking nwhether our information is accurate, complete, and up-to-date, we’re able to nmake corrections early. We avoid making decisions based on outdated, ninaccurate, or incomplete information. Early evaluation enhances our ability to nact safely and effectively. It improves our efficiency by helping us nstay focused on priorities and avoid wasting time continuing useless actions.

There are specific criteria to be used in the process of evaluation. The nevaluation criteria must be planned, goal-directed, objective, verifiable, and nspecific (that is, strengths, weaknesses, achievements, and deficits must be nconsidered).

NURSING CARE PLANS

 

STUDENT____________________________________PATIENT nINITIALS____________ROOM NUMBER__________DATES________________

 

TECHNIQUES

Effective evaluation results nprimarily from the nurse’s accurate use of communication and observatioskills. Both verbal and nonverbal communication between the nurse and the nclient can yield important information about the accuracy of the goals and nexpected planned outcomes and the nursing interventions that have been executed nfor resolution of the client’s problems. The nurse needs to be sensitive to nclients’ willingness or hesitation to discuss their responses to nursing nactions and must use the techniques of therapeutic communication to collect all nnecessary data.

The nurse must be sensitive to nchanges in the client’s physiological condition, emotional status, and nbehavior. Because these changes are often subtle, they require astute nobservational skills on the part of the nurse. Observation occurs through use nof the senses. In other words, what the nurse sees, hears, smells, and feels nwhen touching the client all provide clues to the client’s current health nstatus.

 

SOURCES OF DATA

Evaluation is a mutual process noccurring among the nurse, client, family, and other health care providers. nBoth subjective and objective data are used in evaluating the client’s status. Asking clients to describe how they feel results in subjective ndata. Objective data consist of observable facts, such as laboratory nvalues and the client’s behavior. When a nurse communicates an assessment of a nclient’s response to an actual or potential health problem, clients and nfamilies are empowered to discuss their concerns and questions. When feedback nis given, the nurse must avoid being defensive, because that attitude may cause nclients or families to avoid being open and honest. As a result, they may only nsay what they think the nurse wants to hear or they may completely refuse to nparticipate in the evaluation process.

The nurse’s verbal and nonverbal ncommunication establishes the atmosphere in which clients and families freely nshare their comments, both positive and negative.

GOALS AND EXPECTED nOUTCOMES

The effectiveness of nursing ninterventions is evaluated by examination of goals and expected outcomes. Goals nprovide direction for the plan of care and serve as measurements for the nclient’s progress or lack of progress toward resolution of a problem.

Realistic goals are necessary for neffective evaluation. These goals must take into consideration the client’s nstrengths, limitations, resources, and the time frame for achievement of the nobjectives. Examples of client strengths are educational background, family nsupport, and financial resources (for instance, money to purchase medications nand foods that support the prescribed interventions). Examples of client nlimitations are delayed developmental level, poverty, and unwillingness to nchange (lack of motivation).

METHODS OF EVALUATION

The nurse who successfully evaluates nnursing care uses a systematic approach that ensures thorough, comprehensive ncollection of data. Evaluation is an orderly process consisting of seven steps, nwhich are explained here.

ESTABLISHING STANDARDS

Specific criteria are used to ndetermine whether the demonstrated behavior indicates goal achievement. nStandards are established before nursing action is implemented. Evaluation of ncriteria examines the presence of any changes, direction of change (positive or nnegative), and whether the changes were expected or unexpected.

COLLECTING DATA

Assessment skills are used to gather ndata pertinent to goals and expected outcomes. The nurse must be proficient iassessment skills for effective, comprehensive evaluation to occur. Evaluatiodata are collected to answer the following question: Were the treatment goals nand expected outcomes achieved?

DETERMINING GOAL nACHIEVEMENT

Data are analyzed to determine nwhether client behaviors indicate goal achievement. This process is validated nthrough analysis of the client’s response to the specific nnursing interventions that are developed in the plaof care. For example, these data can take the form of either physiological nresponses (such as the client’s being able to cough productively in order to npromote effective breathing patterns) or psychosocial responses (such as the nclient’s being able to verbalize concerns about an impending surgical procedure nin order to alleviate anxiety).

RELATING NURSING nACTIONS TO CLIENT STATUS

Nursing interventions are examined to ndetermine their relevance to the client’s needs and nursing diagnoses.

Efficient nursing actions are those that address pertinent client needs nand are proven to be primary factors in helping clients appropriately resolve nactual or potential problems.

JUDGING THE VALUE OF nNURSING INTERVENTIONS

Critical-thinking skills are employed nto determine the degree to which nursing actions have contributed to the nclient’s improved status. These skills enable the nurse to apply an analytical nfocus to the client’s responses to the nursing interventions and thus to nevaluate the benefits of those actions and identify additional nopportunities for change.

 

REASSESSING THE nCLIENT’S STATUS

The client’s health status is nreevaluated through use of assessment and observation skills. Evaluatiofocuses on the client’s health status and compares it with baseline data ncollected during the initial assessment. Omissions or incomplete data withithe database are identified so that an accurate picture of the client’s health nstatus is obtained.

MODIFYING THE PLAN OF nCARE

If the evaluation data indicate a lack nof progress toward goal achievement, the plan of care is modified. These nrevisions are developed through the following process:reassessment nof the client; formulation of more appropriate nursing diagnoses; development nof new or revised goals and expected outcomes; and implementation of different nnursing actions or repetition of specific actions to maximize their neffectiveness (for instance, client teaching).

 

Evaluation is performed by every nnurse, regardless of the practice setting. For example, the home health nurse nevaluates the care provided regularly throughout the client’s relationship with nthe agency. Evaluation of the home care client is carried out in order to ndetermine whether the care was delivered in an effective and efficient manner, nto modify the plan of care as needed, and to decide when the client is ready nfor discontinuation of home care services. The accompanying display provides aexample of evaluation performed by the home health care nurse.

CRITICAL THINKING AND EVALUATION

Evaluation is a critical thinking activity. It is a ndeliberate mechanism used to analyze and make judgments. Nurses need to remaiobjective when evaluating client care in order to modify care based on reasorather than emotion. One critical thinking strategy, juxtaposing, is described nas “putting the present state conditioext to the outcome state in a nside-by-side contrast” (Pesut & Herman, n1999, p. 93). Nurses use juxtaposing throughout evaluative activities by ncomparing client responses to expected behaviors. They make conclusions about nwhether expected outcomes have been met. In order to make such conclusions, nassessment data is needed to determine client progress toward achievement of nobjectives. Evaluation involves analysis and is much more complex than merely nanswering questions

.

 

EVALUATION AND QUALITY nOF CARE

Evaluation is performed at the individual and ninstitutional levels. For example, individual evaluation focuses on the nclient’s achievement of goals and also on the individual nurse’s delivery of ncare. Quality and evaluation are closely related. This section examines the nrole of evaluation in assuring the delivery of quality health care. Because it nis the mechanism used by nurses in determining the need for improvement, nevaluation assists in the provision of quality care.

The aspects that need to be evaluated to ndetermine the quality of health care are:

• nAppropriateness (the care provided adhered nto standards and resulted in achievement of goals)

• nClinical outcomes

• nClient satisfaction

• nCost-effectiveness

• nAccess to care

• nAvailability of resources

Quality nmanagement involves constant, ongoing evaluation (monitoring of activities).

ELEMENTS IN EVALUATING nTHE QUALITY OF CARE

Organizational evaluation examines nthe agency’s overall ability to deliver quality care. Evaluation can be nclassified according to what is being evaluated: the structure, the process, or nthe outcome.

STRUCTURE EVALUATION

Structure evaluation is a determination of the health care agency’s ability to provide the nservices offered to its client population. This type of evaluation focuses oassessing the systems by which nursing care is delivered (Barnum & Kerfoot, n1995). Structure evaluation examines the physical facilities, resources, nequipment, staffing patterns, organizational patterns, and the agency’s nqualifications for staff. The majority of problems with providing effective nhealth care stems from problems in the structural area. The purpose of structure nevaluation is to identify any system errors, which can then be corrected. nStructure evaluation involves determining whether client care meets legal and nprofessional standards. A frequently used method to evaluate whether the agency nprovides care within legal parameters is a review of policy and procedure nmanuals to check for compliance with regulations.

 

PROCESS EVALUATION

Process evaluation is the measurement of nursing actions by examination of each phase of nthe nursing process. This type of evaluation is done to determine whether nnursing care was adequate, appropriate, effective, and efficient. Nursing ninterventions are judged to be effective when use of the action results in the ndesired outcome. A nursing intervention is determined to be efficient through nanalysis of the intervention’s cost–benefit ratio (Gillies, 1994). Process nevaluation determines the nurse’s ability to establish an environment that npromotes the client’s health.

 

OUTCOME EVALUATION

Outcome evaluation is the process of comparing the client’s current status with the nexpected outcomes. This type of evaluation examines all direct care activities nthat affect the client’s health status. According to Kenney (1995), “Outcome nevaluation, though difficult, is the most meaningful way to judge nthe effectiveness of nursing interventions”.

 

Outcome evaluation focuses on changes in the client’s health status. A nbasic question to ask when evaluating the outcome is: Has the expected change noccurred? Such changes may include “modifications of symptoms; signs; nknowledge; attitudes; satisfaction; skill; and compliance with treatment nregimen” (Gillies, 1994, p. 517). Another variable assessed during outcome nevaluation is the client’s self-care ability. Has the client demonstrated aimproved ability to care for self? Does the client verbalize knowledge related nto self-care needs?

 

NURSING AUDIT

A nursing audit is the process nof collecting and analyzing data to evaluate the effectiveness of nursing ninterventions. A nursing audit can focus on implementation of the nursing nprocess, client outcomes, or both in order to evaluate the quality of care provided. nNursing audits examine data related to:

• Safety measures

• Treatment interventions and client nresponses to the interventions

• Preestablished outcomes used as basis for ninterventions

• Discharge planning

• Client teaching

• Adequacy of staffing patterns

Audits are based on components such as institutional policies; federal, nstate, and local regulations; accreditation standards; and professional nstandards

Audits assist in identifying strengths and weaknesses nthat, in turn, provide direction for areas needing revision. Corrective actioplans are developed in accordance with the audit results.

PEER EVALUATION

Another method of evaluating quality nof care is peer evaluation (also referred to as peer review), the nprocess by which professionals provide to their peers critical performance nappraisal and feedback that are geared toward corrective action. According to nthe ANA (1988):

 

Peer review iursing is the process nby which practicing Registered Nurses systematically assess, monitor, and make njudgments about the quality of nursing care provided by peers, as measured nagainst professional standards of practice.

In 1984, Lucille Joel postulated that peer review is the basis of nnursing’s autonomy and self-governance (Joel, 1984). This perspective is still nvery relevant in today’s health care climate.

By evaluating itself, nursing is ndemonstrating an essential criterion by which professions are recognized. Peer nevaluation promotes both

professional and individual accountability.

The quality of nursing care is nstrongly evident to coworkers and nurses who are expected to assess the work of ntheir peers. “Peer review is an essential mechanism for nevaluating the judgment and performance of clinical providers” (Wakefield, nHelms, & Helms, 1995, p. 11).

Such judgment may result in one of the following outcomes:

• Destructive: Complaints and attacks that nundermine morale and cohesiveness

• Constructive: Positive feedback that nimproves the quality of care

Peer evaluation can be destructive if the parties involved begin to npersonalize the process, misunderstand the purpose, or deliver feedback in aunfeeling and

nonobjective manner.

Peer evaluation can be threatening when guidelines have not been established nfor the process and when the assessment focuses on emotions and personalities ninstead of on behaviors. Conversely, peer evaluation is constructive when the nfocus remains on quality improvement and encourages the continued growth and nlearning of all the parties involved. The accompanying display provides nprinciples that promote the use of objective, nonbiased peer evaluation.

EVALUATION AND nACCOUNTABILITY

Accountability means assuming responsibility nfor one’s actions. Evaluation enhances nursing accountability by providing a nmechanism for assisting the nurse to define, explain, and measure the results nof nursing actions. Accountability is increased by ongoing evaluation; nurses nare continually checking their own progress against predetermined standards.

Accountability is an integral part of nprofessional nursing practice and is an important method through which ncommitment to quality client care can be demonstrated. “Nurses nare accountable for designing effective care plans, implementing appropriate nnursing actions, and judging the effectiveness of their nursing interventions” n(Kenney, 1995, p. 195).

In other words, nurses are naccountable, for their judgments, decisions, and actions, to:

• Clients, families, and significant others

• Colleagues

• Employers

• The general public (society)

• The nursing profession

• Themselves.

 

MULTIDISCIPLINARY nCOLLABORATION IN EVALUATION

Evaluating the quality of care nprovided is a responsibility shared among members of the health care team. Iaddition to those directly involved (the health care providers, clients, and nfamilies), others interested in the outcomes of evaluation include the ncommunity and third-party payers (both public and private reimbursement norganizations).

An ongoing monitoring process is nimplemented to evaluate quality of care. Ideally, every discipline monitors its nown quality efforts. No single discipline is responsible for all-inclusive nevaluation of client care. However, in most health care agencies, nurses are nactively involved in monitoring evaluation activities. Many agencies have nnurses on staff who function either as quality nmanagement coordinators, utilization review evaluators, or both.

When health care providers from all nthe relevant disciplines are involved in evaluation, the result is decreased nfragmentation of care. The team approach mandates active involvement of all ncare providers in the evaluation of quality care. Multidisciplinary evaluatiohelps promote a continuum of care for the client, from the preadmission phase nto discharge planning and follow-up care.

 

KEY CONCEPTS

• Evaluation, the fifth step in the nursing nprocess, involves determining whether the client goals have been met, have beepartially met, or have not been met.

• The purposes of evaluation are to ndetermine the client’s progress or lack of progress toward achievement of nclient objectives, to judge the value of nursing actions in helping clients to nachieve objectives, to determine the health care agency’s overall ability to ndeliver care in an effective and efficient manner, and to promote nursing naccountability.

• Evaluation is based primarily on the nskills of communication and observation.

• Evaluation is a mutual, ongoing process noccurring among the nurse, client, family, and other health care providers.

• The effectiveness of nursing interventions nis evaluated by examination of goals and expected outcomes that provide ndirection for the plan of care and serve as standards by which the client’s nprogress is measured.

• Evaluation is an orderly process nconsisting of seven steps: establishing standards; collecting data related to nthe goals and expected outcomes; determining goal achievement; relating nursing nactions to client status; judging the value of nursing interventions iassisting clients to achieve goals and objectives; reassessing the client’s nstatus; and modifying the plan of care if necessary.

• There is a relationship between quality nmanagement and evaluation. Evaluation is necessary in the provision of quality ncare because it is the mechanism used by nurses in determining how to improve ncare.

• Structure evaluation judges a health care nagency’s ability to provide the services offered to its client population.

• Process evaluation measures nursing nactions by examining each phase of the nursing process to determine the neffectiveness of the actions in helping clients meet expected outcomes and ngoals.

• Outcome evaluation compares the client’s current nstatus with the expected outcomes and examines all direct care activities that naffect the client’s status.

• A nursing audit can focus oimplementation of the nursing process, client outcomes, or both in order to nevaluate the quality of care provided.

• Peer evaluation (peer review) is the nprocess by which professionals provide to their peers performance appraisal nfeedback geared toward corrective action.

• Evaluation enhances professional nursing naccountability by providing a mechanism for assisting the nurse to define, nexplain, and measure the results of nursing actions.

• Evaluating the quality of care is a shared nresponsibility among members of the health care team.

CRITICAL THINKING ACTIVITIES

1. When does evaluation of nursing care noccur?

2. Describe the three types of evaluation and ncompare them in terms of purpose and methodology.

3. How does evaluation promote the individual nnurse’s accountability?

4. State specific ways in which a nurse caperform process evaluation.

5. What are the advantages of peer nevaluation?

6. Develop criteria for conducting a nursing naudit related to client safety in an extended-care facility.

NURSING nCARE PLAN DEFENCE

 

NURSING CARE PLANS, also known as care plans, are necessary for providing care to npatients in a variety of settings and for varied lengths of time, depending othe patient’s condition, diagnosis and prognosis. Many different components nmake up a commoursing plan. Knowing the key elements found in a nursing plaand how to formulate an effective and well-thought-out plan enables nurses to nprovide better patient-cantered care.
n

INSTRUCTION

1  Write a nnursing plan that takes a number of factors into consideration. For example, a nnursing plan must form some sort of action or response to the patient’s illness nor condition. You should develop a plan of care that assesses and addresses how nyou plan to care for the patient in a well-thought-out process, basing your nplan on facts regarding the case and the patient’s current and potential nproblems, suggests Virtual Nurse.

2  Define nthe basic elements of the nursing plan in outline form. The basic elements of a nnursing care plan include risk factors, rationales, interventions and outcomes, nall based on the patient’s diagnosis. For example, to develop a care plan for a npatient diagnosed with chronic pain, your nursing outcomes may include paicontrol, coping measures and improved quality of life.

3  Write ndown possible interventions you may perform to achieve your nursing care plagoals. In a patient diagnosed with chronic pain, for example, consider possible ninterventions aimed at reducing pain and increasing comfort levels. Your nnursing interventions may include — but are not limited to — pain management, neducation regarding managing medications, and complementary or alternative pairelief therapies such as massage, acupuncture or acupressure, heat therapy and nso forth.

4  Assess nthe patient on a regular basis, but when creating your care plan, pay special nattention to details. For example, again using the chronic-pain patient as an model, note the location of pain, the duration of the npain, the severity of the pain rated on a scale of 1 to 10, and other factors. nThis information-gathering process will help you focus specifically on the npatient’s complaint or illness and determine the best methods for increasing nhis comfort levels and independence.

5  Help nthe patient develop management strategies to deal with his chronic pain by nproviding education, answering questions and offering continuity of care, all ndetails of which should be included in the care plan.

6  Evaluate nthe patient’s progress during the treatment or observation phase of care on a ncontinuous basis, creating easily identifiable and measurable goals throughout nthe period of care.

 

 

NURSING CARE PLAN CASE STUDIES

1. nMr. C. is a 57-year-old businessman who was admitted to the nsurgical unit for treatment of a possible strangulated inguinal hernia.

Two days ago he had a partial bowel resection. nPostoperative orders include NPO, intravenous infusion of D51/2 NS at 125 cc/hr nleft arm, nasogastric tube to low intermittent suction. Mr. C. is in a dorsal nrecumbent (supine) position and is attempting to draw up his legs. He appears nrestless and is complaining of abdominal pain (7 on a scale of 0–10)

.Physical Examination

Height: 188 cm (6′3′′)

 Weight: 90.0 kg (200 lb)

 Temperature: 37°C (98.6°F)

 Pulse: 90 nBPM Respirations: 24/minute

 Blood npressure: 158/82 mm Hg

Skin pale and moist, pupils dilated. Midline abdominal incision, sutures dry and intact.

Diagnostic Data

Chest x-ray and urinalysis negative, WBC 12,000

 

2. Jane Lee is a 60-year-old retired nurse nliving with her husband and daughter on a farm that has been in the family for nfour generations.

Mrs. Lee has gained 10 lb (4.5 kg) in the past few nmonths, even though she is rarely hungry and eats much less thaormal. She is nalways tired and weak—so tired that she has not even been able to help with the nchores on the farm or do housework. She is concerned about her appearance and nthe way she sounds when she talks. Her face is puffy, and her tongue always nfeels thick. Mr. Lee convinces his wife to make an appointment at a health ncenter in a nearby town.

ASSESSMENT

Brian Henning, RN, completes the nhealth assessment for Mrs. Lee at the health center.He finds that she now nweighs 150 lb n(68 kg), nan increase of 10 lb n(4.5 kg) nover her weight at her last visit 6 months earlier. Mrs. Lee states that she nalways feels cold, tired, and weak. She also states that she is constipated, nhas difficulty remembering things, and looks different. Physical assessment nfindings include a palpable and bilaterally enlarged thyroid; dry, yellowish nskin; nonpitting edema of the face and lower legs; and slow, slurred nspeech.Diagnostic tests revealed the following abnormal findings: T3, 56 ng/dL n(normal range: 80 to 200 ng/dL); T4, 3.1 (normal range: 5 to 12 mg/dL); TSH nincreased.The medical diagnosis of hypothyroidism is made, and Mrs. Lee is started non levothyroxine 0.05 mg daily.

 

3. nJohti Singh is a 39-year-old secretary who was admitted to the nhospital with an elevated temperature, fatigue, rapid, labored respirations; nand mild dehydration. The nursing history reveals that Ms. Singh has had a “bad ncold” for several weeks that just wouldn’t go away. She has been dieting for nseveral months and skipping meals. Ms. Singh mentions that in addition to her nfulltime job as a secretary she is attending college classes two evenings a nweek. She has smoked one package of cigarettes per day since she was 18 years nold. Chest x-ray confirms pneumonia.

Physical Examination

Height: 167.6 cm (5′6′′)

Weight: 54.4 kg (120 lb)

 Temperature: 39.4°C (103°F

 Pulse: 68 nBP

Respirations: 24/minute

Blood pressure:118/70 mm nHg

Skin pale; cheeks flushed; chills; use of naccessory muscles; inspiratory crackles with diminished breath sounds right nbase; expectorating thick, yellow sputum

Diagnostic Data

Chest x-ray: right lobar infiltration WBC: 14,000 pH: 7.49 PaCO2: 33 mm Hg HCO3 –: 20 mEq/L PaO2: 80 mm nHg O2 sat: 88%

 

4. nMerlyn Chapman, a 27-year-old sales clerk, reports weakness, nmalaise, and flu-like symptoms for 3–4 days. Although thirsty, she is unable to ntolerate fluids because of nausea and vomiting, and she has liquid stools 2–4 ntimes per day.

Physical Examination

Height: 160 cm (5′3′′)

 Weight: n66.2 kg (146 lb)

 Mild nfever: 38.6°C (101.5°F)

Pulse: 86 BPM

Respirations: 24/minute Scant nurine output

 BP: 102/84 nmm Hg Dry oral mucosa, furrowed tongue, cracked lips

Diagnostic Data

Urine specific gravity: 1.035 Serum sodium 155 nmEq/L Serum potassium 3.2 mEq/L Chest x-ray negative.

 

5. Richard Wright is a 48-year-old divorced nfather of two teenagers. Mr.Wright has been admitted to the community hospital nwith ascites and malnutrition.He has had three previous hospital stays for ncirrhosis, the most recent 6 months ago.

ASSESSMENT

Mr.Wright is lethargic but responds nappropriately to verbal stimuli. He complains of “spitting up blood the past nweek or so” and says,“I’m just not hungry.” He has nlost 20 lb (9 kg) since his previous admission. He is jaundiced and has npetechiae and ecchymoses on his arms and legs. Liz Mowdi, Mr.Wright’s nurse, nnotes pitting pretibial edema. Abdominal assessment reveals a tight, nprotuberant abdomen with caput medusae. The liver margin is not palpable; the nspleen is enlarged. Vital signs are T 100°F (37.7°C), P 110, R 24, and BP n110/70. Abnormal laboratory results include WBC 3700/mm3 (normal 4300 to n10,800/mm3); RBC 4.0 million/mm3 (normal 4.6 to 5.9 million/mm3); platelets n75,000/mm3 (normal 150,000 to 350,000/mm3); serum ammonia 105 μm/dL (normal 35 to 65 μm/dL); total bilirubi4.9 μ g/dL (normal 0.1 to 1.0 μg/dL); and serum nsodium 150 mEq/L (normal 135 to 145 mEq/L).Potassium, hemoglobin, hematocrit, ntotal protein, and albumin levels are markedly decreased. Hepatic enzymes are nelevated. Blood urea nitrogen and creatinine levels are marginally elevated. nOxygen saturation (O2 sat) is 88% (normal range: 96% to 100%) per pulse noximetry.

Endoscopy shows bleeding from ngastric ulcer, and the diagnosis of alcoholic cirrhosis with gastritis is made. nMr. Wright is started on Aldactone, 25 mg PO q8h; Riopan, 30 mL 2 hr p.c. and nhs; lactulose, 30 mL q h until onset of diarrhea, then 15 mL t.i.d.; and nlow-protein, 800 mg sodium diet; fluid restriction of 1500 mL/day

 

6. Rose Ortiz is a 72-year-old widow who lives alone, although close nto her daughter’s home. Ms. Ortiz has mild heart failure and is being treated nwith digoxin (Lanoxin) 0.125 mg,furosemide (Lasix) 40 nmg PO daily,and a mildly restricted sodium diet (2 g daily). For the last nseveral weeks, Ms. Ortiz has complained that she feels weak and sometimes nfaint, light-headed, and dizzy. Serum electrolyte tests ordered by her physiciareveal a potassium level of 2.4 mEq/L. Potassium chloride solution (Kaochlor n10%, 20 mEq/15 mL) PO twice daily is prescribed, and Ms. Ortiz is referred to nNancy Walters, RN, for follow-up care.

ASSESSMENT

Ms. Ortiz’s health history reveals nthat she has rigidly adhered to her sodium-restricted diet and has beecompliant in taking her prescribed medications, with the exception of noccasionally taking an additional “water pill”when her ankles swell. She takes na laxative every evening to ensure a daily bowel movement. She states that she nis reluctant to take the potassium chloride the doctor has ordered because her nneighbor complains that his potassium supplement upsets his stomach. Physical nassessment findings included T 98.4, P 70, R 20, and BP 138/84. Muscle strength nin her upper extremities is normal and equal;lower nextremity strength is weak but equal. Sensation is normal.

 

7. Margaret Spezia is a married, 49-year-old Italian American with eight children whose ages range from 3 to 18 nyears. For the past 2 months, Mrs. Spezia has  had frequent morning headaches, and noccasional dizziness and blurred vision. At her annual physical examination 1 nmonth ago, her blood pressure was 168/104 and 156/94.She was instructed to nreduce her fat and cholesterol intake, to avoid using salt at the table,and to nstart walking for 30 to 45 minutes daily.Mrs.Spezia returns to the clinic for nfollow-up.

ASSESSMENT

While escorting Mrs. Spezia to the nexam room and obtaining her weight,blood pressure,and nhistory, Lisa Christos,RN, notices that Mrs. Spezia seems restless and nupset.Ms.Christos says,“You look upset about something. Is everything OK?”Mrs. nSpezia responds, “Well,my head is throbbing, and I’m nsort of dizzy. I think I’m just overdoing it and not getting enough rest. You nknow, raising eight children is a lot of work and expense. I just started nworking part time so we wouldn’t get behind in our bills. I thought the extra nmoney might relieve some of my stress, but I’m not so sure that’s really nhappening. I’m not getting any better and I’m worried that I’ll lose my job or nbecome disabled and that my husband won’t be able to manage the children by nhimself. I really need to go home, but first, I want to get rid of this awful nheadache.Would you please get me a couple of aspirin or something?”

Mrs. Spezia’s history shows a nsteady weight gain over the past 18 years. She has no known family history of nhypertension. Physical findings include height 63 inches (160 cm), weight 225 nlb (102 kg),T 99° F (37.2° C),P 100 regular, R 16, BP 180/115 (lying), 170/110 n(sitting), 165/105 (standing), average 10-point difference in readings betweeright and left arm (lower on left). Skin cool and dry, capillary refill 4 nseconds right hand, 3 seconds left hand.Mrs. Spezia’s total serum cholesterol nis 245 mg/dL (normal < 200 mg/dL). All other blood and urine studies are nwithiormal limits. Based on analysis of the data,Mrs. nSpezia is started on enalapril 5 mg and hydrochlorothiazide 12.5 mg in a ncombination drug (Vaseretic), and placed on a low-fat low-cholesterol, nno-added-salt diet.

 

8. Mr. John Baker is a 68-year-old shopkeeper nwho was admitted to the hospital with urinary retention, hematuria, and fever. nThe admitting nurse gathers the following information when taking a nursing nhistory. Mr. Baker states he has noticed urinary frequency during the day for nthe past 2 weeks, and that he doesn’t feel he has emptied his bladder after nurinating. He also has to get up two or three times during the night to nurinate. During the past few days, he has had difficulty starting urination and ndribbles afterward.

He verbalizes the embarrassment his urinary nproblems cause in his dealings with the public. Mr. Baker is concerned about nthe cause of this urinary problem. He is diagnosed with benign prostatic nhypertrophy (BPH) and referred to a urologist who nsuggests a transurethral resection of the prostate (TURP) in several months. He nis placed on antibiotic therapy.

Physical Examination

Height: 185.4 cm (6′2′′)

Weight: 85.7 kg (189 lb)

Temperature: 38.1°C (100.6°F)

Pulse: 88 BPM

Respirations: 20/minute

Blood pressure: 146/86 mm Hg

Catheterization for urinary retention yielded 300 nmL amber urine,

 Foley left nin place for 2 days

Diagnostic Data

CBC normal; urinalysis: amber, clear, pH 6.5, nspecific gravity 1.025, negative for glucose, protein, ketone, RBCs, and nbacteria; IVP: evidence of enlarged prostate gland

 

9. nRuby Smithson is a 55-year-old mother of four nchildren who is hospitalized with breast cancer. She is scheduled for a nmodified radical mastectomy. Ruby was relatively healthy until she found a lump nin her right breast 1 week ago. She and her husband are extremely anxious about nthe surgery. Ruby confides to the admitting nurse that “I can’t stand the idea nof having one of my breasts cut off; I don’t know how I’m going to be able to neven look at myself.” Mr. Smithson informs the nurse that Ruby has been abusing nalcohol since her diagnosis and neglecting her responsibilities as a mother. nShe is tearful and doesn’t see how she will be able to continue her work as a ndress designer.

Physical Examination

Height: 164 cm (5′5′′)

Weight: 58 kg (158 lb)

Temperature: 37ºC (98.6ºF)

Pulse rate: 88 BPM

Respirations: 16/minute

Blood pressure: 142/88 mm Hg

Diagnostic Data

Chest x-ray negative, CBC, and nurinalysis withiormal limits.

 

10. nRoseline Ukoha is a 45-year-old married school teacher who has two children. For the past n2 days, she has experienced intermittent abdominal pain and bloating.The paiincreased in severity over the past 9 to 10 hours, and she developed nausea, nlower back pain, and discomfort radiating into the perineal region.Mrs.Ukoha nreports having had no bowel movement for the past 2 days.The emergency ndepartment nurse, Jasmine Sarino, RN, completes her admission assessment.

ASSESSMENT

Mrs. Ukoha relates a 10-year nhistory of chronic irritable bowel symptoms, including alternating constipatioand diarrhea and intermittent abdominal cramping. She states that she thought nthese symptoms were due to the stress of teaching middle school, and that they nnever became severe enough to seek medical advice.

When questioned about her diet, she ncalls it a typical American high-fat, fast-food diet,usually consisting of a nsweet roll and coffee for breakfast, a hamburger or sandwich and soft drink for nlunch, and a balanced dinner, usually including meat, a vegetable or salad, and npotatoes or pasta,“except on pizza night!” Physical assessment findings include nT 101°F (38.3°C), P 92, R 24, and BP 118/70. Abdomen is slightly distended and ntender to light palpation. Bowel sounds are diminished.Diagnostic tests include nthe following abnormal results: WBC 19,900/mm3 (normal 3500 to 11,000/mm3) with nincreased immature and mature neutrophils on differential; hemoglobin 12.8 g/dL n(normal 13.3 to 17.7 g/dL); hematocrit, 37.1% (normal 40% to 52%). Abdominal nX-ray films show slight to moderate distention of the large and small bowel nwith suggestion of possible early ileus. A small amount of free air is noted ithe peritoneal cavity. The diagnosis of probable diverticulitis with ndiverticular rupture is made,and Mrs.Ukoha is admitted nto the medical unit for intravenous fluids, antibiotic therapy, and bowel rest.

 

11. Mrs. Opal Hipps, age 75, nlives alone with her dog, Chester, in her family home in the suburbs. She nretired from her job as a postal clerk 10 years ago and now spends a lot of ntime reading and watching television. Over the past week she has developed a nvague aching pain in her right leg. She ignored the pain until last night wheit developed into a much more severe pain in her right calf. She noticed that nher right lower leg seemed larger than the left,and it was very tender to the ntouch.After seeing her physician and undergoing Doppler ultrasound studies, nMrs. Hipps is admitted to the hospital with the diagnosis of deep veithrombosis in the right leg. She is placed on bed rest, and intravenous nheparin. Michael Cookson, RN, is assigned to admit and care for Mrs. Hipps.

ASSESSMENT

Mr. Cooksootices that Mrs. Hipps nwas admitted 14 months ago for repair of a fractured femur. Mrs. Hipps says, n“This business about a blood clot really has me worried.”She also tells Mr. nCookson that she is worried about who will care for her dog while she is in the nhospital. Physical findings include: height 62 inches (157 cm), weight 149 lb n(68 kg), T 99.2 F (37.3°C); vital signs withiormal limits otherwise. Her nleft leg is warm and pink, with strong peripheral pulses and good capillary nrefill. Her right calf is dark red, very warm, and dry to touch. It is tender nto palpation. The right femoral and popliteal pulses are strong, but the pedal nand posterior tibial pulses are difficult to locate. The right calf diameter is n0.5 inch (1.27 cm) larger than the left.

 

12. Kirsten Avis,a 44-year-old nhomemaker and mother of two teenage sons,was ndiagnosed with myasthenia gravis 2 years ago.She takes an anticholinesterase nmedication,pyridostigmine (Mestinon),four times a day. Over the past month she nhas been experimenting with decreasing the dose of her pyridostigmine because nshe has “felt so good.” She was prescribed 60 mg of pyridostigmine three times na day before meals and one-half of a long-acting 180 mg pyridostigmine tablet nat night.

Three days ago, she began having chills nand fever and her myasthenic symptoms became markedly worse.Mrs.Avis is easily nfatigued and has been experiencing increasing weakness, bilateral ptosis, and nmild dysphagia in the late afternoon and evenings.

ASSESSMENT

Lela Silva, RN, is caring for Mrs. nAvis. Physical examination of Mrs. Avis reveals severe muscle weakness nbilaterally in her hands, arms, and thorax. Her voice is nasal, and she speaks nslowly; the longer she speaks, the more difficult it becomes to understand her. nShe is anxious and dyspneic.Her complaints of weakness,dysphagia, dysarthria, nproblems with mobility, and ptosis are more pronounced nlater in the day.Vital signs are as follows: BP 138/88, P 88, R 28, T 102.4°F n(39°C).

Some improvement in muscle weakness is noted nfollowing a restful night’s sleep; however, the respiratory distress is more nevident, and Mrs. Avis is increasingly restless. She is moved to the intensive ncare unit for advanced monitoring and possible ventilatory assistance.The nmedical diagnosis is myasthenic crisis secondary to pulmonary infection.

 

13. nSean O’Donnell is a 47-year-old police officer who lives and works in a metropolitan area.Mr. O’Donnell nhas had “heartburn” and abdominal discomfort for years, but thought it went nalong with his job. Last year, after becoming weak, light-headed, and short of nbreath, he was found to be anemic and was diagnosed as having a duodenal ulcer. nHe took omeprazole (Prilosec) and ferrous sulfate for 3 months before stopping nboth, saying he had “never felt better in his life.”Mr. O’Donnell has now beeadmitted to the hospital with active upper GI bleeding.

ASSESSMENT

Rachel Clark is Mr.O’Donnell’s nadmitting nurse and case manager. On initial assessment, Mr. O’Donnell is alert nand oriented, though very apprehensive about his condition. Skin pale and cool; nBP 136/78, P 98; abdomen distended and tender with hyperactive bowel sounds; n200 mL bright red blood obtained oasogastric tube insertion. Hemoglobin 8.2 g/dL and hematocrit 23% on admission.

Mr. O’Donnell is taken to the nendoscopy lab where his bleeding is controlled using laser photocoagulation.Ohis return to the nursing unit,he receives two units nof packed red blood cells and intravenous fluids to restore blood volume. A n5-day course of high-dose oral omeprazole (40 mg bid) is ordered to prevent nrebleeding, and Mr. O’Donnell is allowed to begin a clear liquid diet 24 hours nafter his endoscopy. Tissue biopsy obtained during endoscopy confirms the npresence of H.pylori infection

 

14. Janet Cirit, a 33-year-old nlegal secretary, lives in a suburban midwestern community. She is unmarried but ndating a maamed Jim Adkins, who lives in an adjacent suburb. Ms. Cirit nvisits her gynecologist because her peri ods have nbecome irregular and she is experiencing pelvic pain and an abnormal amount of nvaginal discharge. Recently she has developed a sore throat. The pelvic paihas begun to disrupt her sleeping pattern, and she is concerned that she might nhave cancer because her mother recently died of ovarian cancer.

 

ASSESSMENT

WheMs. Cirit arrives for her appointment at the gynecologist’s office, Marsha nDavidson, the nurse practitioner, interviews her. Ms. Davidson completes a nthorough medical and sexual history, including questions about her menstrual nperiods, pain associated with urination or sexual intercourse, urinary nfrequency,most recent Pap smear, birth control method, history of STI and drug nuse, and types of sexual activity. Ms. Cirit reports her symptoms and her nconcern about ovarian cancer. She also indicates that she is taking oral ncontraceptives and therefore sees no need for her boyfriend to use a condom nbecause she believes their relationship is monogamous.

Physical nexamination reveals both pharyngeal and cervical inflammation, and lower nabdominal tenderness.Her temperature is 98.5°F (37.0°C).There nare no signs or symptoms of pregnancy.

The ngynecologist orders a Pap smear and cultures of the cervix, urethra, and npharynx to evaluate for gonorrhea and chlamydial infection. Blood is drawn for nWBC. Test results are positive for gonorrhea  and negative for chlamydia. The WBC is nslightly elevated, indicating possible salpingitis. Because Mr. Adkins has beeMs.Cirit’s only sexual partner, it is clear that he is the source of infectioand needs to be treated as well.

 

15. Martha Overbeck is a 74-year-old nwidow of German descent who ives alone in a senior ncitizens’ housing complex. She is active there, as well as in the LutheraChurch. She has been in good health and is independent,but nshe has become progressively less active as a result of arthritic pain and nstiffness.Mrs.Overbeck has degenerative joint changes that have particularly naffected her right hip.On the recommendation of her physician and following a ndiscussion with her friends,Mrs.Overbeck has been admitted to the hospital for nan elective right total hip replacement. Her surgery has been scheduled for n8:00 A.M.the following day.

Mrs. nEva Jackson, a close friend and neighbor, accompanies Mrs. Overbeck to the nhospital. Mrs. Overbeck explains that her friend will help in her home and nassist her with the wound care and prescribed exercises.

ASSESSMENT

Gloria nNobis, RN, is assigned to Mrs. Overbeck’s care on return to her room.Ms.Nobis nperforms a complete head-to-toe assessment and determines that Mrs. Overbeck is ndrowsy but oriented. Her skin is pale and slightly cool.Mrs.Overbeck states she nis cold and requests additional covers. Ms. Nobis places a warmed cottoblanket next to Mrs.Overbeck’s body, adds another blanket to her covers, and nadjusts the room’s thermostat to increase the room temperature.Mrs.Overbeck nstates that she is io pain and would like to sleep. She has even, unlabored nrespirations and stable vital signs as compared to preoperative readings.  Mrs. Overbeck is NPO. An intravenous solutioof dextrose and water is infusing at 100 mL/h per infusion pump.No redness or nedema is noted at the infusion site.Ms. Nobis notes that the antibiotic nciprofloxacin hydrochloride (Cipro) is to be administered by mouth when the nclient is able to tolerate fluids. Mrs. Overbeck has a large gauze dressing nover her right upper lateral thigh and hip with no indications of drainage from nthe wound. Tubing protrudes from the distal end of the dressing and is attached nto a passive suctioning device (Hemovac).Ms. Nobis empties 50 mL of dark red ndrainage from the suctioning device and records the amount and characteristics non a flow record. Mrs. Overbeck has a Foley catheter in place with 250 mL of nclear, light amber urine in the dependent gravity drainage bag. When assessing nMrs. Overbeck’s lower extremities, Ms. Nobis finds her feet slightly cool and npale with rapid capillary refill time bilaterally.Dorsalis pedis and posterior ntibial pulses are strong and equal bilaterally.Ms.Nobis notes slight pitting nedema in the right foot and ankle as compared with the left extremity.She also nnotes sensation and ability to move both feet and toes,without nnumbness or tingling (paresthesia).

Ms. nNobis records the above findings on a postoperative flowsheet.After ensuring nthatMrs.Overbeck is safely positioned and can reach her call light, Ms. Nobis ngives Mrs. Overbeck’s friend, Mrs. Jackson, a progress report.They then go nntoMrs.Overbeck’s room

 

16. Rachel Clemments is a 42-year-old nmother of two, Sarah, age 12, and Jennifer, age 18. Because of a family history nof breast cancer, she has been closely monitored (annual mammograms and nclinical breast examination, monthly BSE, a needle aspiration biopsy with nnegative findings) for 4 years prior to her diagnosis. Mrs. Clemments discovers na lump in her left breast during her monthly BSE. An incisional biopsy reveals ninvasive lobular carcinoma in the left breast. Mrs. Clemments is debating nwhether to have reconstructive breast surgery. Her oncologist has recommended a n6-month course of adjuvant chemotherapy, and she is concerned about side neffects. One of her greatest concerns is how her illness will affect her nability to support and care for her daughters.She is afraid that recovering nfrom the mastectomy and completing the chemotherapy regimen will limit her nability to keep her part-time job, complete her academic work, and continue to nmeet the needs of her daughters.Also, this breast cancer diagnosis seems part nof the family legacy. She wonders, “When will it happen to Jennifer? To Sarah?”

ASSESSMENT

During nthe history, Laura Nelson, RN, the nurse admitting Mrs.Clemments, learns that nher mother, two of her aunts,and one sister had beediagnosed with breast cancer. Her mother and one of the aunts died before age n45. Physical assessment findings include T 98.5°F (37.0°C), BP 110/62, P 65, R n14.Her weight is 120 lb (54 kg); she is 66 inches (168 cm) tall. Modified nradical mastectomy is performed; histologic examination shows a 3 cm tumor; naxillary node dissection shows that 4 of 16 lymph nodes are positive.

 

17. Mr. C. is a 57-year-old nbusinessman who was admitted to the surgical unit for treatment of a possible nstrangulated inguinal hernia. Two days ago he had a partial bowel resection. nPostoperative orders include NPO, intravenous infusion of D51/2 NS at 125 cc/hr nleft arm, nasogastric tube to low intermittent suction. Mr. C. is in a dorsal nrecumbent (supine) position and is attempting to draw up his legs. He appears nrestless and is complaining of abdominal pain (7 on a scale of 0–10)..

 Nursing Assessment Physical Examination

Height: n188 cm (6′ 3′′)

Weight: n90.0 kg (200 lb)

 Temperature: 37°C (98.6°F)

Pulse: n90 BPM

Respirations: n24/minute

Blood npressure: 158/82 mm Hg

Skipale and moist, pupils dilated. Midline abdominal incision, nsutures dry and intact. Diagnostic nData Chest x-ray and urinalysis negative, WBC 12,000

 

18. Janet Carlson is a 19-year-old ncollege student who lives with her parents and one younger sister.Although nJanet had seizures while she was in grade school, they have been controlled nwith medication.However, she had a tonic-clonic seizure yesterday and nimmediately made an appointment with her family physician.She is currently ntaking phenytoin (Dilantin) 300 mg/day as a maintenance medication to prevent nseizures.

ASSESSMENT

Evita nFarias, RN, completes a health history for Ms.Carlson.During the history, she tells Ms. Farias that she has been under stress nbecause of difficulties in completing her course requirements this semester. nShe has not been sleeping as many hours per night, and sometimes she forgets to ntake her medication. Janet’s serum phenytoin level is 8 mg/mL.Therapeutic level nis 10 to 20 mg/ml.

 

19. JB is a 19-year-old nAfrican American man exhibiting symptoms of schizophrenia for the first ntime.  His parents brought him to the nhospital after he was brought home for spring break. He is a freshman at ncollege and is attending on an academic scholarship. He is the oldest child of nthree and is the first in his family to go to college. His father is a foremaat the local auto plant, and his mother is a receptionist for a physician. His nfather’s insurance plan allows for a 15-day stay for mental health services.

JB has always been a quiet, hard worker with a small circle of friends. nHis first semester was a lonely one, with disappointing grades. Although he was nnot at risk to fail out of school, he was at risk of losing his scholarship. At nChristmas time, JB was quieter than usual but participated in family activities nwithout prodding. When grandparents, aunts, and uncles asked him about school nhe was distracted and answered simply that it was fine. His parents returned nhim to school with some anxiety but thought it was just a difficult adjustment nbeing away from home for the first time.

When his parents picked him up for spring break he was disheveled and nhad not bathed. His side of the dorm room was covered with small pieces of ntaped paper with single words on them. The words made no sense but JB stated nthat he put them there “to organize (his) thoughts.” His roommate informed his nparents that this behavior started about the same time JB began staying in the nroom and skipping classes and meals.

JB agreed to leave with his parents only after they agreed to take neverything home with them. As they packed his belongings, JB sat in the corner nof his bed listening to his compact disk player. When his parents asked him nwhat was happening, he merely said, “I have the power.” On the way home JB nresponded to their questions by saying his professors were trying to take away nwhat he knew. He sat huddled in the back seat of the car with his coat over his nhead. He laughed and mumbled in response to nothing his parents could hear.

SETTING:  INTENSIVE CARE PSYCHIATRIC UNIT/GENERAL nHOSPITAL

BASELINE nASSESSMENT:  This is the first admissiofor JB, a 19-year-old single African American college student who has not slept nfor 4 days and is frightened with wide-eyed hypervigilance, pacing, and periods nof extended immobility. Is vague about past drug use. nParents do not believe he has used drugs. He appears to be hallucinating, nconversing as if someone is in the room. At times he says he is receiving ninstructions from “the power.”  He is nunable to write, speak, or think coherently. He is disoriented to time and nplace and is confused. JB is 6’1”, 155 lb, thin in appearance, but normally ndeveloped. Lab values are withiormal limits except Hgb, 10.2 and Hct, 32. He has not eaten for several days.

n

Associated Psychiatric Diagnosis	Medications
Axis I Schizophrenia, catatonic type Axis II None Axis III None Axis IV Educational problems (failing) Social problems (withdrawn from social contacts) Axis V GAF Current = 25 Potential = ?	Risperidone (Risperdal) 2 mg bid then titrate to 3 mg bid if needed Lorazepam (Activan) 2 mg PO or IM PRN IM for agitation

 

20. Ruby Smithson is a 55-year-old nmother of four children who is hospitalized with breast cancer. She is nscheduled for a modified radical mastectomy. Ruby was relatively healthy until nshe found a lump in her right breast 1 week ago. She and her husband are nextremely anxious about the surgery. Ruby confides to the admitting nurse that n“I can’t stand the idea of having one of my breasts cut off; I don’t know how nI’m going to be able to even look at myself.” Mr. Smithson informs the nurse nthat Ruby has been abusing alcohol since her diagnosis and neglecting her nresponsibilities as a mother. She is tearful and doesn’t see how she will be nable to continue her work as a dress designer.

Nursing Assessment Physical nExamination

Height: n164 cm (5′5′′)

Weight: n58 kg (158 lb)

Temperature: n37ºC (98.6ºF)

Pulse nrate: 88 BPM

Respirations: n16/minute

Blood npressure: 142/88 mm Hg

Diagnostic Data

Chest nx-ray negative, CBC, and urinalysis withiormal limits

 

21. Orville Boren is a 68-year-old nAfrican American who had a stroke due to right cerebral thrombosis 1 week ago. nHe is a history instructor at the local community college. His hobbies are wood ncarving and gardening.Mr. Boren is also an active member of his church.For the npast 2 years,Mr.Boren has been taking medication for hypertension, but his wife nEmily reports that he often forgets to take it and that his blood pressure was nhigh at his last physical examination. Mrs. Boren tells the staff that she has nnever had to worry about her husband’s health before and that she wants to nlearn everything she can to care for him at home. However, she says that her nhusband was always the one to make the decisions and pay the bills.Mrs. Boreadds that all the children, grandchildren, neighbors, and family pastor want to nsee Mr. Boren back at home as soon as possible.

ASSESSMENT

Carol nMerck, RN, the nurse assigned to Mr. Boren, completes a health history and nphysical assessment,with Mrs. Boren providing ninformation for the history.Mrs. Boren reports that her husband did have nseveral spells of dizziness and blurred vision the week before his stroke,but they lasted only a few minutes and he believed them to nbe due to “old age and working out in the sun.” On the morning of admission,Mr. Boren woke up and could not move his left arm or leg; nhe also could not speak sensibly. Mrs. Boren called 911, and an ambulance took nher husband to the hospital.

Physical nassessment findings include the following:Mr.Boren is ndrowsy but responds to verbal stimuli. Although he does not respond verbally, nhe caod his head to indicate “yes”when asked questions. Flaccid paralysis is npresent in his left arm and left leg, with no response noted to touch in those nextremities (he is lefthanded). Visual fields are decreased in a patterconsistent with homonymous hemianopia.A CT scan,negative non admission, is repeated on the third day after admission and confirms the nmedical diagnosis of a right-brain stroke due to a thrombus of the middle ncerebral artery.

Mr.Boren’s nmedical treatment includes heparin sodium administered by continuous nintravenous drip,with clotting studies to be performed nevery 4 hours and the dose adjusted accordingly.

 

22. Betty Friedman is a 25-year-old ngrade-school teacher.Her friends and the other teachers regard Ms. Friedman as nan enthusiastic person who sets high standards for herself and strives for nperfection.During the spring semester,Ms. Friedmabegins to miss work and sometimes appears very nervous. One day, another nteacher notices Ms.Friedman running down the hall and into the restroom; the nteacher finds Ms. Friedman vomiting. As she washes up,Ms.Friedman ntells the other teacher that she has been having headaches since she begamenstruating, but that they have never been as intense and frequent as during nthis past year.

They neven wake her from her sleep.Ms. Friedman agrees to see the nurse practitioner, nJane Schickadanz, at the school clinic for evaluation.

ASSESSMENT

During nher health history, Ms. Friedman relates that each month before her menstrual ncycle she becomes nervous and sees flashing lights. She also has difficulty nexpressing herself and thinking clearly. The next day nshe develops a “sick headache.” She states that the headache can last 1 to 2 ndays and that afterwards she cannot brush her hair because her scalp hurts.Ms. nFriedman attributes these symptoms to PMS and adds that she thinks she is nallergic to cheese and nuts because she gets very sick after eating them. After nassessment, and in consultation with the physician,Ms.Schickadanz ndiagnoses Ms. Friedman’s problem as a migraine with aura headache.Sumatriptasuccinate (Imitrex) injections are prescribed.

 

23. Lila Rainey is an 80-year-old nwidow who lives alone in the house she and her late husband built 50 years nago.She has worn glasses for nearsightedness since she was a young girl and was ndiagnosed 4 years ago with chronic open-angle glaucoma, for which she takes ntimolol maleate (Timoptic) 0.5%. Recently she has noticed difficulty reading nand watching television despite a new lens prescription. She has stopped ndriving at night because the glare of oncoming headlights makes it difficult nfor her to see.Mrs.Rainey’s ophthalmologist has told her that she has cataracts nbut that they do not need to come out until they bother her.Although her nglaucoma is still controlled with timolol maleate 0.5%,one ndrop in each eye twice a day, her intraocular pressure measurements have beegradually increasing. Mrs. Rainey has taken 325 mg of aspirin daily since a TIA n8 years ago. She is being admitted to the outpatient surgery unit for a ncataract removal and intraocular lens implant in her right eye.

ASSESSMENT

Mrs. nRainey is admitted to the eye surgery unit by Susan Schafer, RN. In her nassessment,Ms.Schafer finds Mrs.Rainey to be alert and noriented, though apprehensive about her upcoming surgery. Assessment findings ninclude BP 134/72, P 86, R 18. Mrs. Rainey’s nneurologic, respiratory, cardiovascular, and abdominal assessments are nessentially normal.Her pupils are round and equal, and

react briskly to light and accommodation. nHer conjunctivae are pink; sclera and corneas, clear. Using the ophthalmoscope, nMs. Schafer notes that the red reflex in Mrs. Rainey’s right eye is ndiminished.Ophthalmic examination shows visual acuity of 20/150 OD (right eye) nand 20/50 OS (left eye) with corrective lenses. Her intraocular pressures are n21 mmHg OD and 17 mmHg OS.On fundoscopic exam, no disease of the blood vessels, nretina,macula, or disc is found. Ms. Schafer reviews nthe operative procedure with Mrs. Rainey, answering her questions and telling nher what to expect after surgery.Following preoperative protocols,Mrs.Rainey is prepared and transported to surgery.

 

24. G.B. is aintelligent, confident, 5 feet and 4 inches tall, ABO B+, 28-year-old Caucasiafemale patient: G1P1, LMP is February 2, 2006, EDC is November 18, 2006 and ngestation of 39^6/7 weeks confirmed by an ultrasound per chart. nPre-pregnancy weight was 137 lbs and pregnancy weight is 174 lbs for a total ngain of 37 pounds. G.B. stated she eats a “semi-strict vegetarian diet” (no ndairy, no red meat), rarely drinks alcohol (no alcohol while pregnant), and she nhas never smoked cigarettes or taken recreational drugs. Prenatal labs are nnegative. G.B. was admitted to GAMC after an attempted home birth via midwife nassistance with intact membranes at 0710 hrs on November 16, 2006. The patient nstated her cervix dilated to “only 3 cm after laboring over 24 hours at home”. nG.B. stated she prepared for labor and delivery by learning the Bradley method nand she hired a doula for the postpartum period. G.B. plans on breastfeeding nher neonate for at least 1 year. She is allergic to penicillin, amoxicillin, nand erythromycin. Significant medical history includes systemic lupus nerythematosus (SLE), past positive PPD and negative xray within last 5 years, nand adenomyosis (endometriosis interna) via laparoscopy in 2002 per chart. No nsignificant family medical history. G.B.’s supportive, caring, and protective nhusband was at bedside throughout the labor and delivery and postpartum.

     IV Lactated Ringers 1000 mL at 125 mL/hr nand external fetal monitoring was initiated shortly after admission. Throughout nthe labor phases, there were several accelerations, but no late decelerations nof the FHR per chart. G.B. was placed on continuous epidural of Fentanyl, 0.2% nNoropin and 0.25% Marcaine at 14 mL/hr for pain at 4 cm dilation. A stress dose nof 100 mg of hydrocortisone was given IM at 5 cm dilation. An AROM was nperformed at 1815hrs resulting in clear amniotic fluid and negative meconium nstain. The fetus was in vertex presentation and LOA position. A right nmediolateral 2° episiotomy was performed before a normal spontaneous vaginal ndelivery without maneuvers or complications. A healthy male neonate was ndelivered at 0054hrs on November 17, 2006: birth weight 3203 gr (7.1 ½ noz), length 51 cm (21 in) and APGARs 8¹ and 9⁵. The numbilical cord had 2 arteries and 1 vein. The placenta was delivered intact and nspontaneously with minimal assistance. Estimated maternal blood loss was 200 nmL. After bulb suctioning, the newborn was transferred to the nursery.

         The mother and newborn bonded very nwell after birth per chart. G.B.’s IV in her left forearm and Foley catheter nwere immediately discontinued per the patient’s request. The parents refused nPKU and signed a state refusal form. The parents also denied the initial bath, n“eyes and thighs” (erythromycin eye ointment and Vitamin K injection), and nhospital photographs of the newborn per chart. The parents are allowing a nhearing test to be conducted in the afternoon per patient. According to the nnight RN, no one has visited with the new parents yet, but the mother-in-law is ncoming to visit in the afternoon to allow the husband to rest per the patient.

Assessment

Subjective Data: nThe patient complains of feeling slightly dizzy while sitting, an increase of ndizziness upon standing, and she is experiencing tinnitus “whistling, ringing nand loud whooshing like a jet engine” in her ears bilaterally. The patient ndenies history of tinnitus, balance problems, or syncope. Pain scale is 3/10 iuteral and perineal areas. The patient stated she has not yet experienced any nflatulence after the birth of her son. G.B. stated she already experiences the nletdown (milk ejection) reflex whenever her son cries and he “breastfeeds ofteand heartily”.

Objective Data: nPrior to my assessment, the mother was gazing, smiling, and talking softly to nher newborn and seemed slightly reluctant to give the newborn to the father iorder for me to perform an assessment. The father looks tired as he holds the nnewborn closely and fondly. The father smiles at his son when he opens his eyes nand excitedly informs his wife. The patient’s vital signs are WNL: oral ntemperature is 36.8°C (98.2°F), apical pulse is 60, respirations are 20, and nblood pressure is 110/60. Lung sounds are clear bilaterally. The trachea is nmidline, respirations are regular and symmetrical on room air, and there is no nuse of accessory muscles. S₁ and S₂ are present, rhythm nis regular and there are no murmurs, clicks, thrills, or heaves. Radial, nfemoral, popliteal, pedal pulses are 2+ bilaterally and cap refill <3 nseconds on all digits. Skin is slightly pale, warm, and dry. No edema in the nlower extremities bilaterally.

BUBBLE-HE: nBreasts are semi-soft, non-tender without any erythema or areas of increased nwarmth. Nipples are not inverted bilaterally. The fundus of the uterus is firm, ncentered, and located 1.5 finger breadths below the umbilicus. Facial grimacing nand furrowed brows occur upon brief, gentle palpation of fundus. The bladder is nnot distended or palpable. G.B. has voided a total of 450 ml of clear, yellow nurine this morning. The last bowel movement was November 16, 2006 per patient. nBowel sounds are hypoactive in all 4 quadrants. Abdomen is soft, non-tender, nand rounded. Lochia rubra is scant, without clots or odor. RML 2° episiotomy is nintact without erythema or edema. There are no visible hemorrhoids. Homan’s nsign is negative bilaterally. Upon gentle palpation bilaterally of the nposterior lower extremities, there are no areas of  warmth, tenderness or swelling. nEmotional issues are G.B.’s deep, deep desire to control her environment and nthe disappointment of not adhering to her well-researched birthing plan. The npatient is bonding very well to her newborn and enjoys watching her husband nbond with their newborn too. 

Pertinent Labs

n

Laboratory	11/17/2006 0950hrs	11/16/2006 0700hrs	Before / During Pregnancy MS Text
Hematology
WBC	H 20.2	H 11.9	4.5-10 /  5-15
HGB	L 10.8	12.7	10-14  /  12-16
HCT	L 32.5	37.0	37-47 %  /  32-42 %
RBC, MCV, MCH, MCHC, RDW, PLT, PLT Est., MPV                              WNL
Differential Type
Neuts %		H  83	*3-7
Lymphs %		L  12	38-46 %  /  15-40 %
Abs Neut Count		H    9.877	*1.5-8
Bands%, Monos%, Eos%, Basos%, Abs Eos Ct, Nucleated RBCs, RBC Morph                 WNL
Chemistry
Chloride	H 108		*96-106
Random Glucose	H 170		*60-110
BUN/Creatinine Ratio	L 10.0		*10:1-20:1
Calcium	L   7.7		*8.8-10.4
Sodium, Potassium, CO2, Anion Gap, BUN, Creatinine, GFR                        WNL
Blood Bank
Band Pt, Hold Tube in Blood Bank		Drawn @ 2311hrs

*Fischbach’s Lab & Diagnostic Book Values nfor Adult Norms

Lab Results: Neutrophilia nobserved during labor and early postpartum is caused by the physiologic nresponse to the stress of labor and delivery (London, Ladewig, Ball & nBindler, 2007). Lymphopenia can occur in SLE and long-term hydrocortisone ntherapy (Fischbach, 2004). Low hemoglobin and hematocrit (H&H) can reflect nthe condition of physiologic or relative anemia due to blood loss during ndelivery (London, et. al., 2007). High chloride levels can be caused by dehydratioand long term hydrocortisone therapy (Mann, D. and Chang, L., 2006). The npatient requested to discontinue her IV post delivery which probably ncontributed to a dehydrated state. Hyperglycemia can cause glucosuria which ncauses an increase in urine output (Fischbach, 2004) and can result from being npregnant (slight elevation) and long-term hydrocortisone therapy. SLE required na stress dose of 100 mg hydrocortisone IM before delivery per chart. The npatient’s dizziness may be also related to hyperglycemia (Fischbach, 2004). nDecreased BUN/creatinine ratio can be caused by the state of pregnancy and a nlow-protein diet (Fischbach, 2004). Low calcium levels can be caused by not nreceiving enough calcium in the diet (Fischbach, 2004).

 

25. Sara Lu is a 26-year-old nelementary school teacher who lives with her parents and two younger nsisters.Ms.Lu is very close to her parents and sisters; they share everything nwith each other.During the required physical for admission to graduate nschool,Ms.Lu tells her physician that lately she has felt fatigued. She also nstates that she has had a persistent sore throat, intermittent bouts of ndiarrhea, and mild shortness of breath for about a month.She takes no routine nmedications other than a daily multivitamin and an occasional acetaminophetablet for a headache. She is active in a drama club in her community, and she njogs 3 miles three to four times a week.She is engaged to be married;her wedding date is 6 months away. Her fiancé is the nonly person with whom she has had sexual relations.Her sexual activity has beeunprotected.Ms. Lu has a history of open heart surgery 7 years ago to correct a ncongenital valve defect. She has been physically healthy since that time, until nabout a month or two ago. The physician orders a mononucleosis test, nenzyme-linked immunosorbent assay (ELISA),Western blot nanalysis,CD4 T-cell count, a p24 antigen test, and an erythrocyte sedimentatiorate (ESR). She has been asked to return in 1 week for follow-up.

ASSESSMENT

On Ms. Lu’s nfollow-up visit,Carole Kee, RN, obtains her nursing nhistory.Ms. Lu continues to have flulike symptoms but has improved somewhat. nShe states that she just has not been as active as usual and is worried about nher health. Her appetite has decreased because of soreness in her mouth, and she nhas noted some whitish patches on her tongue and cheeks.

A chest X-ray nfilm reveals no abnormality.The results of her laboratory tests are as follows:

•ELISA:positive for antibodies against HIV

•Western blot nanalysis: positive for antibodies against HIV

•p24 antigetest: positive for circulating HIV antigens

•ESR:increased to 25 mm/h (normal for women is 15 to 20 mm/h; nnormal for men is 10 to 15 mm/h) mm/h; normal for men is 10 to 15 mm/h)

•CD4 T-cell ncount: 599/mm3 (normal range is 600 to 1200 mm3) Ms. Lu’s physical examinatioreveals that she has enlarged lymph nodes in her neck and white patches on her noral mucosa. Her skin is warm to the touch. Her vital signs are as follows: T n99.9°F (37.7°C), P 84, R 20, and BP 120/78.

Ms.Lu is told nof the results of her laboratory tests and the medical diagnosis of HIV ninfection.Ms. Lu is obviously distressed and wants to know how this happened, nits meaning,whether she has infected her loved ones, nand whether she will get better.

 

26. Harry Facée, age 53, narrives at a metropolitan public health clinic complaining of aching chest paithat has lasted for the past few days.He says that his sputum also is bloody.He nis afraid he might have lung cancer, so he came in to see a doctor.

ASSESSMENT

Raj Kamil,RN, the public health nurse at the clinic,obtains aadmission history and physical examination of Mr. Facée.Mr. Kamil notes nthat Mr. Facée is a homeless person who has lived on the streets and ivarious shelters for the past “10 years or so.” He usually prefers to sleep outdoors, taking refuge in shelters only during very cold or nvery wet weather.He has a small disability in come, but usually scrounges for nfood or eats with other homeless people at soup kitchens.Mr. Facée nstates that he has had a cough for a long time, which has become worse nrecently. It is now productive, especially in the mornings. He also admits that nhe has recently been waking up drenched with sweat in the middle of the night nand is more tired than usual. Although Mr. Facée’s clothes are tattered, nhe is fairly clean. He answers questions appropriately and intelligently.Mr. nKamil does not detect any odor of alcohol on his breath. He is very thin, nalmost emaciated.

 Mr. Facée’s vital signs are

BP 152/86,

P 92, R 20,

and T 100.2°F (37.8°C).

Suspecting ntuberculosis,Mr.Kamil obtains a sputum specimen for nGram stain and culture,administers a tuberculin test,and sends Mr. Facée nfor a chest X-ray before he sees the clinic physician.

Although the nchest X-ray is inconclusive, the Gram stain is positive for acid-fast bacilli. nThe diagnosis of probable active pulmonary tuberculosis is made. The physiciaprescribes isoniazid, 300 mg orally; rifampin, 600 mg orally; and pyrazinamide, n1500 mg orally daily for 2 months, to be followed by twice weekly isoniazid 900 nmg orally and rifampin 600 mg orally. The physician also orders weekly sputum ncultures for the first month.

 

27. Walter Cohen, 45 years nold, is the print shop manager at a local community college. He has been a type n1 diabetic since the age of 20, and was diagnosed with diabetic nephropathy 10 nyears ago.Despite blood pressure control with antihypertensive medications and nfrequent blood glucose monitoring with insulin coverage, nhe developed overt proteinuria 5 years ago and has now progressed to end-stage nrenal disease. He enters the nephrology unit for temporary hemodialysis to nrelieve uremic symptoms. While there, a CAPD catheter will be ninserted.Mr.Cohen’s desire to continue working is the primary factor in his nchoice of CAPD over hemodialysis.

ASSESSMENT

Richard nGonzalez,Mr.Cohen’s care manager, obtains a nursing nassessment.Mr.Cohen states that his diabetes has always been difficult to ncontrol.He has had numerous hypoglycemic episodes and has been hospitalized n“four or five times”for ketoacidosis.Recently he has developed symptoms of nperipheral neuropathy and increasing retinopathy. He attributed his lack of nappetite, nausea, vomiting, and fatigue over the past month to “a touch of the nflu.” His weight remained stable, so he did not worry about not eating much.

Physical nassessment findings include

T 97.8° F n(36.5° C) PO,

 P 96, R 20,

and BP 178/100.

Skin cool and dry, with minor excoriations on forearms nand lower legs. Breath odor nfetid.Scattered fine rales noted in bilateral lung bases. Soft S3 gallop noted nat cardiac apex. Bilateral pitting edema of lower extremities to just below the nknees; fingers and hands also edematous.Abdominal assessment essentially nnormal, with hypoactive bowel sounds.

Urinalysis nshows a specific gravity of 1.011,gross proteinuria, nand multiple cell casts.CBC results:RBC 2.9 mill/mm3;hemoglobin 9.4 g/dL; nhematocrit 28%. Blood chemistry abnormalities include BUN 198 mg/dL;creatinine 18.5 mg/dL; sodium 125 mEq/L;potassium 5.7 nmEq/L; calcium 7.1 mg/dL; phosphate 6.8 mg/dL. A termporary jugular venous ncatheter will be placed for hemodialysis the next day, followed by peritoneal ncatheter insertion later in the week.

 

28. Judy Devak is ndriving home late one evening when she loses control of her car trying to avoid nhitting a deer in the road.Her car strikes a tree and rolls into a deep ditch nbeside the road,out of sight of passing cars.The wreek nis not discovered until 2 hours later.On arrival at the accident scene, the nparamedics find Ms.Devak hypotensive:BP 90/60,P 120, and R 24. She is alert and nin severe pain, with a fractured right femur. After immobilizing Ms.Devak’s nneck and back and extricating her from the car, they apply a traction splint to nher leg and transport her to the local hospital.

ASSESSMENT

Katie Leaper, nRN, obtains a nursing history on Ms. Devak’s admission to the intensive care nunit. Ms. Devak indicates that she has been healthy, having experienced only nminor illnesses and chickenpox as a child.She has never been hospitalized,and knows of no allergies to medications. Ms. Devak is not ncurrently taking prescription or nonprescription drugs. Physical assessment nfindings include T 97.4° F (36.3° C) PO,P 100,R 18, nand BP 124/68. Skin pale, cool, and dry,with multiple nscrapes,minor abrasions, and bruises on face and extremities. A linear bruise nis noted on her chest and abdomen from the seat belt. Lung sounds clear, heart ntones normal, and abdomen tender but soft to palpation. Right leg alignment nmaintained with skeletal traction. One unit of whole blood was infused prior to nICU admission, a second unit is currently infusing. Aindwelling urinary catheter and a nasogastric tube are in place.

During the nfirst few hours after admission, Ms. Leaper notes that Ms.Devak’s hourly output nhas dropped from 55 mL to 45 mL to 28 mL of clear yellow urine. The physiciaorders a 500 mL intravenous fluid challenge, STAT urinalysis, BUN, and serum ncreatinine.The fluid challenge elicits only a slight increase in urine output. nUrinalysis results show a specific gravity of 1.010 and the presence of WBCs, nred and white cell casts, and tubular epithelial cells in the nsediment.Ms.Devak’s BUN is 28 mg/dL; her serum cretinine, 1.5 mg/dL. The nphysician diagnoses probable acute renal failure and orders a nephrology nconsultation. In addition, the physician orders aluminum hydroxide,10 mL every 2 hours per nasogastric tube, and ranitidine 50 nmg intravenously every 8 hours.

 

29. Jesus Rivera is a 34-year-old nmigrant farm worker who currently lives in temporary housing in a rural area of nthe southwestern United States.His family includes his wife,Marta,who is 3 nmonths’pregnant, and two children, ages 3 and 5. He takes his wife to a medical nclinic staffed by volunteer nurses, physicians, and students from a nearby nuniversity for a prenatal checkup.The clinic is open only on Saturday and nprovides care on a sliding fee scale or for free if the family is unable to npay.While Mrs. Rivera is being examined,Mr. Rivera nasks the nurse to have someone look at some very painful blisters on his chest nthat developed about a week ago.

He is afraid nthat exposure to pesticides has caused the sores.

ASSESSMENT

Mr.Rivera nspeaks Spanish and is able to communicate only slightly in English. The initial nassessment of Mr. Rivera is performed by Anita Mendez, a student nurse fluent nin Spanish. Mr. Rivera’s history reveals problems with lower back pain but no nsignificant past medical illnesses. He is not aware of any allergies and cannot nremember having had chickenpox as a child. Two years ago, both children were nsick and had blisters on their bodies, and a friend told them it was nchickenpox.Mrs. Rivera thinks she had chickenpox as a child.

Because Mr. nRivera has not had any medical care for several years,baseline nlaboratory tests are ordered to screen for any other illnesses; the complete nblood count (CBC), blood chemistry, and urinalysis are all withiormal nlimits. Mr. Rivera says that he did not feel well for several days before the nblisters appeared, having experienced chills and general achiness. He had not ntaken his temperature because the family does not own a thermometer. Current vital signs are as follows:

T 99°F n(37.2°C),

p 74,

R 22, and BP 148/88.

Physical nexamination of the trunk reveals a bandlike pattern of lesions across the left nthorax.Some of the lesions are vesicles filled with serous fluid; others are ndarker in color and are oozing a light yellow drainage. The skin around the nlesions is red and inflamed. Mr. Rivera complains of a severe, burning paiwith itching across his chest.He is diagnosed with herpes zoster.

 

30. Johti Singh is a 39-year-old secretary who nwas admitted to the hospital with an elevated temperature, fatigue, rapid, nlabored respirations; and mild dehydration. The nursing history reveals that nMs. Singh has had a “bad cold” for several weeks that just wouldn’t go away. nShe has been dieting for several months and skipping meals. Ms. Singh mentions nthat in addition to her fulltime job as a secretary she is attending college nclasses two evenings a week. She has smoked one package of cigarettes per day nsince she was 18 years old. Chest x-ray confirms pneumonia.

Physical Examination

Height: 167.6 cm (5′6′′) n

Weight: 54.4 kg (120 lb)

 Temperature: 39.4°C (103°F)

Pulse: 68 BPM

Respirations: 24/minute

Blood pressure: 118/70 mm Hg

Skin pale; cheeks flushed; nchills; use of accessory muscles; inspiratory crackles with diminished breath nsounds right base; expectorating thick, yellow sputum

Diagnostic Data Chest x-ray: nright lobar  ninfiltration

WBC: 14,000

pH: n7.49

PaCO2: 33 mm Hg

HCO3–: 20 nmEq/L

PaO2: 80 mm Hg O2 sat: 88%

31. Jim Valdez, a 19-year-old college sophomore, nis admitted to the hospital by ambulance following an automobile accident.His nfamily (father,mother, and sister) live 100 miles away nand cannot visit often,although they are very concerned.On admission to the nhospital, a CT scan of the spine shows a fracture and partial laceration of the ncord at the C7 level.Mr.Valdez is in halo traction.One night, he tells the nnurse, “I wish I had just died when I got hurt. I don’t think I can stand to nlive like this.”

ASSESSMENT

When Mr.Valdez is admitted to nthe intensive care unit,he has flaccid paralysis ninvolving all extremities. He has no sensation below the clavicle or iportions of his arms and legs. His bladder is dis tended and bowel sounds are absent.

Other assessment findings ninclude:

BP 90/56,

P 50,

T 97°F (36.1°C),

 arterial blood gases nPh 7.4,

PaO2 96, nPaCO2 37, SaO2 96%.

Oxygen per nasal cannula is ngiven at 2 L/min, and halo traction is applied. A Foley catheter is inserted ninto his bladder, and a nasogastric tube is inserted into his stomach and nattached to lowpressure continuous suction.

After 7 days,Mr.Valdez nis moved from the intensive care unit to the neurosurgical unit for continuing ncare and planning for transfer to a rehabilitation hospital in his home town. nHis vital signs have stabilized and are normal for his age; respirations and noxygenation are normal. Other neurologic assessments remain the same.

 

32. Merlyn Chapman, a 27-year-old sales clerk, nreports weakness, malaise, and flu-like symptoms for 3–4 days. Although nthirsty, she is unable to tolerate fluids because of nausea and vomiting, and nshe has liquid stools 2–4 times per day.

Physical Examination Height: n160 cm (5′3′′)

Weight: 66.2 kg (146 lb)

 Mild fever: 38.6°C (101.5°F)

Pulse: 86 BPM

Respirations: 24/minute Scant nurine output BP: 102/84 mm Hg Dry oral mucosa, furrowed tongue, cracked lips

Diagnostic Data

Urine specific gravity: 1.035

Serum sodium 155 mEq/L

Serum potassium 3.2 mEq/L

Chest x-ray negative

 

33. Eddie Kratz, age 22, works as a bellmaat a large hotel. For the past year,he has shared a nsmall apartment with Marla Jones,who is 5 months pregnant with his nchild.Although he intends to marry Ms. Jones before the baby is born, he has ncontinued a previous relationship with a womaamed Justine Simpson. His nsexual activities with Ms. Simpson have increased in frequency as Ms. Jones’s npregnancy has advanced. Recently Mr. Kratz has noticed a swelling in his groiand a sore on his penis.

ASSESSMENT

When Mr. Kratz comes to the ncommunity clinic, he is interviewed by the nurse practitioner, Sally Morovitz. nShe takes a thorough medical and sexual history, including questions about drug nuse, allergies, difficulty with urination, urinary frequency, itching or ndischarge from the penis, recent sexual activities, precautions taken against ninfection, history of STIs, and sexual function. She determines that Mr. Kratz nhas been having unprotected sex with both Ms. Jones and Ms. Simpson. He nbelieves that Ms. Jones is not having sex with anyone except him, but he is not nsure. Physical assessment reveals a classic syphilitic chancre on the shaft of nthe penis and regional lymphadenopathy. A specimen of exudate from the chancre nis sent for dark field examination. Ms. Morovitz discusses with Mr. Kratz the nlikelihood that he has syphilis and the need to tell both Ms. Jones and Ms. nSimpson so that they can be tested and, if necessary, treated. Ms. Morovitz nalso suggests that Mr. Kratz be tested for HIV since he has been having nunprotected sex with two women, at least one of whom may be sexually active nwith other partners. He agrees, and blood is drawn for an ELISA test. Darkfield nanalysis of the chancre exudate confirms the diagnosis of syphilis; the ELISA nresults are negative for HIV.

 

34. Robert Cerulli is a 72-year-old retired ncommercial fisherman who has experienced arthritic pain in his hips for the npast 10 to 15 years.Over the past year, the pain in his right hip has become nsevere, prompting him to seek medical attention. Significant degenerative nchanges in both hip joints are noted on X-ray films. The physician recommends a ntotal replacement of the right hip, and total replacement of the left hip to nfollow in 6 to 12 months.Mr. Cerulli has preoperative teaching and tests the nafternoon prior to his surgery, scheduled for 0800 the following morning.

ASSESSMENT

Christie Phlaugh, RN, ncompletes a nursing history and examination of Mr.Cerulli on admission. nReviewing his medical record, she notes that Mr. Cerulli has mild Parkinson’s ndisease and is taking carbidopa/levodopa (Sinemet 25-100) four times a day to ncontrol his symptoms. No other chronic medical conditions have been reported.Mr.Cerulli nsays he has been essentially healthy his entire life.He has no known allergies nto medications, has never smoked, and consumes only small amounts of alcohol.

On examination of Mr.Cerulli,Ms.Phlaugh notes that he is alert and oriented. His vital nsigns are BP 116/64, P 68 regular, R 18, T 97.4°F (36.3°C) PO. Peripheral npulses are strong and equal in the upper extremities, and slightly weaker but nequal in the lower extremities. His feet are cool to touch but have immediate ncapillary refill.He has full ROM of his shoulders,elbows,and nwrists.The ROM of both hips is significantly restricted. Hip flexion beyond 90 ndegrees prompts pain on both sides. Both flexion and extension of the knees are nlimited slightly.Mr.Cerulli walks with a limp, favoring his right hip, and has na shuffling gait. Preoperative laboratory studies including CBC, coagulatiostudies,chemistry panel,and urinalysis show a serum ncreatinine of 1.7 mg/dL and BUN of 30 mg/dL, with no other abnormal values nnoted. His ECG and chest X-ray show no apparent pathologies. Cefazolin (Ancef ) 500 mg is to be administered intravenously at 0600 nprior to surgery, and Mr. Cerulli is to shower and shampoo with antibacterial nsoap at bedtime. The physical therapist meets with Mr. Cerulli to evaluate his nmobility and begin teaching him about postoperative weight-bearing nrestrictions.

 

35. Catherine Cole is a 37-year-old secretary nwho lives with her husband, Ray,and teenage ndaughter,Amy, in an apartment in a large metropolitan area. About 2 months ago,Mrs. Cole began to tire easily and experience night sweats nseveral times a week. She also noted that she was pale, bruised easily, and was nhaving heavier menstrual periods. Blood tests ordered by her primary care nprovider are abnormal. She is admitted for a bone marrow biopsy.

ASSESSMENT

Mary Losapio, RN, obtains a nnursing history and physical assessment for Mrs. Cole. Mrs. Cole tells her, n“I’m so tired, and I have these bruises all over me. I’m so afraid of the nresults of the bone marrow examination. I don’t know what we will do if I have ncancer.”Mrs. Cole clutches her husband’s hand and then begins to cry.

Physical assessment data include:

Height 64 inches (156 cm),

weight n106 lb (48.1 kg);

vital nsigns

 T 100°F,

 P 102,

 R 22,

BP 130/82.

Numerous petechiae scattered nover trunk and arms;ecchymoses noted on lower right narm and right calf. Oral mucosa is red, with several small ulcerations ibuccal areas.

Blood count shows reduced RBCs,hemoglobin,and hematocrit levels. The WBC is high,with myeloblasts seen on differential. The platelet count nis very low.A tentative diagnosis of acute myelogenous leukemia is made.

 

36. Betty Williams, a 62-year-old psychologist, nis admitted to the emergency department with complaints of severe substernal nchest pain. Mrs. Williams states that the pain began after lunch,about 4 hours ago.She initially attributed the pain to nindigestion. She described the pain, which now radiates to her jaw and left narm, as “really severe heartburn.” It is accompanied by a “choking feeling,” nsevere shortness of breath, and diaphoresis.The pain is unrelieved by rest, nantacids,or three sublingual nitroglycerin tablets n(0.4 mg). Oxygen is started per nasal cannula at 5 L/min.Central and peripheral nintravenous lines are inserted. A 12-lead ECG and the following labwork are nobtained: cardiac troponins, CK and CK isoenzymes, ABGs, CBC, and a chemistry npanel. Morphine sulfate relieves Mrs.Williams’s pain. Mrs. Williams’s medical nhistory includes type 2 diabetes, angina, and hypertension. She has a 45-year nhistory of cigarette smoking, averaging 1.5 to 2 packs per day. Family history nreveals that Mrs.Williams’s father died at age 42 of AMI, and her paternal ngrandfather died at age 65 of AMI.Mrs.Williams is taking the following nmedications: tolbutamide (Orinase), hydrochlorothiazide, and isosorbide n(Isordil).

Based on ECG changes and ncardiac markers, an acute anterior MI is diagnosed.Mrs.Williams has no ncontraindications to thrombolytic therapy and is deemed a good candidate. nIntravenous alteplase (t-PA, Activase) is given by bolus followed by nintravenous infusions of alteplase and heparin. She is transferred to the ncoronary care unit (CCU).

 

 

 

 

 

ASSESSMENT

(supportive data)

FACTUAL nDATA

Supports your problem.  This information has to be current, nor perhaps past history and NOT “make believe”.  nThink of it as supportive data that proves you have an actual or npotential problem.  It must have at least n2 pieces of information to support problem.

Ask nyourself, “Why do I think this is a problem?”

Think about your pt’s:

1. Medical Diagnoses

    S & S from Dx that your pt is nhaving right now

    If no S&S right now, njust list the Dx as support

2. Medication List      Side effects?

3. Abnormal Lab?

NURSING DIAGNOSIS

(patient’s need)

 

PROBLEM nSTATEMENT

This is the name you ngive the problem.  Ask yourself, “What nis the problem?”  You can use the nNANDA list of problem statements OR if none apply, make a problem statement nusing one of the words:

Alteration          Impaired

Deficit              nIneffective

Dysfunction      Intolerance

Excess

 

Refrain from nusing:

Decreased Cardiac Output*

Disuse Syndrome

Impaired Gas Exchange*

Impaired Physical Mobility

Decreased Mobility (of any kind)

Risk for Infection**

Risk of Ineffective Management of Therapeutic Regimen*

  *These problems must have specific data, nmeasurements, lab tests, etc. in order to use these problems.

 **There may be some very specific cases where nit may be applicable.  Think, what can a“infection” can cause?  Use that as a nproblem instead.

 

Goal:  What do you plan to accomplish?  Must be pt -centered, AND specific, nmeasurable, attainable,  realistic, & time-sequenced.

PLANNING

(nursing care needed)

NURSING PLAN nFOR PROBLEM

Ask yourself, n“What can I do for the problem?”

These are not to be nnumbered.

Think about the following:

Observations nyou make related to this problem, (include assess-ment of the pt re: to the nbody system re: this problem, diag-nostic tests, and reporting of findings to ncharge nurse.  (Use your senses).

Tasks nyou can do (things you can do to prevent, repair, or reduce nthe problem).  This includes medicatioadm., oxygen, dressing changes, turning, enema, catheter insertion, nutrition, nfluids, etc.

Teaching nof patient & family (includes not only what the doctor orders but what you nas the “nurse” will teach the patient.  nAlso should include how you will determine the patient’s nunderstanding of the teaching.)

Be very SPECIFIC nand very THOROUGH.  Include ndetails like how much, frequency (how often), etc.

    DATE REVISIONS OR ADDITIONS EVERY DAY!

 

IMPLEMENTATION

(documentation of care)

DOCUMENTATION

Ask, “What nwill I document?”

Any information that pertains to the problem.

This is your actual narrative ncharting notes just like on your Assessment Sheet in Level 1 or charted nobservations in the nurses notes in the chart.  NOTE:  nThis is NOT a restatement of your plan in the past tense!  Also it DOES NOT have to address each part of nthe plan.  DO NOT number this section or nleave spaces.  Also any conclusions, or judgments that are improper icharting are not proper here. 

Students nhave best results in learning how to word this section when they do not evelook at the planning section.

 

Document: Date/Time

 

1. Observations nyou made

2. Reporting observations and changes in conditioto appropriate personnel

3. Care ngiven to the patient

4. Response nof the pt to the care

5. Results of your actions, diagnostic tests, nmedications administered, etc.

6.  Teaching nspecific to patient meds, needs, problems, preventative care.

DATE nENTRY EVERY DAY!

 

EVALUATION

(status of goal)

STATUS OF THE nGOAL

Ask yourself, n“Did I accomplish my goal?”

1.  Look at your goal & ask nyourself a question related to it  – whether your Goal was met ncompletely, met partially, or not met at all.  Write this down.

2.  Answer the question in a Summarized nEvaluation Statement and relate it to the Measurable Part of nthe Goal.  Write this down.

3.  Does the nproblem or potential for the problem still exist?  Write this down. 

4.  Then, state nif you will Continue with your plan -either as nstated or as revised or Discontinue Plan.

Write this down.

NOTE:  You must have something to back up this nevaluation in your documentation in the Implementation column (Implementatiosupports or proves your evaluation statement).

Examaple:

Goal nwas partially met.  The patient washed nhis face but did not brush his teeth himself.   nThe problem still exists.  nContinue with the plan as revised.  n