Nursing of the Critically Ill

N40010

Nursing Process Paper Grading Criteria

Student's Name Kristi Rittenhouse Semester Spring 2011 .

Page 1 NPP #1 (due no later

than week 3)

NPP #2 (due no later than

week 6)

Demographic, Diagnostic, Treatment and other Relevant

Information (see left and right columns) (2)

Integration/Synthesis (3)

Page 2

6 Nursing Diagnoses with Relational Statement (2)

Selection of Appropriate N.D. and Definition (must select two different nursing diagnoses for each paper and

cite source) (1)

Relational Statement (1)

Defining Characteristics (AEB) (2)

STG and specific and measureable Outcome Criteria (2)

Interventions

Nursing Interventions (NI) (5)

Evaluation of NI (2)

WIWDD S/U

Medication Sheet (minimum of 6 meds) (5)

Late Points Deducted minus five (5) points per day

Vertical Points Earned (each paper) (25)

Total Points Earned (50)

Note: Must select two (2) different nursing diagnoses for each paper

ND #1 _____________________

ND #2 _____________________

Medications

(see paper from clinical rotation)

Student Name Kristi Rittenhouse Client Initials J.L. Date 02/21/11

Age 65 Gender Female Room # ICU-03 Admit Date 02/15/11

CODE Status FULL Allergies Phenothiazines, Hydroxyzine, Thiothixene Procaine,

Doxepin

Diet Dysphagia I(NPO during my time with J.L.) Activity Bedrest Braden Score 15

State lab values and identify abnormal

results relevant to this admission

Identify other diagnostic test results

relevant to this admission

2/21/11

- Na- 144

- K- 4.1

- Cl- 103

- Carbon Dioxide- 36 (H)

- BUN- 22

- CREAT- 0.81

- Ca 2+- 8.3 (L)

- Phosphorus- 3.1

- Mg- 2.0

- WBC- 11.1 (H)

- RBC- 3.31 (L)

- Hemoglobin- 10.1 (L)

- Hematocrit- 31.5 (L)

- Platelet- 94 (L)

- Neutrophils Absolute- 9.2

(H)

- BS- 170 (H)

IV Sites/Fluids/Rate

Right Femoral Triple Lumen Catheter

Right Brachial A-Line

D5W @ 50ml/hr

TPN @ 70ml/hr

Monitoring: Invasive/Non-Invasive

State specific monitoring device and

specific values with each device

- ECG- see paper from clinical

rotation

- Tele monitor

- EGD

Chief Complaint: Mental Status Change, Unresponsive at home on floor

Admitting Diagnosis: Hypothermia, Mental Status Changes

Medical Diagnosis: Hypothermia, Mental Status Changes, Pneumonia

ECG Interpretation

(see paper from clinical rotation)

. J.L. was found on her floor in her apartment, unresponsive, with mental status changes

and a low temperature. Once admitted, she was diagnosed with Hypothermia, Mental Status

Changes, and Pneumonia.

Hypothermia is when the body temperature is less than 94 degrees F, which is usually

unintentional (Black & Hawks, 2009, p. 2212). The healthcare team was unaware of how J.L.

developed hypothermia. During my assessment, J.L. temp increased to 97.6 degrees F, which

is not considered hypothermic. J.L. complained of being cold throughout my time with her.

Therefore, I put an extra blanket on her and turned the heat up in the room a bit. Hypothermia

can cause mental status changes. In turn, the mental status change can cause the hypothermia

to get worse. During my assessment, J.L. was A & O X3 with drowsiness. J.L. was also

diagnosed with Pneumonia. Pneumonia is an inflammatory process in the lungs and is usually

associated with an increase in interstitial and alveolar fluid (Black & Hawks, 2009, p. 1599).

During my assessment, I heard coarse crackles throughout her lobes. Also, WBC were elevated

to 11.1 indicating infection. The Neutrophil Absolute count was also elevated at 9.2. I also

found J.L. to be fatigued. This could be due to the low RBC, hemoglobin, and hematocrit. See

page 3 for further assessment findings.

J.L. also has Diabetes Mellitus. Although this was not her admitting diagnosis, this

disease adds to complications associated to her diagnosis. Diabetes Mellitus is a disorder in

which beta-cells no longer respond to high glucose levels which results in no insulin

production, or the body no longer responds to the insulin being secreted (Black & Hawks,

2009, p. 1066). This results in decreased glucose utilization, increased fat mobilization and

increased protein utilization (Black & Hawks, 2009, p. 1066). Diabetes Mellitus potentially

caused a multitude of her signs and symptoms. The incidence of infections in increased due to

diabetes mellitus and an infection can cause an increase in blood sugar (hyperglycemia), which

was 170. Her other complications that Diabetes Mellitus adds to is the pneumonia, HTN, and

possibly her generalized, aching 8/10 pain.

The main focus during my time with J.L was providing comfort measures due to the

generalized, aching pain of 8 out of 10 with guarding and grimacing. J.L was NPO for the

EGD and had only PRN pain meds PO. The RN checked into seeing if we could get an IV pain

med order. Antibiotics were scheduled; however, none were due for the time I was present.

Past Medical/Surgical History

Relevant to this admission

- Schizophrenia

- Dementia

- HTN

- DM

- Achalasia

- Pulmonary Fibrosis

- Esophagectomy & Heller

Myotomy

Treatments

Medical and Nursing Interventions

Relevant to this admission

- BS- AC/HS

- BIPAP 12/8 30% for 1 hour

QID, HS & PRN

- O2- 2L NC

- Daily Weights

- I&O

- Antibiotic therapy

- SCDs

- EGD

- Assessment q2h

- V/S qh

- Foley

- Respiratory therapy

- Diet- Dysphagia I

Primary Nursing Diagnosis with Relational Statement

Risk for infection r/t Stage I pressure ulcer on coccyx

and compromised host defenses secondary to history of

infections, increased hospital stay, DM, TPN, two IV

sites, foley, and prolonged immobility

Short Term Goal Relevant to Nursing Diagnosis

1. J.L. will exhibit no signs of infection at Stage I ulcer

on coccyx while hospitalized.

2. J.L. will demonstrate knowledge about methods for

preventing and detecting infection by discharge.

3. J.L. will remain free of infection during

hospitalization.

6 Nursing Diagnosis with Relational Statement

1. Risk for infection r/t Stage I pressure ulcer on coccyx

and compromised host defenses secondary to history of

infections, increased hospital stay, DM, TPN, two IV

sites, foley, and prolonged immobility AEB increased

WBC count and increased Neutrophil Absolute count.

2. Impaired oral mucous membrane r/t drying effects

of NPO AEB dry mouth, and coated tongue.

3. Risk for falls r/t altered mobility secondary to

unsteady gait, generalized weakness, and medications.

4. Risk for Aspiration r/t insufficient airway clearance,

and impaired swallowing, secondary to achalasia AEB

weak, non-productive cough, and difficulties swallowing.

(However, she was NPO for my time with her; therefore,

not my priority nursing diagnosis.)

5. Acute Pain r/t immobility/improper positioning

secondary to unsteady gait, and generalized weakness.

6. Impaired Skin Integrity r/t related to Stage I pressure

ulcer on coccyx and decreased blood and nutrients to

tissues secondary to NPO status, hypothermia, DM, and

edema.

7. Risk for Nutritional Imbalance: less than body

requirements r/t decreased ability to feed self secondary

to generalized weakness, and living alone.

Definition (State definition and source)

“The state in which an individual is at risk to be invaded

by an opportunistic or pathogenic agent (virus, fungus,

bacterium, protozoan, or other parasite) from endogenous

or exogenous sources (Carpenito-Moyet, 2008, p. 236).”

Outcome Criteria (Must be specific and measurable)

- Pressure ulcer will remain a Stage I or heal by

discharge. (Partially met- it was still a Stage I during my

shift. Will continue to monitor)

- WBC count will decrease before discharge. (Unable to

assess because I only worked a short shift and she is not

being discharged yet.)

- The number of microorganisms will be limited by

nurses washing hands while J.L. is hospitalized.

(Partially met- this was met during my shift as I made

sure myself and others who entered the room at least

used Purell.)

- Protein intake with meals will be increased while

hospitalized. (Unmet- during my shift, J.L. was NPO for

her EGD scope; therefore, will continue to encourage)

- J.L. will be able to wash her hands effectively and know

when to prior to discharge. (Unmet- I was unable to

perform this intervention. However, staff will continue to

implement.)

- J.L.’s Foley and IV sites will not have redness or

inflammation. (Met during my shift)

- J.L.’s temps will remain normal. (Unmet- her

temperature was low when I assessed it. Will continue to

monitor)

AEB: Defining characteristics specifically exhibited by

your patient that support primary nursing diagnosis

- Right Femoral Triple Lumen Catheter

- Right Brachial A-Line

- WBC- 11.1 (H)

- Neutrophils Absolute- 9.2 (H)

- Hospital stay- 7 days

- Prolonged immobility due to generalized

weakness

- Hx of DM

- Age- 65

- Dependent with bathing, personal care, and

turning

- RBC, HCT, HGB are all decreased

Identify nursing interventions that you implemented with this patient.

Evaluate patient progress towards achieving outcome criteria as a result of nursing interventions.

STG #1 Interventions

1. Assess ulcer q shift and at each drsg. change to evaluate for infection.

- There was no break in the skin, it is just slighty red. Will continue to monitor and pass on to staff.

2. Monitor WBC for indication of infection as ordered.

- WBC is elevated at 11.1, but continue to monitor to be sure it does not increase and to see when it will

decrease.

3. All visitors and healthcare personnel wash hands or use purell upon entry of the room.

- This will cut back on the microorganisms that enter the room and may be transferred when providing

patient care. This was performed by everyone and will continue to do so.

4. Encourage protein intake to promote tissue repair with meals.

- J.L. was NPO during my shift, but this will continue to be encouraged by other staff members.

STG #2 Interventions

1. Review principles of good hand-washing prn.

- Hand hygiene is the single most important mechanism in stopping transmission of pathogenic organisms. I

did not get a chance to perform this intervention. However, the staff will continue to implement.

2. Provide J.L. with written instructions concerning signs and symptoms of infection, and when to call the

physician.

- Providing more than one learning method optimizes retention. Written instructions provide a hand

reference. I did not provide J.L. with written instructions. However, I did explain to her that she is at an

increased risk for infection and what signs and symptoms to look for.

STG #3 Interventions

1. Practice good hand washing techniques prn.

- This was explained for an earlier intervention.

2. Assess foley and IV sites for redness and inflammation q shift.

- I assessed these and saw no signs of infection. Will continue to monitor during J.L.’s hospitalization.

3. Assess temp at least twice during your shift and compare to baseline temp taken on admission.

- A fever is usually indicated of an infection. Also, when we compare J.L.’s temp to her baseline temp on

admission, it will most likely be higher now, because she was hypothermic. Therefore, an average of a

couple temps may be needed to achieve a baseline to compare later temps to. J.L.’s temp during my shift

was 97.6. I could not get a second temp because she was in recovery from an EGD.

4. Assess WBC count daily.

- This was also discussed in previous intervention.

What I Would Do Differently

- I wish I would have found another way to manage J.L.’s

pain. Throughout my time with her, she had a pain of

8/10. She only had po pain meds, however she was NPO.

The RN checked about getting an IV pain med. However,

I wish I would have pressed the issue a little more to get

the order quicker. Also, I could have offered heat

application or dimmed the lights and taught about

distractions to decrease her pain.

- I also wish I would have questioned wheter or not she

should be diagnosed with anemia due to her RBC,

hemoglobin, and hematocrit levels being low.

Assessment:

o A&O X3

o Skin: pale, warm, normal capillary refill <3 seconds, normal turgor, Braden Score- 15, +1

edema bilateral upper arms, ecchymosis right hip, and left and right upper arms, and

Stage 1 pressure ulcer on coccyx.

o Musculoskeletal: standards not met: severe generalized weakness,

o Respiratory: Course, and diminished throughout lobes; Moist, non-productive, harsh, and

weak cough

o GI: Abdomen semi- firm, tender, BS present

o Pulses: Radial +2, Dorsalis pedis +1, Posterior tibial +1

o Pt. states she has difficulty swallowing

o Dry mucous membranes, coated tongue

Vital Signs

2/21/2011

Temperature 97.6 degrees- oral

Heart Rate 92 bpm

B/P 107/53 Monitor

Arterial BP 127/54

Respirations 15

O2 saturation 96% on 2L NC

Pain 8/10 generalized aching

with grimacing and

guarding (NPO for EGD, no

IV pain medications- talked

about getting an order)

References

Black, J.M., & Hawks, J.H. (2009). Medical-surgical nursing: Clinical management of positive

outcomes (8th

ed.). St. Louis, MS: Saunders.

Carpenito-Moyet, L.J. (2008). Nursing diagnosis: Application to clinical practice (12th

ed.).

Pittsburg, PA: Lippincott Williams &Wilkins.