nurs 201-3 medical/surgical nursing practice...
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Running head: NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 1
NURS 201-3 Medical/Surgical Nursing Practice Theory: Case Study and Care Plan
Trina Skinner
Stenberg College
NURS 201-3
K. Bagshaw April 28th, 2013
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 2
NURS 201-3 Medical/Surgical Nursing Practice Theory: Case Study and Care Plan
IDENTIFYING DATA AND GENERAL DESCRIPTION
Name: A.K.D. Sex: F Race: Caucasian Culture: Canadian
Relationship Status: Married
Appearance and referral source:
Admitted from home (resides with husband). Prior to admission for CVA able to perform ADL’s
independently, able to mobilize independently (walk/transfer). Slightly underweight/
malnourished, well-adjusted, as per patient chart records. *
CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS
Reason for admission:
L side Cerebral Vascular Accident (CVA/stroke), occult hip fracture (ruled out)
Significant signs & symptoms:
Loss of sensation entire R side of body, patient verbalized she was experiencing moderate pain
in leg affected by stroke (Right leg). Unable to mobilize leg on stroke affected side, maintained
use of R arm (minimal strength upon assessment), lack of coordination, patient reports difficulty
swallowing, states she must “eat slowly” (AK.D., 2013)..
Stresses & precipitating factors:
Cardiovascular health compromised; History of Hypertension, Atrial Fibrillation, TIA’s.
History of medication compliance & treatment program:
Willingly took all prescribed medications, A.K.D. explained that during the week she would
mobilize under supervision/care of physiotherapist.
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 3
Patient was optimistic regarding discharge plan, although reluctant to mobilize with nursing staff
(or myself); A.K.D. felt comfortable mobilizing exclusively with physiotherapist. I was able to
convince patient to transfer from bed to Broda chair @ meal times.
Medications:
Medication Dose Route Time
*Metoprolol (Lopressor/Betaloc)
50 mg Lopressor25 mg. Betaloc
PO- BID 09001700
Levothyroxine (Synthoid)
50 mcg/0.05 mg PO 0900
Atrovastatin (Lipitor)
40 mg PO 0900
Felodipine ER (Plendil)
10 mg PO 0900
Tramacet 325 mg Acetaminophen/ 37.5 Tramadol
PO- TID 090017002100
Citalopram 10 mg PO 0900
Baclofen 100mg PO 1700
Ferrous fumerate (Palafer)
300 mg PO 2100
*Warfarin (Coumadin)
Pharmacist Managed1 Dose QD
PO 1600
Pantoprazole Magnesium (Tecta)
40 mg PO- BID unit stock 09002100
Risodronate (Actonel)
35 mg PO QThurs
Ergocalciferol (Ostoforte)
50 000 Int. Unit PO QThurs
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 4
PAST MEDICAL HISTORY
A.K.D. has a fairly extensive medical history, affecting all body systems. Past and current
medical conditions include: Atrial fibrillation, Transient Ischemic Attack’s (TIA’s),
Hypothyroidism, Glaucoma, Heart Disease- Class I Corotid artery disease, Osteoporosis,
Hypertension, Cerebral Vascular Accident- CVA (Right side)
SURGICAL HISTORY
A.K.D.’s surgical history includes a bowel resection, partial hysterectomy CABG (Coronary
Artery Bypass Graft surgery).
ALLERGIES
A.K.D. has been identified as having allergic reactions to both Codeine, and Sulpha drugs;
specific reaction (not available)
. DISEASE PROCESS
TEXTBOOK DESCRIPTION OF DISEASE PROCESS
CLIENTS PRESENTATION OF DISEASE PROCESS
Diagnosis: Cerebral Vascular Accident (CVA)
Physician confirmed CVA had occurred Right side
of brain (left side of body affected) post CT scan
Etiology/Pathophysiology: CVA, or stroke
(apoplexy) “is the sudden onset of weakness,
numbness, paralysis, slurred speech, aphasia,
problems with vision and other manifestations
of a sudden interruption of blood flow to a
particular area of the brain. The ischemic area
A.K.D. was admitted following a fall at her home
on the premise of a possible occult hip fracture and
CVA. Following an X-ray, the possible hip
fracture was ruled out. A CT scan revealed
evidence that a stroke had occurred
“Computerized tomography (CT) scan.
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 5
involved determines the type of focal deficit
that is seen in the patient” (ISC, 2012).
Brain imaging plays a key role in determining if
you're having a stroke and what type of stroke you
may be experiencing. A CT scan uses a series of X-
rays to create a detailed image of your brain. A CT
scan can show a brain hemorrhage, tumors, strokes
and other conditions” (MayoClinic, 2012).
Clinical Signs and Symptoms:
Trouble with walking. You may
stumble or experience sudden dizziness,
loss of balance or loss of coordination.
Trouble with speaking and
understanding. You may experience
confusion. You may slur your words or
have difficulty understanding speech.
Paralysis or numbness of the face,
arm or leg. You may develop sudden
numbness, weakness or paralysis in
your face, arm or leg, especially on one
side of your body. Try to raise both your
arms over your head at the same time. If
one arm begins to fall, you may be
having a stroke. Similarly, one side of
your mouth may droop when you try to
The patient exhibited signs and symptoms such
that included numbness and tingling on left side of
body. It was yet to be determined if permanent
hemi paralysis would ensue. The upper left
quadrant of A.K.D.’s body (including arm and
face) were unaffected by visual assessment. The
patient stated that she could not mobilize her leg
and was experiencing loss of sensation as well as
occasional sharp pains, particularly on
movement/when repositioned. This patient was
experiencing dysphagia (difficulty swallowing),
which she was aware of and explained to me that
she would require my assistance with feeding,
although she had use of both upper extremities,
A.K.D. explained that she was experiencing
systemic weakness. I assisted with feeding, and did
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 6
smile.
Trouble with seeing in one or both
eyes. You may suddenly have blurred or
blackened vision in one or both eyes, or
you may see double.
Headache. A sudden, severe headache,
which may be accompanied by
vomiting, dizziness or altered
consciousness, may indicate you're
having a stroke.
so at a very slow pace, as this patient was at high
risk for choking/aspiration. Patient was able to
squeeze my hands with minimal strength and lift
her arms slightly for only a few seconds. Patient
denied any visual disturbance/effect and
complained frequently of headaches and dizziness
(Mayoclinic, 2010)
LAB RESULTS
The following is a panel of laboratory results that outlines abnormal values in comparison to
levels that are of ‘normal range’. All lab tests were performed by laboratory technicians on site
@ Nanaimo Regional General Hospital. The following information is extracted from VIHA’s
online charting system, on operating system Cerner (VIHA Intranet).
*International Normalized Ratio
Lab Test Patient’s Value Normal Range
Neutrophils 6.59-High 2.00-6.00
Lymphocytes 0.87-Low 120-150
Monocytes 0.81-Low 0.35-0.45
*INR 5.8-High 0.9-1.1
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 7
Chloride 96 -Low 96-106
Sodium 132-Low 135-145
Urea Level 11.5-High 3.0-7.5NURSING PHYSICAL ASSESSMENT
Upon introducing myself to A.K.D., I assessed her level of orientation, she is oriented x 3 (to
person, place, and time). Upon visual assessment I noted that this patient was extremely thin with
a distinct lack of muscle tone. Her pallor was pale, her affect was congruent with her mood and
she was very pleasant to interact with. I noted her pupils were equal in diameter and reactive and
her lips were dry and chapped, which indicated that she may be dehydrated. I then assessed
A.K.D’s vitals, the first set I recorded @ 0800 hrs are as follows: BP 149/87, HR 81, Oxygen
sats. 98%, Temp. 37.0.
Upon auscultation of heart and lungs, I noted a distinct irregular heart beat. Her lungs were clear,
no adventitious sounds in all lobes. A.K.D. presented as somewhat nervous in regards to certain
aspects of her care. For instance she was concerned that Tecta be administered 30 minutes ac
breakfast to reduce symptoms of GERD. Capillary refill was good, skin was think and fragile.
Bowel sounds present in all four quadrants and A.K.D.’s abdomen was soft upon palpitation. IV
site was absent of redness, swelling, & pain. Patient stated that on a pain scale of 1-10 (1 being
no pain, and 10 being the worst pain she had experienced in her life) A.K.D. stated her pain level
was a 4. The pain she described was sharp and intermittent occurring on her entire left side. She
explained that she was thirsty and her mouth was dry, but she had difficulty swallowing and
required my assistance. Skin was dry and intact, my only concern was a reddened area on her
right heel which she said was painful when pressure applied to the area. A.K.D. also presented
with slight pedal edema bilaterally. A.K.D. was able to grip my hands with hers with a moderate
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 8
level of strength. While assessing this patient’s ROM (range of motion) it was clear that
attempting to mobilize the patient (without use of the overhead lift) would not be safe as she was
unable to raise her legs or resist the pressure of my hands against her feet. Pedal pulse was
palpable bilateral. This patient was underweight and undernourished as per clinical
manifestations noted throughout assessment phase. Patient was clean, comfortable, dry, & safe
when released from my care. well done
TREATMENT PLAN
The current treatment plan on the unit is to promote comfort, and pain management for this
patient. One goal is to decrease incidence of heartburn/nausea in order to increase adequate
nutrition, promote client ability to feed herself. The main focus/goal in this case is to have
A.K.D. mobilize and restore patient to equal or greater level of functioning prior to admission to
hospital. Patient is transferred from bed to chair pc breakfast- pc lunch. Encourage patient to
mobilize and perform ROM’s as much as possible, promote increased input to increase strength
to the point A.K.D. can return home safely. Medication education is necessary, as this patient is
on a number of medications, several *high alert cardiac meds that require compliance and
comprehension of what these medications are for. AAT (Activities as tolerated), presently
movement of muscles and joints and encouragement to gradually restore ability to perform own
personal care as much as possible. A.K.D. must be educated on the importance of mobilization
as the primary factor in her recovery. A.K.D. will also receive education upon discharge in terms
of outpatient treatment to obtain highest quality level of health and wellness. Patient will
continue to receive treatment from resident physiotherapist. Patient’s emotional state is pleasant
and she maintains an optimistic attitude regarding her current state of health and continued
recovery. The client is interested in which medications she is prescribed and the function of each
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 9
prior to administration. In terms of receptiveness with plan of care, patient is reluctant in terms of
proceeding forward with efforts to mobilize, she voices some concern about the rate at which she
is being encouraged to mobilize.
Patient also expresses some fear of further injury if she attempts to mobilize; patient’s concerns
are validated and patient education regarding the necessity of obtaining adequate nutrition and
mobilizing daily in order to be discharged was implemented.
TEACHING AND DISCHARGE PLAN
In regards to necessary patient teaching upon discharge, A.K.D. must have her medication
regime explained in a way that we are able to verify understanding. Perhaps meds can be
prepared in blister packs labeled and if the patient finds the medication regime overwhelming;
A.K.D. must also be encouraged to seek clarification and address any concerns she may have
prior to or regarding discharge. The plan is for A.K.D. to be discharged and return home with the
assistance of her husband following the ability to mobilize safely and achieve a safe level of
intake food & fluids. The patient will be discharged as per physician’s order. Whatever follow up
treatment and medication will be presented and explained with assurance that patient or next of
kin understand in order to enhance the likelihood of compliance. Outpatient treatment and
community resources will be provided upon discharge, and follow-up with GP or specialists as
per physician’s orders.
STUDENT REFLECTION UPON WRITING CASE STUDY
Over the course of the few days I worked with A.K.D. I enjoyed the interaction I shared with her.
She was consistently pleasant and maintained a very positive attitude. Upon further studying of
her past medical history, I became very humbled and touched by her sunny disposition in spite of
all the major health concerns she is faced with. Her smile is radiant, and the time that we spent
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 10
communicating throughout provision of care and whenever I had a few free minutes, I felt very
grateful for my health and all the loving support and opportunity I have in my life. Working with
A.K.D. helped remind me how crucial it is to live in the present.
I noticed I had quite an emotional response to caring for this client, as it was reminiscent of my
former work as an HCA and the patients I had developed therapeutic relationships with. After
working with more patients who have been affected by CVA than I can recall, I felt a familiar
anxiety and slight fear arise in me, as after caring for a large population of older adults who have
suffered strokes, I developed a fear of one day suffering a stroke myself. I am extremely
empathetic for patients who experience TIA’s or strokes as the thought of losing my ability to
communicate and persistent numbness/tingling, let alone full on hemi paralysis. I certainly feel
grateful that I made drastic lifestyle changes prior to the start of the RDPN program, giving up
smoking, drinking alcohol, healthy/clean eating, and regular exercise and meditation/yoga
practice. I would like to work to reduce the risks of developing cardiovascular problems as much
as possible. Following this experience, I am more committed to maintain my current, as well as
broaden my healthy lifestyle choices in the future. excellent reflection.
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 11
References
Jaap H. Buurke, Anand V. Nene, Gert Kwakkel, Victorien Erren-Wolters, Maarten J. IJzerman
& Hermie J. Hermens (2008) Recovery of Gait After Stroke: What Changes?
Neurorehabil Neural Repair. 22: 676 DOI: 10.1177/1545968308317972
Kim, T. Y., Lang, N. M., Berg, K., Weaver, C., Murphy, J., & Ela, S. (2007). Clinician adoption
patterns and patient outcome results in use of evidence-based nursing plans of care. AMIA
2007 Symposium Proceedings, 423-427.
Lewis, S.L., Heitkemper, M.M.Dirksen, S.R., Bucher, L., and O’Brien, P.G. (2010). Medical-
Surgical Nursing in Canada (Canadian 2nd Ed.). Toronto, ON: Elsevier Canada
Mayoclinic.com (2012). Stroke symptoms. Retrieved from
http://www.mayoclinic.com/health/stroke/DS00150/DSECTION=symptoms
Tourangeau, A. E., Doran, D. M., McGillis Hall, L., O’Brien Pallas, L., Pringle, D., Cranley, L.
A., & Tu, J. V. (2006). Impact of hospital nursing care on 30-day mortality for acute
medical patients. Journal of Advanced Nursing,57(1), 32-44.doi.org/10.1111/j.1365-
2648.2006.04084.x
Williams, L. (2007). The fluid and electrolyte balancing act. Nursing Homes: Long Term Care
Management, 56(12), 31-33. Retrieved from
http://web.ebscohost.com.proxy.lib.sfu.ca/ehost/detail?vid=3&sid=6163230c-aa8a-44c5-
bc5ea1cc6e749523%40sessionmgr4&hid=24&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d
%3d#db=hxh&AN=33020811
Appendix
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 12
Nursing Diagnosis
Desired Outcomes
Interventions (I)-Independent(C) - Collaborative
Rationale & APA Reference
Evaluation of Interventions
NDX: (Problem)
Impaired skin integrity
R/T: (etiology/factor):
Related to inability to mobilize or reposition self
AEB: (s/sx; defining characteristics)
1. Inability to turn from back onto either side without assistance
2. Reddened area on left heel as a result of pressure (bed rest)
3. Inability to mobilize transfer from bed
*If ‘risk for’ would exhibit:Decubitus ulcers, reddened/ open/blistered areas of skin over bony prominences, maceration of skin
NDX: Problem
Goal (Reversal of Problem)
Patient’s skin integrity is no longer compromised by when *
Client will (list measurable outcomes; reverse signs and symptoms)
1. No presence of redness over bony prominences
2. No evidence of maceration of skin prone to moisture (perineal area)
3. Increased mobility to improve circulation/systemic blood flow maintaining skin integrity by means of adequate tissue perfusion (integumentary system is nourished)
Evaluation of Outcomes (address each outcome)
1. Patient’s skin is intact
2.Healthy pallor
3. No evidence of signs related to skin breakdown
N-1 Assess skin daily for signs of irritation so that early treatment can provided (C)
N-1 Wash and dry skin thoroughly, paying special attention to areas @ higher risk for breakdown (i.e. groins/abdominal skin folds) where bacteria can accumulate(C)
N-2 Promote independence in terms of encouraging patient to wash and dry herself thoroughly as per instruction (I)
N-3 Implement patient education regarding significance of properly drying and moisturizing skin (C)
N-4 Encourage patient to perform ROM exercise/AAT in order to retain ability to reposition/mobilize self (I)
N6- Turn Q2h as preventative measure (decubitus ulcers)
N7- protect bony prominences with pillows/padding & elevate heels off the bed (no direct pressure applied)
Educate patient on risks associated with skin breakdown in order to increase likelihood patient will participate in own care RE: maintenance of skin integrity
Explain process of development of decubitus ulcers
Encourage patient to regain independence or perform as much personal care as possible; to increase likelihood of patient continuing to care for skin upon discharge; ability to perform own personal care will expedite scheduled discharge
Reposition patient frequently (Q2h) to avoid extended periods of pressure on any area of the body- which decreases circulation of vital nutrients to support/maintain healthy skin
Pillows or other protective aids will promote prevention of skin breakdown
ROM’s will help to promote healthy circulation to ensure skin is nourished
(Tourangeau, 2006)
Patient is washing and drying herself safely & effectively
Patient makes effort to reposition herself as per her ability; or requests assistance from nurse to reposition if in same side-lying or supine position for extended period of time
Patient understands the relationship between mobility and impaired skin integrity & therefore makes effort to mobilize as much as possible in order to avoid constant pressure on skin and to promote circulation
Patient summarizes knowledge obtained regarding the necessity of proper skin care in order to allow nurse to check for understanding
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 13
Nursing Diagnosis
Desired Outcomes
Interventions (I)-Independent(C) - Collaborative
Rationale & APA Reference
Evaluation of Interventions
Deficient fluid volume, risk for
R/T: (etiology/factor):
Related to Insufficient fluid intake, compromised cardiac health
AEB: (s/sx; defining characteristics)
1. Abnormal levels of sodium, chloride as evidenced in lab values
2. Presence of pedal edema, bilateral
3. Decreased intake/output related to difficulty swallowing
*If ‘risk for’ would exhibit:
Poor skin turgor
Electrolyte imbalances
Poor muscle tone
NDX: Problem
Goal (Reversal of Problem)
Patient will achieve sufficient fluid volume by discharge
Client will (list measurable outcomes; reverse signs and symptoms)
1. Lab values RE: electrolyte balance will return to within normal range
2. Exhibit no edema
3. Establish consistent intake/output fluid volume
Evaluation of Outcomes (address each outcome)
1. Resolution of dysphagia
2. Increased muscle tone
3. Patient records indicate adequate intake/output
N-1 Request swallowing assessment to be performed by OT (C)
N-2 If patient is unable to swallow to obtain adequate fluid/electrolyte balance; IV fluids will be ordered (physician) and administered by nursing staff (C)
N-3 Monitor intake/output as accurately as possible each shift
N-4 Elevate feet (above heart)
N-5 Patient on cardiac diet
N-6 Assess vitals QID, with special attention to HR, BP
N1- Establish schedule
R1- If patient is unable to swallow, initiative must be taken to ensure sufficient fluid volume
R2- If patient is unable to obtain fluid PO, hydration via IV may be necessary
R3- An accurate account of patient’s fluid volume intake and output will demonstrate evidence of adequate hydration/fluid-electrolyte balances
R4- Elevating feet/lower legs above heart level will function to prevent/reduce edema
R5- As the patient has significant cardiac issues, a diet that takes these comorbid disorders into account will function to increase likelihood of maintaining adequate nutrition/fluid balance
(Williams, 2007)
(Lewis, et al., 2010)
E1- Patient’s ability to swallow is regained or alternate means of nutrition is undertaken (IV, nasogastric tube, parenteral feeding) if necessary
E2- Patient will monitor fluid intake/output; notify healthcare provider if inadequate amounts/patient will identify signs of fluid deficiency as per nursing education/teaching
E-3 Patient will continue to elevate feet/lower legs at rest. Consider need for TED stockings with physician
E-4 Patient will adhere to ‘heart healthy’ diet and follow guidelines of patient teaching prior to discharge RE: nutrition
E1- Patient is able to
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 14
Nursing Diagnosis
Desired Outcomes
Interventions (I)-Independent(C) - Collaborative
Rationale & APA Reference
Evaluation of Interventions
Mobility, impaired physical
R/T: (etiology/factor):
Related to
Immobility as result of CVA
AEB: (s/sx; defining characteristics)
1. Patient is incapable of reposition/transferindependently
2. Patient’s lack of confidence/initiative to attempt to mobilize
3. Pain and discomfort verbalized upon reposition/transfer
Goal (Reversal of Problem)
Patient is rehabilitated and able to mobilize independently (mobility aides prn, i.e. walker) following discharge
Client will (list measurable outcomes; reverse signs and symptoms)
1. Patient will continue to work with PT upon discharge RE: mobility
2. Patient will perform ROM’s & AAT upon discharge
3. Patient will be made aware of and establish contact with community resources RE: heart & stroke
Evaluation of Outcomes (address each outcome)
1. Patient practices healthy lifestyle habits in relation to her co-morbid diagnoses
2. Patient maintains appropriate diet in relation to health status upon discharge
with PT to assist patient with rehabilitation (C)
N2- Encourage patient to mobilize as tolerable to restore patient to highest level of health possible (C)
N3- Teach client significance of ROM’s/ perform ROM’s daily (C)
N4- Address and validate patient’s concerns/anxiety RE: rehabilitation, regaining mobility (C)
N5- Promote independence as every opportunity, encourage patient to do as much for herself as possible in preparation for discharge
N6- Administer all patient medications as per physician’s orders
R1- Patient feels comfortable working with PT, PT specialize in rehabilitation of physical health impairment
R2- Promote restoration of mobility to highest level possible (post-CVA)
R3- ROM’s are extremely important in maintaining health in the elderly and bed ridden patient, in order to promote/maintain mobility & circulation. All body systems require movement/exercise of some sort to function adequately
R4- Patient must regain ability to provide care for herself or arrange provision of care upon discharge from hospital
R(5)- Patient’s compliance with medication regime and established enables proper management of co-morbid conditions
(Jaap, 2008)
(Lewis, et al., 2010)
mobilize independently upon discharge
E2- Mobility aides are provided and implemented with proper patient teaching if necessary
E3- Patient performs ROM’s daily and understands significance of doing such
E4- Patient maintains healthy diet that takes cardiac issues into consideration
E5- Patient is educated on signs/symptoms of CVA and is informed on when to contact health care provider
E6- Patient refrains from any risk factors associated with CVA and cardiovascular system
E7- Patient is made aware of and establishes/maintains communication with community resources i.e. heart and stroke foundation
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 15
Nursing Diagnosis
Desired Outcomes
Interventions (I)-Independent(C) - Collaborative
Rationale & APA Reference
Evaluation of Interventions
PSY 201-3 Med/Surg TheoryCase Study and Care Plan (20%)
Mark Assigned
Mark Earned
Comments
APA Format (5%) 1 1
Structure and Scholarly Presentation (15%)Well structured paper, logically & coherently developed content
1 1
Reference list reflecting depth and breadth of reading
1 1
Spelling, punctuation and grammar 1 1
Content and Care Plans (80%)Accuracy and depth of head to toe assessment, treatment and teaching plan and other pertinent information
6 6
Demonstrated critical thinking & reflection both throughout paper and in student reflection section
2 2
Sound rationale for ideas and conclusions
2 2
Thoughts & opinions substantiated with relevant & current sources
1 2
Care plans concise, patient focused with clear diagnoses, interventions, rationales and evaluation
5 4.5 See comments.
Total 20 19.5 Well done.
NURS 201-3 MED/SURG: CASE STUDY & CARE PLAN 16