Question

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Minnie Taylor, 62 years old Primary Concept Infection/Inflammation Interrelated Concepts (In order of emphasis) • Perfusion • Clinical Judgment • Patient Education • Communication • Collaboration

History of Present Problem:

Minnie Taylor is a 62-year-old African-American female with a history of diabetes mellitus type II, hypertension, and peripheral arterial disease who had a left below the knee amputation (LBKA) three days ago. She had two small loose, watery stools last night and a third large watery brown stool this afternoon that had a distinct foul odor. Minnie is now complaining of generalized lower abdominal cramping that she rates 3/10. She does not have an appetite and does not feel like drinking fluids. Minnie was awake and alert after lunch, but later that afternoon just before supper you note that Minnie is sleepy and once aroused, falls right back to sleep.

Personal/Social History:

Minnie is a retired teacher who never married and has no close friends. She lives alone in her own apartment.

Her medication record and note the following scheduled medications:

✓ Pantoprazole 40 mg PO daily
✓ Lisinopril 20 mg PO BID
✓ Metoprolol 50 mg PO BID
✓ Vancomycin 1000 mg IVPB daily

✓ Metformin 1000 mg PO BID

Current Assessment:

GENERAL SURVEY: Pleasant, in no acute distress, calm, body relaxed, no grimacing, appears to be resting comfortably.

NEUROLOGICAL: Lethargic, does not stay awake once aroused, oriented to person only, (was oriented x4 last recorded assessment 4 hours ago), has no focal neurologic deficits

HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips dry, tongue, and oral mucosa pink and tacky dry.

RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air.

CARDIAC: Pale, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees

ABDOMEN: Abdomen round, slightly distended, and tender to gentle palpation, BS + in all 4 quadrants
GU: 100 mL clear, dark amber urine four hours ago

INTEGUMENTARY: Skin normal color for ethnicity. No clubbing of nails, cap refill <3 seconds, Hair soft- distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present.

Patient Care Begins:

Current VS:

4 Hours Ago:

Current PQRST:

T: 100.8 F/38.2 C	T: 98.7 F/37.1 C	Provoking/Palliative: Quality: Movement provokes pain
P: 98 (reg)	P: 84 (reg)	Quality: Cramping
R: 20 (reg)	R: 18 (reg)	Region/Radiation: Generalized lower abdomen
BP: 92/64 MAP: 73	BP: 118/74 MAP: 89	Severity: 3/10
O2 sat: 94% RA	O2 sat: 95% RA	Timing: Ongoing since onset two hours ago

1. What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab (s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Complete Blood Count (CBC)	WBC	HGB	PLTS	%Neuts	Bands
Today:	11.8	11.5	140	86	0
Yesterday:	8.9	11.4	137	74	0

2. What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab (s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

   

Basic Metabolic Panel (BMP)	Na	K	Gluc	Creat.
Today:	143	4.1	142	1.3
Yesterday:	140	3.9	138	1.0

3. Interpreting relevant clinical data, what is the most likely 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: Nursing

4. What body system(s) will you assess most thoroughly based on the primary/priority problem? (Reduction of Risk Potential/Physiologic Adaptation):

Priority Body System:

Priority Nursing Assessments:

5. What is the worst possible/most likely complication(s) to anticipate based on the primary problem of this patient? (Reduction of Risk Potential/Physiologic Adaptation)

Nursing Interventions to PREVENT this Complication:

Assessments to Identify Problem EARLY:

Nursing Interventions to Rescue:

6. What nursing priority (ies) will guide your plan of care? (Management of Care)

Nursing PRIORITY:

PRIORITY Nursing Interventions:

Rationale:

Expected Outcome:

Answer 1

1. The lab report of Minnie Taylor, 62 yrs. old woman, that is relevant and must be recognised by the nurse is the WBC is increased more than normal.

Here previous WBC count was 8.9 billion cells/lit. but in present date it is increased into 11.8 billion cells/lit.

This increased WBC count indicate presence of infection/inflamation in her body.

The inflamation tend to worsening as the WBC count is increasing than the previous day.

2. Here the most relevant lab. report is the glucose level.

The normal blood glucose level is 72 - 110 mg/dl. But she had an increased level of blood glucose i.e. 142 mg/dl in present date.

It is more significant for her as she has a lower knee amputation. Increased blood glucose level will delay the wound healing process. So, this increased blood glucose level is significant for her present health condition.

It is tend to worsening as the blood glucose level is increased than the previous date i.e. 138 to 142 mg/dl.

3. The most likely primary problem is that she is suffering from diarrhoea and desyntery and it can deteriorated patients present condition.

Pathophysiology = Due to various present inflamation and prolonged hospitalization the patient has increased body temperature i.e. 100.8°F and she passed wattery brown coloured stool. This frequent loss of water and electrolytes causes fluid volume deficit and nutritional deficiencies. This leads to low blood pressure 92/64 mm of Hg and generalized lower abdominal pain.

The collaborative management of this condition includes =

- monitor vital signs in 1 hours interval.

- proper intravenous fluids like as Ringer lactate, normal saline etc has to be administered.

- proper antibiotics like as Metronidazole, Ceftriaxone has to be administered as per physician prescribed.

- pain medication and antipyretics like as Paracitamol has to be administered.

- frequent liquid diet with low carbohydrate contain has to be administer.

- proper aseptic techniques has to be perform during all procedures.

4. The primary body system that has to be assessed based on the primary probe are - the gastrointestinal system and the cardiovascular system.

The primary nursing assessment =

- assess the vital signs of the patient.

- abdominal assessment has to be done.

- monitor the fluid intake and output of the patient.

- assess the surgical sites of the patient. Check for any necrosis, discoloration of skin, any odor if arise.