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.

1. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT Data from Present Problem:

Clinical Significance:

RELEVANT Data from Social History:

Clinical Significance:

As part of your pre-clinical prep you review 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

2. Which medication(s) are clinically significant and have a relationship to the current problem?

RELEVANT Medication(s):

Clinical Significance:

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

3. What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT VS Data:

Clinical Significance:

TREND: Improve/Worsening/Stable:

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.

4. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT Assessment Data:

Clinical Significance:

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

5. 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

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

RELEVANT Lab (s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Clinical Reasoning Begins...

1. 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

2. 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:

3. 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:

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

Nursing PRIORITY:

PRIORITY Nursing Interventions:

Rationale:

Expected Outcome:

Answer 1

1.Relevant data from present problem :the patient is having two small loose stools and large brown loose stools stools that is foul smelling.

Clinical significance :since the patient is receiving antibiotic (vancomycin) that can cause antibiotic associated diarrhoea.

Relevant data from social history :old aged, unmarried, living alone

Clinical significance :lack of emotional support and care from the family in this stressful time can lead to mental tension and depression.

2.Relevant medication : Vancomycin

Clinical significance :Vancomycin can cause destruction of microbial flora in the gut and can cause diarrhoea. Vancomycin also has a side effect of causing black or tarry stool.

3.Relevant VS data :temperature :100.8F,PR:98,BP:92/64

Clinical significance :the patient is having focus of infection (100.8F), and in shock (BP:92/64,PR:98).

Trends :the condition of the patient is worsening.

4.Relevant assessment data :the tongue and lips are dry, lethargic, abdomen distended, tender on palpation.

Clinical significance :patient is having signs of dehydration and shock. Abdominal distension and tenderness and fever indicate focus of infection in the abdominal viscera.