What is the main purpose of the implementation phase of the nursing process?

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A nursing audit is the process of collecting and analyzing data to evaluate the effectiveness of nursing interventions. A nursing audit can focus on implementation of the nursing process, client outcomes, or both in order to evaluate the quality of care provided. Nursing audits examine data related to:

• Safety measures

• Treatment interventions and client responses to the interventions

• Preestablished outcomes used as basis for interventions

• Discharge planning

• Client teaching

• Adequacy of staffing patterns

Audits are based on components such as institutional policies; federal, state, and local regulations; accreditation standards; and professional standards

Audits assist in identifying strengths and weaknesses that, in turn, provide direction for areas needing revision. Corrective action plans are developed in accordance with the audit results.

PEER EVALUATION

Another method of evaluating quality of care is peer evaluation (also referred to as peer review), the process by which professionals provide to their peers critical performance appraisal and feedback that are geared toward corrective action. According to the ANA (1988):

Peer review in nursing is the process by which practicing Registered Nurses systematically assess, monitor, and make judgments about the quality of nursing care provided by peers, as measured against professional standards of practice.

In 1984, Lucille Joel postulated that peer review is the basis of nursing’s autonomy and self-governance (Joel, 1984). This perspective is still very relevant in today’s health care climate.

By evaluating itself, nursing is demonstrating an essential criterion by which professions are recognized. Peer evaluation promotes both

professional and individual accountability.

The quality of nursing care is strongly evident to coworkers and nurses who are expected to assess the work of their peers. “Peer review is an essential mechanism for evaluating the judgment and performance of clinical providers” (Wakefield, Helms, & Helms, 1995, p. 11).

Such judgment may result in one of the following outcomes:

• Destructive: Complaints and attacks that undermine morale and cohesiveness

• Constructive: Positive feedback that improves the quality of care

Peer evaluation can be destructive if the parties involved begin to personalize the process, misunderstand the purpose, or deliver feedback in an unfeeling and

nonobjective manner.

Peer evaluation can be threatening when guidelines have not been established for the process and when the assessment focuses on emotions and personalities instead of on behaviors. Conversely, peer evaluation is constructive when the focus remains on quality improvement and encourages the continued growth and learning of all the parties involved. The accompanying display provides principles that promote the use of objective, nonbiased peer evaluation.

EVALUATION AND ACCOUNTABILITY

Accountability means assuming responsibility for one’s actions. Evaluation enhances nursing accountability by providing a mechanism for assisting the nurse to define, explain, and measure the results of nursing actions. Accountability is increased by ongoing evaluation; nurses are continually checking their own progress against predetermined standards.

Accountability is an integral part of professional nursing practice and is an important method through which commitment to quality client care can be demonstrated. “Nurses are accountable for designing effective care plans, implementing appropriate nursing actions, and judging the effectiveness of their nursing interventions” (Kenney, 1995, p. 195).

In other words, nurses are accountable, for their judgments, decisions, and actions, to:

• Clients, families, and significant others

• Colleagues

• Employers

• The general public (society)

• The nursing profession

• Themselves.

MULTIDISCIPLINARY COLLABORATION IN EVALUATION

Evaluating the quality of care provided is a responsibility shared among members of the health care team. In addition to those directly involved (the health care providers, clients, and families), others interested in the outcomes of evaluation include the community and third-party payers (both public and private reimbursement organizations).

An ongoing monitoring process is implemented to evaluate quality of care. Ideally, every discipline monitors its own quality efforts. No single discipline is responsible for all-inclusive evaluation of client care. However, in most health care agencies, nurses are actively involved in monitoring evaluation activities. Many agencies have nurses on staff who function either as quality management coordinators, utilization review evaluators, or both.

When health care providers from all the relevant disciplines are involved in evaluation, the result is decreased fragmentation of care. The team approach mandates active involvement of all care providers in the evaluation of quality care. Multidisciplinary evaluation helps promote a continuum of care for the client, from the preadmission phase to discharge planning and follow-up care.

KEY CONCEPTS

• Evaluation, the fifth step in the nursing process, involves determining whether the client goals have been met, have been partially met, or have not been met.

• The purposes of evaluation are to determine the client’s progress or lack of progress toward achievement of client objectives, to judge the value of nursing actions in helping clients to achieve objectives, to determine the health care agency’s overall ability to deliver care in an effective and efficient manner, and to promote nursing accountability.

• Evaluation is based primarily on the skills of communication and observation.

• Evaluation is a mutual, ongoing process occurring among the nurse, client, family, and other health care providers.

• The effectiveness of nursing interventions is evaluated by examination of goals and expected outcomes that provide direction for the plan of care and serve as standards by which the client’s progress is measured.

• Evaluation is an orderly process consisting of seven steps: establishing standards; collecting data related to the goals and expected outcomes; determining goal achievement; relating nursing actions to client status; judging the value of nursing interventions in assisting clients to achieve goals and objectives; reassessing the client’s status; and modifying the plan of care if necessary.

• There is a relationship between quality management and evaluation. Evaluation is necessary in the provision of quality care because it is the mechanism used by nurses in determining how to improve care.

• Structure evaluation judges a health care agency’s ability to provide the services offered to its client population.

• Process evaluation measures nursing actions by examining each phase of the nursing process to determine the effectiveness of the actions in helping clients meet expected outcomes and goals.

• Outcome evaluation compares the client’s current status with the expected outcomes and examines all direct care activities that affect the client’s status.

• A nursing audit can focus on implementation of the nursing process, client outcomes, or both in order to evaluate the quality of care provided.

• Peer evaluation (peer review) is the process by which professionals provide to their peers performance appraisal feedback geared toward corrective action.

• Evaluation enhances professional nursing accountability by providing a mechanism for assisting the nurse to define, explain, and measure the results of nursing actions.

• Evaluating the quality of care is a shared responsibility among members of the health care team.

CRITICAL THINKING ACTIVITIES

1. When does evaluation of nursing care occur?

2. Describe the three types of evaluation and compare them in terms of purpose and methodology.

3. How does evaluation promote the individual nurse’s accountability?

4. State specific ways in which a nurse can perform process evaluation.

5. What are the advantages of peer evaluation?

6. Develop criteria for conducting a nursing audit related to client safety in an extended-care facility.

NURSING CARE PLAN DEFENCE

NURSING CARE PLANS, also known as care plans, are necessary for providing care to patients in a variety of settings and for varied lengths of time, depending on the patient's condition, diagnosis and prognosis. Many different components make up a common nursing plan. Knowing the key elements found in a nursing plan and how to formulate an effective and well-thought-out plan enables nurses to provide better patient-cantered care.

INSTRUCTION

1  Write a nursing plan that takes a number of factors into consideration. For example, a nursing plan must form some sort of action or response to the patient's illness or condition. You should develop a plan of care that assesses and addresses how you plan to care for the patient in a well-thought-out process, basing your plan on facts regarding the case and the patient's current and potential problems, suggests Virtual Nurse.

2  Define the basic elements of the nursing plan in outline form. The basic elements of a nursing care plan include risk factors, rationales, interventions and outcomes, all based on the patient's diagnosis. For example, to develop a care plan for a patient diagnosed with chronic pain, your nursing outcomes may include pain control, coping measures and improved quality of life.

3  Write down possible interventions you may perform to achieve your nursing care plan goals. In a patient diagnosed with chronic pain, for example, consider possible interventions aimed at reducing pain and increasing comfort levels. Your nursing interventions may include -- but are not limited to -- pain management, education regarding managing medications, and complementary or alternative pain relief therapies such as massage, acupuncture or acupressure, heat therapy and so forth.

4  Assess the patient on a regular basis, but when creating your care plan, pay special attention to details. For example, again using the chronic-pain patient as an model, note the location of pain, the duration of the pain, the severity of the pain rated on a scale of 1 to 10, and other factors. This information-gathering process will help you focus specifically on the patient's complaint or illness and determine the best methods for increasing his comfort levels and independence.

5  Help the patient develop management strategies to deal with his chronic pain by providing education, answering questions and offering continuity of care, all details of which should be included in the care plan.

6  Evaluate the patient's progress during the treatment or observation phase of care on a continuous basis, creating easily identifiable and measurable goals throughout the period of care.

NURSING CARE PLAN CASE STUDIES

1. Mr. C. is a 57-year-old businessman who was admitted to the surgical unit for treatment of a possible strangulated inguinal hernia.

Two days ago he had a partial bowel resection. Postoperative orders include NPO, intravenous infusion of D51/2 NS at 125 cc/hr left arm, nasogastric tube to low intermittent suction. Mr. C. is in a dorsal recumbent (supine) position and is attempting to draw up his legs. He appears restless and is complaining of abdominal pain (7 on a scale of 0–10)

.Physical Examination

Height:188 cm(6′3′′)

 Weight:90.0 kg(200 lb)

 Temperature:37°C(98.6°F)

 Pulse: 90 BPM Respirations: 24/minute

 Blood pressure: 158/82 mm Hg

Skin pale and moist, pupils dilated. Midline abdominal incision, sutures dry and intact.

Diagnostic Data

Chest x-ray and urinalysis negative, WBC 12,000

2. Jane Lee is a 60-year-old retired nurse living with her husband and daughter on a farm that has been in the family for four generations.

Mrs. Lee has gained10 lb(4.5 kg) in the past few months, even though she is rarely hungry and eats much less than normal. She is always tired and weak—so tired that she has not even been able to help with the chores on the farm or do housework. She is concerned about her appearance and the way she sounds when she talks. Her face is puffy, and her tongue always feels thick. Mr. Lee convinces his wife to make an appointment at a health center in a nearby town.

ASSESSMENT

Brian Henning, RN, completes the health assessment for Mrs. Lee at the health center.He finds that she now weighs150 lb(68 kg), an increase of10 lb(4.5 kg) over her weight at her last visit 6 months earlier. Mrs. Lee states that she always feels cold, tired, and weak. She also states that she is constipated, has difficulty remembering things, and looks different. Physical assessment findings include a palpable and bilaterally enlarged thyroid; dry, yellowish skin; nonpitting edema of the face and lower legs; and slow, slurred speech.Diagnostic tests revealed the following abnormal findings: T3, 56 ng/dL (normal range: 80 to 200 ng/dL); T4, 3.1 (normal range: 5 to 12 mg/dL); TSH increased.The medical diagnosis of hypothyroidism is made, and Mrs. Lee is started on levothyroxine 0.05 mg daily.

3. Johti Singh is a 39-year-old secretary who was admitted to the hospital with an elevated temperature, fatigue, rapid, labored respirations; and mild dehydration. The nursing history reveals that Ms. Singh has had a “bad cold” for several weeks that just wouldn’t go away. She has been dieting for several months and skipping meals. Ms. Singh mentions that in addition to her fulltime job as a secretary she is attending college classes two evenings a week. She has smoked one package of cigarettes per day since she was 18 years old. Chest x-ray confirms pneumonia.

Physical Examination

Height:167.6 cm(5′6′′)

Weight:54.4 kg(120 lb)

 Temperature:39.4°C(103°F

 Pulse: 68 BP

Respirations: 24/minute

Blood pressure:118/70 mm Hg

Skin pale; cheeks flushed; chills; use of accessory muscles; inspiratory crackles with diminished breath sounds right base; expectorating thick, yellow sputum

Diagnostic Data

Chest x-ray: right lobar infiltration WBC: 14,000 pH: 7.49 PaCO2: 33 mm Hg HCO3 –: 20 mEq/L PaO2: 80 mm Hg O2 sat: 88%

4. Merlyn Chapman, a 27-year-old sales clerk, reports weakness, malaise, and flu-like symptoms for 3–4 days. Although thirsty, she is unable to tolerate fluids because of nausea and vomiting, and she has liquid stools 2–4 times per day.

Physical Examination

Height: 160 cm (5′3′′)

 Weight: 66.2 kg (146 lb)

 Mild fever: 38.6°C (101.5°F)

Pulse: 86 BPM

Respirations: 24/minute Scant urine output

 BP: 102/84 mm Hg Dry oral mucosa, furrowed tongue, cracked lips

Diagnostic Data

Urine specific gravity: 1.035 Serum sodium 155 mEq/L Serum potassium 3.2 mEq/L Chest x-ray negative.

5. Richard Wright is a 48-year-old divorced father of two teenagers. Mr.Wright has been admitted to the community hospital with ascites and malnutrition.He has had three previous hospital stays for cirrhosis, the most recent 6 months ago.

ASSESSMENT

Mr.Wright is lethargic but responds appropriately to verbal stimuli. He complains of “spitting up blood the past week or so” and says,“I’m just not hungry.” He has lost 20 lb (9 kg) since his previous admission. He is jaundiced and has petechiae and ecchymoses on his arms and legs. Liz Mowdi, Mr.Wright’s nurse, notes pitting pretibial edema. Abdominal assessment reveals a tight, protuberant abdomen with caput medusae. The liver margin is not palpable; the spleen is enlarged. Vital signs are T 100°F (37.7°C), P 110, R 24, and BP 110/70. Abnormal laboratory results include WBC 3700/mm3 (normal 4300 to 10,800/mm3); RBC 4.0 million/mm3 (normal 4.6 to 5.9 million/mm3); platelets 75,000/mm3 (normal 150,000 to 350,000/mm3); serum ammonia 105 μm/dL (normal 35 to 65 μm/dL); total bilirubin 4.9 μ g/dL (normal 0.1 to 1.0 μg/dL); and serum sodium 150 mEq/L (normal 135 to 145 mEq/L).Potassium, hemoglobin, hematocrit, total protein, and albumin levels are markedly decreased. Hepatic enzymes are elevated. Blood urea nitrogen and creatinine levels are marginally elevated. Oxygen saturation (O2 sat) is 88% (normal range: 96% to 100%) per pulse oximetry.

Endoscopy shows bleeding from gastric ulcer, and the diagnosis of alcoholic cirrhosis with gastritis is made. Mr. Wright is started on Aldactone, 25 mg PO q8h; Riopan, 30 mL 2 hr p.c. and hs; lactulose, 30 mL q h until onset of diarrhea, then 15 mL t.i.d.; and low-protein, 800 mg sodium diet; fluid restriction of 1500 mL/day

6. Rose Ortiz is a 72-year-old widow who lives alone, although close to her daughter’s home. Ms. Ortiz has mild heart failure and is being treated with digoxin (Lanoxin) 0.125 mg,furosemide (Lasix) 40 mg PO daily,and a mildly restricted sodium diet (2 g daily). For the last several weeks, Ms. Ortiz has complained that she feels weak and sometimes faint, light-headed, and dizzy. Serum electrolyte tests ordered by her physician reveal a potassium level of 2.4 mEq/L. Potassium chloride solution (Kaochlor 10%, 20 mEq/15 mL) PO twice daily is prescribed, and Ms. Ortiz is referred to Nancy Walters, RN, for follow-up care.

ASSESSMENT

Ms. Ortiz’s health history reveals that she has rigidly adhered to her sodium-restricted diet and has been compliant in taking her prescribed medications, with the exception of occasionally taking an additional “water pill”when her ankles swell. She takes a laxative every evening to ensure a daily bowel movement. She states that she is reluctant to take the potassium chloride the doctor has ordered because her neighbor complains that his potassium supplement upsets his stomach. Physical assessment findings included T 98.4, P 70, R 20, and BP 138/84. Muscle strength in her upper extremities is normal and equal;lower extremity strength is weak but equal. Sensation is normal.

7. Margaret Spezia is a married, 49-year-old Italian American with eight children whose ages range from 3 to 18 years. For the past 2 months, Mrs. Spezia has  had frequent morning headaches, and occasional dizziness and blurred vision. At her annual physical examination 1 month ago, her blood pressure was 168/104 and 156/94.She was instructed to reduce her fat and cholesterol intake, to avoid using salt at the table,and to start walking for 30 to 45 minutes daily.Mrs.Spezia returns to the clinic for follow-up.

ASSESSMENT

While escorting Mrs. Spezia to the exam room and obtaining her weight,blood pressure,and history, Lisa Christos,RN, notices that Mrs. Spezia seems restless and upset.Ms.Christos says,“You look upset about something. Is everything OK?”Mrs. Spezia responds, “Well,my head is throbbing, and I’m sort of dizzy. I think I’m just overdoing it and not getting enough rest. You know, raising eight children is a lot of work and expense. I just started working part time so we wouldn’t get behind in our bills. I thought the extra money might relieve some of my stress, but I’m not so sure that’s really happening. I’m not getting any better and I’m worried that I’ll lose my job or become disabled and that my husband won’t be able to manage the children by himself. I really need to go home, but first, I want to get rid of this awful headache.Would you please get me a couple of aspirin or something?”

Mrs. Spezia’s history shows a steady weight gain over the past 18 years. She has no known family history of hypertension. Physical findings include height 63 inches (160 cm), weight 225 lb (102 kg),T 99° F (37.2° C),P 100 regular, R 16, BP 180/115 (lying), 170/110 (sitting), 165/105 (standing), average 10-point difference in readings between right and left arm (lower on left). Skin cool and dry, capillary refill 4 seconds right hand, 3 seconds left hand.Mrs. Spezia’s total serum cholesterol is 245 mg/dL (normal < 200 mg/dL). All other blood and urine studies are within normal limits. Based on analysis of the data,Mrs. Spezia is started on enalapril 5 mg and hydrochlorothiazide 12.5 mg in a combination drug (Vaseretic), and placed on a low-fat low-cholesterol, no-added-salt diet.

8. Mr. John Baker is a 68-year-old shopkeeper who was admitted to the hospital with urinary retention, hematuria, and fever. The admitting nurse gathers the following information when taking a nursing history. Mr. Baker states he has noticed urinary frequency during the day for the past 2 weeks, and that he doesn’t feel he has emptied his bladder after urinating. He also has to get up two or three times during the night to urinate. During the past few days, he has had difficulty starting urination and dribbles afterward.

He verbalizes the embarrassment his urinary problems cause in his dealings with the public. Mr. Baker is concerned about the cause of this urinary problem. He is diagnosed with benign prostatic hypertrophy (BPH) and referred to a urologist who suggests a transurethral resection of the prostate (TURP) in several months. He is placed on antibiotic therapy.

Physical Examination

Height: 185.4 cm (6′2′′)

Weight: 85.7 kg (189 lb)

Temperature: 38.1°C (100.6°F)

Pulse: 88 BPM

Respirations: 20/minute

Blood pressure: 146/86 mm Hg

Catheterization for urinary retention yielded 300 mL amber urine,

 Foley left in place for 2 days

Diagnostic Data

CBC normal; urinalysis: amber, clear, pH 6.5, specific gravity 1.025, negative for glucose, protein, ketone, RBCs, and bacteria; IVP: evidence of enlarged prostate gland

9. Ruby Smithson is a 55-year-old mother of four children who is hospitalized with breast cancer. She is scheduled for a modified radical mastectomy. Ruby was relatively healthy until she found a lump in her right breast 1 week ago. She and her husband are extremely anxious about the surgery. Ruby confides to the admitting nurse that “I can’t stand the idea of having one of my breasts cut off; I don’t know how I’m going to be able to even look at myself.” Mr. Smithson informs the nurse that Ruby has been abusing alcohol since her diagnosis and neglecting her responsibilities as a mother. She is tearful and doesn’t see how she will be able to continue her work as a dress designer.

Physical Examination

Height: 164 cm (5′5′′)

Weight: 58 kg (158 lb)

Temperature: 37ºC (98.6ºF)

Pulse rate: 88 BPM

Respirations: 16/minute

Blood pressure: 142/88 mm Hg

Diagnostic Data

Chest x-ray negative, CBC, and urinalysis within normal limits.

10. Roseline Ukoha is a 45-year-old married school teacher who has two children. For the past 2 days, she has experienced intermittent abdominal pain and bloating.The pain increased in severity over the past 9 to 10 hours, and she developed nausea, lower back pain, and discomfort radiating into the perineal region.Mrs.Ukoha reports having had no bowel movement for the past 2 days.The emergency department nurse, Jasmine Sarino, RN, completes her admission assessment.

ASSESSMENT

Mrs. Ukoha relates a 10-year history of chronic irritable bowel symptoms, including alternating constipation and diarrhea and intermittent abdominal cramping. She states that she thought these symptoms were due to the stress of teaching middle school, and that they never became severe enough to seek medical advice.

When questioned about her diet, she calls it a typical American high-fat, fast-food diet,usually consisting of a sweet roll and coffee for breakfast, a hamburger or sandwich and soft drink for lunch, and a balanced dinner, usually including meat, a vegetable or salad, and potatoes or pasta,“except on pizza night!” Physical assessment findings include T 101°F (38.3°C), P 92, R 24, and BP 118/70. Abdomen is slightly distended and tender to light palpation. Bowel sounds are diminished.Diagnostic tests include the following abnormal results: WBC 19,900/mm3 (normal 3500 to 11,000/mm3) with increased immature and mature neutrophils on differential; hemoglobin 12.8 g/dL (normal 13.3 to 17.7 g/dL); hematocrit, 37.1% (normal 40% to 52%). Abdominal X-ray films show slight to moderate distention of the large and small bowel with suggestion of possible early ileus. A small amount of free air is noted in the peritoneal cavity. The diagnosis of probable diverticulitis with diverticular rupture is made,and Mrs.Ukoha is admitted to the medical unit for intravenous fluids, antibiotic therapy, and bowel rest.

11. Mrs. Opal Hipps, age 75, lives alone with her dog, Chester, in her family home in the suburbs. She retired from her job as a postal clerk 10 years ago and now spends a lot of time reading and watching television. Over the past week she has developed a vague aching pain in her right leg. She ignored the pain until last night when it developed into a much more severe pain in her right calf. She noticed that her right lower leg seemed larger than the left,and it was very tender to the touch.After seeing her physician and undergoing Doppler ultrasound studies, Mrs. Hipps is admitted to the hospital with the diagnosis of deep vein thrombosis in the right leg. She is placed on bed rest, and intravenous heparin. Michael Cookson, RN, is assigned to admit and care for Mrs. Hipps.

ASSESSMENT

Mr. Cookson notices that Mrs. Hipps was admitted 14 months ago for repair of a fractured femur. Mrs. Hipps says, “This business about a blood clot really has me worried.”She also tells Mr. Cookson that she is worried about who will care for her dog while she is in the hospital. Physical findings include: height 62 inches (157 cm), weight 149 lb (68 kg), T 99.2 F (37.3°C); vital signs within normal limits otherwise. Her left leg is warm and pink, with strong peripheral pulses and good capillary refill. Her right calf is dark red, very warm, and dry to touch. It is tender to palpation. The right femoral and popliteal pulses are strong, but the pedal and posterior tibial pulses are difficult to locate. The right calf diameter is 0.5 inch (1.27 cm) larger than the left.

12. Kirsten Avis,a 44-year-old homemaker and mother of two teenage sons,was diagnosed with myasthenia gravis 2 years ago.She takes an anticholinesterase medication,pyridostigmine (Mestinon),four times a day. Over the past month she has been experimenting with decreasing the dose of her pyridostigmine because she has “felt so good.” She was prescribed 60 mg of pyridostigmine three times a day before meals and one-half of a long-acting 180 mg pyridostigmine tablet at night.

Three days ago, she began having chills and fever and her myasthenic symptoms became markedly worse.Mrs.Avis is easily fatigued and has been experiencing increasing weakness, bilateral ptosis, and mild dysphagia in the late afternoon and evenings.

ASSESSMENT

Lela Silva, RN, is caring for Mrs. Avis. Physical examination of Mrs. Avis reveals severe muscle weakness bilaterally in her hands, arms, and thorax. Her voice is nasal, and she speaks slowly; the longer she speaks, the more difficult it becomes to understand her. She is anxious and dyspneic.Her complaints of weakness,dysphagia, dysarthria, problems with mobility, and ptosis are more pronounced later in the day.Vital signs are as follows: BP 138/88, P 88, R 28, T 102.4°F (39°C).

Some improvement in muscle weakness is noted following a restful night’s sleep; however, the respiratory distress is more evident, and Mrs. Avis is increasingly restless. She is moved to the intensive care unit for advanced monitoring and possible ventilatory assistance.The medical diagnosis is myasthenic crisis secondary to pulmonary infection.

13. Sean O’Donnell is a 47-year-old police officer who lives and works in a metropolitan area.Mr. O’Donnell has had “heartburn” and abdominal discomfort for years, but thought it went along with his job. Last year, after becoming weak, light-headed, and short of breath, he was found to be anemic and was diagnosed as having a duodenal ulcer. He took omeprazole (Prilosec) and ferrous sulfate for 3 months before stopping both, saying he had “never felt better in his life.”Mr. O’Donnell has now been admitted to the hospital with active upper GI bleeding.

ASSESSMENT

Rachel Clark is Mr.O’Donnell’s admitting nurse and case manager. On initial assessment, Mr. O’Donnell is alert and oriented, though very apprehensive about his condition. Skin pale and cool; BP 136/78, P 98; abdomen distended and tender with hyperactive bowel sounds; 200 mL bright red blood obtained on nasogastric tube insertion. Hemoglobin 8.2 g/dL and hematocrit 23% on admission.

Mr. O’Donnell is taken to the endoscopy lab where his bleeding is controlled using laser photocoagulation.On his return to the nursing unit,he receives two units of packed red blood cells and intravenous fluids to restore blood volume. A 5-day course of high-dose oral omeprazole (40 mg bid) is ordered to prevent rebleeding, and Mr. O’Donnell is allowed to begin a clear liquid diet 24 hours after his endoscopy. Tissue biopsy obtained during endoscopy confirms the presence of H.pylori infection

14. Janet Cirit, a 33-year-old legal secretary, lives in a suburban midwestern community. She is unmarried but dating a man named Jim Adkins, who lives in an adjacent suburb. Ms. Cirit visits her gynecologist because her peri ods have become irregular and she is experiencing pelvic pain and an abnormal amount of vaginal discharge. Recently she has developed a sore throat. The pelvic pain has begun to disrupt her sleeping pattern, and she is concerned that she might have cancer because her mother recently died of ovarian cancer.

ASSESSMENT

When Ms. Cirit arrives for her appointment at the gynecologist’s office, Marsha Davidson, the nurse practitioner, interviews her. Ms. Davidson completes a thorough medical and sexual history, including questions about her menstrual periods, pain associated with urination or sexual intercourse, urinary frequency,most recent Pap smear, birth control method, history of STI and drug use, and types of sexual activity. Ms. Cirit reports her symptoms and her concern about ovarian cancer. She also indicates that she is taking oral contraceptives and therefore sees no need for her boyfriend to use a condom because she believes their relationship is monogamous.

Physical examination reveals both pharyngeal and cervical inflammation, and lower abdominal tenderness.Her temperature is 98.5°F (37.0°C).There are no signs or symptoms of pregnancy.

The gynecologist orders a Pap smear and cultures of the cervix, urethra, and pharynx to evaluate for gonorrhea and chlamydial infection. Blood is drawn for WBC. Test results are positive for gonorrhea  and negative for chlamydia. The WBC is slightly elevated, indicating possible salpingitis. Because Mr. Adkins has been Ms.Cirit’s only sexual partner, it is clear that he is the source of infection and needs to be treated as well.

15. Martha Overbeck is a 74-year-old widow of German descent who ives alone in a senior citizens’ housing complex. She is active there, as well as in the Lutheran Church. She has been in good health and is independent,but she has become progressively less active as a result of arthritic pain and stiffness.Mrs.Overbeck has degenerative joint changes that have particularly affected her right hip.On the recommendation of her physician and following a discussion with her friends,Mrs.Overbeck has been admitted to the hospital for an elective right total hip replacement. Her surgery has been scheduled for 8:00 A.M.the following day.

Mrs. Eva Jackson, a close friend and neighbor, accompanies Mrs. Overbeck to the hospital. Mrs. Overbeck explains that her friend will help in her home and assist her with the wound care and prescribed exercises.

ASSESSMENT

Gloria Nobis, RN, is assigned to Mrs. Overbeck’s care on return to her room.Ms.Nobis performs a complete head-to-toe assessment and determines that Mrs. Overbeck is drowsy but oriented. Her skin is pale and slightly cool.Mrs.Overbeck states she is cold and requests additional covers. Ms. Nobis places a warmed cotton blanket next to Mrs.Overbeck’s body, adds another blanket to her covers, and adjusts the room’s thermostat to increase the room temperature.Mrs.Overbeck states that she is in no pain and would like to sleep. She has even, unlabored respirations and stable vital signs as compared to preoperative readings.  Mrs. Overbeck is NPO. An intravenous solution of dextrose and water is infusing at 100 mL/h per infusion pump.No redness or edema is noted at the infusion site.Ms. Nobis notes that the antibiotic ciprofloxacin hydrochloride (Cipro) is to be administered by mouth when the client is able to tolerate fluids. Mrs. Overbeck has a large gauze dressing over her right upper lateral thigh and hip with no indications of drainage from the wound. Tubing protrudes from the distal end of the dressing and is attached to a passive suctioning device (Hemovac).Ms. Nobis empties 50 mL of dark red drainage from the suctioning device and records the amount and characteristics on a flow record. Mrs. Overbeck has a Foley catheter in place with 250 mL of clear, light amber urine in the dependent gravity drainage bag. When assessing Mrs. Overbeck’s lower extremities, Ms. Nobis finds her feet slightly cool and pale with rapid capillary refill time bilaterally.Dorsalis pedis and posterior tibial pulses are strong and equal bilaterally.Ms.Nobis notes slight pitting edema in the right foot and ankle as compared with the left extremity.She also notes sensation and ability to move both feet and toes,without numbness or tingling (paresthesia).

Ms. Nobis records the above findings on a postoperative flowsheet.After ensuring thatMrs.Overbeck is safely positioned and can reach her call light, Ms. Nobis gives Mrs. Overbeck’s friend, Mrs. Jackson, a progress report.They then go ntoMrs.Overbeck’s room

16. Rachel Clemments is a 42-year-old mother of two, Sarah, age 12, and Jennifer, age 18. Because of a family history of breast cancer, she has been closely monitored (annual mammograms and clinical breast examination, monthly BSE, a needle aspiration biopsy with negative findings) for 4 years prior to her diagnosis. Mrs. Clemments discovers a lump in her left breast during her monthly BSE. An incisional biopsy reveals invasive lobular carcinoma in the left breast. Mrs. Clemments is debating whether to have reconstructive breast surgery. Her oncologist has recommended a 6-month course of adjuvant chemotherapy, and she is concerned about side effects. One of her greatest concerns is how her illness will affect her ability to support and care for her daughters.She is afraid that recovering from the mastectomy and completing the chemotherapy regimen will limit her ability to keep her part-time job, complete her academic work, and continue to meet the needs of her daughters.Also, this breast cancer diagnosis seems part of the family legacy. She wonders, “When will it happen to Jennifer? To Sarah?”

ASSESSMENT

During the history, Laura Nelson, RN, the nurse admitting Mrs.Clemments, learns that her mother, two of her aunts,and one sister had been diagnosed with breast cancer. Her mother and one of the aunts died before age 45. Physical assessment findings include T 98.5°F (37.0°C), BP 110/62, P 65, R 14.Her weight is 120 lb (54 kg); she is 66 inches (168 cm) tall. Modified radical mastectomy is performed; histologic examination shows a 3 cm tumor; axillary node dissection shows that 4 of 16 lymph nodes are positive.

17. Mr. C. is a 57-year-old businessman who was admitted to the surgical unit for treatment of a possible strangulated inguinal hernia. Two days ago he had a partial bowel resection. Postoperative orders include NPO, intravenous infusion of D51/2 NS at 125 cc/hr left arm, nasogastric tube to low intermittent suction. Mr. C. is in a dorsal recumbent (supine) position and is attempting to draw up his legs. He appears restless and is complaining of abdominal pain (7 on a scale of 0–10)..

 Nursing Assessment Physical Examination

Height: 188 cm (6′ 3′′)

Weight: 90.0 kg (200 lb)

 Temperature: 37°C (98.6°F)

Pulse: 90 BPM

Respirations: 24/minute

Blood pressure: 158/82 mm Hg

Skin pale and moist, pupils dilated. Midline abdominal incision, sutures dry and intact. Diagnostic Data Chest x-ray and urinalysis negative, WBC 12,000

18. Janet Carlson is a 19-year-old college student who lives with her parents and one younger sister.Although Janet had seizures while she was in grade school, they have been controlled with medication.However, she had a tonic-clonic seizure yesterday and immediately made an appointment with her family physician.She is currently taking phenytoin (Dilantin) 300 mg/day as a maintenance medication to prevent seizures.

ASSESSMENT

Evita Farias, RN, completes a health history for Ms.Carlson.During the history, she tells Ms. Farias that she has been under stress because of difficulties in completing her course requirements this semester. She has not been sleeping as many hours per night, and sometimes she forgets to take her medication. Janet’s serum phenytoin level is 8 mg/mL.Therapeutic level is 10 to 20 mg/ml.

19. JB is a 19-year-old African American man exhibiting symptoms of schizophrenia for the first time.  His parents brought him to the hospital after he was brought home for spring break. He is a freshman at college and is attending on an academic scholarship. He is the oldest child of three and is the first in his family to go to college. His father is a foreman at the local auto plant, and his mother is a receptionist for a physician. His father’s insurance plan allows for a 15-day stay for mental health services.

JB has always been a quiet, hard worker with a small circle of friends. His first semester was a lonely one, with disappointing grades. Although he was not at risk to fail out of school, he was at risk of losing his scholarship. At Christmas time, JB was quieter than usual but participated in family activities without prodding. When grandparents, aunts, and uncles asked him about school he was distracted and answered simply that it was fine. His parents returned him to school with some anxiety but thought it was just a difficult adjustment being away from home for the first time.

When his parents picked him up for spring break he was disheveled and had not bathed. His side of the dorm room was covered with small pieces of taped paper with single words on them. The words made no sense but JB stated that he put them there “to organize (his) thoughts.” His roommate informed his parents that this behavior started about the same time JB began staying in the room and skipping classes and meals.

JB agreed to leave with his parents only after they agreed to take everything home with them. As they packed his belongings, JB sat in the corner of his bed listening to his compact disk player. When his parents asked him what was happening, he merely said, “I have the power.” On the way home JB responded to their questions by saying his professors were trying to take away what he knew. He sat huddled in the back seat of the car with his coat over his head. He laughed and mumbled in response to nothing his parents could hear.

SETTING:  INTENSIVE CARE PSYCHIATRIC UNIT/GENERAL HOSPITAL

BASELINE ASSESSMENT:  This is the first admission for JB, a 19-year-old single African American college student who has not slept for 4 days and is frightened with wide-eyed hypervigilance, pacing, and periods of extended immobility. Is vague about past drug use. Parents do not believe he has used drugs. He appears to be hallucinating, conversing as if someone is in the room. At times he says he is receiving instructions from “the power.”  He is unable to write, speak, or think coherently. He is disoriented to time and place and is confused. JB is 6’1”, 155 lb, thin in appearance, but normally developed. Lab values are within normal limits except Hgb, 10.2 and Hct, 32. He has not eaten for several days.

Associated Psychiatric Diagnosis

Medications

Axis I Schizophrenia, catatonic type

Axis II None

Axis III None

Axis IV Educational problems (failing)

Social problems (withdrawn from social contacts)

Axis V GAF Current = 25

Potential = ?

Risperidone (Risperdal) 2 mg bid then titrate to 3 mg bid if needed

Lorazepam (Activan) 2 mg PO or IM PRN IM for agitation

20. Ruby Smithson is a 55-year-old mother of four children who is hospitalized with breast cancer. She is scheduled for a modified radical mastectomy. Ruby was relatively healthy until she found a lump in her right breast 1 week ago. She and her husband are extremely anxious about the surgery. Ruby confides to the admitting nurse that “I can’t stand the idea of having one of my breasts cut off; I don’t know how I’m going to be able to even look at myself.” Mr. Smithson informs the nurse that Ruby has been abusing alcohol since her diagnosis and neglecting her responsibilities as a mother. She is tearful and doesn’t see how she will be able to continue her work as a dress designer.

Nursing Assessment Physical Examination

Height: 164 cm (5′5′′)

Weight: 58 kg (158 lb)

Temperature: 37ºC (98.6ºF)

Pulse rate: 88 BPM

Respirations: 16/minute

Blood pressure: 142/88 mm Hg

Diagnostic Data

Chest x-ray negative, CBC, and urinalysis within normal limits

21. Orville Boren is a 68-year-old African American who had a stroke due to right cerebral thrombosis 1 week ago. He is a history instructor at the local community college. His hobbies are wood carving and gardening.Mr. Boren is also an active member of his church.For the past 2 years,Mr.Boren has been taking medication for hypertension, but his wife Emily reports that he often forgets to take it and that his blood pressure was high at his last physical examination. Mrs. Boren tells the staff that she has never had to worry about her husband’s health before and that she wants to learn everything she can to care for him at home. However, she says that her husband was always the one to make the decisions and pay the bills.Mrs. Boren adds that all the children, grandchildren, neighbors, and family pastor want to see Mr. Boren back at home as soon as possible.

ASSESSMENT

Carol Merck, RN, the nurse assigned to Mr. Boren, completes a health history and physical assessment,with Mrs. Boren providing information for the history.Mrs. Boren reports that her husband did have several spells of dizziness and blurred vision the week before his stroke,but they lasted only a few minutes and he believed them to be due to “old age and working out in the sun.” On the morning of admission,Mr. Boren woke up and could not move his left arm or leg; he also could not speak sensibly. Mrs. Boren called 911, and an ambulance took her husband to the hospital.

Physical assessment findings include the following:Mr.Boren is drowsy but responds to verbal stimuli. Although he does not respond verbally, he can nod his head to indicate “yes”when asked questions. Flaccid paralysis is present in his left arm and left leg, with no response noted to touch in those extremities (he is lefthanded). Visual fields are decreased in a pattern consistent with homonymous hemianopia.A CT scan,negative on admission, is repeated on the third day after admission and confirms the medical diagnosis of a right-brain stroke due to a thrombus of the middle cerebral artery.

Mr.Boren’s medical treatment includes heparin sodium administered by continuous intravenous drip,with clotting studies to be performed every 4 hours and the dose adjusted accordingly.

22. Betty Friedman is a 25-year-old grade-school teacher.Her friends and the other teachers regard Ms. Friedman as an enthusiastic person who sets high standards for herself and strives for perfection.During the spring semester,Ms. Friedman begins to miss work and sometimes appears very nervous. One day, another teacher notices Ms.Friedman running down the hall and into the restroom; the teacher finds Ms. Friedman vomiting. As she washes up,Ms.Friedman tells the other teacher that she has been having headaches since she began menstruating, but that they have never been as intense and frequent as during this past year.

They even wake her from her sleep.Ms. Friedman agrees to see the nurse practitioner, Jane Schickadanz, at the school clinic for evaluation.

ASSESSMENT

During her health history, Ms. Friedman relates that each month before her menstrual cycle she becomes nervous and sees flashing lights. She also has difficulty expressing herself and thinking clearly. The next day she develops a “sick headache.” She states that the headache can last 1 to 2 days and that afterwards she cannot brush her hair because her scalp hurts.Ms. Friedman attributes these symptoms to PMS and adds that she thinks she is allergic to cheese and nuts because she gets very sick after eating them. After assessment, and in consultation with the physician,Ms.Schickadanz diagnoses Ms. Friedman’s problem as a migraine with aura headache.Sumatriptan succinate (Imitrex) injections are prescribed.

23. Lila Rainey is an 80-year-old widow who lives alone in the house she and her late husband built 50 years ago.She has worn glasses for nearsightedness since she was a young girl and was diagnosed 4 years ago with chronic open-angle glaucoma, for which she takes timolol maleate (Timoptic) 0.5%. Recently she has noticed difficulty reading and watching television despite a new lens prescription. She has stopped driving at night because the glare of oncoming headlights makes it difficult for her to see.Mrs.Rainey’s ophthalmologist has told her that she has cataracts but that they do not need to come out until they bother her.Although her glaucoma is still controlled with timolol maleate 0.5%,one drop in each eye twice a day, her intraocular pressure measurements have been gradually increasing. Mrs. Rainey has taken 325 mg of aspirin daily since a TIA 8 years ago. She is being admitted to the outpatient surgery unit for a cataract removal and intraocular lens implant in her right eye.

ASSESSMENT

Mrs. Rainey is admitted to the eye surgery unit by Susan Schafer, RN. In her assessment,Ms.Schafer finds Mrs.Rainey to be alert and oriented, though apprehensive about her upcoming surgery. Assessment findings include BP 134/72, P 86, R 18. Mrs. Rainey’s neurologic, respiratory, cardiovascular, and abdominal assessments are essentially normal.Her pupils are round and equal, and

react briskly to light and accommodation. Her conjunctivae are pink; sclera and corneas, clear. Using the ophthalmoscope, Ms. Schafer notes that the red reflex in Mrs. Rainey’s right eye is diminished.Ophthalmic examination shows visual acuity of 20/150 OD (right eye) and 20/50 OS (left eye) with corrective lenses. Her intraocular pressures are 21 mmHg OD and 17 mmHg OS.On fundoscopic exam, no disease of the blood vessels, retina,macula, or disc is found. Ms. Schafer reviews the operative procedure with Mrs. Rainey, answering her questions and telling her what to expect after surgery.Following preoperative protocols,Mrs.Rainey is prepared and transported to surgery.

24. G.B. is an intelligent, confident, 5 feet and 4 inches tall, ABO B+, 28-year-old Caucasian female patient: G1P1, LMP is February 2, 2006, EDC is November 18, 2006 and gestation of 396/7 weeks confirmed by an ultrasound per chart. Pre-pregnancy weight was 137 lbs and pregnancy weight is 174 lbs for a total gain of 37 pounds. G.B. stated she eats a “semi-strict vegetarian diet” (no dairy, no red meat), rarely drinks alcohol (no alcohol while pregnant), and she has never smoked cigarettes or taken recreational drugs. Prenatal labs are negative. G.B. was admitted to GAMC after an attempted home birth via midwife assistance with intact membranes at 0710 hrs on November 16, 2006. The patient stated her cervix dilated to “only 3 cm after laboring over 24 hours at home”. G.B. stated she prepared for labor and delivery by learning the Bradley method and she hired a doula for the postpartum period. G.B. plans on breastfeeding her neonate for at least 1 year. She is allergic to penicillin, amoxicillin, and erythromycin. Significant medical history includes systemic lupus erythematosus (SLE), past positive PPD and negative xray within last 5 years, and adenomyosis (endometriosis interna) via laparoscopy in 2002 per chart. No significant family medical history. G.B.’s supportive, caring, and protective husband was at bedside throughout the labor and delivery and postpartum.

     IV Lactated Ringers 1000 mL at 125 mL/hr and external fetal monitoring was initiated shortly after admission. Throughout the labor phases, there were several accelerations, but no late decelerations of the FHR per chart. G.B. was placed on continuous epidural of Fentanyl, 0.2% Noropin and 0.25% Marcaine at 14 mL/hr for pain at 4 cm dilation. A stress dose of 100 mg of hydrocortisone was given IM at 5 cm dilation. An AROM was performed at 1815hrs resulting in clear amniotic fluid and negative meconium stain. The fetus was in vertex presentation and LOA position. A right mediolateral 2° episiotomy was performed before a normal spontaneous vaginal delivery without maneuvers or complications. A healthy male neonate was delivered at 0054hrs on November 17, 2006: birth weight 3203 gr (7.1 ½ oz), length 51 cm (21 in) and APGARs 81 and 95. The umbilical cord had 2 arteries and 1 vein. The placenta was delivered intact and spontaneously with minimal assistance. Estimated maternal blood loss was 200 mL. After bulb suctioning, the newborn was transferred to the nursery.

         The mother and newborn bonded very well after birth per chart. G.B.’s IV in her left forearm and Foley catheter were immediately discontinued per the patient’s request. The parents refused PKU and signed a state refusal form. The parents also denied the initial bath, “eyes and thighs” (erythromycin eye ointment and Vitamin K injection), and hospital photographs of the newborn per chart. The parents are allowing a hearing test to be conducted in the afternoon per patient. According to the night RN, no one has visited with the new parents yet, but the mother-in-law is coming to visit in the afternoon to allow the husband to rest per the patient.

Assessment

Subjective Data: The patient complains of feeling slightly dizzy while sitting, an increase of dizziness upon standing, and she is experiencing tinnitus “whistling, ringing and loud whooshing like a jet engine” in her ears bilaterally. The patient denies history of tinnitus, balance problems, or syncope. Pain scale is 3/10 in uteral and perineal areas. The patient stated she has not yet experienced any flatulence after the birth of her son. G.B. stated she already experiences the letdown (milk ejection) reflex whenever her son cries and he “breastfeeds often and heartily”.

Objective Data: Prior to my assessment, the mother was gazing, smiling, and talking softly to her newborn and seemed slightly reluctant to give the newborn to the father in order for me to perform an assessment. The father looks tired as he holds the newborn closely and fondly. The father smiles at his son when he opens his eyes and excitedly informs his wife. The patient’s vital signs are WNL: oral temperature is 36.8°C (98.2°F), apical pulse is 60, respirations are 20, and blood pressure is 110/60. Lung sounds are clear bilaterally. The trachea is midline, respirations are regular and symmetrical on room air, and there is no use of accessory muscles. S1 and S2 are present, rhythm is regular and there are no murmurs, clicks, thrills, or heaves. Radial, femoral, popliteal, pedal pulses are 2+ bilaterally and cap refill <3 seconds on all digits. Skin is slightly pale, warm, and dry. No edema in the lower extremities bilaterally.

BUBBLE-HE: Breasts are semi-soft, non-tender without any erythema or areas of increased warmth. Nipples are not inverted bilaterally. The fundus of the uterus is firm, centered, and located 1.5 finger breadths below the umbilicus. Facial grimacing and furrowed brows occur upon brief, gentle palpation of fundus. The bladder is not distended or palpable. G.B. has voided a total of 450 ml of clear, yellow urine this morning. The last bowel movement was November 16, 2006 per patient. Bowel sounds are hypoactive in all 4 quadrants. Abdomen is soft, non-tender, and rounded. Lochia rubra is scant, without clots or odor. RML 2° episiotomy is intact without erythema or edema. There are no visible hemorrhoids. Homan’s sign is negative bilaterally. Upon gentle palpation bilaterally of the posterior lower extremities, there are no areas of  warmth, tenderness or swelling. Emotional issues are G.B.’s deep, deep desire to control her environment and the disappointment of not adhering to her well-researched birthing plan. The patient is bonding very well to her newborn and enjoys watching her husband bond with their newborn too. 

Pertinent Labs

Laboratory

11/17/2006

0950hrs

11/16/2006

0700hrs

Before / During

Pregnancy

MS Text

Hematology

WBC

H 20.2

H 11.9

4.5-10 /  5-15

HGB

L 10.8

   12.7

10-14  /  12-16

HCT

L 32.5

    37.0

37-47 %  /  32-42 %

RBC, MCV, MCH, MCHC, RDW, PLT, PLT Est., MPV                              WNL

Differential Type

Neuts %

H  83

*3-7

Lymphs %

L  12

38-46 %  /  15-40 %

Abs Neut Count

       H    9.877

*1.5-8

Bands%, Monos%, Eos%, Basos%, Abs Eos Ct, Nucleated RBCs, RBC Morph                 WNL

Chemistry

Chloride

H 108

*96-106

Random Glucose

H 170

*60-110

BUN/Creatinine Ratio

L 10.0

*10:1-20:1

Calcium

L   7.7

*8.8-10.4

Sodium, Potassium, CO2, Anion Gap, BUN, Creatinine, GFR                        WNL

Blood Bank

Band Pt, Hold Tube in Blood Bank

Drawn @ 2311hrs

*Fischbach’s Lab & Diagnostic Book Values for Adult Norms

Lab Results: Neutrophilia observed during labor and early postpartum is caused by the physiologic response to the stress of labor and delivery (London, Ladewig, Ball & Bindler, 2007). Lymphopenia can occur in SLE and long-term hydrocortisone therapy (Fischbach, 2004). Low hemoglobin and hematocrit (H&H) can reflect the condition of physiologic or relative anemia due to blood loss during delivery (London, et. al., 2007). High chloride levels can be caused by dehydration and long term hydrocortisone therapy (Mann, D. and Chang, L., 2006). The patient requested to discontinue her IV post delivery which probably contributed to a dehydrated state. Hyperglycemia can cause glucosuria which causes an increase in urine output (Fischbach, 2004) and can result from being pregnant (slight elevation) and long-term hydrocortisone therapy. SLE required a stress dose of 100 mg hydrocortisone IM before delivery per chart. The patient’s dizziness may be also related to hyperglycemia (Fischbach, 2004). Decreased BUN/creatinine ratio can be caused by the state of pregnancy and a low-protein diet (Fischbach, 2004). Low calcium levels can be caused by not receiving enough calcium in the diet (Fischbach, 2004).

25. Sara Lu is a 26-year-old elementary school teacher who lives with her parents and two younger sisters.Ms.Lu is very close to her parents and sisters; they share everything with each other.During the required physical for admission to graduate school,Ms.Lu tells her physician that lately she has felt fatigued. She also states that she has had a persistent sore throat, intermittent bouts of diarrhea, and mild shortness of breath for about a month.She takes no routine medications other than a daily multivitamin and an occasional acetaminophen tablet for a headache. She is active in a drama club in her community, and she jogs 3 miles three to four times a week.She is engaged to be married;her wedding date is 6 months away. Her fiancé is the only person with whom she has had sexual relations.Her sexual activity has been unprotected.Ms. Lu has a history of open heart surgery 7 years ago to correct a congenital valve defect. She has been physically healthy since that time, until about a month or two ago. The physician orders a mononucleosis test, enzyme-linked immunosorbent assay (ELISA),Western blot analysis,CD4 T-cell count, a p24 antigen test, and an erythrocyte sedimentation rate (ESR). She has been asked to return in 1 week for follow-up.

ASSESSMENT

On Ms. Lu’s follow-up visit,Carole Kee, RN, obtains her nursing history.Ms. Lu continues to have flulike symptoms but has improved somewhat. She states that she just has not been as active as usual and is worried about her health. Her appetite has decreased because of soreness in her mouth, and she has noted some whitish patches on her tongue and cheeks.

A chest X-ray film reveals no abnormality.The results of her laboratory tests are as follows:

•ELISA:positive for antibodies against HIV

•Western blot analysis: positive for antibodies against HIV

•p24 antigen test: positive for circulating HIV antigens

•ESR:increased to 25 mm/h (normal for women is 15 to 20 mm/h; normal for men is 10 to 15 mm/h) mm/h; normal for men is 10 to 15 mm/h)

•CD4 T-cell count: 599/mm3 (normal range is 600 to 1200 mm3) Ms. Lu’s physical examination reveals that she has enlarged lymph nodes in her neck and white patches on her oral mucosa. Her skin is warm to the touch. Her vital signs are as follows: T 99.9°F (37.7°C), P 84, R 20, and BP 120/78.

Ms.Lu is told of the results of her laboratory tests and the medical diagnosis of HIV infection.Ms. Lu is obviously distressed and wants to know how this happened, its meaning,whether she has infected her loved ones, and whether she will get better.

26. Harry Facée, age 53, arrives at a metropolitan public health clinic complaining of aching chest pain that has lasted for the past few days.He says that his sputum also is bloody.He is afraid he might have lung cancer, so he came in to see a doctor.

ASSESSMENT

Raj Kamil,RN, the public health nurse at the clinic,obtains an admission history and physical examination of Mr. Facée.Mr. Kamil notes that Mr. Facée is a homeless person who has lived on the streets and in various shelters for the past “10 years or so.” He usually prefers to sleep outdoors, taking refuge in shelters only during very cold or very wet weather.He has a small disability in come, but usually scrounges for food or eats with other homeless people at soup kitchens.Mr. Facée states that he has had a cough for a long time, which has become worse recently. It is now productive, especially in the mornings. He also admits that he has recently been waking up drenched with sweat in the middle of the night and is more tired than usual. Although Mr. Facée’s clothes are tattered, he is fairly clean. He answers questions appropriately and intelligently.Mr. Kamil does not detect any odor of alcohol on his breath. He is very thin, almost emaciated.

 Mr. Facée’s vital signs are

BP 152/86,

P 92, R 20,

and T 100.2°F (37.8°C).

Suspecting tuberculosis,Mr.Kamil obtains a sputum specimen for Gram stain and culture,administers a tuberculin test,and sends Mr. Facée for a chest X-ray before he sees the clinic physician.

Although the chest X-ray is inconclusive, the Gram stain is positive for acid-fast bacilli. The diagnosis of probable active pulmonary tuberculosis is made. The physician prescribes isoniazid, 300 mg orally; rifampin, 600 mg orally; and pyrazinamide, 1500 mg orally daily for 2 months, to be followed by twice weekly isoniazid 900 mg orally and rifampin 600 mg orally. The physician also orders weekly sputum cultures for the first month.

27. Walter Cohen, 45 years old, is the print shop manager at a local community college. He has been a type 1 diabetic since the age of 20, and was diagnosed with diabetic nephropathy 10 years ago.Despite blood pressure control with antihypertensive medications and frequent blood glucose monitoring with insulin coverage, he developed overt proteinuria 5 years ago and has now progressed to end-stage renal disease. He enters the nephrology unit for temporary hemodialysis to relieve uremic symptoms. While there, a CAPD catheter will be inserted.Mr.Cohen’s desire to continue working is the primary factor in his choice of CAPD over hemodialysis.

ASSESSMENT

Richard Gonzalez,Mr.Cohen’s care manager, obtains a nursing assessment.Mr.Cohen states that his diabetes has always been difficult to control.He has had numerous hypoglycemic episodes and has been hospitalized “four or five times”for ketoacidosis.Recently he has developed symptoms of peripheral neuropathy and increasing retinopathy. He attributed his lack of appetite, nausea, vomiting, and fatigue over the past month to “a touch of the flu.” His weight remained stable, so he did not worry about not eating much.

Physical assessment findings include

T 97.8° F (36.5° C) PO,

 P 96, R 20,

and BP 178/100.

Skin cool and dry, with minor excoriations on forearms and lower legs. Breath odor fetid.Scattered fine rales noted in bilateral lung bases. Soft S3 gallop noted at cardiac apex. Bilateral pitting edema of lower extremities to just below the knees; fingers and hands also edematous.Abdominal assessment essentially normal, with hypoactive bowel sounds.

Urinalysis shows a specific gravity of 1.011,gross proteinuria, and multiple cell casts.CBC results:RBC 2.9 mill/mm3;hemoglobin 9.4 g/dL; hematocrit 28%. Blood chemistry abnormalities include BUN 198 mg/dL;creatinine 18.5 mg/dL; sodium 125 mEq/L;potassium 5.7 mEq/L; calcium 7.1 mg/dL; phosphate 6.8 mg/dL. A termporary jugular venous catheter will be placed for hemodialysis the next day, followed by peritoneal catheter insertion later in the week.

28. Judy Devak is driving home late one evening when she loses control of her car trying to avoid hitting a deer in the road.Her car strikes a tree and rolls into a deep ditch beside the road,out of sight of passing cars.The wreek is not discovered until 2 hours later.On arrival at the accident scene, the paramedics find Ms.Devak hypotensive:BP 90/60,P 120, and R 24. She is alert and in severe pain, with a fractured right femur. After immobilizing Ms.Devak’s neck and back and extricating her from the car, they apply a traction splint to her leg and transport her to the local hospital.

ASSESSMENT

Katie Leaper, RN, obtains a nursing history on Ms. Devak’s admission to the intensive care unit. Ms. Devak indicates that she has been healthy, having experienced only minor illnesses and chickenpox as a child.She has never been hospitalized,and knows of no allergies to medications. Ms. Devak is not currently taking prescription or nonprescription drugs. Physical assessment findings include T 97.4° F (36.3° C) PO,P 100,R 18, and BP 124/68. Skin pale, cool, and dry,with multiple scrapes,minor abrasions, and bruises on face and extremities. A linear bruise is noted on her chest and abdomen from the seat belt. Lung sounds clear, heart tones normal, and abdomen tender but soft to palpation. Right leg alignment maintained with skeletal traction. One unit of whole blood was infused prior to ICU admission, a second unit is currently infusing. An indwelling urinary catheter and a nasogastric tube are in place.

During the first few hours after admission, Ms. Leaper notes that Ms.Devak’s hourly output has dropped from 55 mL to 45 mL to 28 mL of clear yellow urine. The physician orders a 500 mL intravenous fluid challenge, STAT urinalysis, BUN, and serum creatinine.The fluid challenge elicits only a slight increase in urine output. Urinalysis results show a specific gravity of 1.010 and the presence of WBCs, red and white cell casts, and tubular epithelial cells in the sediment.Ms.Devak’s BUN is 28 mg/dL; her serum cretinine, 1.5 mg/dL. The physician diagnoses probable acute renal failure and orders a nephrology consultation. In addition, the physician orders aluminum hydroxide,10 mL every 2 hours per nasogastric tube, and ranitidine 50 mg intravenously every 8 hours.

29. Jesus Rivera is a 34-year-old migrant farm worker who currently lives in temporary housing in a rural area of the southwestern United States.His family includes his wife,Marta,who is 3 months’pregnant, and two children, ages 3 and 5. He takes his wife to a medical clinic staffed by volunteer nurses, physicians, and students from a nearby university for a prenatal checkup.The clinic is open only on Saturday and provides care on a sliding fee scale or for free if the family is unable to pay.While Mrs. Rivera is being examined,Mr. Rivera asks the nurse to have someone look at some very painful blisters on his chest that developed about a week ago.

He is afraid that exposure to pesticides has caused the sores.

ASSESSMENT

Mr.Rivera speaks Spanish and is able to communicate only slightly in English. The initial assessment of Mr. Rivera is performed by Anita Mendez, a student nurse fluent in Spanish. Mr. Rivera’s history reveals problems with lower back pain but no significant past medical illnesses. He is not aware of any allergies and cannot remember having had chickenpox as a child. Two years ago, both children were sick and had blisters on their bodies, and a friend told them it was chickenpox.Mrs. Rivera thinks she had chickenpox as a child.

Because Mr. Rivera has not had any medical care for several years,baseline laboratory tests are ordered to screen for any other illnesses; the complete blood count (CBC), blood chemistry, and urinalysis are all within normal limits. Mr. Rivera says that he did not feel well for several days before the blisters appeared, having experienced chills and general achiness. He had not taken his temperature because the family does not own a thermometer. Current vital signs are as follows:

T 99°F (37.2°C),

p 74,

R 22, and BP 148/88.

Physical examination of the trunk reveals a bandlike pattern of lesions across the left thorax.Some of the lesions are vesicles filled with serous fluid; others are darker in color and are oozing a light yellow drainage. The skin around the lesions is red and inflamed. Mr. Rivera complains of a severe, burning pain with itching across his chest.He is diagnosed with herpes zoster.

30. Johti Singh is a 39-year-old secretary who was admitted to the hospital with an elevated temperature, fatigue, rapid, labored respirations; and mild dehydration. The nursing history reveals that Ms. Singh has had a “bad cold” for several weeks that just wouldn’t go away. She has been dieting for several months and skipping meals. Ms. Singh mentions that in addition to her fulltime job as a secretary she is attending college classes two evenings a week. She has smoked one package of cigarettes per day since she was 18 years old. Chest x-ray confirms pneumonia.

Physical Examination

Height: 167.6 cm (5′6′′)

Weight: 54.4 kg (120 lb)

 Temperature: 39.4°C (103°F)

Pulse: 68 BPM

Respirations: 24/minute

Blood pressure: 118/70 mm Hg

Skin pale; cheeks flushed; chills; use of accessory muscles; inspiratory crackles with diminished breath sounds right base; expectorating thick, yellow sputum

Diagnostic Data Chest x-ray: right lobar  infiltration

WBC: 14,000

pH: 7.49

PaCO2: 33 mm Hg

HCO3–: 20 mEq/L

PaO2: 80 mm Hg O2 sat: 88%

31. Jim Valdez, a 19-year-old college sophomore, is admitted to the hospital by ambulance following an automobile accident.His family (father,mother, and sister) live 100 miles away and cannot visit often,although they are very concerned.On admission to the hospital, a CT scan of the spine shows a fracture and partial laceration of the cord at the C7 level.Mr.Valdez is in halo traction.One night, he tells the nurse, “I wish I had just died when I got hurt. I don’t think I can stand to live like this.”

ASSESSMENT

When Mr.Valdez is admitted to the intensive care unit,he has flaccid paralysis involving all extremities. He has no sensation below the clavicle or in portions of his arms and legs. His bladder is dis tended and bowel sounds are absent.

Other assessment findings include:

BP 90/56,

P 50,

T 97°F (36.1°C),

 arterial blood gases Ph 7.4,

PaO2 96, PaCO2 37, SaO2 96%.

Oxygen per nasal cannula is given at 2 L/min, and halo traction is applied. A Foley catheter is inserted into his bladder, and a nasogastric tube is inserted into his stomach and attached to lowpressure continuous suction.

After 7 days,Mr.Valdez is moved from the intensive care unit to the neurosurgical unit for continuing care and planning for transfer to a rehabilitation hospital in his home town. His vital signs have stabilized and are normal for his age; respirations and oxygenation are normal. Other neurologic assessments remain the same.

32. Merlyn Chapman, a 27-year-old sales clerk, reports weakness, malaise, and flu-like symptoms for 3–4 days. Although thirsty, she is unable to tolerate fluids because of nausea and vomiting, and she has liquid stools 2–4 times per day.

Physical Examination Height: 160 cm (5′3′′)

Weight: 66.2 kg (146 lb)

 Mild fever: 38.6°C (101.5°F)

Pulse: 86 BPM

Respirations: 24/minute Scant urine output BP: 102/84 mm Hg Dry oral mucosa, furrowed tongue, cracked lips

Diagnostic Data

Urine specific gravity: 1.035

Serum sodium 155 mEq/L

Serum potassium 3.2 mEq/L

Chest x-ray negative

33. Eddie Kratz, age 22, works as a bellman at a large hotel. For the past year,he has shared a small apartment with Marla Jones,who is 5 months pregnant with his child.Although he intends to marry Ms. Jones before the baby is born, he has continued a previous relationship with a woman named Justine Simpson. His sexual activities with Ms. Simpson have increased in frequency as Ms. Jones’s pregnancy has advanced. Recently Mr. Kratz has noticed a swelling in his groin and a sore on his penis.

ASSESSMENT

When Mr. Kratz comes to the community clinic, he is interviewed by the nurse practitioner, Sally Morovitz. She takes a thorough medical and sexual history, including questions about drug use, allergies, difficulty with urination, urinary frequency, itching or discharge from the penis, recent sexual activities, precautions taken against infection, history of STIs, and sexual function. She determines that Mr. Kratz has been having unprotected sex with both Ms. Jones and Ms. Simpson. He believes that Ms. Jones is not having sex with anyone except him, but he is not sure. Physical assessment reveals a classic syphilitic chancre on the shaft of the penis and regional lymphadenopathy. A specimen of exudate from the chancre is sent for dark field examination. Ms. Morovitz discusses with Mr. Kratz the likelihood that he has syphilis and the need to tell both Ms. Jones and Ms. Simpson so that they can be tested and, if necessary, treated. Ms. Morovitz also suggests that Mr. Kratz be tested for HIV since he has been having unprotected sex with two women, at least one of whom may be sexually active with other partners. He agrees, and blood is drawn for an ELISA test. Darkfield analysis of the chancre exudate confirms the diagnosis of syphilis; the ELISA results are negative for HIV.

34. Robert Cerulli is a 72-year-old retired commercial fisherman who has experienced arthritic pain in his hips for the past 10 to 15 years.Over the past year, the pain in his right hip has become severe, prompting him to seek medical attention. Significant degenerative changes in both hip joints are noted on X-ray films. The physician recommends a total replacement of the right hip, and total replacement of the left hip to follow in 6 to 12 months.Mr. Cerulli has preoperative teaching and tests the afternoon prior to his surgery, scheduled for 0800 the following morning.

ASSESSMENT

Christie Phlaugh, RN, completes a nursing history and examination of Mr.Cerulli on admission. Reviewing his medical record, she notes that Mr. Cerulli has mild Parkinson’s disease and is taking carbidopa/levodopa (Sinemet 25-100) four times a day to control his symptoms. No other chronic medical conditions have been reported.Mr.Cerulli says he has been essentially healthy his entire life.He has no known allergies to medications, has never smoked, and consumes only small amounts of alcohol.

On examination of Mr.Cerulli,Ms.Phlaugh notes that he is alert and oriented. His vital signs are BP 116/64, P 68 regular, R 18, T 97.4°F (36.3°C) PO. Peripheral pulses are strong and equal in the upper extremities, and slightly weaker but equal in the lower extremities. His feet are cool to touch but have immediate capillary refill.He has full ROM of his shoulders,elbows,and wrists.The ROM of both hips is significantly restricted. Hip flexion beyond 90 degrees prompts pain on both sides. Both flexion and extension of the knees are limited slightly.Mr.Cerulli walks with a limp, favoring his right hip, and has a shuffling gait. Preoperative laboratory studies including CBC, coagulation studies,chemistry panel,and urinalysis show a serum creatinine of 1.7 mg/dL and BUN of 30 mg/dL, with no other abnormal values noted. His ECG and chest X-ray show no apparent pathologies. Cefazolin (Ancef ) 500 mg is to be administered intravenously at 0600 prior to surgery, and Mr. Cerulli is to shower and shampoo with antibacterial soap at bedtime. The physical therapist meets with Mr. Cerulli to evaluate his mobility and begin teaching him about postoperative weight-bearing restrictions.

35. Catherine Cole is a 37-year-old secretary who lives with her husband, Ray,and teenage daughter,Amy, in an apartment in a large metropolitan area. About 2 months ago,Mrs. Cole began to tire easily and experience night sweats several times a week. She also noted that she was pale, bruised easily, and was having heavier menstrual periods. Blood tests ordered by her primary care provider are abnormal. She is admitted for a bone marrow biopsy.

ASSESSMENT

Mary Losapio, RN, obtains a nursing history and physical assessment for Mrs. Cole. Mrs. Cole tells her, “I’m so tired, and I have these bruises all over me. I’m so afraid of the results of the bone marrow examination. I don’t know what we will do if I have cancer.”Mrs. Cole clutches her husband’s hand and then begins to cry.

Physical assessment data include:

Height 64 inches (156 cm),

weight 106 lb (48.1 kg);

vital signs

 T 100°F,

 P 102,

 R 22,

BP 130/82.

Numerous petechiae scattered over trunk and arms;ecchymoses noted on lower right arm and right calf. Oral mucosa is red, with several small ulcerations in buccal areas.

Blood count shows reduced RBCs,hemoglobin,and hematocrit levels. The WBC is high,with myeloblasts seen on differential. The platelet count is very low.A tentative diagnosis of acute myelogenous leukemia is made.

36. Betty Williams, a 62-year-old psychologist, is admitted to the emergency department with complaints of severe substernal chest pain. Mrs. Williams states that the pain began after lunch,about 4 hours ago.She initially attributed the pain to indigestion. She described the pain, which now radiates to her jaw and left arm, as “really severe heartburn.” It is accompanied by a “choking feeling,” severe shortness of breath, and diaphoresis.The pain is unrelieved by rest, antacids,or three sublingual nitroglycerin tablets (0.4 mg). Oxygen is started per nasal cannula at 5 L/min.Central and peripheral intravenous lines are inserted. A 12-lead ECG and the following labwork are obtained: cardiac troponins, CK and CK isoenzymes, ABGs, CBC, and a chemistry panel. Morphine sulfate relieves Mrs.Williams’s pain. Mrs. Williams’s medical history includes type 2 diabetes, angina, and hypertension. She has a 45-year history of cigarette smoking, averaging 1.5 to 2 packs per day. Family history reveals that Mrs.Williams’s father died at age 42 of AMI, and her paternal grandfather died at age 65 of AMI.Mrs.Williams is taking the following medications: tolbutamide (Orinase), hydrochlorothiazide, and isosorbide (Isordil).

Based on ECG changes and cardiac markers, an acute anterior MI is diagnosed.Mrs.Williams has no contraindications to thrombolytic therapy and is deemed a good candidate. Intravenous alteplase (t-PA, Activase) is given by bolus followed by intravenous infusions of alteplase and heparin. She is transferred to the coronary care unit (CCU).

ASSESSMENT

(supportive data)

FACTUAL DATA

Supports your problem.  This information has to be current, or perhaps past history and NOT “make believe”.  Think of it as supportive data that proves you have an actual or potential problem.  It must have at least 2 pieces of information to support problem.

Ask yourself, “Why do I think this is a problem?”

Think about your pt’s:

1. Medical Diagnoses

    S & S from Dx that your pt is having right now

    If no S&S right now, just list the Dx as support

2. Medication List      Side effects?

3. Abnormal Lab?

NURSING DIAGNOSIS

(patient's need)

PROBLEM STATEMENT

This is the name you give the problem.  Ask yourself, “What is the problem?”  You can use the NANDA list of problem statements OR if none apply, make a problem statement using one of the words:

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