Nur 101 Data Base 1
Nur 101 Data Base 1
Nur 101 Data Base 1
Fundamentals of Nursing
DATE: _______________________________________________________
1. Risk for impaired skin integrity r/t potential for alterations in epidermis aeb foley catheter in place
causing swelling, and irritation.
2. Risk for infection r/t increased risk for invasion of pathogens aeb foley catheter in place, and recurring
urinary tract infection.
3. Risk for falls r/t increased susceptibility to falling aeb diminished mental status, history of falls, use of
wheelchair, use of diuretics, anemia, decreased lower extremity strength, and hearing difficulties.
4. Risk for unstable blood glucose level r/t variations in blood sugar levels from the normal range aeb accu
checks daily, physical activity level, and knowledge of condition.
5. Constipation r/t difficult passage of stool aeb use of laxatives, and client stating I have problems having
bowel movements.
6. Activity intolerance r/t imbalance between oxygen supply and demand aeb SOB while moving.
7. Impaired physical mobility r/t activity intolerance aeb inability to perform ADLs, inability to stand
without assistance, and inability to walk.
8. Ineffective health maintenance r/t ineffective individual coping aeb denial of medical condition,
deficient knowledge regarding health, and cognitive impairment.
9. Impaired memory r/t impaired ability to recall bits of information aeb inability to recall day events,
inability to recall factual information, and inability to recall if a behavior was performed.
Note: All observations that indicate a deviation from normal in any area need a thorough assessment.
10/04/1927 Age: 87
At home
Gender:
Male
Baptist
Plumber
Marital status:
Single/never married
VITAL SIGNS
ASSESSMENT [COLDSPA]
Temperat 97.7F
Charact
ure
er
orally
Pulse
64
Onset
(rate, rhythm,
regular
amplitude)
and
strong
Respirati 12
Locatio
ons
n
Regular
(rate, rhythm,
depth)
rate and
rhythm
Blood
102/62
Duratio
Pressure
n
(L) sitting
(arm, position)
Severit
y
Associa
ted
Factors
PAIN
Dull
0800 Today
Bowels
All day
2
Nothing much helps, moving makes it worse.
Simvastatin-unknown reaction.
TYPE
Immunizations Status
Check if current - (date
If not current describe follow-up protocol
received)
Childhood
Tetanus
Influenza
Pneumonia
Siblings
Living (age)
Deceased (age/year)
Died 1971 at
age 72
Died 1982 at
age 82
Presence of any
heredity diseases:
(Diabetes, HTN, Heart
disease, Cancer/type)
Diabetes and
cancer
Not known
REVIEW OF SYSTEMS
Skin, Hair, Nails
Minimum History Components
Ask questions regarding:
* in pigmentation / moles *Hx of pruritus, rash,
lesions, easy bruising *Hair loss * in nail color or
condition
SUBJECTIVE:
OBJECTIVE:
groomed.
SUBJECTIVE:
Denies any headaches, pain or stiffness. No
hx of recent head injury/concussion. Denies
hx of dizziness or fainting. Denies any
problems with lymph nodes. Client states
If I sleep the wrong way I get a stiff neck.
OBJECTIVE:
Head, and facial structures symmetric.
Neck symmetric, no masses noted.
Performs full ROM with ease. Trachea
midline. No lymphadenopathy.
Eyes
Minimum History Components
SUBJECTIVE:
Reports hx of cataracts, denies hx of
OBJECTIVE:
Able to read words on newspaper if up
Ears
Minimum History Components
Ask questions regarding:
*Pain (COLDSPA) *Ringing *Drainage *Difficulty
hearing *Date/year of last ear exam *Exposure
to loud noises *Vertigo
SUBJECTIVE:
Denies any ear pain, discomfort, ringing, or
drainage. Does report difficult hearing
sometimes. Does not recall date of last
hearing exam. No hx of exposure to loud
noises or vertigo.
OBJECTIVE:
Ears symmetric. No discharge or lesions.
Able to hear loud conversational voice. No
use of hearing aids.
*Lips- Color, moisture, lesions *Buccal mucosaColor, Lesions *Gums- Color, Moisture, Lesions
*Teeth/dentures ability to chew food (CN V)
*Tongue- Location, Lesions *Uvula-Position (CN
IX, X) *Swallowing (CN IX)
SUBJECTIVE:
OBJECTIVE:
using chewing tobacco. States I do not see with elevation of soft palate. Able to
the dentist, I have no teeth.
SUBJECTIVE:
Denies any chest pain. Minimal cough, and
no sputum. Reports dyspnea. Denies any
hemoptysis, or orthopnea. Reports SOB
OBJECTIVE:
RR 12 regular rate and rhythm. No use of
accessory muscles. Chest rises
SUBJECTIVE:
OBJECTIVE:
Denies pain, lumps, discharge from nipples, Breasts symmetric, no lesions, or
or changes in breast size. Denies any
tenderness on palpation.
SUBJECTIVE:
Denies hx of HTN. Cannot recall cholesterol
levels. Denies chest pain, palpations,
OBJECTIVE:
BP 102/62 (L) arm sitting; apical pulse 64
bpm, regular. Apical and Pulmonic S2>S1,
fatigue, or edema.
SUBJECTIVE:
Denies any upper and lower extremity
coldness, numbness, tingling &/or swelling,
or discoloration of hands and feet. Reports
some pain, and cramping when moving
legs. No hx of blood clots.
OBJECTIVE:
Upper and lower extremities equal in
length, and symmetric, pink/tan, warm, no
edema, and small lesion on (R) upper arm.
Equal hair distribution on both arms and
almost no hair on legs. Peripheral pulses
(carotid, brachial, radial, femoral, pedal,
posterior tibial). No varicose veins. Upper
and lower extremity capillary refill <3
seconds.
Gastrointestinal Abdomen
Minimum History Components
Ask questions regarding:
*Indigestion/heartburn *Nausea & vomiting
(hematemesis) *Appetite *Abdominal pain (COLDSPA)
Bowel: *Usual bowel pattern * in bowel pattern
*Use of aids (laxatives, etc.) *Incontinence
*Hemorrhoids,
*Sigmoidoscopy &/or Colonoscopy (Date & findings)
SUBJECTIVE:
Denies problems with indigestion and
heartburn, nausea, and vomiting. Reports a
OBJECTIVE:
Abdomen rounded, symmetric, with well
healed scars. Bowel sounds active in all
SUBJECTIVE:
Denies any changes in urinary elimination
OBJECTIVE:
Urine clear, straw color, no odor. Foley.
Endocrine
Minimum History Components
SUBJECTIVE:
Denies any thyroid trouble, or problems
OBJECTIVE:
No presence of goiter, exophthalmia,
161.
SUBJECTIVE:
Denies hx of thrombocytopenia, or anemia.
OBJECTIVE:
Generalized pink, moist skin, and mucous
Musculoskeletal
Minimum History Components
Ask questions regarding:
*Joint: deformity, pain (COLDSPA), swelling,
stiffness
*Muscle: pain (COLDSPA) or weakness
*Hx of bone trauma or deformity
*Musculoskeletal- related interference/limitation
with ADLs
SUBJECTIVE:
Reports problems with joints every once in
OBJECTIVE:
Joints symmetric, no swelling, masses or
Neurological
Minimum History Components
Ask questions regarding:
* in LOC *Attitude *Mood *Cognitive
disturbances- ( in ability to understand,
communicate, remember, make decisions)
*Seizures *Tremors *TIA *CVA *Dizziness
*Numbness * in sensory abilities
vision/eyesight, auditory, olfactory, gustatory
exam)
SUBJECTIVE:
Denies any changes in LOC, attitude,
mood, memory, or cognitive abilities.
Denies any problems with speech,
numbness, or dizziness. Denies any
OBJECTIVE:
Alert and oriented x3 (person, place, time).
walk anymore.
Height:
54
Weight:167lbs
General diet
supplements.
Food allergies / intolerances: Denies any.
Appetite:
Typical % of food eaten: Reports eating whatever they give, but likes soups. Usually
consumes 100% of meals.
Fluid intake (daily intake types & amounts):
Use of over the counter medications and other substances (herbal / home remedies,
caffeine, nicotine, alcohol, recreational drugs): Denies any use of over the counter
medications or other herbal/home remedies. Minimal caffeine, no alcohol, recreational
drugs, or nicotine.
If yes to above, describe daily intake:
N/A
exercise, breathing lesson, dinner, bingo, free time, get ready for bed.
Activities on a typical day: Reports participating in bingo, cards, does cross word puzzles,
naps, and builds puzzles.
Exercise habits and patterns: Reports going to exercise activity a couple times a week,
and wheels around the hall.
Sleep - Rest Assessment
Sleep and rest habits and patterns - (Usual pattern of sleep (hours per nights):
Sleeps about 6 hours a night, feels well rested.
Daytime naps:
Utilization of health resources (i.e., regular dental, medical, vision exams): States
having regular vision exams, no dental exams, and doctor visits every once in awhile.
Personal safety (seatbelts, sexual practices, throw rugs, railings):
Uses a seatbelt in
Reports
N/A
Social Activities
Social / leisure activities for fun and relaxation: Enjoys bingo, puzzles and crosswords.
Social activities contributing to society - (clubs, organizations etc.):
Relationships
Exercise group.
Relationships with family / significant other, and pets: Reports having a niece and
nephew that visit.
Family/significant other visit and show support: Reports niece and nephew sometimes.
How is your family coping with your current health status? States Okay.
Stress Level / Coping Styles
Family/significant others or support persons (availability):
Who is the main financial supporter of your family?
Financial concern r/t healthcare & treatment (i.e., adequate insurance coverage):
Reports none.
What gives you strength and hope?
Reports nothing.
(including treatment):
Physical:
Reports not able to walk.
Psychological:
Reports none.
Describe personal stress management:
Poor 1 2 3 4 5 6 7 8 9 10 Excellent
vs
Isolation
MIDDLE
ADULT
Generativity
vs
Stagnation
OLDER
ADULT
Ego
Integrity
vs
Despair
Client maintains relationship with some family members, and seems to coping well
with not having relationships with other family members. Client is unable to continue
with some interests due to his weakness with walking. Does not form many
relationships with others his age due to his general weakness. Is unable to maintain
maximum level of physical functioning due to his giving up attitude when it comes to
walking.
1ST PATHOPHYSIOLOGY
Describe the disease process, signs and symptoms, diagnostic tests, possible complications and treatment.
Remember to reference source.
Pathophysiology:
Chronic obstructive pulmonary disease is a slow progressive obstruction of bronchial
airflow. This is a chronic condition, and can take many forms accompanied with varying
symptoms. The primary cause is cigarette smoking.
Signs and Symptoms:
Symptoms can vary depending on the stage you are in of the disease. The first signs and
symptoms include: productive cough, colorless sputum, and potentially cause chest pain.
The most significant symptom/sign is shortness of breath. In the early stages it may
occur only occasionally and will eventually progress to breathlessness when doing simple
things such as walking to the bathroom or around the room. Some people can also
develop wheezing. Staging of the disease is generally based on the results of a
pulmonary function test, a certain percentage puts you in a certain stage of the disease.
Diagnosis:
COPD is diagnosed by a patients breathing history, history of tobacco use or exposure,
exposure to air pollutants, or a history of lung disease. Chest x rays, or a CT scan may be
done. Another common test is an arterial blood gas or a pulse oximeter may be used to
look at the saturation level of oxygen. A patient can also be sent to a lung specialist to
determine the results of a pulmonary function test.
Treatment:
The most important treatment is to stop smoking right away. Many other medical
treatments are available such as the use of bronchodilators, steroids, mucolytic agents,
and oxygen therapy. You can also go the surgical route and undergo various procedures:
bullectomy, lung volume reduction surgery and a lung transplant. You should quit
smoking and avoid being around smoke. You can use nicotine replacement therapy or an
oral medication such as chantix to help with the quitting process.
Source:
Davis, C., & Cunha, J. (2014). COPD (Chronic Obstructive Pulmonary Disease). Retrieved
from
http://www.medicinenet.com/copd_chronic_obstructive_pulmonary_disease/page4.htm
2ND PATHOPHYSIOLOGY
Describe the disease process, signs and symptoms, diagnostic tests, possible complications and treatment.
Remember to reference source.
Pathophysiology:
Diabetes is a disorder of metabolism characterized by high blood sugar levels. The
pancreas produces to little or no insulin, or the cells do not respond appropriately to the
insulin being produced. Thus glucose builds up in the blood and passes out of the body
via urine. As the disease progresses it can affect muscle cells and fat tissue resulting in
insulin resistance. When type 2 diabetes is diagnosed the pancreas is most likely
producing enough insulin, however the body cannot use the insulin as it should.
Signs and symptoms:
Type 1 diabetes usually develops over a short time period. Signs and symptoms include
increased thirst and urination, hunger, weight loss, blurred vision, and very fatigued.
Type 2 diabetes (which my client has) insulin production declines after several years, and
is generally present in adequate amounts when diagnosed. Signs and symptoms develop
gradually, with their onset not being as sudden as type 1 diabetes. Signs and symptoms
include elevated blood sugar levels, which leads to high amounts of glucose in ones
urine. Dehydration, weight loss, nausea, vomiting, more prone to developing infections
of skin, vaginal areas, and the bladder, fluctuations in sugar levels can also lead to
blurred vision.
Diagnosis:
Diabetes is diagnosed best by a fasting blood glucose test, a fasting glucose reading of
126 mg/dl on two or more tests on different days points towards diabetes. The oral
glucose tolerance test can also be used to determine type 2 diabetes; however it is not
routinely used anymore.
Treatment:
The main goal in treating diabetes is to control the blood glucose levels without causing
abnormally low levels. Type 1 is generally treated with insulin, exercise, and a diabetic
diet. Type 2 is first treated with weight loss, a diabetic diet, and exercise. If this is not
sufficient oral medications will be used and if this does not work it can be managed via
insulin.
Source:
Shiel, W., & Conrad, M. (2014). Diabetes (Type 1 and Type 2). Retrieved from
http://www.medicinenet.com
DIAGNOSTIC TESTS
Date of
Test
Test
Normal
Value
Initial
Value
High or Low
3/26/15
3/06/15
1/22/15
11/25/14
10/14/1
4
Urinalysis:
Color
Leukocyte
Esterase
W.B cells
R.B cells
Bacteria
Follow-up Value if
Available
Clear
Neg
Cloudy
Large
0-5
0-5
None
>100
12
Many
BMP:
Sodium
Potassium
Chloride
BUN
Creatinine
GFR
134-146
3.5-5.0
98-109
5-27
0.70-1.20
>59
130
3.9
96
18
1.10
>60
CBC:
WBC
RBC
Hemoglobin
Hematocrit
4.4-12.0
3.3-5.50
12.6-17.4
36-53
14.8
3.96
10.8
33.3
4.2-5.8
5.9
122
6.7
115
HbA1c:
Hemoglobin
Glucose
Uric acid
ESR
ALLERGIES:
CLIENT #:
Generic name
2.6-7.2
0-20
MEDICATION SUMMARY
Brand name
Classification
Normal dose
Albuterol Sulfate
2.5-5mg q 20
min for 3 doses
then 2.5-10mg q
1-4 hr prn
0.083% inhalation
every 6 hours
while awake.
Dulcolax Suppository
(Bisacodyl)
10 mg single
dose
Fleet enema
(Sodium phosphate)
118 mL Fleet
Enema
10mg insert 1
suppository
rectally for
constipation if no
results from milk
of magnesia.
118mL insert 1
application rectally
as needed for
constipation.
Given at 1900.
Glucagon
(GlucaGen)
IV,IM,Subcut 1
mg may be
repeated in 15
min if necessary.
Inject 1 vial IM as
needed for low
blood sugar.
HydrocodoneAcetaminophen
(Norco, Vicodin)
2.5-10mg q 3-6
hr as needed
Insulin
Lantus
(insulin glargine)
O:3-4hr
P: none
D: 24hr
Magnesium and
Aluminum
Action of Drug
Items to check
before giving
Two sid
Used as a bronchodilator to
control and prevent reversible
airway obstruction caused by
asthma or COPD. (Binds to
beta2 adrenergic receptors in
airway smooth muscle,
leading to activation of adenyl
cyclase and increased levels
of cyclic 3 and cAMP)
Treatment of constipation.
(Stimulates peristalsis. Alters
fluid and electrolyte transport,
producing fluid accumulation
in the colon).
Chronic Airway
Obstruction
CNS: nerv
restlessne
headache
CV: chest
palpitatio
arrhythmi
Constipation
Abdominal distention,
presence of bowel
sounds, and unusual
pattern of bowel
function.
GI: abdom
cramps, n
diarrhea,
burning.
Intermittent treatment of
chronic constipation.
(Osmotically active in the
lumen of the GI tract.
Produces laxative effects by
causing water retention and
stimulation of peristalsis).
Acute management of severe
hypoglycemia when
administration of glucose is
not feasible. (Stimulates
hepatic production of glucose
from glycogen stores).
Constipation
Fever, abdominal
distention, presence
of bowel sounds,
unusual pattern of
bowel function.
CNS: dizzi
headache
GI: cramp
abdomina
abdomina
CV: hypot
GI: nause
1 tablet po every 6
hours as needed
for pain.
Pain
Signs of
hypoglycemia
(sweating, hunger,
weakness, headache,
dizziness, tremor,
irritability,
tachycardia, anxiety).
Neurological status.
Bp, pulse, and
Respirations
0.1-0.2 units/kg
once daily in the
morning or 10
units once or
twice daily
Inject 20 units
subcutaneously 1
time a day
Diabetes
Give 30 cc by
mouth every 2
hours as needed
for gastric distress
Hypogluce
Allergic re
5-10mL between
meals and at
bedtime
Control of hyperglycemia in
patients with type 1 or type 2
diabetes. (Lower blood
glucose by: stimulating
glucose uptake in skeletal
muscle and fat, inhibiting
hepatic glucose production).
Useful in a variety of GI
complaints. (Neutralize gastric
acid following dissolution in
gastric contents).
30-60mL single
or divided dose
or 10-20 mL as
concentrate
1200mg/15mL
suspension oral
give 30 mL per
bowel protocol
Treatment/prevention of
hypomagnesemia. (Essential
for the activity of many
enzymes).
Constipation
Diarrhea,
sweating
(Maalox)
Magnesium hydroxide
(Milk of magnesia)
Gastric Distress
CNS: conf
dizziness,
EENT: blu
Resp: dep
GI: constip
diarrhea
ALLERGIES:
CLIENT INITIALS:
Generic name
Brand name
Classification
Normal dose
Polyethylene glycol
(MiraLax)
17g in 8oz of
water
Morphine
Antifungals
(Nystatin cream)
Potassium chloride
20-40 mEq/day
Ropinirole
(Requip)
MEDICATION SUMMARY
Pt. dose &
times to give
Action of Drug
Items to check
before giving
Two sid
Treatment of occasional
constipation. (Polyethylene
glycol in solution acts as an
osmotic agent, drawing water
into the lumen of the GI tract).
Constipation
Abdominal distention,
presence of bowel
sounds, unusual
pattern of bowel
function.
Abdomina
cramping
nausea.
Pain
Type, location,
intensity of pain.
CNS: conf
sedation,
EENT: blu
CV: hypot
bradycard
Treatment of a variety of
cutaneous fungal infections.
(Affects the synthesis of the
fungal cell wall, allowing
leakage of cellular contents).
Treatment/prevention of
potassium depletion.
(Maintain acid-base balance,
isotonicity, and
electrophysiologic balance of
the cell).
Compromised skin.
Burning, i
hypersens
redness
Hypokalemia
0.25 mg once
daily initially 1-3
hours before
bedtime
Torsemide
(Demadex)
10-20 mg once
daily
10-20mg. Give 1
tablet by mouth
one time a day for
edema. 30 mg BID
Edema
Fluid status-daily
weight, I&O
Bp and pulse
Acetaminophen
(Tylenol)
325-650mg q 4-6
hr
Pain, fever
Ondansetron
(Zofran)
8mg every 8
hours
325mg tablet by
mouth for pain.
Elevated
temperature may
take 2 tablets PO
every 6 hours as
needed.
4mg. Give 1 tablet
by mouth every 8
hours as needed
for nausea and
vomiting
CNS: conf
restlessne
weakness
CV: arrhyt
GI: abdom
diarrhea,
nausea, v
CNS: slee
dizziness,
fatigue
CV:edema
GI: constip
nausea, v
CNS: dizzi
headache
nervousne
EENT: hea
GI: constip
diarrhea
GI: hepati
GU:renal f
Rash
CNS: Hea
dizziness,
fatigue
GI: constip
diarrhea,
pain
NURSING INTERVENTIONS
The nurse will:
RATIONALE FOR
INTERVENTIONS (INCLUDE
AUTHOR & PAGE #)
EVAL
C
GOAL
Monitor skin condition once a
Client
integri
Ladwig, p.739)
1.
lesions.
conditions, or lesions.
2.
3.
=Area
as ordered-Nystatin cream.
excess
=RSA
=Repo
rashes
p. 740)
a day.