Question

Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
William “Butch” Welka is a 72-year-old male with a history of heart failure, COPD, hypertension, diabetes type II and dementia who has been hospitalized for exacerbation of heart failure three times the past six months. He is now a resident of Pineville Estates, a local long-term care facility the past four months because his dementia progressed and his wife Rita was unable to care for him. When Rita visited Butch this morning, she reports to the nurse that he is more confused and is concerned because Butch is easily angered. Butch insists that he sees his friend Roger, who served with him in the Navy, is in the room, but he died ten years ago. Rita approaches the nursing station with tears in her eyes and states,
“What is happening to my husband? This just isn’t like Butch to act like this! Please do something to help him!”

Personal/Social History:
Butch has been married to Rita for 51 years. They have three adult children who visit him weekly. Rita comes to visit Butch every day after work. Butch was a salesman for 35 years before he retired seven years ago. Butch believes he is at Pineville Estates for rehab, but his family is concerned that it is no longer safe at home if he were alone. Rita was just awarded guardianship due to his declining mental status.

Patient Care Begins:

Current VS:   P-Q-R-S-T Pain Assessment:
T: 99.8 F/37.7 C (oral)   Provoking/Palliative:   “Standing and moving.”
P: 60 (regular)   Quality:   “Dull”
R: 16 (regular)   Region/Radiation:   “Lower back”
BP: 115/72   Severity:   “4/10”
O2 sat: 96% room air   Timing:   “It is always there.”
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data:   Clinical Significance:
  

Mental Status Examination (MSE):
APPEARANCE:   Dressed in t-shirt and pants. His pants are urine soaked. Wearing a sweater even though it is
summer.
MOTOR BEHAVIOR:   Ambulates with a walker, shuffling gait
SPEECH:   Clear
MOOD/AFFECT:   Pleasant, except when talking about being at Pineville Estates, becomes agitated Anxiety increases, and angry affect displayed; emotionally labile – can become easily
angered
THOUGHT PROCESS:   Generally coherent conversation; can make himself understood
THOUGHT CONTENT:   Preoccupied with not wanting to be at Pine Estates. Talks about how they are not helping
him. Wants to go home and get his hunting license so he can go hunting.
PERCEPTION:   Reports having seen a friend, Roger, from the Navy climbing down the side of the building
yesterday. No other current evidence of hallucinations
INSIGHT/JUDGMENT:   Insight – poor- not understanding why he needs to be at a facility and not at home. (thinks he is here for rehab) Unable to recognize own deficits in functioning
Judgment Poor-often asks his wife to bring him take-out food (which she does), then he eats an additional dinner in the cafeteria.
COGNITION:   Alert and Oriented to person and place. Not oriented to time or purpose. Believes it is 2017. Able to recognize it is spring.
Short-term memory impaired: Doesn’t always remember that he has eaten; sometimes forgets when wife visits.
Long-term memory seems to be intact. Remembers personal history Attention span is adequate when tested. Able to state months backwards
INTERACTIONS:   Pleasant when spoken to. Hesitant to initiate conversation.
SUICIDAL/HOMICIDAL:   “If I don’t get out of here soon, I might just walk into traffic.”

What MSE assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data:   Clinical Significance:
  

Current Assessment:
GENERAL APPEARANCE:   Calm, body relaxed, no grimacing, appears to be resting comfortably in chair.
RESP:   Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
CARDIAC:   Pink, warm & dry, no edema, heart sounds strong and regular, S1 S2 with no murmurs or
abnormal beats, pulses 3+, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill
NEURO:   Alert & oriented to person, place, but not to time or date and situation/purpose (Oriented
x2), difficulty falling asleep and wakes up 1-2 times during the night
GI:   Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants
GU:   Voiding without difficulty, incontinent of urine. Reported that he just changed himself.
SKIN:   Skin integrity intact, tenting of the skin

What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data:   Clinical Significance:
  

Lab Results:
Basic Metabolic Panel (BMP)
   Na   K   Gluc.   Creat.  
Current:   140   3.4   225   1.2  
Most Recent:   140   3.5   182   1.1  

What lab results are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s):   Clinical Significance:   TREND:
Improve/Worsening/Stable:
      

Complete Blood Count (CBC)
   WBC   HGB   PLTs   % Neuts   Bands
Current:   6.0   15.2   202   55   0%
Most Recent:   5.8   14.5   198   52   0%

What lab results are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s):   Clinical Significance:   TREND:
Improve/Worsening/Stable:
      

Urinalysis + UA Micro
   Color:   Clarity:   Sp. Gr.   Protein   Nitrite   LET   RBCs   WBCs   Bacteria   Epithelial
Current:   Yellow   Clear   1.015   Neg   Neg   Neg   0   4   Trace   Few
Most Recent:   Yellow   Clear   1.018   Neg   Neg   Neg   0   0   None   None

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s):   Clinical Significance:   TREND:
Improve/Worsening/Stable:
      

Part II: Put it All Together to THINK Like a Nurse!
⦁   Interpreting relevant clinical data, what is the primary problem? What primary health related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation)
Problem:   Pathophysiology of Problem in OWN Words:   Primary Concept:
      

Collaborative Care: Medical Management
⦁   State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)
Care Provider Orders:   Rationale:   Expected Outcome:
Neuropsychiatric evaluation Urinalysis (UA) Haloperidol 2.5 mg PO BID
Acetaminophen 325mg two tablets PO every 6 hours PRN

Insulin glargine 10 units sub q HS

Increase memantine to 10 mg PO daily

Donepezil 5 mg PO daily

Trazodone 50 mg PO at HS PRN      

Collaborative Care: Nursing
⦁   What nursing priority (ies) will guide your plan of care? (Management of Care)
Nursing PRIORITY:  
PRIORITY Nursing Interventions:   Rationale:   Expected Outcome:
      

⦁   What psychosocial/holistic care PRIORITIES need to be addressed for this patient?
(Psychosocial Integrity/Basic Care and Comfort)
Psychosocial PRIORITIES:  
PRIORITY Nursing Interventions:   Rationale:   Expected Outcome:
      

⦁   What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family?
(Health Promotion and Maintenance)
Education PRIORITY:  
PRIORITY Topics to Teach:   Rationale:

Answer 1

Mr Butch has been suffering from dementia and other diagnosis also. Due to lack of lovable care from his wife might be a cause of his agitated behaviour.. Her wife might a person who identified by Mr.Butch.Recent hospitalisations also affected him.

patient had proteinuria that idicate kidney disease but his creatineine and electrolytes levels are normal. Patient had diabetes but it is improving.

Mr.Butch need holistic and comprehensive care for mental health as well as physical helath also. He needs emotional support from loved ones.Which will help to improve his mental and physical status.

Home care for Mr.Butch

Provide nutritious diet

provide good environment

Provide assistance to his all activities

help him to understand the things

Mr.Butch need psycholosupport from who all are taking care of him. If he get proper diet proper medicines, good environment it will help him .

Need to control his blood sugar that may lead to cause any other underlying diseases.