Running head MEDICAL / SURGICAL CASE STUDY AND CARE PLAN 1

Medical/Surgical Case Study and Care Plan Dermot Connolly Stenberg College 0312 NURS 201-3 Medical/Surgical Nursing Practice - Theory April 2013

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN 2

Identifying Data and General Description: Nancy Berndt is a 72 year old widowed Caucasian female admitted to Ridge Meadows hospital on March 29th complaining of weakness. On March 28th, patient went to church and then to lunch with some friends before becoming acutely weak and was unable to get into her apartment. Patient presented with a productive cough and clear phlegm with no blood. Patient is an overweight non smoker, non drinker with no observed edema. Patient lives on her own on the second floor of an apartment complex in Maple Ridge. She has two sons with whom she is very close, one lives in British Columbia while the other resides in Ontario. Patient receives home care support from We Care after dislocating her shoulder in Nov 2012 (We care 2013), and Molly Maid cleaning services on Fridays. (Molly Maid 2013). Patient has a strong network of friends and neighbors who assist her with her shopping. Chief Complaint / History of Present Illness: Upon admission, patient stated she had being feeling week over the past few days with a loss of appetite, shortness of breathe with no reported chest pains. Patient did not complain of fever, chills or dysuria but presented with frequent urination and urgency with no blood noted in urine. Patients blood pressure was 97/57, with a pulse of 89, O2 saturation of 98% and a temperature of 37oC. Urinalysis tested positive for nitrites indicating a significant presence of bacteria in patients urine. Patient also tested positive for WBC in urine indicating a bladder

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN 3 infection. (Buzzle 2013). Patient was diagnosed with right lower lobe pneumonia with a urinary tract infection. Patient has no history of pneumonia or urinary tract infections. Due to complaints of shortness of breath, patient initially placed on 4 liters of O2 via nasal prongs before being reduced to 2 liters of O2 following reassessment. Stressors and precipitating factors include patients history of COPD and asthma, being over 65 years of age, her history of seizures (although no reported seizures for 30 years) and the location of her residence on the second floor of her apartment complex. (Lewis, Heitkemper & Dirkson 2006). Patient has no reported history of medication non compliance and is currently prescribed the following medications; 1) Dalteparin injection 5000 units / 0.2ml SC daily at 1700hrs to reduce the risk of blood clots. (Davis drug guide 2013). 2) Levofloxacin IV in IV bag q24 hrs infuse over 60 mins at 1200hrs. An antibiotic used to treat bacterial infections. (Davis drug guide 2013). 3) Salmeterol / Fluticasone 50/250 mcg diskus inhaled BID at 1000 and 2200hrs. Used to treat asthma. (Davis drug guide 2013). 4) Tiotropium 18mcg inhaled capsule daily at 0800hrs. Used in the treatment of breathing difficulties such as COPD. (Davis drug guide 2013). 5) Divalproex EC 500mg tab PO BID at 0800hrs. Used in the suppression of seizure activity. (Davis drug guide 2013). 6) Furosemide 40mg tablet PO daily at 0800hrs. A diuretic used in the elimination of sodium and water from the body. (Davis drug guide 2013). 7) Levothyroxine 100mcg tablet PO daily at 0800hrs. A synthetic T4 hormone prescribed for hypothyroidism. (Davis drug guide 2013). 8) Montelukast Sodium 10mg tablet PO daily at 0800hrs. Prescribed for the treatment of asthma and exercised induced narrowing of the airways. (Davis drug guide 2013). 9) Nitrofurantoin 100mg capsule PO BID at 0800 and 1700hrs. An antibiotic used in the treatment of urinary tract

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN 4 infections. (Davis drug guide 2013). 10) Phenobarbital 30mg tablet PO BID at 0800hrs. A long term anticonvulsant for the treatment of local seizures and short term treatment of insomnia. (Davis drug guide 2013). 11) Phenobarbital 15mg tablet PO BID at 2200hrs. A long term anticonvulsant for the treatment of local seizures and short term treatment of insomnia. (Davis drug guide 2013). 12) Phenytoin 100mg capsule PO BID at 0800, 1400 and 2200hrs. An anticonvulsant used in the treatment of seizures. (Davis drug guide 2013). PRN Medication 1) Acetaminophen 325mg tablet. 650mg (2 tablets) PO Q4H PRN for the treatment of pain. (Davis drug guide 2013). 2) Dimenhydrinate 50mg tablet. 25-50mg (0.5-1 tablet) PO Q4H PRN for the treatment of nausea. (Davis drug guide 2013). 3) Zopiclone 5mg tablet. PO HS PRN for the short term treatment of insomnia. (Davis drug guide 2013). Past Medical History: Patient has a past medical history of obesity, dyslipidemia, (a disorder in the overproduction or deficiency of lipoproteins), (Medicine Net 2013). Shoulder dislocation, hypothyroidism, GERD, COPD, Asthma and seizure disorder, although patient has not reported any instances of seizures for 30 years. Surgical History: Patient has no history of any surgical procedures. Allergies: Patient allergic status is NKDA meaning she has no known drug allergies. (Your Dictionary-Medical 2013).

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN 5 Disease Process: Diagnosis. Right Lower Lobe Pneumonia Textbook Description of the Disease Process. Pneumonia is described as the acute inflammation of the lung parenchyma as a result of infection from a microbial agent. (Lewis, Heitkemper & Dirkson 2006). Etiology / Pathophysiology. Pneumonia is more likely to occur when the airways normal defense mechanisms such as air filtration, warming and humidification of inspired air and cough reflex are compromised by viral or bacterial infections. (Lewis, Heitkemper & Dirkson 2006). Certain factors predispose the patient to infection such as the impairment of the mucociliary escalator mechanism caused by cigarette smoke, ageing and upper respiratory infections such as COPD and asthma. (Lewis, Heitkemper & Dirkson 2006). The pathophysiology of pneumonia begins with a) congestion after the hosts alveoli are infected, b) red hepatization after the dilation of the capillaries and alveoli, c) grey hepatization when leukocytes and fibrin consolidate in the infected portion of the lung and d) resolution and healing after the infection has being cleared. (Lewis, Heitkemper & Dirkson 2006). Clinical Signs and Symptoms. Patients with pneumonia typically present with multiple symptoms such as fever, chills, productive cough and pleuritic chest pains. Sign of pulmonary consolidation may also be present such as dull percussion sound and breathing crackles. In the elderly, confusion may also be demonstrated. (Lewis, Heitkemper & Dirkson 2006). Clients Presentation of Disease Process. Although patient is a non smoker, she has a medical history of COPD and asthma which predisposes her to pneumonia. Patients presented with a productive cough with clear phlegm and auditable crackles throughout her right lung

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN 6 during auscultation examination. Patient presented with a shortness of breath and no fever. Also patient is also over 65 years of age which also increases her susceptibility to pneumonia infection. Diagnosis. Urinary Tract Infection. Textbook Description of the Disease Process. Urinary tract infections is a common bacterial disease that affects all age groups with woman being the most susceptible. In the older adult, urinary tract infections are prevalent in 30 to 50% of woman. (Lewis, Heitkemper & Dirkson 2006). Etiology / Pathophysiology. The urinary tract is normally sterile due to the bodys natural defense mechanisms such as voiding of the bladder and the natural ability of the bladder mucosa and urine to protect against bladder infection. Alterations in these defense mechanisms results in an increased risk to contracting a urinary tract infection. (Lewis, Heitkemper & Dirkson 2006).Most infections are from gram negative bacteria normally found in the GI tract. Infections are usually introduced through the ascending route of the urethra or less commonly from the bloodstream or lymphatic system. Common contributing factors to urinary tract infections are hospital acquired infections from the use of urological instrumentation such as in dwelling urinary catheters. (Lewis, Heitkemper & Dirkson 2006). Clinical Signs and Symptoms. Symptoms of urinary tract infections include painful urination (dysuria), frequent urination and urgency to urinate. (Lewis, Heitkemper & Dirkson 2006). Other symptoms include visibility of blood or sediment in the urine. In the older adult, abdominal discomfort may be present instead of dysuria as well as cognitive impairment. Fever

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN 7 is less common in the older adult suffering from a urinary tract infection of the upper urinary tract. (Lewis, Heitkemper & Dirkson 2006). Clients Presentation of Disease Process. Patient presented with frequent urination and urgency but did not present with blood in her urine or dysuria. Urinalysis tested positive for nitrites and WBC in the patients urine indicating the presence of a bladder infection. (Buzzle 2013). The patient is an older adult who did not present with a fever or cognitive impairment as she was oriented X 3 to day, time and location. Lab Results: Attached below is a summary table of the patient relevant lab results. All other lab values except for those listed below were within normal range.

Patients Results Test WBC Count (White Blood Cell) PLT (Platelet Count) Neutrophils Monocytes Chloride Acceptable Range March 29 4.0 11.0 x109/L
th

Comments March 30
th

March 31st 10.1(Normal) 114 (Low) 7.1 (Normal) 1.1 (High) 102 (Normal) High levels are an indication of infection* Low levels are an indication of infection* High levels are an indication of acute infection* High levels are an indication of infection* Low levels are an indication of dietary deficiency possible related to patients loss of appetite prior to admission.* High levels are an indication of chronic use of loop diuretics such as Furosemide which the patient has being prescribed.* Low levels may indicate

20.0 (High) 135 (Low) 15.6 (High) 3.1 (High) 96 (Low)

17.4 (High) 112 (Low) 13.9 (High) 1.0 (High) 100 (Normal)

150 400 x 109/L 2.0-8.0 x109/L 0.1-0.9 x109/L 98-108 mmol/L

Bicarbonate

20 30 mmol/ L

30 (Normal)

31 (High)

32 (High)

EGFR (Estimated

>60ml/min

53 (Low)

56 (Low)

59 (Low)

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Glomerular Filtration Rate) Calcium Magnesium kidney disease**

2.10-2.60mmol/ L 0/7-1.2mmol / L

2.18 (Normal) 0.8 (Normal)

Calcium and Magnesium tests relevant because low levels of Calcium and high levels of Magnesium are indicators of Hypothyroidism of which the patient has a history. *

* (Lewis, Heitkemper & Dirkson 2006). ** (American Kidney Fund 2013). Nursing Physical Assessment: Patient is a 72 year old Caucasian female admitted on March 29th complaining of weakness. Once admitted, patient stated she has experienced shortness of breath and loss of appetite. Patient presented with frequent urination and urgency with no blood reported in urine. Vitals were bp 97/57, pulse 89, O2 sat 98% and temp.37oC. Patient is on 2litres of O2 via nasal prongs, respirations are even and unlabored, apical pulse regular. An auditable crackle throughout her right lung was noted during auscultation and presents with a productive cough with clear phlegm. Patient is alert and oriented X 3 to day, time and location. Denies any pain or discomfort and responds appropriately to verbal communication with no speech abnormalities noted. Patient is independent to feeding and toileting and requires minimum assistance in bathing. Skin turgor normal with no observed edema. Abdomen obese, soft, non tender and has an IV port with no infection, infiltration and phlebitis noted. Bowel sounds noted on all quadrants. Patient requires minimum assistance while walking but exercise limited to short walks

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN 9 due to shortness of breath. Hand grips are equal and strong, Patients feet are warm and dry with sign of skin damage and will continue to monitor patient. Treatment Plan: Patient is encouraged to sit in her chair after meals to maximize her breathing efficiency through slow deep breathing. In addition, regular short walks with the aid of a walker or nurse are encouraged. Patient is positioned in a manner that minimizes strain on her breathing, with the head of the bed positioned upright. Nutritional information is presented to the patient and her nutritional intake is noted and recorded as patient presented with loss of appetite. Patients vitals are monitored four times / day to determine any variations from baseline. In addition, shortness of breath, chest pains, fever and changes in frequency or quality of cough are also observed. Patients urine will continue to be monitored for presence of infection. Administered medications include, antibiotics for the treatment bacterial infection, inhalers to treat patients history of asthma and COPD. Patient is also prescribed Levothyroxine to treat her history of hypothyroidism and Divalproex to help suppress seizure activity. Teaching and Discharge Plan: The patient should be taught about the importance of maintaining good health habits such as proper diet and hygiene to reduce the risk of infection. Proper and adequate rest is also important in the fight against infection. (Lewis, Heitkemper & Dirkson 2006). As the patient is an older adult, she should be encouraged to receive the pneumococcal and influenza vaccinations. In addition the patient must be educated on the importance of medication compliance including drug and food interactions and the dangers of overmedicating such as depressed cough reflex. (Lewis, Heitkemper & Dirkson 2006). The patient must also be made

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN 10 aware that it may be several weeks before a complete recovery is made. (Lewis, Heitkemper & Dirkson 2006). Health promotion activities can help prevent urinary tract infections such as emphasizing the importance of emptying the bladder regularly and completely, wiping the perineal area from front to back after using the bathroom and drinking adequate amounts of fluids every day. (Lewis, Heitkemper & Dirkson 2006). Cranberry juice in particular may reduce certain urinary tract infections. The patient should in educated that while drinking fluids will increase urination at first, it will also dilute the urine and flush out the bacteria before it has time to colonize. (Lewis, Heitkemper & Dirkson 2006). The patients diet is also important and certain foods should be avoided such as caffeine, alcohol, citrus juices and spicy foods as they are potential bladder irritants. (Lewis, Heitkemper & Dirkson 2006). Student Reflection Upon Writing Case Study: I learned a lot from this experience; in particular I now have a greater understanding of the role that underlying heath conditions can play in the onset of pneumonia. For example, my case study patient has a history of COPD, asthma and seizures, all of which are predisposing factors to pneumonia. I witnessed the importance of regular exercise and proper positioning of the patient in the bed and chair in the treatment of labored breathing. This case study also offered me the opportunity to hear breathing crackles through lung auscultations and for the first time I also had the opportunity to spike and prime an IV bag. In addition, I had the experience of cleaning and flushing an IV port for the first time. On a personal note, I found the patient to be extremely co operative and open to all nursing interventions and treatment plans which made the learning experience much more enjoyable.

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References: American Kidney Fund (2013). Estimated glomerular filtration rate. Retrieved from: http://www.kidneyfund.org/kidney-health/kidney-tests/kidney-test-egfr.html Buzzle (2013). What do white blood cells in urine mean? Retrieved from: http://www.buzzle.com/articles/what-does-white-blood-cells-in-urine-mean.html Davis drug guide (2013). Up to date drug information. Retrieved from: http://www.drugguide.com/ddo/ub/ Elsevier Evolve (2010). Care plans. Patient with pneumonia. Retrieved from: https://evolve.elsevier.com/Resources/Canada_Lewis_medsurg2e_ER#resource? id=22691999&open=22563426%2C22591242%2C22604808%2C22612348%2C225912 39%2C22604299%2C22611884

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN 12 Lewis, S.L., Heitkemper, M.M. & Dirkson, S. R. (2006). Medical- surgical nursing in Canada (1st Ed.). Toronto, Canada: Mosby Elsevier. Medicine Net (2013). Definition of dyslipidemia. Retrieved from: http://www.medterms.com/script/main/art.asp?articlekey=33979 Molly Maid (2013). Retrieved from: http://www.mollymaid.ca/ Nurse Labs (2012). Risk of infection pneumonia nursing care plan. Retrieved from: http://nurseslabs.com/risk-for-infection-pneumonia-nursing-care-plans/ We care (2013). Home health care in Vancouver Health at home services. Retrieved from: http://www.wecare.ca/senior-home-care-services?Location=home-health-care-invancouver-bc Your Dictionary-Medical (2013). NKDA medical definition. Retrieved from: http://medical.yourdictionary.com/nkda

Running head MEDICAL / SURGICAL CASE STUDY AND CARE PLAN Appendix 1 Nursing Care Plans Short Term
Nursing Diagnosis Desired Outcomes Interventions (I)-Independent (C) - Collaborative N1-(I) (C) Auscultate patients breath sounds noting areas of decreased ventilation and sounds of crackles.* Rationale & APA Reference

13

Evaluation of Interventions

NDX: (Problem) * Airway clearance ineffective R/T: (etiology/factor): * Retained secretions and excessive mucous. AEB: (s/sx; defining characteristics) * 1)Evidenced by Patients persistent cough 2) Evidenced by Patients dyspnea

Goal: Educate patient of effective methods of coughing and maximize air exchange. * Client will: 1) Demonstrate the ability to clear airways effectively * 2) Demonstrate ability to maximize air exchange *

R1Compare patients auscultations against baseline data to verify effectiveness of treatment.*

E1At time of writing, patient still exhibited crackles throughout her right lung. Daily auscultations were being collected to verify effectiveness of treatment plan. E2Patient demonstrates effective methods of breathing although still experiencing shortness of breath. E3At this of writing, patient was demonstrating effective coughing through productive coughing and the elimination of sputum.

N2-(I) (C) Educate the patient in the correct way to sit with head slightly flexed, shoulders relaxed and knees bent. * N3-(I) (C)

R2Aids in the patients ability to breathe effectively. * R3Promotes effective coughing technique for the patient. *

Evaluation of Outcomes At time of writing patient was demonstrating effective methods of coughing and removal of sputum from airways.

Educate the patient on the importance of inhaling deeply and exhaling slowly. Also encourage patient to cough at the end of each exhalation. *

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Nursing Diagnosis Desired Outcomes Interventions (I)-Independent (C) - Collaborative Rationale & APA Reference

14
Evaluation of Interventions

At time of writing, client was still demonstrating signs of dyspnea Evaluation of Goal: (circle one) Goal met Goal not met NDX: (Problem) Nutrition imbalanced, less than body requirements. (Goal partially met) will Goal: Patients appetite be restored through eating (If goalwell not met, describe regular balanced outcomes not met) Evolve 2010). meals. Client will: N2-(I) (C) R2E2-

Appendix 2 Nursing Care Plans Long Term - Hospital

*(Elsevier

R/T: (etiology/factor): Patient reported loss of appetite for several days

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN

Nursing Diagnosis Desired Outcomes Interventions (I)-Independent (C) - Collaborative Rationale & APA Reference

15
Evaluation of Interventions

prior to admission. AEB: (s/sx; defining characteristics) * 1) Evidenced by Patients reported weakness at time of admittance.

1) Report any loss of appetite. 2) Demonstrate ability to eat through consumption of regular well balanced meals. Evaluation of Outcomes At time of writing patient was not showing or reporting any loss of appetite. Meal consumption was being charted with no concerns noted. Evaluation of Goal: (circle one) (Goal met) Goal not met Goal partially met (If goal not met, describe outcomes not met) N/A Continuation of plan:

Monitor patients food intake daily and note any abnormalities. **

Helps to determine if the patient nutritional requirements are being met or if the patient reports feelings of hunger or loss of appetite. **

Patients food intake has being recorded daily with any abnormalities noted. In addition, patients energy levels and appetite levels are assessed every day. E3All of the patients activities such as exercise, medications and personal care are scheduled around her meals to ensure no disruption.

N3-(I) (C) Ensure treatments and procedures are scheduled around patients mealtimes. **

R3Helps the patient to conserve energy and ensures adequate time for patient to consume all meals. **

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN

Nursing Diagnosis Desired Outcomes Interventions (I)-Independent (C) - Collaborative Rationale & APA Reference

16
Evaluation of Interventions

(circle one) (Continue plan of care) Discontinue plan of care Revise plan of care

**(Lewis, Heitkemper & Dirkson 2006).

Appendix 3 Nursing Care Plans Long Term - Discharge

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN

Nursing Diagnosis Desired Outcomes Interventions (I)-Independent (C) - Collaborative N1-(I) (C) Educate the patient on the importance of raising airway secretions instead of swallowing them. Patient needs to be educated on the importance of noting changes in color amount and odor of secretions. *** N2-(I) (C) 2) Understand the importance of proper toileting. 3) Demonstrate proper disposition of airway secretions. Educate the patient on the importance of good hand washing technique. *** Rationale & APA Reference

17
Evaluation of Interventions

NDX: (Problem) Risk for infection. R/T: (etiology/factor): Patient diagnosed with Pneumonia and a urinary tract infection. AEB: (s/sx; defining characteristics) * 1) Evidenced by Patients crackles in right lung and presence of nitrites and WBC in patients urine.

Goal: Patient will be educated on the importance of effective management of infection once discharged from hospital. Client will: 1) Demonstrate effective hand washing technique.

R1Changes in the characteristics of airway secretions can help determine if patient pneumonia is resolved of if infection is progressing. ***

E1At time of writing, patient has being educated on the importance of raising airway secretions and examining them for color, odor and amount. This will prove very useful for the client once she is discharged to her apartment. E2Patient has being education on the importance of good hand washing technique demonstrated by the patients regular use on anti bacterial gels and hand washing after toileting. E3At time of writing patient had not received training on proper toileting techniques.

R2Helps prevents the client from coming in contact with infection and also helps prevent the spread of infection. ***

N3-(I) (C) Educate the patient on the importance of emptying the bladder fully and wiping the perineal area from front to back after using the bathroom. **

R3Reduces the risk of patient contracting a urinary tract infection. **

Evaluation of Outcomes

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN

Nursing Diagnosis Desired Outcomes Interventions (I)-Independent (C) - Collaborative Rationale & APA Reference

18
Evaluation of Interventions

At time of writing had not being educated on the importance of proper toileting but had being education on proper hand washing technique and proper disposition of airway secretions. Evaluation of Goal: (circle one) Goal met Goal not met (Goal partially met) (If goal not met, describe outcomes not met) Continue to assess patients hand washing and airway secretion techniques with the aim of education patient on proper toileting prior to discharge.

Continuation of plan: (circle one)

MEDICAL / SURGICAL CASE STUDY AND CARE PLAN

Nursing Diagnosis Desired Outcomes Interventions (I)-Independent (C) - Collaborative Rationale & APA Reference

19
Evaluation of Interventions

(Continue plan of care) Discontinue plan of care Revise plan of care

**(Lewis, Heitkemper & Dirkson 2006). *** (Nurse Labs 2012).