Student: Natalia Pierog

Patient Initials: EP

Date of Care : 10/26/11

Nursing Diagnosis # 1 Acute pain R/T inflammatory response AEB verbalization of pain Assessment Findings: Subjective o Patient stated I have pain and pressure in my legs Objective o Patient had difficulty turning in bed o Non-verbal signs of discomfort when turning Short Term Goals o Patient verbalizes methods that provide pain relieve Long-Term Goal o The patient will report that pain/discomfort has improved Expected Outcomes o The patient will be pain free, and will be able to sleep/rest and engage in desired activity by the day of discharge Interventions: o Assess for location, intensity and quality of pain. o Ask patient to rate pain intensity using numeric pain rating scale o Maintain bed-rest and encourage patient to change position frequently o Monitor vital signs and assess respiratory status o Implement non-pharmacological interventions for pain management ; such as music and relaxation o Assess effectiveness of interventions to relieve pain Nursing Diagnosis # 2 Ineffective tissue perfusion: Peripheral R/T decreased venous circulation AEB bilateral lower extremities edema Assessment Findings: Subjective o Patient Stated I have pressure/pain in my legs Objective: o B/L lower extremities edema + 4 B/L below the knee edema +3 B/L above the knew edema o B/L lower extremities are warm and dry to touch o B/L lower extremities tender on palpitation o Diminished B/L lower extremity pulses Short Term Goals o The patient will display increasing tolerance to activity Long-Term Goal o The patient will not have signs or symptoms of pulmonary emboli Expected Outcomes o The patient will not have warmth or edema in lower extremities by the fifth day of hospitalization

Student: Natalia Pierog

Patient Initials: EP

Date of Care : 10/26/11

Interventions: o Encourage bed-rest o Elevate legs slightly above the level of heart o Increase fluid intake, administer 0.45% NS at 50mL/hr o Administer Heparin at a rate of 10mL/hr o Apply warm, moist soaks to affected area o Monitor patient for signs of bleeding, monitor APTT levels and adjust dosing as ordered o Assess the patient for response to treatment by re-evaluating the sings and symptoms of DVT o Assess the patient for signs and symptoms of pulmonary embolism; such as shortness of breath and chest pain Nursing Diagnosis # 3 Excess Fluid Volume R/T compromised regulatory mechanism AEB bilateral lower extremities edema Assessment Data: Subjective o Patient Stated My legs have a lot of pressure o Patient Stated Sometimes its hard for me to breath Objective: o Patient reported dyspnea o Hypertension, BP 143/51 o Bilateral lower extremity edema o +4 edema below knees o +3 edema above knees o Loud, irregular respirations Short Term Goals o The patients fluid and electrolyte balance will be corrected Long-Term Goal o The patient will lose weight during treatment Expected Outcomes o The patient will have no edema by the fifth day of hospitalization Interventions: o Assess location and extent of edema o Assess respiratory system and breath sounds for crackles o Place patient in high Fowlers Position o Administer oxygen, 2L NC o Weight patient daily at the same time and on the same scale o Administer Lasix 40mg PO daily o Obtain accurate intake and output, noting color of urine o Monitor electrolytes and laboratory studies o Protect edematous skin in extremities and sacrum Nursing Diagnosis # 4 Anxiety related to unexpected hospitalization AEB restlessness Assessment findings Subjective

Student: Natalia Pierog

Patient Initials: EP

Date of Care : 10/26/11

o Patient verbalized fear Objective o Patient seems nervous and agitated o Patient seems restless Short Term Goals o The patient will verbalize that anxiety has been reduced Long-Term Goal o The patients anxiety will be relieved Expected Outcomes o The patient will use resources effectively and use problem solving skills by day of discharge Interventions o Assess level of anxiety on a scale 1 to 10 o Keep patient informed of all that is going on o Use calm, reassuring manner with the patient o Stay with the patent as much as possible, especially during acute episodes of anxiety o Encourage patient to verbalize fears and concerns o Control multiple sources of stimuli Nursing Diagnosis # 5 Deficient knowledge R/T new onset of disease AEB asks many questions Assessment Findings: Subjective o Patient verbalized lack of knowledge about DVT o Patient asked about disease process Short Term Goals o The patient will participate in learning process Long-Term Goal o The patient will verbalize understanding of disease process and treatment regimen Expected Outcomes o The patient will identify signs and symptoms that require medical evaluation by the day of discharge Interventions o Assess patients current knowledge and her ability/ readiness to learn o Create a quiet environment conductive to learning o Teach patient about disease process, risk factors, medications and signs /symptoms of possible complications o Teach patient about activity restrictions and avoidance of crossing legs o Teach patient to elevate her legs when in bed and in a chair o Instruct the patient to wear knee or thigh high compression stocking for an extended period, demonstrate correct application/removal of compression stockings. o Instruct the patient not to massage the affected extremity o Assess the patients understanding of all teaching by asking her to repeat information o Provide the patient with resources required to be compliant

Student: Natalia Pierog

Patient Initials: EP

Date of Care : 10/26/11

Diagnoses:

DVT Dehydration Acute Renal Insufficiency

PMH: Non-insulin dependent diabetes mellitus Hypertension Multilevel degenerative disk disease Peripheral weakness History of hypercalcemia secondary to hyperparathyroidism Status post parathyroidectomy Multinodular goiter S/P left thyroidectomy Medications
Lasix 40mg PO DAILY Multivitamin 1tab PO DAILY Diovan 320mg PO DAILY Folic Acid 1mg PO QAM Cardizem CD 240mg PO QHR Glucotrol XL 10mg PO Novolog Flex Pen SQ ACHS Heparin 25000units/D5W 250mL

Rationales:
Used to reduce the swelling and fluid retention Used to provide vitamins Used to treat high blood pressure Used to treat or prevent folic acid deficiency Used to treat high blood pressure Oral blood-glucose-lowering drug Used to treat diabetes mellitus. Used to treat DVT

Date 11/14/11

Test RBC HGB HCT Chloride CO2 GLU-FAST BUN Creatinine GFR Calcium Total Protein Albumin

Client Value 2.98 L 9.2 L 27.1 L 116 H 20 L 147 H 27 H 1.300 H 48 L 7.9 L 5.8 L 2.5 L

Normal Value(s) 4.00-5.33 M/mm3 12.0-16.0 G/dL 36.0-46.0 % 98-107 meq/L 22 30 meq/ L 70- 110 md/dL 7 17 mg/dL 0.7 1.2 mg/dL >60 ml/min/1.73SQM 8.4-10.2 mg/dL 6.3 8.2g/dL 3.2 4.6g/dL

Reason for

Difference

Seen in anemia Anemia Anemia seen in dehydration,acute renal failure, as well as too much water crossing the cell membrane Can be caused by dehydration, renal failure and starvation diabetes mellitus can be caused by excessive protein intake, kidney damage, certain drugs, low fluid intake Renal failure suggests kidney damage may be due to prolonged anticonvulsant therapy, diurectics, glucose, insulin, excessive laxitives may be due to poor nutrition, it reflects decrease in albumin may be caused by edema and poor diet (low protein or low

Student: Natalia Pierog HDL 34 L

Patient Initials: EP 35 85 mg/dL

Date of Care : 10/26/11

calories diet) considered a coronary heart disease risk factor

Student: Natalia Pierog

Patient Initials: EP

Date of Care : 10/26/11

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