Student Name:	Christina Weinzettle	Date of Service: 2/21/2013

Care Plan

Age Range (e.g. 60-65 yr.): 47 years old

Gender: Male	Hospital Day #: 19

Advanced Directives (e.g. Living Will, Medical Durable Power of Attorney, Do Not Resuscitate or Allow Natural Death): Full Code with no other advanced directives on file. When the patient is intubated and unable to make his own decisions his wife has to be consulted for medical decisions. There was no note in the patient’s chart saying she has formal medical power of attorney.

Allergies (Drug/Food/Environment): No known drug or food allergies noted in the chart.

Patients stated Chief Complaint: Elective total bilateral nephrectomy complicated by the development of renal abscesses in the retroperitoneal cavity, hypotension, tachycardia, hyperkalemia, adrenal insufficiency, anemia and pancreatitis. The patient also suffers from end stage renal disease.

Briefly describe Hospital Course: The patient reported to the emergency room on 2/03/2013 for dialysis prior to his elective total bilateral nephrectomy. The patient’s surgery was performed on 2/04/2013 with complications. During the surgery there was injury to the distal pancreas when the kidney was removed as well as a partial left adrenalectomy due to severe scar adherence to the left kidney. A Jackson Pratt drain was placed during surgery. These complications hindered the patient’s recovery. During the postoperative period the patient developed hypotension and tachycardia requiring urgent intubation, hyperkalemia, adrenal insufficiency, pancreatitis, and anemia. The patient developed sepsis due to the formation of renal abscesses in the retroperitoneal cavity and went into an exploratory laparotomy on 2/16 where he received an abdominal wash, colectomy with a colostomy placed, biliary tube placement, and abdominal packing with abthera. The abdomen was left open with a wound vac attached. The patient went in for another exploratory laparotomy on 2/17 where the patient received irrigation, repacking with abthera, splenectomy, gastrorrhaphy, debridement of lesser sac, and control of hemorrhage. The patient also had surgery on the day of care because of increased bleeding. The surgery on 2/21/2013 was to freshly pack the abdomen and drain the blood. The abdominal cavity was left open packed with abthera and a wound vac attached. The patient returned from the OR on the day of care still intubated and lightly sedated with versed. The patient resumed his Continuous Renal Replacement Therapy (CRRT).

Previous 24 hour I & O totals: I=7662.5 and O=5938 (Controlled with CRRT b/c patient anuria).

Ht., Wt., and BMI: Ht.: 165.1 cm; Wt.: 72.1 kg; BMI: 26.5

Current Orders (exclude labs/medications/diagnostic tests):

Activity: Bedrest

Diet: Tube feed; NovaSource Renal enteral formula 10 ml/hr

IV type/site: CVC triple lumen R. subclavian dwell day 7; Arterial line R. femoral dwell day 4; Udall catheter for CRRT in L. femoral vein dwell day 4; Ateriovenous fistula L. upper arm for hemodialysis

IV fluids: Lactated Ringers 10 ml/hr; 2,000 ml/hr dialysate CRRT

Others: 2-point restraints while intubated; fall risk=bed down with 2 x rails; strict I & O monitoring; for CRRT nurse; duotube placed in left nare; nasogastric tube placed in right nare; tube feed; SCD’s; oral care q2hrs while on ventilator; HOB at 30 degrees; contact precations

Interdisciplinary Services/Consults (e.g. PT, OT, ST, dietary, hospice):

Spiritual consult: The patient is Roman Catholic and requested a consult with the priest. The catholic priest visited the patient on the day of care to pray with him and his wife who was at bedside.

Nutrition: The patient is anemic and is on a renal tube feed formula. The patient has low albumin of 2.0 and has been diagnosed with malnutrition. Due to complications of the surgery patient only able to tolerate tube feed at 10 ml/hr.

Nephrology: The patient has ESRD and was admitted for a bilateral nephrectomy.

Urology: The patient no longer has kidneys to produce urine and is anuria. He is on dialysis and CRRT.

PT: Physical therapy helps patient perform active and passive range of motion while he is on bedrest.

Language spoken: Spanish

Religious preference: Roman Catholic

Insurance: Fee for service

Immunization status: Tetanus 2009, Flu August 2012, and Pneumonia 2012

Domestic/Child/Elder abuse issues: None.

Briefly describe the Medical and Surgical History (Describe the medical diagnoses, surgical procedure(s) and/or chronic illness that initiate the admission or reason for the continuing condition. Include smoking history.).

Medical History	Description of each Diagnosis
1) Purified Protein Derivative positive 2) Hypertriglyceridemia 3) Anemia, chronic disease 4) Chronic urinary tract infection (UTI) 5) End stage renal disease (ESRD) on dialysis 6) Pyelonephritis, chronic 7) Xanthogranulomatous pyelonephritis 8) Adrenal insufficiency 9) Pancreatitis 10) Leukocytosis 11) Hyperchloremia 12) Malnutrition 13) Septic shock 14) Intra-abdominal hemorrhage 15) Perinephric abcess 16) Hypertension	1) A purified protein derivative (PPD) test is used to diagnose latent tuberculosis (“PPD skin test”, 2011). A positive PPD test indicates that the person has been infected with the bacteria that cause TB (“PPD skin test”, 2011). The chart for the patient noted that it was an abnormal result and that the patient had the BCG vaccine, which can cause a false positive (“PPD skin test”, 2011). 2) Hypertriglyceridemia is a medical condition where the patient’s triglyceride levels are elevated (Citkowitz, 2013). The patient has developed Xanthogranulomatous pyelonephritis and abnormal lipid metabolism is a possible etiologic factor for its development (Deem, 2012). 3) Anemia is a condition that is caused when there are not enough healthy red blood cells circulating in the persons body (Chen, 2012). Anemia of chronic disease is when the decline in red blood cells is caused by the patient’s medical condition (Chen, 2012). His chronic kidney disease has caused his anemia and since he has no kidneys he cannot produce erythropoietin. 4) A chronic urinary tract infection is a repeated or prolonged infection of the bladder or urethra (McCance & Huether, 2010). The patient’s chronic UTI’s contributed to the deterioration of his kidney’s and made him susceptible to the infection that lead to him choosing to remove both of his kidney’s. 5) End stage renal disease (ESRD) is when the patient’s kidneys are no longer able to function at the level needed for day-to-day life (Zieve & Lin, 2011). The patient is diagnosed with ESRD and has to be on dialysis. His AV fistula was created during the surgery where both of his kidneys were removed. 6) Chronic pyelonephritis is persistent or recurrent infection of the kidney leading to scarring of one or both kidneys (McCance & Huether, 2010). The patient’s chronic pyelonephritis was a contributing factor to him developing chronic kidney disease and caused the patient to have impaired urine-concentrating ability. His chronic pyelonephritis left him susceptible to the infection that resulted in him choosing to remove both his kidneys. 7) Xanthogranulomatous pyelonephritis (XGP) is a rare and serious disorder that affects the kidneys by having a destructive mass invade the renal parenchyma (Deem, 2012). XGP is associated with Proteus, Pseudomonas, or Escherichia coli infection. This disorder had to be surgically managed and is the reason the patient had to get a bilateral nephrectomy because medical care rarely suffices for treatment. 8) Adrenal insufficiency occurs when the adrenal glands located above the kidney’s do not produce enough steroid hormones specifically cortisol (McCance & Huether, 2010). The patient had to have a partial adrenalectomy during his kidney removal surgery that caused an insufficiency. 9) Pancreatitis is an inflammation of the pancreas that can be caused by trauma or obstructive biliary tract disease (McCance & Huether, 2010). During his kidney removal surgery the patient’s pancreas was injured and he had an obstructed biliary tract the required placement of a PCT. 10) Leukocytosis is an increase in the total number of any or all of WBC types in a person (McCance & Huether, 2010). The patient has bacteremia and his lab show high levels of WBC’s, neutrophils, and monocytes. 11) Hyperchloremia is an electrolyte imbalance and is caused by a high level of chloride in the blood (McCance & Huether, 2010). Hyperchloremia can be associated with the patients ESRD. 12) Malnutrition occurs when the body does not get enough nutrients (McCance & Huether, 2010). Malnutrition can be caused by inadequacies, problems with digestion, and certain medical conditions (McCance & Huether, 2010). Because of the patient’s medical condition he has become malnourished with a low albumin level of 2.0. 13) Septic shock is a medical condition that occurs when an overwhelming infection causes life-threatening low blood pressure (Heller, 2010). Common causes of septic shock include diseases of biliary system, recent surgery, recent infection, and long-term antibiotic therapy (Heller, 2010). The patient developed septic shock after his initial surgery. The patient’s other risk factors of septic shock include biliary system dysfunction, Xanthogranulomatous pyelonephritis, and his bacteremia. 14) Intra-abdominal hemorrhage is an excessive discharge of blood from the blood vessels in the abdomen (McCance & Huether, 2010). The patient developed an intra-abdominal hemorrhage post-surgery that required further abdominal surgeries and evacuation of the abdominal cavity. 15) Perinephric abcess are pockets of pus that form around one or both kidneys. They are caused by a UTI, surgery around the urinary tract, and bloodstream infections (Vorvick, 2010). The patient had abscesses form post-bilateral nephrectomy that had to be drained in IR. 16) Hypertension is described as an elevated blood pressure reading over 140 systolic and 90 diastolic (McCance & Huether, 2010).
Surgical History	Description of each Surgery
1) Exploratory Laparotomy 2) Dialysis fistula creation 3) Total bilateral nephrectomy (elective) 4) Colectomy with colostomy placement 5) Splenectomy 6) Biliary tube placement 7) Gastrorrhaphy	1) Exploratory Laparotomy is a surgical procedure used to visualize and examine the structure of the abdominal cavity (Kate, 2013). The patient has had multiple exploratory laparotomies during his hospital stay for intra-abdominal hemorrhage, sepsis, and abdominal washes. 2) Dialysis fistulas are surgically created communications between an artery and a vein (Sofocleous, 2011). They are created for use during dialysis. The patient had one created during his bilateral nephrectomy surgery for dialysis use post-surgery. 3) Total bilateral nephrectomy is the complete removal of both kidneys at the same time. The patient elected to have this surgery and it is the reason for his initial admittance to the hospital. 4) Colectomy is the surgical removal of all or part of a person’s colon (“Colectomy”, 2012). The patient had a colostomy placed at the time of the surgery. 5) Splenectomy is the surgical removal of the spleen (“Splenectomy”, 2012). The patient had to have his spleen removed due to his sepsis. 6) Biliary tube placement is a medical procedure that places a catheter into the biliary tube to allow bile to drain into the collection bag (“PTC”, 2013). 7) Gastrorrhaphy is a surgical procedure where the surgeons suture a perforated stomach (“Gastrorrhaphy”, 2013). The patient developed sepsis post-surgery and during his abdominal surgery on 2/17 the surgeons had to perform this procedure.

References:

Chen, Y.B. (2012). Anemia of chronic disease. PubMed Health. Retrieved on March 8, 2013 from

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001591/

Citkowitz, E. (2013). Hypertriglyceridemia. MedScape Reference. Retrieved on March 8, 2013 from

http://emedicine.medscape.com/article/126568-overview

Deem, S.G. (2012). Xanthogranulomatous pyelonephritis. MedScape Reference. Retrieved on March 8. 2013

from http://emedicine.medscape.com/article/2050430-treatment#a1156

Heller, J.L. (2010). Septic shock. MedlinePlus. Retrieved on March 8, 2013 from

http://www.nlm.nih.gov/medlineplus/ency/article/000668.htm

Kate, V. (2013). Exploratory laparotomy. Medcape Research. Retrieved on March 8, 2013 from

http://emedicine.medscape.com/article/1829835-overview

McCance, K. L., & Huether, S. E. (2010). Pathophysiology: The Biological Basis for Disease in Adults and Children (6th ed., pp. 745-751). Missouri: Elsevier Health Sciences.

MedlinePlus. (2011). PPD skin test. Retrieved on March 8, 2013 from

http://www.nlm.nih.gov/medlineplus/ency/article/003839.htm

MediLexicon. (2013).Gastrorrhaphy. Retrieved on March 8, 2013 from

http://www.medilexicon.com/medicaldictionary.php?t=36489

E-radiograpy.net. (2013). PTC. Retrieved on March 8, 2013 from http://www.e-

radiography.net/technique/ptc/ptc.htm

Sofocleous, C.T. (2011). Dialysis fistula. Medscape Reference. Retrieved on March 8, 2013 from

http://emedicine.medscape.com/article/419393-overview

Vorvick, L.J. (2010). Perirenal abscess. University of Maryland Medical Center. Retrieved on March 8, 2013

from http://www.umm.edu/ency/article/001274.htm

Zieve, D. & Lin, H.Y. (2011). End-stage kidney disease. MedlinePlus. Retrieved on March 8, 2013 from

http://www.nlm.nih.gov/medlineplus/ency/article/000500.htm

Pathophysiology Worksheet (Use additional sheets as needed)

Student____________________________________ Date___________

Describe pathophysiology for one medical diagnosis to the cellular level (in your own words/ use additional sheet if needed),

Personalized to your patient (link to labs, meds, and co-morbidities).

References:

Medical/Surgical Diagnosis	Pathophysiology	Patient’s Manifestations (Signs and Symptoms)
Elective total bilateral nephrectomy due to chronic UTI and Xanthogranulomatous Pyelonephritis	Xanthogranulomatous pyelonephritis (XGP) is a rare and serious chronic inflammatory disorder of the kidney that is associated with Proteus, Escherichia coli, and Pseudomonas (Deem, 2012). XGP causes a destructive granulomatous process in the renal parenchyma (Li & Parwani, 2011). The etiology of XGP is unknown, but the disease process is related to long-term renal blockage and infection (Deem, 2012). My patient had chronic UTI and pyelonephritis that made him susceptible to this disease process. XGP is characterized by lipid-laden foamy macrophages that can be seen microscopically (Deem, 2012). This looks like a mass of yellow tissue around the kidney with areas of necrosis and hemorrhage (Deem, 2012). XGP has similar characteristics to renal cell carcinoma and diagnosis has to be verified histologically (Deem, 2012). XGP has neoplasm like properties and can invade and destroy local tissue and adjacent organs such as the spleen, pancreas, or duodenum (Deem, 2012). A kidney infected with XGP will be enlarged with hydronephrosis, pelvic calculi, multiple yellow/orange nodules, abscess formation, and diffuse cortical scarring (Li & Parwani, 2011). Patients that had XGP are chronically ill with the follow symptoms: anorexia, fever, chills, weight loss, and flank pain (Deem, 2012). XGP can also cause fistulas to form. Laboratory findings indicative of XGP include leukocytosis, anemia, increase erythrocyte sedimentation rate, raised alkaline phosphatase, low albumin, and a high fasting blood sugar (Li & Parwani, 2011). XGP develops in approximately 1% of all renal infections and is more likely in females than males (Deem, 2012). XGP can affect both or one kidney, but bilateral disease is usually fatal if left untreated (Deem, 2012). The definitive treatment for XGP is a total nephrectomy because medical management has not been proven very effective. My patient had bilateral XGP disorder and elected to have a total bilateral nephrectomy. A bilateral nephrectomy is the complete removal of both kidneys. The goal of the surgery is to remove all of the granulomatous tissue caused by the XGP. Complications of the surgery include postoperative abscesses, cutaneous fistulization, pancreatic injuries, splenic injury, and liver lacerations (Deem, 2012).	Patient was diagnosed with XGP. He had the following lab values indicative of XG: leukocytosis, low albumin (2.0), elevated ALP (163), anemia, and high fasting blood glucose. Also, the patient has a medical history of chronic UTI and pyelonephritis, which can cause blockage and infection in the kidneys. The XGP disease process is related to these medical conditions. The patient also developed some of the surgical complications from the bilateral nephrectomy. There was an injury to the patient’s pancreas during surgery and the cortical scarring caused by the XGP on the L. kidney resulted in a partial adrenalectomy. Post-surgery the patient also developed right and left retroperitoneal renal fossa fluid collection abscesses. The patient also had to have a splenectomy, gastrorrhaphy and developed pancreatitis. These procedures indicated that the XGP could have spread to the adjacent organs.

References:

Deem, S.G. (2012). Xanthogranulomatous pyelonephritis. MedScape Reference. Retrieved on March 8. 2013

from http://emedicine.medscape.com/article/2050430-treatment#a1156

Li, L. & Parwani, A.V. (2011). Xanthogranulomatous pyelonephritis. Archives of Pathology & Laboratory Medicine 135(5): 671-674. Retrieved

on March 8, 2013 from http://www.archivesofpathology.org/doi/full/10.1043/2009-0769-RSR.1

Health Perception-Health Management Pattern

Vital Signs

BP: 126/50	Pulse: 104 RR: 14 (set with ventilator)	Temp: 36.8 (98.2)

Pain Scale Type: Verbal, when not intubated. On the day of care the patient had just returned from surgery and was intubated so was not able to verbally express pain.

If this person has pain, describe characteristics and cause (PQRST): The patient was alert and intubated. He was not able to speak but shook his head no when asked about pain. He did express anxiety about being intubated and nodded when asked wanted something for anxiety so my nurse administered Versed.

Nutritional-Metabolic Pattern:

Assess patient’s nutritional status, daily patterns, and alterations (e.g. economics, social, cultural, religious):

The patient currently does not have a good nutritional status. Prior to hospitalization the patient was overweight with a BMI of 26.5. During his intake assessment he admitted to eating a regular diet but that sometimes he “did not eat as well as he should”. However, since his hospitalization on 2/3 the patient has been diagnosed as malnourished. This diagnosis is supported by the patient’s lab values for albumin that is 2.0 (L) and a total protein level of 4.3 (L). The nutritionist noted in the patient’s chart that it has been a struggle to meet the patient’s nutritional needs of 1800-2160 kcal and protein 86-122g because of the strict fluid restrictions the patient has related to his kidney issues and multiple abdominal surgeries. The nutritionist also noted that the patient’s renal formula ordered was not meeting his protein needs. Also, the patient stomach from multiple abdominal surgeries can only tolerate 10 ml/hr tube feed which severely limits his nutritional intake.

Elimination Pattern:

Assess abdomen, bowel pattern (including LBM), urinary patterns, and alterations (e.g. foley, ostomy, tube/drains):

The patient is anuria because he had a total bilateral nephrectomy and he is currently on Continuous Renal Replacement therapy (CRRT). The CRRT nurse’s current orders are to match intake to output. On the day of care the patient had just returned from abdominal surgery so during the assessment he had no bowel sounds present. The patient has an open abdomen with abthera attached to a wound vac with good suction and SS output. The patient abdomen on assessment was distended with tenderness and no flatulence. There was no guarding or rebound present. The patient has a foley and there is an ostomy present in the right lower quadrant. The ostomy is pink, patent, and productive. The patient has a right JP drain with clear bilious output.

Activity-Exercise Pattern:

Assess mobility/exercise patterns including gait, restraints, assistive devices, safety measures, and musculoskeletal alterations.

The patient is on bed rest so gait could not be assessed. The patient currently does not have on restraints. The patient has no joint tenderness, deformity, or swelling. The patient’s AVF is present on the left upper extremity with a palpable thrill. There is distal pitting edema 2+ on the patient’s lower extremities. The patient has been rated as a high fall risk and has bed set low with two side rails. PT comes in qShift to practice passive/active range of motion with the patient.

Fall risk score:	High	Tool used: Maricopa Standard Tool Interpretation:	High

Sleep-Rest Pattern:

Assess sleep habits, disturbances, and alterations.

The patient has been in the SICU since 2/3/13 and his normal sleeping patterns have been disturbed from the environment. ICU environmental factors include the noise of the machines, medications, continuous CRRT, and the physiological factors of his disease process. He has had several surgical procedures requiring him to be intubated and some of the time he was not sedated while he was intubated. When the patient was intubated but not sedated he was anxious and had to be medicated. Overall, the patient was anxious about his situation and hospitalization and that affected his sleep. There was no notation in the chart about post-hospitalization sleeping issues.

Cognitive-Perceptual Pattern:

Assess LOC, GCS, neurological status/alterations (speech, hearing, vision, PERRLA, motor, and sensation).

Overall, when the patient is not sedated due to intubation he is alert, able to follow commands, and he responds appropriately. He is alert and oriented times 3 with normal speech patterns. The patient’s pupils are 3mm and exhibit PERRL. The GCS measured on the day of care was 11. There is no evidence of motor disorders and no focal findings are evident. The patient does have diminished sensation on the distal portion of his lower extremities with 2+ pitting edema present. The patient’s chart did not note any vision deficiencies. He does have diminished and abnormal hearing in his right ear.

Respiratory System

Breathing Pattern (e.g. depth, rate, rhythm, use of accessory muscles):

At the beginning of the shift the patient was intubated with an ETT and on the ventilator because he had just returned from surgery. He was extubated on the day of care and post-extubation his breathing pattern was shallow with a rate of 14 breaths per minute and a regular rhythm. He exhibited no signs of accessory muscle use. The patient had symmetric air entry on both sides.

Breath Sounds (e.g. clear, course, wheezes, location, etc.):

The patient’s breath sounds upon auscultation are shallow and diminished at the bases. The patient’s breath sounds are also coarse bilaterally with crackles present at the bases. The patient has bilateral pleural effusions that were diagnosed on multiple chest X-rays.

Describe any Cyanosis (e.g. location, severity):

There are no signs of cyanosis present on the patient.

Cough (e.g. productive, nonproductive):

The patient does have a productive cough when he is not intubated. Also, the patient is on continuous intermitted suction via his nasogastric tube.

Sputum (e.g. color, amount, consistency, odor, how obtained):

When the patient has oral suctioning the sputum is small, clear, and thin.

Use of O2 (e.g. nasal cannula, mask, trach collar, other):

The patient was initially on the ventilator on the day of care. He was extubated midday and was placed on a nasal cannula at a rate of 4 liters.

Flow rate of O2:	4	Oxygen sat: 100

Humidification: On per vent settings Type of airway: ETT	cm mark: 22 cm at teeth

Vent settings: TV: 400 Rate: 16/NA Mode: SIMV/PSW	FIO2: 60/40

PEEP:	5/5	PS: 14/5

Cardiovascular system

Pulses (e.g. strong, weak, bilateral, with locations):

The patient’s pulses were strong 2+ bilaterally for the radial, pedal, and posterior tibialis pulses.

Capillary Refill (in seconds): Less than 3 seconds.

Jugular Vein Distention (JVD): No, JVD present on the patient upon assessment.

Edema (e.g. location, degree, pitting):

The patient has generalized edema. There is 2/3+ pitting edema present on all four extremities.

Extremity temperatures:

The patient’s extremities are cool and dry because of his generalized edema. His trunk is warm and dry.

Sounds (e.g. S1, S2, regular/irregular, murmur): S1S2 present with a normal regular rhythm; no murmurs are present

Chest pain (e.g. PQRST): The patient does not have any complaints of chest pain.

Other (Pacemaker, AICD, etc.): The patient does not have any cardiac assistive device.

Telemetry (describe cardiac rhythm): The patient has sinus tachycardia.

Other monitor devices (swan, a-line, CVP, IABP): The patient has an arterial line in his right femoral artery and a central venous pressure monitor (flow tract) in his right subclavian vein.

Skin and Wounds

Assess patient’s skin, wounds, pressure ulcer (stage), dressings, and drains.

Overall, the patient’s skin is pale and dry. He had exerosis (dry flaky skin) on his feet. Upon assessment there were no signs of a rash, skin breakdown, or suspicious lesions. The patient’s skin turgor was normal and 2/3+ pitting edema was present on all extremities. The patient has an open abdominal surgical wound that is packed with abthera and has a wound vac attached with suction. The abdominal wound cannot be assessed fully because of the wound vac placement. He also has a colostomy with the ostomy site located in the right lower quadrant that is in place, pink, patent, and productive. The patient also has a right JP drain in place with clear bilious output.

Risk for pressure ulcer score:	15	Tool used: Braden scale

Risk interpretation: High

Eyes, Ears, Nose, Throat (EENT)

Assess patient’s EENT:

The patient’s scleras are yellow and he has abnormal hearing levels in his right ear. The yellow scleras are because the patient had a blocked biliary tube that required placement of a PCT and a JP drain for bilious discharge. His head is normocephailic and atraumatic. He has a nasogastric tube placed in his right nostril and at the start of shift had an endotracheal tube inserted at 22 cm. He also has a duotube placed in his right nare. The patient’s mucus membranes are moist. He is PEERLA and EOMI.

Coping-Stress Pattern

Assess patient and family’s coping strategies with psychological, medical, socioeconomic, cultural, and spiritual issues:

The patient is Catholic and very spiritual. He and his family members have brought in religious paraphernalia for the patient’s area and they pray at the bedside. He also requested a spiritual consult and the priest came around to pray with him and his wife on the day of care. The patient’s family is very supportive and his wife is at the patient’s bedside most of the day of care. His children come and sit with him when his wife needs a break. The family is very supportive but they are also are having some difficulty grasping the patient’s medical condition. His wife and the patient would ask during the shift when the patient could go home. The wife and the patient expressed that since the initial surgery was elective they do not understand why he is still in the ICU. Statements like this indicate that the patient does not understand his medical condition and he is having difficulty coping. Also, the patient does not have any insurance and is paying fee for service. Monetary concerns could be prompting him into questioning his length of stay. Culturally, the patient is Hispanic and only speaks Spanish.

Overall, the patient is able to remain clam and cooperative with his treatments. He is emotional when he is intubated and alert. The patient requests anxiety medications to help him manage his reaction to the intubation. His physical and emotional reactions are mostly appropriate for the situation.

Role-Relationship Pattern

Assess patient’s primary relationships, marital status, support systems, education level, and occupation.

The patient has a strong relationship with his family. He has two older daughters in high school and college. They visit him at bedside to relieve their mother. The patient’s wife is at bedside most of the day and she helped to keep the patient calm while he was intubated after surgery. The patient also has support from his church. He has members of his Catholic parish come by to pray with him and his family members at bedside. The patient completed high school and has a technical degree. He was working as an electrician until his current medical issues occurred.

The patient’s extended family is also supportive of his medical condition. Kidney disease runs in the patient’s family with his father, sister, uncle, and cousin having issues. The family history includes chronic UTI and episodes of pyelonephritis. Since the patient’s family has similar kidney issues they are understanding and supportive of his medical condition. According to the notes in the patient’s chart when he was considering the elective bilateral nephrectomy he had multiple friend and family members that offered to be tested to donate him their kidneys. The patient has an extensive support system that is sticking by the patient during his complicated recovery from his surgery.

Erickson’s developmental stage (mastery or maladjustment):

The patient is 47 years old, which places him in the middle adulthood stage. The psychosocial conflict listed for the middle adulthood stage is Generativity versus Stagnation. The major question for this stage is “How do I contribute to this world”? The contribution could be children or contributing positive changes for others. People that fail in this stage feel isolated and disconnected from their community. This patient has more of a mastery of this stage participating in generative activities.

Rationale: The patient has two children who he cares about and they are actively involved in his life. Also, the patient is active in his church community so he is contributing to the world through his spiritual activities.

Self-Perception-Self-Concept Pattern

Assess patient’s view of self:

Prior to the patient’s hospitalization he had a positive outlook on the situation. He and his family had extensively discussed all of the options for his medical treatment prior to electing to have a total bilateral nephrectomy. Several members of his family and friends had even volunteered to donate kidneys to the patient. The patient’s surgery was on 2/04 and the resulting complications have caused him to have a prolonged hospital stay. The patient view of himself has changed during the long hospital stay. He is discourage that he is not recovering and worried about the increased cost of his hospitalization. The patient is on contact precautions and he does not like that his wife has to wear the gown to be with him.

Sexuality-Reproductive Pattern

Assess patient’s sexuality:

The patient is married and has two daughters. He is 47 and currently is not concerned about this issue because of his current complicated medical condition.

Value-Belief Pattern

Assess patient’s cultural, ethnic, religious, and/or regional values and beliefs:

The patient is Hispanic and his entire extended family has been involved in his care. His wife has been continually at bedside and other family members rotate through. He is Catholic and very spiritual. The patient has taken advantage of the spiritual services offered by the hospital and their priest/chaplain comes by to pray with him at bedside. Also, members of the patient’s church come by and visit him at bedside.

Additional information to obtain from clinical units specific to patient diagnosis

Standardized Nursing Care Plan:

P: Safety related to hospitalization

G: Absence of injury

O: Met this shift. Patient remained safe in bed. Bed was set to low with two rails up.

P: Pain/Discomfort

G: Control/reduce

O: Met this shift. Patient did not complain of pain during the shift.

P: Skin integrity

G: Intact

O: Met this shift. Patient did not develop any new skin breakdown.

P: Endotracheal tube

G: Reduce agitation/alleviate anxiety

O: Met this shift. The patient was medicated PRN with Ativan and was extubated during the

shift.

Patient education provided (e.g. medications, post procedure, etc.):

During the day of care the patient and his family received education about being intubated and the necessity of contact precautions. The patient was alert and intubated for part of the day of care. The nurse had to remind the patient to not talk or pull on the tube. The nurse also had to educate the wife about not giving the patient water to drink because he was post-abdominal surgery and was not able to handle liquids by mouth. Also, the patient’s family was educated on the necessity of contact precautions and the need to wear gloves and gown when coming into contact with the patient.

Evidenced-Based Practice

Summarize (in your own words) one nursing journal article that is evidence-based which supports the nursing care plan for your patient. Cite your source(s). Use APA style, 6th Edition.

This Cochrane Database systematic review “Oxygen therapy for pneumonia in adults” provided important rationale for the interventions in this care plan. This review looked to verify how effective oxygen therapy is as a treatment for pneumonia and other lung diseases including pleural effusions (Zhang, Fang, Dong, Wu, & Deng, 2012). The authors decided to perform this review because there have been inconsistent reports of the effectiveness of oxygen therapy. Three random control trials met the studies inclusion criteria for review. The studies included 151 participants that were immunosuppressed with pulmonary infiltrates (Zhang et al., 2012). The author’s specific inclusion criteria included the following interventions: oxygen therapy (administered alone or as an adjuvant therapy), venturi mask, CPAP, and BiPAP (Zhang et al., 2012). The outcomes measured by the review were: mortality, need for invasive mechanical ventilation, length of hospital stay, and ventilator-free days (Zhang et al., 2012).

The authors reached several conclusions after reviewing the available evidence. They concluded that the use of non-invasive ventilation could reduce the risk of death in the ICU, shorten the length of the ICU stay, and the length of intubation (Zhang et al., 2012). The review concluded that non-invasive ventilation reduced the risk of death in the ICU with an odd ratio of 0.28 with a 95% confidence interval 0.09 to 0.88 and shorten the duration of ICU stay with a mean duration (MD) -3.28, 95% CI -5.41 to -1.61 (Zhang et al., 2012). The authors did note that there needed to be more randomized controlled trials done to make the evidence more conclusive and to fully answer the clinical question they posed.

This review was pertinent to the care plan because he had issues with ineffective airway clearance due to his excess fluid overload, worsening pleural effusions, and his multiple intubations and extubations. Also, on the day of care the patient had coarse lung sounds diminished in the bases with crackles at the bases. This review gave an evidenced based rationale for why oxygen therapy is a good intervention of patients in the ICU that have pulmonary infiltrates (Zhang et al., 2012).

Reference:

Zhang, Y., Fang, C., Dong, B.R., Wu, T. & Deng, J.L. (2012). Oxygen therapy for pneumonia in

adults. Cochrane Database of Systematic Reviews. DOI: 10.1002/14651858.CD006607.

pub4

Medication Worksheet

Drug Name Generic and Brand & TIME DUE	Classification/ Mechanism of action	Actions/Indications (Reason MY patient is on this medication)	Patient dose/ route/ frequency	Most common or serious side effects	Contraindications & Major Interactions (Food/Drug)	Nursing Interventions / Patient Teaching (What you need to know/ do before administering)
Epoetin Alfa (0546)	It is an antianemic/hormone that acts by stimulating the production of red blood cells (Deglin, Vallerand, & Sanoski, 2013).	The drug is used to treat anemia’s associated with chronic kidney disease. The patient has had his kidneys removed so he cannot produce erythropoietin to stimulate red blood cell production. Also, the patient has had multiple surgeries and on the day of care had returned from surgery for evacuating a hemoperitoneum (2 liters).	40,000 units q7days; IV; infusion range: 1- 2 hours	Seizures, headache, stroke, thromboembolic events, hypertension, transient rashes, and MI (Deglin, Vallerand, & Sanoski, 2013).	Contraindications include: hypersensitivity to albumin or mammalian, uncontrolled hypertension, history of seizures or stroke, and cardiovascular disease (Deglin, Vallerand, & Sanoski, 2013). Possible interactions is that it might increase the requirement of heparin anticoagulation during hemodialysis (Deglin, Vallerand, & Sanoski, 2013).	Monitor the patient’s BP before and during therapy for severe hypertension. Report BP increases to provider (Deglin, Vallerand, & Sanoski, 2013). Monitor renal function studies and electrolytes. Increased in BUN, creatinine, uric acid, phosphorus, and potassium may occur (Deglin, Vallerand, & Sanoski, 2013).
Hydrocortisone (0846; 2100)	Hydrocotisone is a corticosteroids and acts by replacing endogenous cortisol in deficiency states (Deglin, Vallerand, & Sanoski, 2013).	The drug can be used to manage adrenocortical insufficiency. The patient had to have part of his right adrenal gland removed during his initial surgery. This lead to the patient having adrenal insufficiencies requiring replacement.	80 mg; q12hrs; IV push over 1-10 minutes	Depression, euphoria, headache, hypertension, nausea, anorexia, decreased wound healing, ecchymoses, muscle wasting, vomiting, restlessness and osteoporosis (Deglin, Vallerand, & Sanoski, 2013).	Contraindicated in active untreated infections, hypothyroidism, ulcerative colitis, and know alcohol hypersensitivity (Deglin, Vallerand, & Sanoski, 2013). Drug interaction include: increase risk of GI effects when used with NSAIDS and may increase requirement of insulin (Deglin, Vallerand, & Sanoski, 2013).	Monitor intake and output ratios and daily weight prior to and periodically during therapy (Deglin, Vallerand, & Sanoski, 2013). Monitor lab electrolytes and glucose because may cause hyperglycemia or hypokalemia (Deglin, Vallerand, & Sanoski, 2013).
Insulin regular (0600; 1200; 1800) Onset: 30-60 min Peak: 2-4 hours Duration: 5-7 hours	It is a pancreatics and acts by enhancing protein synthesis and lowers blood glucose by stimulating glucose uptake (Deglin, Vallerand, & Sanoski, 2013).	The insulin is just a PRN order for the ICU in case the patient’s blood sugars measured in his labs or urine match set parameters. On the day of care the patient did not receive any insulin.	0-20 units; q6hrs; subq; PRN if BS indicates	Hypoglycemia, allergic reactions including anaphylaxis, pruritus, erythema, and swelling (Deglin, Vallerand, & Sanoski, 2013).	Contraindicated in hypoglycemia and allergy (Deglin, Vallerand, & Sanoski, 2013).	Assess the patient periodically for signs of hypoglycemia after administration (Deglin, Vallerand, & Sanoski, 2013). Monitor the patient’s body weight periodically because it could indicate need for changes in insulin regime (Deglin, Vallerand, & Sanoski, 2013).
Linezolid (0252; 1352)	The drug class is oxazolidinones and it acts by inhibiting bacterial protein synthesis (Deglin, Vallerand, & Sanoski, 2013).	The drug is used to treat infections caused by vancomycin-resistant Enterococcus faecium or MRSA. The patient had a positive blood culture for bacteroides vulgatus and a positive gram stain culture for Vancomycin-resistant Enterococcus and Multi-drug resistant bacteria. The patient is on contact precautions for his infection.	600 mg; q2day; IV; infusion range: 30-120 minutes	Pseudomembranous colitis, diarrhea, increase liver enzymes, headache, insomnia, and lactic acidosis (Deglin, Vallerand, & Sanoski, 2013).	Contraindicated in hypersensitivity, phenylketonuria, concurrent or recent use of MAO inhibitors, and thrombocytopenia (Deglin, Vallerand, & Sanoski, 2013). Interactions include increased risk of hypertensive response with MAO inhibitors and increase risk of serotonin syndrome with SSRIs (Deglin, Vallerand, & Sanoski, 2013).	Monitor the patient for signs of infection at beginning and during therapy (Deglin, Vallerand, & Sanoski, 2013). The drug can cause lactic acidosis monitor patient for recurrent nausea and vomiting, unexplained acidosis or low bicarbonate levels (Deglin, Vallerand, & Sanoski, 2013).
Metoclopramide HCL (1131)	The drug is a prokinetic agent and acts by stimulating upper GI motility (Deglin, Vallerand, & Sanoski, 2013).	The patient has had multiple abdominal surgeries and this drug has been used to treat acute and chronic postsurgical gastric stasis. The patient had just returned from abdominal surgery and upon assessment had no bowel sounds.	5 mg; q8hrs; IV push over 1-2 minutes	Slow or jerky muscle movements, depressed mood, jaundice, seizure, nausea, vomiting, diarrhea, and insomnia (Deglin, Vallerand, & Sanoski, 2013).	Contraindicated in situations of mechanical obstruction or perforation, GI hemorrhage, history of seizures, and known intolerance of metoclopramide (Deglin, Vallerand, & Sanoski, 2013).	Monitor patient for signs of a movement disorder and extrapyramidal symptoms such as akathisia (Deglin, Vallerand, & Sanoski, 2013).
Oxycodone (0600; 1000; 1400)	It is an opioid agonist and acts by binding to opiate receptors in the CNS (Deglin, Vallerand, & Sanoski, 2013).	The patient is an ICU patient and has an open abdominal wound. This drug is prescribed for the patient as part of his pain management regime.	5 mg; q4hr; oral	Confusion, sedation, respiratory depression, constipation, flushing, sweating, dizziness, and blurred vision (Deglin, Vallerand, & Sanoski, 2013).	Contraindications include hypersensitivity, head trauma, severe renal disease, hypothyroidism, adrenal insufficiency, and alcoholism (Deglin, Vallerand, & Sanoski, 2013). Use cautiously with patients on MAO inhibitors.	Assess type, intensity, and location of pain prior to and after administration. Monitor the patient’s BP, pulse, and respirations before and after administration. If RR is less than 10, assess level of sedation (Deglin, Vallerand, & Sanoski, 2013).
Pantoprazole (0800)	The drug is a proton pump inhibitor and acts by decrease the acid in the gastric area (Deglin, Valleran, & Sanoski, 2013).	The drug is used as part of the ICU patient’s prophylaxis regime at MIHS to prevent gastric ulcers from stress. Also, the patient has had multiple abdominal surgeries.	40 mg; qMorning; IV push over 1-3 minutes.	Headache, abdominal pain, diarrhea, hyperglycemia, hypomagnesmia, and flatulence (Deglin, Valleran, & Sanoski, 2013).	Hypersensitivity and prolonged use can increase risk bone fractures (Deglin, Valleran, & Sanoski, 2013).	Assess patient routinely signs of abdominal pain and for frank or occult blood in stool or aspirate. Watch lab values because may cause hypomagnesemia (Deglin, Valleran, & Sanoski, 2013).
Zosyn (0800; 1400;1800)	The drug is an antibiotic and is used for nosocomial pneumonia (Deglin, Valleran, & Sanoski, 2013).	This drug is an antibiotic and is part of the antibiotic therapy prescribed for the patient because of his positive blood and gram stain cultures.	3.375 g/100ml; q3day; IV infusion rate 4 hours or 25 ml per hour	Seizures in high doses, confusion, dizziness, rashes, bleeding, and hypersensitivity (Deglin, Valleran, & Sanoski, 2013).	Hypersensitivity to penicillins and increase risk of hepatotoxicity with other hepatotoxic agents (Deglin, Valleran, & Sanoski, 2013).	Assess patient for signs of infection (VS, appearance of wound, sputum, and urine) at beginning or at end of therapy. Observe for signs of anaphylaxis (Deglin, Valleran, & Sanoski, 2013).
Beneprotein (0800; 1600)	This drug is a medical nutritional protein supplement.	The patient is malnourished and has a 2.0 albumin level. The patient is prescribed this supplement to try and overcome his protein deficiencies.	2 packets; q2day; oral/down patient’s duotube	Localized infection, liver function test abnormalities, alopecia, and pancreatitis (Deglin, Valleran, & Sanoski, 2013).	Contraindicates are to not supplement when increase protein and albumin levels are present (Deglin, Valleran, & Sanoski, 2013).	Monitor patient for signs of abdominal discomfort and keep patient elevated 30 degrees after administered. Check stomach for residual before administering down the patients duotube withhold for greater than 200 ml residual (Deglin, Valleran, & Sanoski, 2013).
Bicarbonate replacement solution (hourly CRRT)	It is classified as a hemofiltration solution and is used to replace plasma volume and correct electrolytes and acid-base imbalances (Deglin, Valleran, & Sanoski, 2013).	This drug is a sterile hemofiltration and hemodiafiltration solution used for the patients CRRT.	2000 ml/hr; for CRRT	Side effects include fluid overload; swelling of the feet, ankles or legs; increased urination; and unusual tiredness (Deglin, Valleran, & Sanoski, 2013).	The solution can interact with kalexate, kayexalate, and kionex (Deglin, Valleran, & Sanoski, 2013).	Monitor the patient intake and output to determine if proper amount of solution is being administered (Deglin, Valleran, & Sanoski, 2013). Monitor patient’s labs for electrolytes replacement values.
Dialysate (hourly CRRT)	It is a hemofiltration solution and is used to remove small waste molecules during CRRT (Deglin, Valleran, & Sanoski, 2013).	This drug is a cleansing fluid used for the patients CRRT to help prevent the blood from clotting when it goes through the machine.	2000 ml/hr; for CRRT	Side effects include fluid overload, edema, and increased urination (Deglin, Valleran, & Sanoski, 2013).	The solution does not have any listed interactions (Deglin, Valleran, & Sanoski, 2013).	Monitor the patient intake and output to determine if proper amount of solution is being administered (Deglin, Valleran, & Sanoski, 2013). Monitor patient’s labs for electrolytes replacement values.

References:

Deglin, J. H., Vallerand, A. H., & Sanoski, C. A. (2009). Davis’s drug guide for nurses 13th edition (13th ed.). Philadelphia, PA: E.A. Davis Company.

Laboratory Values Worksheet

Lab Data (per Level)	Description of Lab Test	Normal Value	Result/ Date 2/23/13	Result/ Date 2/24/13	Result/ Date 2/25/13	Pathophysiology : explanation of abnormal lab value, including trends and correlation with disease process. In your own words.
WBC	WBC’s are components of the blood that respond to allergies, infections and inflammation. The test measures the amount present in the blood (Chabner, 2011, p. 508).	5.0-10.01^3/ µl	23.7 (H)	23.2 (H)	18.0 (H)	High values indicate the possibility of a bacterial infection (Chabner, 2011, p. 989). The patient has a positive blood culture for Bacteroides vulgatus and a positive gram stain culture for Vancomycin-resistant Enterococcus and Multi-drug resistant bacteria. The infection is in his blood stream and sputum. He is on antibiotic therapy to fight the infection and that is why his WBC’s are elevated. Also, this lab value is elevated with patients diagnosed with Xanthogranulomatous Pyelonephritis (Li & Parwani, 2011).
Neutrophils (ANC)	Neutrophils are WBC’s that accumulate at the site of infection (Chabner, 2011, p. 508). The test measures the amount present in the blood.	1.3-5.4 x 109 L	19.4 (H)	19.7 (H)	14.4 (H)	High values indicate the possibility of a bacterial infection (Chabner, 2011, p. 989). The patient has a positive blood culture for Bacteroides vulgatus and a positive gram stain culture for Vancomycin-resistant Enterococcus and Multi-drug resistant bacteria. The infection is in his blood stream and sputum. He is on antibiotic therapy to fight the infection and that is why his neutrophils are elevated. Also, this lab value is elevated with patients diagnosed with Xanthogranulomatous Pyelonephritis (Li & Parwani, 2011).
Lymphocyte	Lymphocytes are WBC’s that accumulate at the site of infection and inflammation (Chabner, 2011, p. 508). The test measures the amount present in the blood.	1.0-3.9 x 109 L	1.4	0.9 (L)	1.4	Low values indicate the possibility of viral infection and aplastic anemia (Chabner, 2011, p.989). The patient has anemia due to his lack of kidneys so he is not producing erythropoietin and also the patient has an active bloodstream infection causing him to be on contact precautions.
Monocytes	Monocytes are WBC’s that accumulate at the site of injuries and inflammation (Chabner, 2011, p. 508). The test measures the amount present in the blood.	0.1-0.8 x 109 L	2.8 (H)	2.6 (H)	2.0 (H)	High values indicate the possibility of a bacterial infection (Chabner, 2011, p. 989). The patient has a positive blood culture for Bacteroides vulgatus and a positive gram stain culture for Vancomycin-resistant Enterococcus and Multi-drug resistant bacteria. The infection is in his blood stream and sputum. He is on antibiotic therapy to fight the infection and that is why his monocytes are elevated. Also, this lab value is elevated with patients diagnosed with Xanthogranulomatous Pyelonephritis (Li & Parwani, 2011).
Hemoglobin (Hgb)	Hgb is a blood protein that is part of the erythrocyte. It is the portion that contains iron to carry oxygen (Chabner, 2011, p. 990). The test measures the amount present in the blood.	13.5-17.5 g/dl	8.5 (L)	9.2 (L)	10.3 (L)	Low values indicate loss of blood and anemia (Chabner, 2011, p. 990). The patient has had bleeding in his retroperitoneal cavity since his initial surgery and on the day of care had 2 liters of hemoperitoneum evacuated. Also, since the patient has had both kidneys removed he is not producing erythropoietin, which stimulates red blood cell production causing anemia.
Hematocrit (Hct)	Hct is the percentage of erythrocytes in a volume of blood (Chabner, 2011, p. 523). The test measures the amount present in the blood.	38.0-54.0 %	26.6 (L)	28.0 (L)	31.4 (L)	Low values indicate loss of blood and anemia (Chabner, 2011, p. 990). The patient has had bleeding in his retroperitoneal cavity since his initial surgery and on the day of care had 2 liters of hemoperitoneum evacuated. Also, since the patient has had both kidneys removed he is not producing erythropoietin, which stimulates red blood cell production causing anemia.
Platelets	Platelets are located in blood and help with clotting. The test measures the amount present in the blood.	140-440 K/ µl	278	248	241	Patient lab values are within normal limits.
Serum Na	The test measures the amount of sodium present in the blood serum (Chabner, 2011, p. 991).	137-145 mmol/L	137	137	137	Patient lab values are within normal limits.
Serum K	The test measures the amount of potassium present in the blood serum (Chabner, 2011, p. 991).	3.5-5.1 mmol/L	4.6	4.6	4.7	Patient lab values are within normal limits.
Serum Cl	The test measures the amount of CL present in the blood serum.	98-107 mmol/L	102	101	101	Patient lab values are within normal limits.
Serum CO2	The test measures the amount of CO2 present in the blood serum.	22.0-30.0 mmol/L	23	23	24	Patient lab values are within normal limits.
BUN	BUN stands for blood, urea, and nitrogen. The test measures the amount of each in blood serum (Chabner, 2011, p. 990).	7-20 mg/dL	46 (H)	30 (H)	21 (H)	High BUN levels indicate that your kidneys are not working (Chabner, 2011). The patient had a total bilateral nephrectomy so he no longer has kidneys and is currently being treated with CRRT.
Creatinine	The test measures the amount of creatinine in the blood serum.	0.66-1.25 mg/dL	3.87 (H)	2.45 (H)	1.83 (H)	High creatinine levels indicate that you kidneys are not working well (Chabner, 2011). The patient had a total bilateral nephrectomy so he no longer has kidneys and is currently being treated with CRRT.
Glucose	The test measures the amount of glucose present in the blood serum (Chabner, 2011, p. 991).	74-106 mg/dL	116	99	101	Patient lab values are within normal limits.
Ca	The test measures the amount of calcium present in the blood serum (Chabner, 2011, p. 991).	8.4-10.2 mg/dL	8.5	8.1 (H)	8.0 (H)	High calcium levels can be found in people with slow or reduced kidney function or on dialysis (Chabner, 2011). The patient has had both kidneys removed and is receiving CRRT.
Mg	The test measures the amount of MG present in blood serum (Chabner, 2011, p. 991).	1.6 - 2.4 mEq/L	2.5 (H)	2.4	2.4	High magnesium levels can occur in patients with kidney failure (Chabner, 2011). The patient is in end stage renal failure and has just had a total bilateral nephrectomy. The kidneys are the organs that excrete excess magnesium and the patient does not have kidneys.

Lab Data (per Level)	Description of Lab Test	Normal Value	Result/ Date 2/23/13	Result/ Date 2/24/13	Result/ Date 2/25/13	Pathophysiology: explanation of abnormal lab value, including trends and correlation with disease process
Troponin 1	Measures the troponin levels in the blood. Troponin is released when damage to heart muscle occurs and is part of cardiac markers tested for MI (Chabner, 2011).	0 - 0.1 ng/m	2/15/13: 0.018	Patient lab values are within normal limits.
CK	Maker for muscle damage and is used as a cardiac markers tested for MI (Chabner, 2011).	<150 U/L	2/15/13: 113	Patient lab values are within normal limits.
CK-MB	MB is both a sensitive and specific marker for myocardial infarction. MB usually becomes abnormal three to four hours after an MI, peaks in 10–24 hours, and returns to normal within 72 hours (Chabner, 2011).	>5% in MI	2/15/13: 2.27	Patient lab values are within normal limits.
Prothrombin Time (PT)	The test measures the amount of time it takes blood to clot (Chabner, 2011, p. 991).	9.4-12.0 seconds	15.1 (H)	15.2 (H)	14.7 (H)	High PT can indicate an increased clotting time. The patient has high PT values because of his kidney disease treatment with CRRT.
International Normalized Ratio (INR)	This test is for the amount of time it takes blood to clot (Chabner, 2011, p. 991).	0.8-1.0 INR	1.4 (H)	1.5 (H)	1.4 (H)	High INR can indicate an increased clotting time. The patient has high INR values because of his kidney disease treatment with CRRT.
Activate Partial Thromboplastin time (APTT)	This test for clotting factors in the blood and can be related to see what heparin levels are in a person’s blood (Chabner, 2011, p. 991).	25.6-36.7 s	34.3	32.8	29.2	Patient lab values are within normal limits.
ALT	Is an enzyme mainly found in the liver; the best test for detecting hepatitis (Chabner, 2011).	7 to 72 U/L	34	Patient lab values are within normal limits.
AST	Is an enzyme found in the liver and a few other places, particularly the heart and other muscles in the body (Chabner, 2011).	8 to 55 U/L	20	Patient lab values are within normal limits.
ALP	Is an enzyme related to the bile ducts; often increased when they are blocked (Chabner, 2011).	45 to 115 U/L	163 (H)	High levels of ALP indicate a blockage in the bile duct (Chabner, 2011). The patient had blockage of his bile duct that required the placement of biliary tube and drain to evacuate excess bilious matter. Also, this lab value is elevated with patients diagnosed with Xanthogranulomatous Pyelonephritis (Li & Parwani, 2011).
Amylase/Lipase	This test is used to help diagnose and monitor acute or chronic pancreatitis and other disorders that may involve the pancreas (Chabner, 2011).	50 – 150 U/dL	Amylase body fluids >2400	The patient’s results are elevated supporting his diagnosis of pancreatitis. His pancreas was injured during his kidney removal surgery.
Urinalysis	This test for issues in the kidneys. Color Pale yellow to amber Turbidity Clear to slightly hazy Specific Gravity 1.015-1.025 pH 4.5-8.0	No results available in the patient’s chart for this test.	No results available in the patient’s chart for this test.
ABGs pH pO2 pCO2 HCO3 BE On RA, % O2, vent settings	This test for the level of oxygen and carbon dioxide in the blood (Chabner, 2011). Arterial Venous 7.35 - 7.45 7.32 - 7.42 35 - 45 38 - 52 70 – 100 28 - 48 19 - 25 19 - 25 90 - 95 40 - 70	7.427 97.1 39.3 25.3 1.0 97.5	7.390 187.4 (H) 48.6 (H) 28.8 (H) 3.2 (H) 99.3	The high p02 value is the result of the patient being still ventilated post surgery with a high Fi02 setting. The patient’s other high values indicate respiratory acidosis or a mixed blood gas results. These finds could be abnormal because the patient is post-op and the Fi02 oxygenation levels patient is receiving.
TB test	Test for tuberculosis.	2009: negative	Patient lab values are within normal limits.
Albumin	Albumin is a protein made by the liver. A serum albumin test measures the amount of this protein in the clear liquid portion of the blood (Chabner, 2011).	3.4 - 5.4 g/dL	2.0 (L)	Protein, total= 4.3 (L)	Low values indicated malnutrition (Chabner, 2011). The patient can only tolerate tube feeds at 10 ml/hr and is getting a protein supplement. The nutritionist has diagnosed malnutrition and is concerned about the patient’s nutritional status.
Total Bilirubin	Bilirubin testing checks for levels of bilirubin in your blood (Chabner, 2011).	0.3 to 1.9 mg/dL	2/24/13: 163 (H)	High levels indicate the possibility of a blocked bile duct (Chabner, 2011). The patient’s scleras are yellow and the surgeons placed a biliary tube to drain out bilious drainage.
Blood culture	This is a test to detect infection in the patient’s bloodstream (Chabner, 2011).	None	2/13/13: Positive for bacteroides vulgatus	Positive blood cultures indicate that the patient has a blood stream infection. The patient’s elevated WBC levels support this culture and he is on antibiotic therapy to treat the infection.
Culture fluid with gram stain	This is a test performed on the patient’s body fluid to test for infection (Chabner, 2011).	None	2/13/13: Positive for Vancomycin-resistant Enterococcus and Multi-drug resistant bacteria	A positive gram stain of the patient’s bodily fluids means the patient had a bacterial infection. The patient’s elevated WBC levels support this culture and he is on antibiotic therapy to treat the infection.

References:

Chabner, D. (2011). The language of medicine (9th ed.). Saint Louis, MO: Saunders Elsevier.

Li, L. & Parwani, A.V. (2011). Xanthogranulomatous pyelonephritis. Archives of Pathology & Laboratory Medicine 135(5): 671-674. Retrieved

on March 8, 2013 from http://www.archivesofpathology.org/doi/full/10.1043/2009-0769-RSR.1

Diagnostic Testing Worksheet (e.g. x-ray, ECG, colonoscopy, etc.)

Tests	Purpose of Test	Date of Test	Test Results
CT Chest Abdomen Pelvis w/ IV contrast	Leukocytosis post-op	2/13/13	There was a large amount of interval peritoneal fluid with no definitive evidence of loculation. Scattered air bubbles were noted in the peritoneal fluid suggesting presence of infection. There are also small to moderate-sized pleural effusions associated with compressive atelectasis at left lung base. There is a small right pleural effusion also associated with a compressive atelectasis at the right lung base. Pleural calcifications are present at the right posterior lung base. There are abscesses presented in both retroperitoneal nephrectomy sites. The abscess is greater on the left than the right.
CT Guided abscess drain	2/14: Set up Left Abscess drain 2/15: Set up Right Abscess drain	2/14/13 2/15/13	Successful CT guided catheter drainage of R. retroperitoneal renal fossa fluid collection. Left retroperitoneal renal fossa fluid collection successfully drained but had a resolving hematoma present that required placement of 16 French pigtail catheter and drainage bag.
X-ray abdomen AP	Confirm duotube placement	2/20/13	Weighted tube is in the expected place in the 4th portion of duodenum. Left lower airspace opacity noted.
X-ray Chest AP only	Shortness of breath	2/21/13	Increase in the size of pleural effusions on both the left and right side. Stable bilateral basilar opacities.
X-ray Chest AP only	Pleural effusions	2/22/13	The patient has stable bilateral lung airspace diseases and bilateral effusions. Interval placement of left upper abdomen packing material.
US Doppler venous legs bilateral	Prolonged bedrest	2/22/13	Negative examination for bilateral lower extremity DVT.
X-ray Chest AP only	Pleural effusions	2/24/13	The patient has stable bilateral airspace opacities. Worsening right and left pleural effusions.
US left upper extremity	Pain/Edema Left upper extremity, AVF	2/24/13	Stenosis was present at sight of AV fistula. Possible enlarged lymph node.

References:

Maricopa Integrated Health Services. (2013).Patient’s chart. Retrieved on March 4, 2013.

MIND MAP (PER LEVEL) Key Problem: Excess fluid volume R/T compromised regulatory mechanisms, dialysis, adventitious breath sounds, and altered electrolytes AEB coarse lung sounds with diminished breath sounds and crackles at bases, patient on CRRT with orders to match intake with output, chest X-ray 2/21 showing worsening pleural effusions, patient had bilateral nephrectomy so has no kidney’s and their regulatory mechanisms, generalized pitting edema 2/3+, and elevated Ca 8.0 (H) and Mg 2.5 (H). Supporting Data: The patient had his kidneys removed and lost the regulatory mechanisms that they provide for the body. The patient was in surgery at the start of the day of care and was off of his CRRT therapy, which could contribute to the worsening fluid overload symptoms. Once CRRT was resumed post-surgery his orders were changed to match intake with output. Previously, it was maintain plus 200 intake. Upon auscultation the LS were coarse with crackles at bases. A chest x-ray was ordered and showing worsening pleural effusions. The altered electrolytes are related to his ESRD. GE pitting 2/3+. Reason for needing health care/ Medical Diagnosis: Elective total bilateral nephrectomy complicated by the development of renal abscesses in the retroperitoneal cavity, hypotension, tachycardia, hyperkalemia, adrenal insufficiency, anemia and pancreatitis. The patient also suffers from end stage renal disease. Anticipated assessments (prep): Intake & Output, PERRL, EOM, respiratory status pre and post-extubation, check for signs of infection, Line assessment (A-Line & Central), restraints while intubated at start of day of care, ECG review, medication review, wound assessment, and lab review. Assessment Data (concept map): patient returned from abdominal surgery intubated on the day of care and was extubated before end of shift; contact precautions for bacteremia; restraints removed upon assessment patient not at risk for pulling out ETT tube; A-line and Udall catheter dwell day 4; CVC dwell day 7; patient placed back onto CRRT therapy an hour post-surgery; CRRT nurse at bedside monitoring patient intake and output; CRRT orders changed to match output with intake; pertinent lab values: total bilirubin 163 (H), Albumin 2 (L), PT 14.7 (H), INR 1.4 (H), Ca 8 (H), Hgb 10.3 (L) & Hct 31.4 (L). GA: Alert, ill appearing, comfortable and no distress. Head: Normocephailic and atraumatic; Nasogastric tube in R. nare connected to intermitted suction; Duotube in L. nare Neuro: A&0 x 3; normal speech when extubated; no movement disorders noted; follows commands and responds appropriately Resp.: bilateral crackles/coarse at lung bases with diminished breath sounds; pleural effusions both lungs per x-ray; symmetric chest entry CV: RR, tachy, normal S1S2; no murmurs, rubs, clicks, or gallops ABD: No BS; abthera in place with wound vac; non-distended; no guarding or rebound; RLQ ostomy (pink, patent, productive); R. drain in place with clear bilious output GU: R. fem A-line, L. fem Udall; Edematous scrotum MS: no joint tenderness, deformity or swelling, LUE AVF w/ palpable thrill Skin: Generalized pitting edema 2/3+; Normal color and skin turgor; no rashes or suspicious lesions; open abdominal wound not able to assess with wound vac in place Key Problem: Ineffective airway clearance R/T artificial airway in place, fluid overload, adventitious breath sounds, infection, secretion, ABG values AEB bilateral crackles/ coarse lung sounds with diminished breath sounds at the bases, intubated and extubated during shift, bacteremia with positive blood cultures and gram stain, nonproductive cough, thin cloudy clear secretions on oral suctioning, and worsening bilateral pleural effusions present on x-ray 2/21, 2/25 ABG values indicated mixed/respiratory acidosis. Supporting Data: Patient returned from Exploratory Lap on day of care intubated and was extubated mid-day. Upon auscultation lung sounds were coarse and diminished at the bases with crackles present. X-ray on 2/21 showed worsening of bilateral pleural effusions. ABG values on 2/25 of pH: 7.390, pO2: 187.4 (H), pCO2: 48.6 (H), HCO3: 28.8 (H), BE: 3.2 (H), and O2 stat: 99.3 indicating mixed/respiratory acidosis. Also, patient has had multiple surgeries and has had multiple extubations so there might be swelling in his airway. He has had at least one episode of decompensation with hypotension and tachycardia requiring emergent extubation.

Key Problem: Imbalanced nutrition: less than body requirements R/T inability to digest food, inability to absorb nutrients, and medical condition AEB absent BS upon auscultation, medical diagnosis of gastric stasis, patient can only tolerate 10 ml/hr continuous tube feed down duotube, albumin lab level of 2.0 (L), total protein lab level of 4.3 (L), on 2/17 the patient had a perforation in his stomach repaired and medical diagnosis of malnutrition. Supporting Data: The patient chart has a note from the nutritionist that states patient is not receiving adequate nutrition from his tube feeds and it needs to be increased. His lab values for albumin and total protein are low which also indicates malnutrition. The patient is post-surgery on the day of care and upon assessment has absent BS. He had a perforated stomach repaired surgically on 2/17. The patient is on the medication Metoclopramide HCL, which is a pro-kinetic that helps stimulate upper GI motility. The patient can only tolerate a continuous tube feed of 10 ml/hr when the nurse tried to increase to 20 ml/hr per doctor’s order the patient did not tolerate the increase and threw up. Key Problem: Delayed surgical healing R/T extensive and multiple surgical procedures, infection, prolonged hospital stay, malnutrition, and obesity AEB patient had a bilateral nephrectomy on 2/4 and has had multiple exploratory laps afterwards on 2/16, 2/17, 2/21, and 2/23; hospital day 19; patient has positive blood culture for Bacteroides vulgatus and a positive gram stain culture for Vancomycin resistant Enterococcus and MRSA; patient BMI is 26; patient diagnosed with malnutrition has a low albumin lab value of 2.0 and total protein of 4.3; and patient developed septic shock post-kidney removal surgery. Supporting Data: The patient entered the hospital on 2/4 for an elective bilateral nephrectomy and is currently on hospital day 19 due to complications and development of sepsis post-nephrectomy surgery. The patient is malnourished with low album (2.0) and total protein (4.3) lab values. Malnourishment could delay wound healing. The patient had positive blood cultures and gram stains requiring contact precautions. The patient has an open abdomen packed with abthera and a wound vac attached. The patient’s BMI is 26. The patient had multiple complications from his 2/4 surgery including pancreas injury causing pancreatitis, splenectomy, perforated stomach, colectomy, and PCT placement. Key Problem: Risk for bleeding R/T surgery, elevated coagulation studies, impaired liver function, and gastrointestinal disorders AEB PT lab values of: 2/25: 15.1, 2/24: 15.2, 2/23: 14.7; INR lab values of: 2/25: 1.4, 2/24: 1.5, 2/23: 1.4; abdominal surgeries on 2/4, 2/16, 2/17, 2/21, and 2/23; surgery on 2/21 was to evacuate hemoperitoneum 2 liters; surgery on 2/16 was for biliary tube placement; elevated liver studies: ALP 163 (H) and total bilirubin 163 (H); perforated stomach repaired 2/17 surgery; hemorrhage repaired 2/16 surgery Supporting Data: The patient has had multiple abdominal surgeries since his initial kidney removal surgery. The patients lab studies show elevated PT and INR values and the patient is not prescribed anticoagulation therapy. His surgery on the day of care 2/21 was to evacuate 2 liters of hemoperitoneum. The patient has his abdominal wound packed with a wound vac attached to suction that puts out 50 ccs an hour. The patient also had elevated liver studies requiring biliary tube placement with JP drain. The patient has anemia from his ESRF/no kidneys and his H & H values are low 10.3 and 31.4, respectively. However, the patient had received 4 PRBC’s during his surgery on the day of care.

PROBLEM LIST (PER LEVEL)

PROBLEM (Number problems in order of priority)	Nursing Diagnosis with R/T and AEB (Number diagnoses in order of priority)
1) The patient returned from surgery still intubated and was weaned off at the start of shift going from SIMV mode to PSW mode to extubated by noon. The patient had coarse lung sounds and diminished breath sounds at the bases with crackles present. The chest x-ray taken on 2/21 showed worsening of the patient’s bilateral pleural effusions. Making sure the patient maintains his airway after extubation and with his fluid overload symptoms is a priority nursing intervention. 2) The patient is on CRRT and has symptoms related to excess fluid overload including generalized pitting edema 2/3+, bilateral pleural effusions, and altered electrolytes. The excess fluid volume if continued could affect the patient’s respiratory status and should be the 2nd nursing priority. 3) The patient had returned from surgery on the day of care where he had 2 liters of hemoperitoneum evacuated. The surgeons said that the patient had a slow unidentified bleed and that continued treatment would be abdominal washes with changes of wound vac every 2-3 days or as needed. The patient has history of hemorrhage and his PT and INR are elevated. These factors make risk for bleeding a nursing concern. 4) The patient was admitted on 2/4 of a bilateral nephrectomy. He has had multiple surgical complications and developed septic shock. All of these factors have delayed the patients surgical healing and lengthened his hospital stay. The nurse should promote healing for the patient as part of his daily care. 5) The doctor has diagnosed the patient with malnutrition and the patient has low albumin (2.0) and total protein (4.3) lab values corroborating the diagnosis. The patient’s malnutrition can affect the rate of his healing and the level of his generalized edema. That is why this is an important nursing concern to address. Minimal interruptions to the continuous tube feeds are necessary.	1) Ineffective airway clearance R/T artificial airway in place, fluid overload, adventitious breathe sounds, infection, secretion, ABG values AEB bilateral crackles/ coarse lung sounds with diminished breath sounds at the bases, intubated and extubated during shift, bacteremia with positive blood cultures and gram stain, nonproductive cough, thin cloudy clear secretions on oral suctioning, and worsening bilateral pleural effusions present on x-ray 2/21, 2/25 ABG values indicated mixed/respiratory acidosis. 2) Excess fluid volume R/T compromised regulatory mechanisms, dialysis, adventitious breath sounds, and altered electrolytes AEB coarse lung sounds with diminished breath sounds and crackles at bases, patient on CRRT with orders to match intake with output, chest X-ray 2/21 showing worsening pleural effusions, patient had bilateral nephrectomy so has no kidney’s and their regulatory mechanisms, generalized pitting edema 2/3+, and elevated Ca 8.0 (H) and Mg 2.5 (H). 3) Risk for bleeding R/T surgery, elevated coagulation studies, impaired liver function, and gastrointestinal disorders AEB PT lab values of: 2/25: 15.1, 2/24: 15.2, 2/23: 14.7; INR lab values of: 2/25: 1.4, 2/24: 1.5, 2/23: 1.4; abdominal surgeries on 2/4, 2/16, 2/17, 2/21, and 2/23; surgery on 2/21 was to evacuate hemoperitoneum 2 liters; surgery on 2/16 was for biliary tube placement; elevated liver studies: ALP 163 (H) and total bilirubin 163 (H); perforated stomach repaired 2/17 surgery; hemorrhage repaired 2/16 surgery. 4) Delayed surgical healing R/T extensive and multiple surgical procedures, infection, prolonged hospital stay, malnutrition, and obesity AEB patient had a bilateral nephrectomy on 2/4 and has had multiple exploratory laps afterwards on 2/16, 2/17, 2/21, and 2/23; hospital day 19; patient has positive blood culture for Bacteroides vulgatus and a positive gram stain culture for Vancomycin resistant Enterococcus and MRSA; patient BMI is 26; patient diagnosed with malnutrition has a low albumin lab value of 2.0 and total protein of 4.3; and patient developed septic shock post-kidney removal surgery. 5) Imbalanced nutrition: less than body requirements R/T inability to digest food, inability to absorb nutrients, and medical condition AEB absent BS upon auscultation, medical diagnosis of gastric stasis, patient can only tolerate 10 ml/hr continuous tube feed down duotube, albumin lab level of 2.0 (L), total protein lab level of 4.3 (L), on 2/17 the patient had a perforation in his stomach repaired and medical diagnosis of malnutrition.

Nursing Diagnosis and Priority # 1

Ineffective airway clearance R/T artificial airway in place, fluid overload, adventitious breathe sounds, infection, secretion, ABG values AEB bilateral crackles/ coarse lung sounds with diminished breath sounds at the bases, intubated and extubated during shift, bacteremia with positive blood cultures and gram stain, nonproductive cough, thin cloudy clear secretions on oral suctioning, and worsening bilateral pleural effusions present on x-ray 2/21, 2/25 ABG values indicated mixed/respiratory acidosis. General Goal:

Patient will maintain a good respiratory status with an sp02 of at least 95% during the nursing shift.

Outcome Objective(s): (use SMART format)

1. The patient after extubation will be taught and exhibit an effective productive cough by the end of the nursing shift.

2. The patient will maintain a patent airway after extubation for the remainder of the nursing shift. An effective airway will be measured by an sp02 above 95%, capillary refill <2-3 seconds and normal ABG values of a pH between 7.35 - 7.45, paco2 of 35-45 mm Hg, hco3 of 22 to 26 mEq/liter, pao2 of 80 to 100 mm Hg, sao2 of 95% to 100%, and base excess of -5 to +3

3. The patient will not exhibit visual signs of respiratory distress such as dyspnea, desaturation, and cyanosis during the nursing shift.

Interventions with time frames/frequency	Rationale (for each intervention)	Patient Responses (subjective/objective data)
1) The nurse will auscultate the patient’s breath sounds q 1-4 hrs. during the nursing shift (Ackley & Ladwig, 2011). 2) The nurse will monitor the patient’s pulse oxygenation levels and ABG values during the nursing shift (Ackley & Ladwig, 2011). 3) Monitor the patient’s respiratory pattern after extubation including his rate, depth, and effort (Ackley & Ladwig, 2011). 4) Administer 02 as needed for an sp02 value below 95% and if the patient is symptomatic for dyspnea. 5) The nurse should position the client with his head of bed elevated 30-45 degrees to optimize respiration (Ackley & Ladwig, 2011).	1) Normal breath sounds are clear with fine crackles that stop with deep breathing. The presence of coarse crackles indicates fluid in the airway (Fauci et al., 2008). 2) A pulse ox less that 90% and a p02 less than 80 indicate the patient has severe oxygenation problems (Clark, Giuliano, & Chen, 2006). 3) Normal respiratory rate for an adult is 12-16 without dyspnea. Secretions caught in the airway will increase the patient’s respiratory rate (Bickley & Szilagyi, 2009). 4) Oxygen administration has been shown to correct a patient’s hypoxemia (Wong & Elliott, 2009). Non-invasive ventilation can reduce the risk of death in the ICU, endotracheal intubation, shorten ICU stay and length of intubation (Zhang, Fang, Dong, Wu, & Deng, 2012). 5) An upright position allows of maximum lung expansion where lying flat gives abdominal organs the chance to shift compressing lungs. Also, in ventilated patient’s an elevated head of bed decreases incidence of pneumonia (Seckel, 2006).	1) During the nursing shift the patient’s breath sounds were auscultated q2 hrs. and were coarse with crackles at the bases. X-ray was ordered and confirmed worsening of his bilateral pleural effusions. 2) During the nursing shift the patient maintained a pulse ox greater than 95% and his ABG result had a p02 of 187.4 (ABG taken while still on vent post-surgery). 3) During the nursing shift the patient did not exhibit any signs of dyspnea. His respiratory rate was elevated off ventilator averaging around 20. The patient did have trouble clearing secretions from airway. 4) The patient was placed on 2 liters after extubation to maintain his O2 stats about 95%. The patient maintained 99-100% sp02 on the 2 liters for the entire nursing shift. 5) The patient head of bed was elevated at least 30 degrees during he nursing shift.

Evaluation of outcome(s):

1. The outcome was not met the patient was unable to exhibit a productive cough after instruction through a Spanish translator by the end of shift. The nurse had to intervene and perform oral suctioning to help the patient clear his airway.

2. The outcome was partially met because the patient did not desaturate to below 95% and his capillary refill remained < 3 seconds. However, the patient did have an abnormal ABG value of pH: 7.390, pO2: 187.4 (H), pCO2: 48.6 (H), HCO3: 28.8 (H), BE: 3.2 (H), and O2 stat: 99.3.

3. The outcome was met because the patient did not exhibit any signs of respiratory distress during the nursing shift.

Reference for rationales:

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier.

Bickley, L.S. & Szilagyi, P. (2009). Guide to physical examination, ed. 10, Philadelphia, PA: Lippincott, Williams and Wilkins.

Clark, A.P., Giuliano, K., & Chen, H.M. (2006). Pulse oximetry revised. Clinical Nurse Specialist 20(6): 268-272. Retrieved on March 9, 20122 from http://journals.lww.com/cns-journal/pages/default.aspx.

Fauci, et al. (2009). Harrison's principles of internal medicine, ed 17, New York, NY: McGraw-Hill.

Seckel, M. (2006). Implementing evidence-based practice guidelines to minimize ventilator-associated pneumonia, AACN News 24(1):

8-10. Retrieved on March 9, 2013 from http://www.aacn.org/wd/aacnnews/content/anewshome.pcms?menu=practice.

Wong, M. & Elliot, M. (2009). The use of medical orders in acute care oxygen therapy, British Journal of Nursing 18(8): 462-464.

Retrieved on March 9, 2013 from http://www.britishjournalofnursing.com.

Zhang, Y., Fang, C., Dong, B.R., Wu, T. & Deng, J.L. (2012). Oxygen therapy for pneumonia in adults. Cochrane Database of

Systematic Reviews. DOI: 10.1002/14651858.CD006607.pub4

Nursing Diagnosis and Priority # 2

Excess fluid volume R/T compromised regulatory mechanisms, dialysis, adventitious breath sounds, and altered electrolytes AEB coarse lung sounds with diminished breath sounds and crackles at bases, patient on CRRT with orders to match intake with output, chest X-ray 2/21 showing worsening pleural effusions, patient had bilateral nephrectomy so has no kidney’s and their regulatory mechanisms, generalized pitting edema 2/3+, and elevated Ca 8.0 (H) and Mg 2.5 (H).

General Goal:

The patient’s respiratory condition will not worsen due to excess fluid volume during the nursing shift as measured by maintaining sp02 above 95% and no signs of dyspnea.

Outcome Objective(s): (use SMART format)

1. The patient’s edema will not increase over 3+ as measured by tape at start and end of shift.

2. The patient’s pleural effusions will not worsen during the nursing shift per auscultation measurement.

3. The patient will maintain appropriate vital signs, normal CVP pressure, and PCWP during the nursing shift as measured by the patient’s A-line.

Interventions with time frames/frequency	Rationale (for each intervention)	Patient Responses (subjective/objective data)
1) The nurse will monitor the location and degree (1+ to 4+) of the patient’s edema at the start of shift and end noting discrepancies between the patient’s extremities (Ackley & Ladwig, 2011). 2) The patient’s daily weight should be monitored for sudden increases. Monitor weight at same time each shift (Ackley & Ladwig, 2011). 3) Administer CRRT therapy as ordered since the patient is critically ill and has symptoms of excessive fluid volume (Ackley & Ladwig, 2011). 4) Monitor the patient’s serum albumin and prealbumin levels as appropriate during the shift (Ackley & Ladwig, 2011). 5) The nurse should auscultate the patient’s lung sounds q2hrs for crackles as well as monitor respiratory effort and presence of orthopnea (Ackley & Ladwig, 2011).	1) Generalized edema is associated with dependent edema because of increased hydrostatic pressures as a result of renal failure (Fauci et al., 2008). Edema is a sign of fluid overload because excess fluid is third spacing. 2) Studies have shown that taking daily weight changes is a safe way to monitor if a patient had fluid overload (Mank et al., 2003). 3) CRRT is indicated for severe volume overload and for patients in ESRF or sepsis (Dirkes & Hodge, 2007). 4) Serum albumin contributed to serum oncotic pressure, which helps pull fluid out of the interstitial space into the intravascular space. When serum albumin is low, peripheral edema may be severe (Ackley & Ladwig, 2011). 5) All of these are measurable signs of pulmonary edema, which results from excessive shifting of fluid from the vascular space into the pulmonary interstitial space and alveoli (Fauci et al., 2008). PE is a complication of excess fluid overload.	1) The patients GE (pitting) was assessed as a 2/3+ degree at the start and end of shift. 2) The patient was weighed at the start of the shift and there were no significant changes. The patient maintained his weight at 72.1 kg. 3) The patient had a bilateral nephrectomy and requires CRRT because his medical condition does not allow dialysis management at this time. The patient’s had fluid overload symptoms so his CRRT orders were changed from 200+ intake to match intake and output. 4) The patient’s serum albumin level was 2.0 (L) and his prealbumin was low as well. This type of environment makes the patient susceptible to edema. This could be contributing to the patient’s 2/3+ generalized pitting edema. 5) The patient did have crackles at the bases and the doctors ordered an x-ray showing worsening pleural effusions. The patient did not show signs of orthopnea or increased respiratory effort during the nursing shift.

Evaluation of outcome(s):

1. The outcome was met because the patient’s pitting edema remained at 2+ to 3+ on all extremities during the nursing shift.

2. The outcome was not met because the patient’s breath sounds after surgery were worse with coarse lung sounds and diminished breath sounds and crackles at the bases. The doctors ordered a chest x-ray and it showed that the patient’s pleural effusions had gotten worse.

3. This outcome was met because the patient’s CVP, PCWP, and vital signs maintained within the normal set parameters per monitor.

Reference for rationales:

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis,

MO: Mosby Elsevier.

Dirkes, S. & Hodge, K. (2007). Continuous renal replacement therapy in the adult intensive care unit: history and current

trends. Critical Care Nurse 27(2): 61-6. Retrieved on March 9, 2013 from http://ccn.aacnjournals.org.

Fauci, A., et al. (2009). Harrison's principles of internal medicine, ed 17, New York, NY: McGraw-Hill.

Mank, A., et al. (2003). Monitoring hyperhydration during high-dose chemotherapy: body weight or fluid balance. Acta Haematol

109(4):163. Retrieved on March 9, 2013 from http://www.docguide.com/journals/acta-haematol?tsid=5.

Nursing Diagnosis and Priority # 3

Risk for bleeding R/T surgery, elevated coagulation studies, impaired liver function, and gastrointestinal disorders AEB PT lab values of: 2/25: 15.1, 2/24: 15.2, 2/23: 14.7; INR lab values of: 2/25: 1.4, 2/24: 1.5, 2/23: 1.4; abdominal surgeries on 2/4, 2/16, 2/17, 2/21, and 2/23; surgery on 2/21 was to evacuate hemoperitoneum 2 liters; surgery on 2/16 was for biliary tube placement; elevated liver studies: ALP 163 (H) and total bilirubin 163 (H); perforated stomach repaired 2/17 surgery; hemorrhage repaired 2/16 surgery. General Goal:

The patient will not exhibit signs of continued or increase blood loss during the nursing shift.

Outcome Objective(s): (use SMART format)

1. The patient’s vital signs will stay within normal parameters (no increased HR, RR, or decreased BP) during the nursing shift.

2. The patient’s wound vac drainage will not exceed 75 cc’s an hour during the nursing shift.

3. The patient’s coagulation studies and H & H will remain stable and not show changes indicating bleeding during the nursing shift.

Interventions with time frames/frequency	Rationale (for each intervention)	Patient Responses (subjective/objective data)
1) The nurse will monitor for signs of bleeding in the patient’s stool, sputum, and vomitus. Also, the presence of petechiae, purpura, or abnormal bruising (Ackley & Ladwig, 2011). 2) The nurse should monitor the patient’s lab studies that evaluate bleeding including hemoglobin, hematocrit, INR, and PT (Ackley & Ladwig, 2011). 3) The nurse should follow all safety and fall precautions during the shift. Bed low and 2 side rails. 4) The nurse will monitor the patient’s vital signs q1hr to make sure no changes occur the indicate a bleed (increased HR & RR, BP drop). 5) Observe the patient of early signs of bleeding including dizziness, tachycardia, fatigue, and hypotension (Ackley & Ladwig, 2011).	1) All of these are signs of bleeding and could be early signs of DIC. DIC is a critical issue and early identification is key to successful treatment (Armola, 2007). 2) Decreased levels of the patient’s hemoglobin and hematocrit are late signs of bleeding or hemorrhage. PT and INR test for anticoagulants increased levels indicate longer clot times (ICSI, 2007). 3) Nurses should assess for fall risks and implement safety precautions to prevent falls that could increase the incidence of bleeding (Balas, Casey, & Happ, 2008). 4) It is important to monitor a patient’s VS for changes that could indicate bleeding including drop in BP, increased HR, and increased RR. These are some of the earlier signs of hypovolemia that can be caused by bleeding (Lahrmann et al, 2006). 5) Tachycardia in the PACU can indicate dehydration, hypovolemia, anxiety, or inadequate pain or hemorrhage. If other factors are ruled out occult bleeding should be considered. Blood loss during surgery can be underestimated (Noble, 2008).	1) On the day of care the patient did not exhibit any these signs of bleeding. He did have steady output of < 50 ccs on his wound vac drain. 2) The patients H & H on the day of care was 10. 3 and 31.4, which was increased from the night before where he was down to Hgb 6.1 and got 4 PRBC’s total on floor/in surgery. The patient returned from surgery where 2 liters of hemoperitoneum was evacuated from abdomen. During the shift, he maintained his values and no signs of return abdominal bleeding was noted. 3) The patient’s calculated fall risk score at the start of shift was High and the nurse applied safety precautions side rails x 2 , bed in low, yellow wrist band, and falling star. 4) The patient had an A-line monitoring his hemodynamic status and during the shift there were no VS changes indicating a possible blood loss. 5) The patient returned from surgery on the day of care and did not stay long in PACU. He was monitored with post-op vitals and there were no signs of tachycardia or hypotension. The patient did not report feeling dizzy or fatigued.

Evaluation of outcome(s):

1. The outcome was met the patient’s vital signs did not stray outside of normal parameters indicating bleeding. His HR did not increase, RR did not increase, and BP did not drop during the shift.

2. The outcome was partially met the patient’s wound vac drainage after he returned from surgery put out more that 75 ccs in the first hour, but after the first hour drainage was less than 50 an hour.

3. The outcome was met the patient’s lab values have an elevated PT and INR of 14.7 and 1.4. His H & H was 10. 3 and 31.4 but that value is consistent with the patient’s chronic anemia.

Reference for rationales:

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis,

MO: Mosby Elsevier.

Armola, R.R. (2007). Monitor patients for disseminated intravascular coagulation, Nursing in Critical Care 2(5): 9-15.

Retrieved on March 9, 2013 from http://onlinelibrary.wiley.com/journal/10.1111/(ISSN) 1478-5153.

Balas, M.C., Casey, C.M., & Happ, M.B. (2008). Comprehensive assessment and management of the critically ill. In

Capezuti, E., Zwicker, D., & Mezey. M. et al, editors: Evidence-based geriatric nursing protocols for best practice,

ed. 3, New York, NY: Springer.

Institute for Clinical Systems Improvement (ICSI). Antithrombotic therapy supplement, Bloomington, MN: p. 64.

Lahrmann, H., et al. (2006). EFNS guidelines on the diagnosis and management of orthostatic hypotension, European

Journal of Neurology 13(9): 930-936. Retrieved on March 9, 2013 from http://onlinelibrary.wiley.com/journal

/10.1111/(ISSN)1468-1331/issues

Noble, K.A. (2008). The obesity epidemic: the impact of obesity on the perianesthesia patient, Journal of Perianesthesia

Nursing 23(6):418-425. Retrieved on March 9, 2013 from http://www.jopan.org.

Nursing Diagnosis and Priority # 4

Delayed surgical healing R/T extensive and multiple surgical procedures, infection, prolonged hospital stay, malnutrition, and obesity AEB patient had a bilateral nephrectomy on 2/4 and has had multiple exploratory laps afterwards on 2/16, 2/17, 2/21, and 2/23; hospital day 19; patient has positive blood culture for Bacteroides vulgatus and a positive gram stain culture for Vancomycin resistant Enterococcus and MRSA; patient BMI is 26; patient diagnosed with malnutrition has a low albumin lab value of 2.0 and total protein of 4.3; and patient developed septic shock post-kidney removal surgery.

General Goal:

The patient’s abdominal wound will not show signs of infection during the nursing shift.

Outcome Objective(s): (use SMART format)

1. The nurse will provide adequate pain management based on assessment using a 1-10 scale during the nursing shift.

2. The patient will receive required antibiotic therapy per schedule listed on the MAR during the nursing shift.

3. The patient’s open abdominal wound will not show signs of infection such as redness, induration, draining, or immobility during the nursing shift.

Interventions with time frames/frequency	Rationale (for each intervention)	Patient Responses (subjective/objective data)
1) The nurse should perform a through assessment of the patient post-op, including his risk factors to recognize signs of deterioration or complications (Ackley & Ladwig, 2011). 2) The nurse should assess and treat the patient for depression and anxiety when the patient complains of continuing fatigue during the nursing shift (Ackley & Ladwig, 2011). 3) The nurse should place warm blankets or the bear hug warming system on the patient prior to surgery and during the nursing shift to maintain his temperature (Ackley & Ladwig, 2011). 4) The nurse should use aseptic technique and maintain contact precautions when caring for the patient during the nursing shift. 5) The nurse can encourage the client to participate in prayer if spiritual coping is comfortable for the client if he expresses anxiety over wound healing during the shift (Ackley & Ladwig, 2011).	1) Client assessment preoperatively by nursing and medical staff is important to determine the appropriate interventions to aid in recovery. Also, VS collection has been correlated to early detection of complications (Layzell, 2008). 2) A study has shown the fatigue is common after surgery and can delay a patient’s recovery (Rubin, Cleare, & Hotopf, 2004). 3) Studies have shown that warming a client helps them maintain normothermia, which can help lower postoperative infection rates and lower patient anxiety (Leaper, 2006). 4) Studies have shown a correlation between maintaining aseptic technique and the development of hospital-acquired infections (Preston, 2005). Maintaining contact precautions on a patient with an active infection lowers the spread of infection. 5) Hierarchical multiple regression analyses have shown that religious coping styles and optimism contributed to reduced fatigue (Ai et al., 2006).	1) The patient’s post-op assessment was normal and his VS shown on the monitor from his A-line were appropriate for the patient’s medical condition (systolic between 80-120 mm Hg; sp02 >95%; pulse <110). 2) The patient did express anxiety during the shift and the nurse controlled it medically with Ativan. 3) The patient had a bear hugger warming system on during the nursing shift to maintain temperature above 97 F. 4) During the shift the nurse and visitors maintained required contact precautions and aseptic technique when interacting with the patient. 5) The patient is Catholic and is very spiritual. He prays with his wife at bedside and requested a spiritual consult. Priest came on day of care to pray with the patient.

Evaluation of outcome(s):

1. The outcome was met the patient did not rate any pain >4 during the nursing shift and he received his scheduled oxycodone per MAR.

2. The outcome was met the patient received his antibiotics Zosyn and Linezolid as scheduled in the MAR.

3. This outcome was not met because the patient’s open abdominal wound is packed with abthera and has a wound vac attached so we were not able to assess the patient surgical site for signs of infection.

Reference for rationales:

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis,

MO: Mosby Elsevier.

Ai Al, et al. (2006). Faith Differential effects of faith-based coping on physical and mental fatigue in middle-aged and older cardiac

patients, International Journal of Psychiatry Medicine 36(3): 351-365. Retrieved on March 9, 2013 from http://www.baywood

.com/journals/previewjournals.asp?id=0091-2174

Layzell, M. (2008). Current interventions and approaches to postoperative pain management, British Journal of Nursing

17(7): 414-419. Retrieved on March 9, 2013 from http://www.britishjournalofnursing.com.

Leaper, D. (2006). Effects of local and systemic warming on postoperative infections, Surgical Infection (Larchmt) (Suppl 2):S101-

S103. Retrieved on March 9, 2013 from http://www.liebertpub.com/sur.

Preston, R. (2005). Aseptic technique: evidence-based approach for patient safety, British Journal of Nursing 14(10): 540-54. Retrived

on March 9, 2013 from http://www.britishjournalofnursing.com.

Rubin, G.J., Cleare, A., & Hotopf, M. (2004). Psychological factors in postoperative fatigue, Psychosomatic Medicine 66(6): 959-964.

Retrieved on March 9, 2013 from http://www.psychosomaticmedicine.org.

Nursing Diagnosis and Priority # 5

Imbalanced nutrition: less than body requirements R/T inability to digest food, inability to absorb nutrients, and medical condition AEB absent BS upon auscultation, medical diagnosis of gastric stasis, patient can only tolerate 10 ml/hr continuous tube feed down duotube, albumin lab level of 2.0 (L), total protein lab level of 4.3 (L), on 2/17 the patient had a perforation in his stomach repaired and medical diagnosis of malnutrition.

General Goal:

The patient will receive adequate daily nutrition during the nursing shift.

Outcome Objective(s): (use SMART format)

1. The patient will consume the adequate amount of nutrition and protein (1904 calories) for his height and weight during the nursing shift.

2. The patient will not exhibit signs of malnutrition such as brittle hair, bruises, dry skin, and pale skin during the nursing shift.

3. The patient will tolerate his continuous tube feed at 10 ml/hr without vomiting during the shift.

Interventions with time frames/frequency	Rationale (for each intervention)	Patient Responses (subjective/objective data)
1) The nurse should monitor the patient’s lab values associated with nutrition including albumin, prealbumin, serum total protein, hemoglobin, hematocrit, and electrolytes (Ackley & Ladwig, 2011). 2) Monitor the patient for signs of malnutrition including brittle hair, bruises, dry skin, pale skin & conjunctiva, and disorientation (Ackley & Ladwig, 2011). 3) The patient should be monitored qShift for weight loss greater than 10 lbs., not eating for three days, BMI less than 20, ½ normal eating greater than 5 days, and 10% under healthy weight (Ackley & Ladwig, 2011). 4) The nurse should recognize that surgical patients with wounds and protein malnourishment are susceptible to septicemia from impairment of the immune system. The nurse should monitor the patient’s for signs of infection (fatigue, fever, redness, and drainage from abdominal incision) while the patient is malnourished (Ackley & Ladwig, 2011). 5) During the nursing shift, the nurse should minimize the interruptions to the patient’s tube feeding in order to get the ordered tube feedings into the client. That includes frequently checking for residuals, placement, and stopping tube feed multiple times for medications (Ackley & Ladwig, 2011).	1) Serum albumin level of less than 3.5 is an indicator of poor nutritional status. Prealbumin is a reliable indicator of malnutrition (DiMaria-Ghalili & Amella, 2005). 2) Patient’s who exhibit these signs have physiological manifestation of malnutrition and if left untreated for too long can result in death (Fauci et al., 2008). 3) Research has shown that patients who are malnourished have increased length of hospital stay so patient should be regular checked for signs of inadequate nutrition (Baldwin, Parsons, & Logan, 2007). 4) Untreated malnutrition can suppress the immune system leading to septicemia, especially in the critically ill client. Untreated malnutrition can result in death (Fauci et al, 2008). 5) A study found that critical care clients receive only 50% of ordered tube feedings because of frequent interruptions due to problems with small-bore feeding tubes, checking placement, and other care of the tube-fed client (O'Meara et al, 2008).	1) The patient’s albumin level was 2.0 and total protein was 4.3. Both values indicate the patient is malnourished. 2) Upon assessment on the day of care the patient has some of the physiological signs of malnutrition such as dry flaky skin on his feet and pale skin. 3) The patient BMI is 72.1 and he has lost over 10 lbs. over coarse of hospitalization. The patient can only tolerate 10 ml/hr of continuous feed so he is receiving less than ½ normal eating. 4) The patient is currently on contact precautions for his bacteremia and during the nursing shift he showed no new signs of infection. 5) The nurse tried to minimize interruptions to the tube feed by giving medications together and checking residuals less frequently. The patient was paused for an extended period of time after vomiting and because residual volume > 200 ml due to gastric stasis post-surgery.

Evaluation of outcome(s):

1. This outcome was not met the patient is only able to tolerate 10 ml/hr of his continuous tube feed which does not meet his daily caloric needs.

2. This outcome was not met the patient was pale and has flaky skin on his feet which are signs of malnourishment.

3. This outcome was partially met the patient tolerated his continuous tube feed at 10 ml/hr, but he vomited when the nurse tried to increase it to 20 ml/hr per doctor’s orders.

Reference for rationales:

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis,

MO: Mosby Elsevier.

Baldwin, C., Parsons, T., & Logan, S. (2007). Dietary advice for illness-related malnutrition in adults, Cochrane Database Systematic

Reviews. Retrieved on March 9, 2013 from http://www.cochrane.org/cochrane-reviews/cochrane-database-systematic-reviews-

numbers

DiMaria-Ghalili, R.A. (2005). Nutrition in older adults, American Journal of Nursing 105(3): 40. Retrieved on March 9, 2013 from

http://journals.lww.com/ajnonline/pages/default.aspx

Fauci, A., et al. (2009). Harrison's principles of internal medicine, ed 17, New York, NY: McGraw-Hill.

O’ Meara, D., et al. (2008). Evaluation of delivery of enteral nutrition in critically ill patients receiving mechanical ventilation,

American Journal of Critical Care 17(1): 53-61. Retrieved on March 9, 2013 from http://ajcc.aacnjournals.org.

Adapted from:

McHugh Shuster, P. (2002). Concept mapping a critical thinking approach to care planning. Philadelphia, PA.: F.A.Davis Co.

Reference:

Gordon, M. (2008). Assess notes: Nursing assessment and diagnostic reasoning. Philadelphia, PA.: F.A.Davis Co.