102719_Level 3#2

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University of Texas, Arlington *

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N2300

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Nursing

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Apr 29, 2024

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docx

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Weatherford College ADN Program Clinical Portfolio Level III, IV Student Name: Clinical Date:10-25-19 Assessment Include a complete head to toe assessment of the patient. History of Present Illness (HPI): Pt is 45 y/o Caucasian male admitted 10/24/19. Pt came into ER with HTN (191/85) and difficult to urinate for 2days. Pt has uncontrolled DM II (blood glucose 395). Stable vital signs ( BP 191/ 85) T- 36.7 C, R- 16 RA, P- 87 O2 sat-98% RA) Pt stated he was prescribed 9 different antihypertensive medication, and did not take any of them. Pt now admitted to Med Surg 3 for monitoring blood pressure. Plan is to discharge home 10/26/19. Subjective: Pt stated he did not take blood pressure medication for 3weeks. “Doctors have been playing with my blood pressure medication, every time I visited them, they changed my medication. They must not know what they are doing, that’s why I don’t take the medication.” Objective: N: AAOx3, pleasant affect, conversational HEENT: Facial features symmetrical, EOMS intact bilat., nares patent bilat., no septum deviation noted, nasal mucosa pink, no ear drainage bilat., oral mucosa pink, tongue protrudes midline, swallow reflex intact, no JVD noted, non-tender nodes upon palpation, trachea midline, carotid pulses present bilat., thyroid non-palpable. CV: S1 and S2 present, murmur, radial pulses present bilat. 2+, pedal pulses dimished bilat. Pitting Edema (+1), warm lower extremities on palpation bilat. capillary refill less than 3 seconds. Pulm: room air, unlabored respirations, deep inhalation, clear breath sounds upon auscultation x5 lobes. GI: bowel sounds present x4 quads, last BM reported 10/23/19 GU: continent, distended abdomen, painful on palpation over bladder area, urine as yellow, cloudy with foul smell. MS: full ROM upper extremities, muscle strength 5/5 upper extremities bilat without pain, full ROM lower extremities, muscle strength 5/5 bilat without pain. Revised Spring 2018-CB Patient Analysis
Weatherford College ADN Program Clinical Portfolio Level III, IV INTEG: no tenting noted, PIV access in R wrist, no redness and swelling. Warm on palpation on both feet. Dry and intact Antecedents Primary Problem With Definition PMH: HTN, DMII, peyronie’s disease, emphysematous cystitis, retinopathy, venous stasis of LE, MRSA positive RLE, OSA, obesity hypoventilation syndrome Primary Medical Diagnosis: Hypertention Risk Factors: Obesity(BMI : 45.4), Hx of smoking for 15 yrs, DM II, physical inactivity, stress, decreased GFR (41) High-sodium, high-saturated fat diet Primary Conceptual Problem: Perfusion: the flow of blood through arteries and capillaries delivering nutrients and oxygen to cell and removing cellular waste. Pathophysiology of Primary Medical Diagnosis Include a description of the physiological process that occurs in the disease to the cellular level. Hypertension: Blood pressure is the result of cardiac output multiplied by peripheral resistance. Each time the heart contracts, pressure is transferred from the heart muscle to the blood and then pressure is forced by the blood as it flows through the blood vessels. Increases in cardiac output and constriction of the blood vessels lead to expand vascular volume and it causes blood pressure elevated. (Hinkle, 2018) Complete Problem List Label the top three prioritized problems. Problem (S/S, Manifestations, Labs, psychosocial, etc) Related Concept HTN - elevated BP (191/85) - persistent elevated systolic BP 190-210 -murmur heart sound - High-sodium, high-saturated fat diet Perfusion DM II -uncontrolled blood glucose (316) -polydipsia -slow healing ulcer -retinopathy Metabolism Revised Spring 2018-CB
Weatherford College ADN Program Clinical Portfolio Level III, IV -decreased kidney function -OSA - diminished pedal pulse bilat Difficult to urinate -distended abdomen -difficult to urinate for 2 days -when void foul smell & pain - Dribbling after urinating Elimination Sleep Apnea -OSA -wearing CPAP mask on at night -obesity (BMI 45.4) Sleep Cystitis -distended abdomen - painful on palpitation - cloudy and foul smelling urine Immunity Anemia -decreased Hgb: 11 Gas Exchange -Hx of frequent venous stasis ulcer on lower extremities Tissue integrity Revised Spring 2018-CB
Weatherford College ADN Program Clinical Portfolio Level III, IV Prioritized Problem #1 and related concept Hypertension - Perfusion Attributes Include the data specific to the patient that is pertinent to the prioritized problem. Physical Assessment Lab/ Diagnostics Associated Medications -Elevated BP :191/85 -pitting +1 edema on lower extremities bilat. -diminished dorsal pedal bilat. -murmur sound on auscultation persistent elevated systolic BP 190-210 BUN – 35 (Elevated) Creatinine-1.9(Elevated) GFR-41 (Decreased) Chest X ray- Cardiomegaly EKG Lasix-Furosemide- 40mg P.O. daily Antecedents Specific to the prioritized problem PMH: HTN, DMII, peyronie’s disease, emphysematous cystitis, retinopathy, venous stasis of LE, MRSA positive RLE, OSA, obesity hypoventilation syndrome Risk Factors: Obesity(BMI : 45.4), Hx of smoking for 15 yrs, DM II, physical inactivity, stress, decreased GFR (41) High-sodium, high-saturated fat diet Goals Teamwork and Collaboration to Meet Goal Justify why this person should be included Short Term (for your shift): Pt’s systolic blood pressure will be lowered below 150 mmHg. Dietitian: they assist pt to eat heart healthy diet and educate pt to choose appropriate food for heart disease Long Term: Pt will maintain systolic blood pressure between 120 and 130 mmHg. Plan of Care Interventions Rationale with reference in APA Positive Outcomes Negative Outcomes Administer antihypertensive medication as ordered. Loop diuretic medication inhibit water and sodium reabsorption. Decreased fluid volume facilitate to lower blood pressure. (Hinkle, 2018) Pt,s blood pressure has been lowered. Pt’s blood pressure is not controlled. Potassium is below 3.5 mEq/L Pt is dehydrated. Assess blood pressure every 2 hour. Blood pressure medication cause a drop in blood pressure. Pt’s blood pressure has been controlled. Pt’s blood pressure has been elevated or decreased compared to Revised Spring 2018-CB Problem Number 1 Analysis
Weatherford College ADN Program Clinical Portfolio Level III, IV (medical surgical nursing, 10 th ed) base line. Educate pt about DASH diet. Studies suggest that diets high in fruits, vegetables, and low-fat dairy products can prevent the development of hypertension and lower elevated blood pressure (Hinkle, 2018) Pt understands DASH diet and pt knows what to choose for their meal. Pt is unable to choose low sodium and low fat diet. Educate pt regarding HTN complication. The excessive pressure on your artery walls caused by high blood pressure can damage your blood vessels, as well as organs in your body. The higher your blood pressure and the longer it goes uncontrolled, the greater the damage. (mayo clinic, 2018) Pt verbalizes understanding of HTN and its long term effects on target organ. Pt is unable to verbalizes understanding of HTN and its long term effects on target organ. Instruct pt to change position slowly. Instruct pt who are taking antihypertensives to change position slowly to be careful when getting out of bed and ambulating until medication’s effects are fully known. (medical surgical nursing, 10th ed) pt moves slowly when he is getting out of bed. Pt fell when he is getting of bed. Evaluation Was your goal met? Partially (lowerd BP- 171/ 79) What would you recommend to the next shift based on your evaluation? BP has been lowered (171/81) systolic blood pressure still need to be lower than 150. I would reinforce of pt education regarding importance of adhering to medical treatment. Revised Spring 2018-CB
Weatherford College ADN Program Clinical Portfolio Level III, IV Prioritized Problem #2 and related concept DM II - Metabolism Attributes Include the data specific to the patient that is pertinent to the prioritized problem. Physical Assessment Lab/ Diagnostics Associated Medications -Polydipsia -slow healing ulcer -retinopathy -diminished pedal pulse bilat elevated blood glucose – 314 HbA1C – 9% Humalog Lantus Antecedents Specific to the prioritized problem PMH: HTN, DMII, peyronie’s disease, emphysematous cystitis, retinopathy, venous stasis of LE, MRSA positive RLE, OSA, obesity hypoventilation syndrome Risk Factors: Obesity(BMI : 45.4), Hx of smoking for 15 yrs, DM II, physical inactivity, stress, decreased GFR (41) High-sodium, high-saturated fat diet Goals Teamwork and Collaboration to Meet Goal Justify why this person should be included Short Term (for your shift): Pt’s s blood glucose will be lowered below 150. Dietitian: they assist pt to eat low fat diet and educate pt to choose appropriate food to lose weight. Long Term: Pt will maintain blood glucose between 120 and 140. Plan of Care Interventions Rationale with reference in APA Positive Outcomes Negative Outcomes Administer insulin as ordered Insulin therapy helps prevent diabetes complications by keeping your blood sugar within your target range. (American Diabetes Association,2019) Pt’s blood glucose has been lowered. Pt’s blood glucose has not been lowered. Check blood glucose before meal. If glucose levels get too low, we can lose the ability to think and function normally. Pt’s blood glucose is under control. Pt’s blood glucose is too low or too high. Revised Spring 2018-CB Problem Number 2 Analysis
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