Question

I. Assessment:  AB, 65-year-old African American female, who was admitted for generalized weakness and pain in her right foot.

Vital Signs: T - 38.6 oral; P- 110 apical; R- 22; BP- 165/75 LUE, manual, sitting; Sp02 – 96% on RA.

AB is awake, alert, and orientated x4. AB appears to be uncomfortable. AB denies any numbness or tingling. Her skin is appropriate for ethnicity and is warm to the touch. She is tachycardiac, rate of 110 and regular. Pedal pulses are present but unequal in bilateral lower extremities with +3 in L and +2 in R noted. She has IV access, 20 gauge, in her RAC. IV site is clean, dry, and intact. Lung sounds are diminished with expiratory wheezes noted in the bases bilaterally. Her abdomen is soft and non-tender. AB denies N/V/D. AB denies dysuria, hematuria, or frequency with voiding. AB has full and equal ROM bilaterally in all extremities; however, she complains of sharp consistent pain in R heel that increases with activity. AB rates the pain as 5/10 with rest and 8/10 with activity on a 0-10 scale. 2cm x 2cm open wound with a moderate amount of yellow purulent drainage is noted on heel of R foot. The skin surrounding the wound is erythematous and hot to the touch.

Past History: Hypertension, Type II Diabetes, Seasonal and Exercise Induced Asthma, Depression and Generalized Anxiety Disorder

Social & Economic History: AB is a widow. Her husband recently passed away from cancer. AB lives alone with her two cats in the home that she owned with her late husband in the downtown area of the city. AB is a homemaker and never worked outside of the home. She has three grown children (2 boys and 1 girl) who all live nearby; however, AB reports that “they are busy and don’t have time for me.” AB reports that she was an active member in her church until recently when her foot “started giving her trouble.” AB currently receives social security benefits for herself and from her late husband as well as her late husband’s retirement pension. AB’s health insurance in Medicare part A & B. Although AB denies trouble affording her medications; she reports difficulty accessing healthcare services due to transportation. AB never had a driver’s license.

AB is a former cigarette smoker. She admits to smoking one pack a day for 30 years. She reports that she quit smoking approximately 10 years ago. AB admits to drinking one glass of wine every night before bed. She states it helps her relax. AB denies history of drug use or abuse as well any previous drug or alcohol related treatment.

II. Meds: Daily

1) Amlodipine 10mg, qd

2) Aspirin 81mg, qd

3) Metformin 500mg, BID, with meals

4) Lantus 40 units with breakfast and at bedtime.

5) Escitalopram 20mg, qd

6) Vancomycin 1g IVPB q12 hours   

Meds: PRN-

1) Ibuprofen 200mg -3 PO as needed for mild pain

2) Morphine 1mg IVP as needed for moderate pain

3) Morphine 2mg IVP as needed for severe pain

4) Proventil HFA 2 puffs as needed

III. Lab Results:

RBC -   5.0                                  Platelets- 325                                      CL- 107

WBC- 15                                INR- 0.9                                                 Mag- 2.0

HGB-   14                                   K+ - 4.0                                                 CA- 9.0

HCT-   40                                    NA- 138                                                  

Other Pertinent Labs:

BUN - 30

Creatine- 1.28

Blood Glucose - 300

Wound Culture – positive for gram-positive bacteria, methicillin resistant Staphylococcus aureus

IV. Questions to be answered for Medication Administration: Use Unbound Medicine-Davis’s Drug Guide for Nurses

1.      Why is the client taking each daily medication? - do not list the action of the meds.

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2.      What are the important nursing implications of each medication?

3.      Based on your assessment are there any medication(s) that the client should be taking which are not currently ordered? If so, which class of medication should be ordered and why (you do not have to give the name of a specific medication).

Are there any medications that should be held?

4.      What combination of medications ordered poses the greatest risk for the client? Explain why.

V. Questions to be answered for Lab Tests Results:

1.    Explain why the labs were performed- you may group related labs together. i.e. Hgb & Hct

Hint: Make sure to link it to the diagnosis and/or medication that the client is taking.

2.    What do the lab results indicate?

VI. List 3 areas of teaching for the client. Explain in detail what you will teach the client/ significant other concerning the diagnosis.

VII. Nursing Diagnosis:

Problem List	A. Choose 4 Priority Problems for the Concept Map and state in Nursing Diagnosis Format. B. From the 4 Priority Problems; Choose 2 Priority Nursing Diagnosis, of which one must be an actual problem. C. Expand on each of the 2 priority problems-include correct format, goal and 5 interventions. D. Goals must be measurable, short-term and achievable within 48 hours.
List all highlighted/underlined in the assessment

Answer 1

IV. 1)• Amlodipine is taking to reduce blood pressure.

• Aspirin is taking to reduce pain in her right leg.

• Metformin and lantus is taking to reduce blood sugar level.

•Escitalopram is used to reduce depression.

•Vancomycin is used to kill gram positive bacteria.

2) •Amlodipine- Blood pressure should be checked before administration.

•Aspirin- pain level of the patient should be assessed. Assess for hepatotoxicity ( dark urine, clay colour stool.

•Metformin and lantus- Assess for any hypoglycemic reaction before administration.(CBG checking).

• Escitalopram- administer with food to prevent GI irritation.

•Vancomycin- Assess for nephrotoxicity (hematuria, BUN level) before administration.

3) • Client should take diuretics to prevent dysuria, which are not prescribed.

•Vancomycin should be held because vancomycin increases hematuria and BUN level. Patient is already suffering from hematuria and BUN level is 30.

4) combination of amlodipine and Aspirin posses greater risk for patient. Because combination of this two drug increases blood pressure, where patient is already suffering from high blood pressure.

V.1) Haemoglobin is assessed to determine anemia of the patient.

Haematocrit level is assessed to determine any bleeding disorder is suffering by the patient. As, the patient is suffering from hematuria.

WBC count is assess for infection.

BUN, creatinine is assessed for kidney function.

Na, Mg, k, Cl is assessed for electrolyte level.

Blood sugar to determine diabetes.

2) Lab test indicates the patient's kidney function is affected as BUN is high.

• patient is suffering from Diabetes.

•patient is affected by gram positive bacteria.

VI)1) Health teaching to prevent hypertension.

• First food, cholesterol containing food should be avoided.

•Salt restricted diet should be taken.

•DASH(dietary approaches to stop hypertension) diet should be taken. Like cereals, green leafy vegetables, fruits.

2) Health teaching to prevent Diabetes mellitus.

• Carbohydrate rich food should be avoided.

• plenty water should be taken.

•Daily CBG checking should be done.

3) Health teaching to reduce asthma.

• cold food should be avoided.

• Allergy producing food should be prevented.

• Hot water, tea should taken.

• Exercise should be avoided.

VII)A. Four priority problems are Pain in right leg, hypertension, breathing problem, haematuria.

B. 1) Acute pain in right leg related to presence of wound as evidenced by patient's vernalization and physical examination.

2) Impaired haemodynamic status related to hypertension as evidenced by checking vital signs.

C) Planing for 1st diagnosis.

• patient's pain level and vital signs should assessed.

•Comfortable position is given.

• Aspirin or Ibuprofen should be given as per doctor's order.

Planning for 2nd diagnosis.

• Blood pressure should be checked.

•DASH diet and salt restricted diet should be given.

• Amlodipine should be given as per doctor's order.

D) For 1st diagnosis Goal is to reduce pain.

For 2nd diagnosis Goal is to reduce hypertension.