Description
Look at the example care plan and with the information given finish filling out the one that is half complete with the information needed.
Information given:A 70-year-old male with a history of chronic obstructive pulmonary disease (COPD), tobacco use, hypertension (HTN), atrial flutter treated with Xarelto, aortic aneurysm, and prior aortic graft repair in 2009 presents with complaints of shortness of breath. The patient attributes his breathing difficulty to the high temperatures in Pasadena and requests a breathing treatment.
The patient, who typically relies on room air for oxygen, is currently experiencing shortness of breath, accompanied by wheezing and a one-day history of cough. This cough is productive of wet sputum and has shown some improvement with the use of Mucinex. The patient denies having a fever or chills and does not report any chest pain. He mentions having persistent leg swelling, which has not been diagnosed by his doctors and for which he is not taking diuretics at home. Frustrated by his ongoing symptoms, he has sought further evaluation in the emergency department with a request for a breathing treatment.
Medical History:
Aortic aneurysm
COPD (chronic obstructive pulmonary disease)
Left inguinal hernia
Hypertension
Surgical History:
Aortic graft repair
Imaging:
A chest X-ray performed on October 7, 2023, revealed the following findings:
A faint left apical pleural line, possibly indicating a minimal apical pneumothorax or bleb rupture in the context of COPD.
Scattered patchy opacities in the lower regions of both lungs, which have shown improvement compared to the findings from August 2023 and are more suggestive of atelectasis than pneumonia.
Mild vascular congestion in the lung fields.
patient with a complex medical history, including COPD and prior aortic graft repair, presents with acute respiratory symptoms and a history of persistent leg swelling. An evaluation of his medications, imaging, and clinical condition is necessary to determine the appropriate treatment and management plan.
Acute Hypoxic Respiratory Failure (Present on Admission)
COPD Exacerbation (Present on Admission)
Trace Left Apical Pneumothorax (Present on Admission)
Pulmonary Edema (Present on Admission)
Assessment: The patient is suspected to be experiencing an acute exacerbation of COPD based on increased shortness of breath and heightened sputum production. There may also be a cardiogenic component contributing to pulmonary edema, though B-type natriuretic peptide (BNP) levels are not significantly elevated. Clinical indicators include bilateral leg edema, acute hypertension, and bibasilar crackles. The following steps are recommended:
Transthoracic Echocardiography (TTE) to assess left ventricular ejection fraction (LVEF).
Computed Tomography (CT) of the chest to further characterize the pneumothorax.
Administer Duonebs (combination nebulizer therapy) four times daily as well as on an as-needed basis.
Continue prednisone at a daily dose of 40mg.
Maintain a low threshold for considering antibiotics but withhold for the time being.
Resume the patient’s home inhalers, specifically Incruse and Arnuity (pharmacy medication reconciliation is appreciated).
Continue intravenous furosemide (Lasix) at a dose of 20mg twice daily.
Monitor daily weight measurements and maintain strict input and output records.
Adjust potassium and magnesium levels to maintain values at 4 and 2, respectively, twice daily.
Administer supplemental oxygen with the goal of maintaining oxygen saturation between 88% and 92%.
Request a pulmonary consultation.
Regarding the issue of Atrial Flutter with Rapid Ventricular Response (Present on Admission), the electrocardiogram (EKG) initially suggests sinus tachycardia, though a query for atrial flutter with fixed block is raised. Management recommendations include:
Administer a one-time dose of Diltiazem 15mg.
Continue the patient’s home Diltiazem XR at a daily dose of 240mg.
Continue the patient’s home Xarelto at a daily dose of 20mg.
Continue the patient’s daily dose of losartan at 50mg.
Maintain the daily dose of diltiazem at 240mg.
Initiate nifedipine at a daily dose of 30mg, discontinuing amlodipine.
Request a medication reconciliation consultation
Hyperlipidemia (HLD): The patient is on atorvastatin 40mg daily.
Gastroesophageal Reflux Disease (GERD): Proton pump inhibitor (PPI) therapy is ongoing.
Dietary management: Implement a 2-gram sodium diet with a fluid restriction of 2000ml.
Deep vein thrombosis (DVT) prophylaxis: The patient requires therapeutic anticoagulation, as previously discussed.a history of COPD, experiencing symptoms of shortness of breath and wheezing. Additionally, the patient exhibited lower extremity edema. To assess for cardiac strain or myocardial infarction, laboratory tests, including B-type natriuretic peptide (BNP) and troponin, were conducted. A chest X-ray was performed, and radiology noted the possibility of an apical bleb or pneumothorax. In order to confirm whether a pneumothorax was present, a CT chest was ordered. The case was discussed with pulmonology, who recommended following the patient in case of decompensation, potentially requiring a chest tube insertion, though at this stage, oxygen therapy was recommended. The patient received continuous nebulizer treatments and intravenous Solu-Medrol. The patient was also noted to be hypertensive and was treated with nitroglycerin paste and intravenous Lasix for diuresis. The patient is scheduled for admission to the hospitalist service for further treatment and management.Regarding the medication administration, acetaminophen was given in both rectal and oral forms, with dosing intervals of 650mg every six hours as needed for fever or mild pain.
Unformatted Attachment Preview
Pt. initials: J.R.
Sex: Male
Admitting diagnosis(s): Chronic
Obstructive Pulmonary Disease (COPD)
exacerbation and Shortness of Breath (SOB)
Age:70 Y.O.
Date(s) Care Given: 10/8/2023
Admission Date: 10/7/2023
Allergies: NKA
CODE Status: Full
Code
History of Present Illness (HPI):
J.R., a 70-year-old male with COPD, hypertension (HTN), and a history of aortic aneurysm repair in 2009, presents with worsening shortness of
breath. He attributes this to the heat in Pasadena and seeks a breathing treatment. He has a one-day history of wheezing and productive cough,
which improves with Mucinex. There are no associated fevers, chills, or chest pain. J.R. also reports persistent unexplained leg swelling and has
come to the Emergency Department for evaluation and a breathing treatment. While he can’t recall all his medications, he identifies his COPD
inhalers and albuterol nebulizers, along with Xarelto, diltiazem, and losartan, as part of his regimen.
.
ASSESSMENT DATA
•
•
•
•
•
•
•
Objective Data
Upon exhalation, bilateral crackles are audible
in lung sounds.
Prescribed diet: Low-fat with restricted sodium
intake (2 grams).
Bilateral edema graded as 1 is present in both
extremities.
The patient relies on auxiliary muscles when
walking to the bathroom.
Experiences dyspnea during exertion.
Oxygen saturation (SpO2) is at 93%.
Respiration rate increases to 24 while walking
to the restroom.
Updated 5/29/18 Rev EC 10/18
•
•
•
•
•
•
Subjective Data
“I have COPD and it is too hot in Pasadena and I can’t breathe. I need a breathing treatment.”
“I am having a hard
Pain 3/10 in lower extremity. Feet while walking
Reports changes in sleep patterns, such as frequent nighttime awakenings due to breathing
difficulties.
Express concern or anxiety about the impact of COPD on their daily life and overall health.
Sates has a “persistent cough, especially in the mornings.”
1
Height:
5’8”
Weight:
215 lbs
BMI: 32.7
Neuro: The patient is alert, fully oriented in all four domains (AOX4), and demonstrates clear speech and cooperation, responding appropriately to
commands. Upon visual inspection, the patient’s head presents as normocephalic with no visible deformities or lesions. Their neck appears symmetrical,
devoid of noticeable masses, scars, or edema, and the trachea is correctly centered. The pupils are positive for equal, round, and reactive to light
(PERRL), and extraocular movements are evident with no signs of nystagmus. Furthermore, the patient’s facial expression maintains symmetry when
they smile, and there is no observed tenderness in the head or neck, suggesting a healthy and unremarkable examination.
Respiratory: Upon inspection chest rise and fall symmetric; respiratory movements are with regular rhythm, and unlabored; RR 18/min, without effort or
use of accessory muscles. Upon palpation of anterior and posterior thorax no pain, tenderness, or masses. Upon auscultation breath sounds are
crackles bilaterally throughout all lobes; wheezes are heard upon inhalation, no rhonchi,or stridor.
Cardiac: : Upon palpation: carotid, radial, brachial, and femoral, pulses present, regular, +2 bilaterally. Dorsalis pedis and posterior tibialis pulses +2
bilaterally. Pulse rate: 90/min; capillary refill < 3 sec. Upon auscultation aortic, pulmonic, Erb’s point, tricuspid, and mitral valve sounds present and
unremarkable; S1/S2 present; no murmurs; no carotid bruits.
GI/GU: Abdomen presents with symmetrical and round contours, devoid of any visible lesions, masses, or scars. There are no indications of inflammation
or herniation. Auscultation reveals normoactive bowel sounds. Gentle palpation of the abdomen elicits no tenderness or pain. The bladder is nonpalpable. The patient is continent.
Musculoskeletal: Upon examining the upper extremities and joints, there are no observed deformities, edema bilateral grade on lower extremities,
scars, or erythema, and both arms appear symmetric. Hand grip strength is measured at 5/5 bilaterally. The spine is symmetric. Muscle tone is within the
normal range upon palpation. Full active range of motion is noted in the upper extremities, but there is limited range of motion in the lower extremities.
Skin (including IV & wounds): During examination, the patient's skin appears appropriate for their racial background. There is mild edema noted
bilaterally, graded as 1. A 20g peripheral IV is in place on the right forearm, with no signs of swelling, redness, or infiltration. Upon palpation, the skin
feels warm and dry, displaying good skin turgor with no tenting.
Psychosocial: Patient displays a sociable and amicable demeanor, responding appropriately when engaged in conversation. He openly shares details
about his life and expresses contentment. He mentions having a girlfriend and a daughter, and currently, he resides in his RV, combining work and travel.
The patient is well-oriented to his current condition and maintains a pleasant disposition throughout the day. He indicates that he is a hands-on learner,
suggesting a preference for learning through practical experience.
Past Medical & Surgical History: COPD (Chronic Obstructive Pulmonary Disease), Left Inguinal Hernia, Hypertension, Aorta Surgery (aortic aneurysm
and dissection s/p graft repair in 2009)
Social History: The patient's current living arrangement involves sharing an RV with his girlfriend. He made the commendable decision to quit smoking a
decade ago, although he occasionally indulges in a cigarette. He had a 36-year history of smoking half a pack a day. The patient no longer consumes
alcohol, but he did engage in occasional drinking and cocaine use during his twenties. He maintains a close connection with his daughter, with frequent
contact. In terms of occupation, he remains active and productive, selling seashells on the beach, as well as working on floats for parades.
Updated 5/29/18 Rev EC 10/18
2
Pathophysiology of Primary Problem(s)
COPD exacerbation is characterized by a sudden worsening of symptoms in individuals with underlying COPD. It is often triggered by various factors,
including respiratory infections (e.g., viral or bacterial), environmental pollutants, or non-compliance with medications. During an exacerbation, there is an
increased inflammatory response in the airways, leading to acute bronchoconstriction and increased mucus production. This results in further airflow
limitation, reduced oxygen exchange, and a subsequent decline in lung function. Patients may experience increased dyspnea (shortness of breath),
increased cough, sputum production, and a decreased ability to perform daily activities. These exacerbations can be severe and require immediate
medical intervention.
Shortness of breath (dyspnea) is a hallmark symptom of COPD and is caused by several underlying pathophysiological processes. In COPD, there is
chronic inflammation in the airways and alveoli, leading to structural changes such as airway narrowing, mucus hypersecretion, and destruction of lung
tissue (emphysema). These changes reduce the elastic recoil of the lung and result in air trapping during exhalation, leading to increased residual
volume. The reduced airflow and inability to expel air effectively result in hyperinflation and impaired gas exchange. Dyspnea occurs when the work of
breathing becomes significantly increased, and patients may feel as though they can't get enough air, especially during physical exertion.
Lab/Diagnostic Test
Normal labs related to patient’s primary diagnosis + all abnormal labs & diagnostic tests
(include rationale and relevant nursing care)
Pt’s value (high/low?)
Rationale for Abnormal
Relevant Nursing Care
MEDICATION LIST: INCLUDE SCHEDULED AND PRN MEDS
Name of
Drug
(Brand &
Generic)
Class &
Mechanism of
Action
Safe Dosage Range
(Med Book &
Calculate Your
Patient's Safe Range)
Dose/ Route/ Frequency
IV Meds (if applicable):
*mLs of diluent/type of diluent
*Length of infusion:
*IV rate mL/Hr:
Reason
Side Effects
RN
Responsibilities/Assessments
acetaminoph
en tab 650
mg
Dose 650 mg
: Oral : Every
6 hours PRN
: Mild Pain
(Pain Scale 13)
Updated 5/29/18 Rev EC 10/18
3
atorvastati
n tab 40
mg
Dose 40
mg : Oral :
Daily
cyclobenz
aprine tab
5 mg
Dose 5
mg : Oral :
Every
night at
bedtime
pratropiu
malbuterol
0.5-2.5
mg/3 mL
inh soln 3
mL
Dose 3
mL :
Nebulizati
on : 3
times daily
Updated 5/29/18 Rev EC 10/18
4
lasix
20mg IV
bid
Fulmer SPICES: An Overall Assessment Tool for Older Adults
ASSESSMENT
Sleep Disorders
Problems with Eating or Feeding
YES/NO and Explanation
No; the patient reports eating 100% of meals. States that his appetite is good. No swallowing problems or
aspiration of food or liquids.
Incontinence
Confusion
Evidence of Falls
Skin Breakdown
No; he has no recent history of falls but does have a history of falls. Since he has full mobility he is at less of a
risk for falls.
No, he does not have any skin breakdown. The only risk is the edema in his bilateral legs due to swelling.
*See https://consultgeri.org/try-this/general-assessment
Gerontological Competency
Communication
Physiological and Psychological Age
Changes
Pain
Functional Status, including ADLS, IADLs
and mobility.
Evidence of Elder Abuse?
Other Geriatric Specific Interventions (Age >65)
Specific Issues Identified
The patient adeptly articulates his needs and engages in extended conversations without any afternoon
confusion. There is no requirement to reorient the patient to his environment.
The patient is mobile and reports feeling short of breath after extended periods of walking around his
room. However, he can ambulate and maintains a positive attitude. His dyspnea during exertion is
relieved by breathing treatments. He has been advised to continue using his incentive spirometer to
prevent atelectasis.
He reports pain in both lower legs bilateral . Legs should remain elevated and he should be assessed for
pain frequently.
It is essential to assess J.R.’s functional status comprehensively, as the exacerbation of his COPD
symptoms and potential complications, such as the leg swelling he’s experiencing, may impact his overall
functional abilities. Additionally, a review of his medications and potential interactions with his current
health status is necessary to optimize his treatment and overall well-being.
No evidence of elder abuse. No bruising present and the patient responded that he feels safe in his life
and living out of his home.
Discharge Planning, including home
environment and social supports
Updated 5/29/18 Rev EC 10/18
5
Updated 5/29/18 Rev EC 10/18
6
Nursing Plan of Care
Nursing Diagnosis
-3 physical, one
psychosocial NANDA dx
-Limit to one “at risk”
NANDA
-For R/T do not use medical
dx
-For AEB, use objective and
subjective data
Goal
What is it you want the
patient to accomplish,
or what do you want to
have happen?
Objective(s)
Measurable with
time frame
Interventions
-What are you going to do
to meet the goals?
-Must have at least 3
interventions per NANDA
-Include assessments,
interventions, pt. teaching,
referrals, discharge
planning, etc.
-Individualize this to your
patient & be specific.
Scientific Rational
Why are you doing
this for this patient?
MUST include
citations.
Evaluation
First, were
goals/objectives met,
not met or partially
met? Second, what
was the patient’s
response to your
interventions?
1. iNFFECTIVE
BREATHING PATTERN
2. Activity Intolerance
Related to:
Imbalance between oxygen
supply and demand
As evidenced by:
Dyspnea
Fatigue
Weakness SOB
3.Acute pain related to
bilater selling
4.Anixety related to
wheather or not this will be
effecting him
References:
Pavord, I. D., Jones, P. W., Burgel, P. R., & Rabe, K. F. (2016). Exacerbations of COPD. International Journal of Chronic Obstructive
Pulmonary Disease, 11(Spec Iss), 21-30. https://doi.org/10.2147/COPD.S85978
Updated 5/29/18 Rev EC 10/18
7
NURSING CARE PLAN
Pt. initials: M.J.P.
Sex: Female
Admitting diagnosis(s):
Left heel pain secondary to osteomyelitis
Age: 92
Date(s) Care Given: 11/09/2020
Admission Date:
11/04/2020
Allergies:
NKDA
CODE Status:
DNR
History of Present Illness (HPI): M.J.P. is a 92 y.o. female admitted on 11/04/20 to the ED for a worsening L heel ulcer with purulent drainage and
pain. She is a poor historian and has a medical history of L toe osteomyelitis, polycythemia, HTN, HLD, PAD, dementia. Pt. had a L total hip
arthroplasty on 8/2020 which was complicated by a periprosthetic femur fracture and an arterial thrombus. This was revealed when the pt. was
recently admitted to St. John’s Hospital from 8/27/20-8/29/20 after the caregiver found her on the floor. She was treated with apixaban 5 mg PO BID.
She first developed the L heel ulcer at the SNF she resides in, but it is not known when it developed. L heel ulcer appears to be related to
osteomyelitis, not a pressure ulcer. Chronic Obstructive Pulmonary Disease (COPD) exacerbation and Shortness of Breathe (SOB)
ASSESSMENT DATA
Objective Data
Deficient fluid volume
• Poor skin turgor with tenting
• BP: 96/56
• Dry mucous membranes
Impaired tissue integrity
• Necrotic/eschar tissue at L heel
• Localized edema/redness/heat to L heel
Frail elderly syndrome
• L heel wound
• Age: 92 y.o
• Sex: female
• Hx of falls
Subjective Data
Deficient fluid volume
• Pt. states, “I am very thirsty.”
Impaired tissue integrity
• 6/10 aching pain at L heel
• Pt. states, “Ouch! My foot hurts.”
Frail elderly syndrome
• Pt. states, “I can’t walk.”
• Pt. states, ”I live alone.”
Decreased diversional activity engagement
• Pt. states, “I can’t walk or do anything.”
• Pt. states, “I don’t have any family.”
Decreased diversional activity engagement
• Prolonged hospitalization per pt. chart
Updated 5/29/18 Rev EC 10/18
1
Height:
1.542 m
Weight:
45.4 kg
BMI: 19.1
Neuro: AOX4, speech clear, cooperative, follows commands and responds appropriately. Upon inspection: head normocephalic; no apparent deformities
or lesions; neck symmetric without visible masses, scars, or edema; trachea midline. Positive PERRL. Extraocular movements present; no nystagmus.
Facial symmetry present upon smiling, No tenderness noted to head or neck.
Respiratory: Upon inspection chest rise and fall symmetric; respiratory movements are with regular rhythm, and unlabored; RR 18/min, without effort or
use of accessory muscles. Upon palpation of anterior and posterior thorax no pain, tenderness, or masses. Upon auscultation breath sounds are clear
bilaterally throughout all lobes; no wheezes, rhonchi, crackles, or stridor.
Cardiac: Upon palpation: carotid, radial, brachial, and femoral, pulses present, regular, +2 bilaterally. Dorsalis pedis and posterior tibialis pulses weak +1
bilaterally. Pulse rate: 84/min; capillary refill < 3 sec. Upon auscultation aortic, pulmonic, Erb’s point, tricuspid, and mitral valve sounds present and
unremarkable; S1/S2 present; no murmurs; no carotid bruits.
GI/GU: Upon inspection, abdomen symmetrical with round contour, no lesions, masses or scars noted; no signs of inflammation or herniation. Upon
auscultation, bowel sounds normoactive. With light palpation, no tenderness or pain noted. Bladder non palpable. Patient has functional incontinence
secondary to limited mobility.
Musculoskeletal: Upon inspection of upper extremities and joints, no deformities, edema, scars or erythema noted; arms are symmetric. Upper
extremity, hand grip 5/5 strength bilaterally. Left heel with eschar, redness, swelling; no drainage or warmth noted. Patient reports 6/10 sharp pain to left
heel. Sensory motor movement intact to both feet. Spine is symmetric; with some lordosis. Upon palpation, muscles have normal tone. Full active ROM in
upper extremities. Limited ROM to lower extremities.
Skin (including IV & wounds): Upon inspection skin is appropriate for race; redness to left forearm that patient states was due to tape. Peripheral IV to
dorsal side of left forearm; no swelling, redness, or infiltration noted. Upon palpation skin is warm and dry; poor skin turgor with tenting.
Psychosocial: Patient is quiet and friendly; answers questions appropriately when asked. Appears content in sharing her life story. She reports having
only one family member, but also a close personal aid. She is oriented to her condition but became confused later on in the afternoon. She states she
can’t do what she used to do due to her limited mobility, and when asked about what she enjoys doing as a diversional activity, she said “I can’t do
anything.” She appeared content and pleasant throughout the day. She learns best by listening.
Past Medical & Surgical History: Acute kidney injury (8/20/20), DVT after hip replacement (8/2020), hyperlipidemia, HTN (essential), memory deficit,
osteoporosis with fracture, polycythemia, osteomyelitis. Surgeries: L knee arthroplasty, mastoidectomy, L rotator cuff repair, L total hip replacement
Social History: Patient lives in a skilled nursing facility. She is a non-smoker and denies ever smoking tobacco or doing illicit drugs. She used to drink
alcohol socially over “40 years ago.” She reports having no children or husband. Her previous careers were being a “postmodern dancer” and pilot.
Updated 5/29/18 Rev EC 10/18
2
Pathophysiology of Primary Problem(s): Osteomyelitis is an infection of the bone that can be caused by a bacteria, virus, parasite, or fungi. The
infection can either enter from outside of the body—such as with an open fracture—or from inside the body—such as through the blood. Often,
osteomyelitis infections occur after total joint replacements (McCance & Huether, 2019). In M.J.P, this most likely occurred with her total hip
replacements. The pathophysiology involves the invasion of the pathogen which the causes an inflammatory response. This leads to edema, vascular
engorgement, and abscess formation. This can cause a disruption in the blood supply to the bone, which then leads to necrosis and an area of dead
bone called sequestrum. Osteoblasts form new bone cells around this area called involucrum, which has openings that allow purulent drainage to leave
the area (McCance & Huether, 2019). Symptoms of osteomyelitis vary with the degree of the infection. They typically include fever, malaise, and weight
loss. At the area of the infection one can see exudate, lymphadenopathy, swelling, and pain (McCance & Huether, 2019).
Lab/Diagnostic Test
WBC
Hgb
Normal labs related to patient’s primary diagnosis + all abnormal labs & diagnostic tests
(include rationale and relevant nursing care)
Pt’s value (high/low?)
Rationale for Abnormal
Relevant Nursing Care
▪ Monitor for s/s of infection or systemic
inflammation (Temp, HR, RR, etc.)
▪ Administer prescribed antibiotics if ordered
8.10 K/uL (4.5-11.0)
N/A
for suspected/confirmed infection
▪ Monitor trends overtime and report
significant changes to provider
▪ Monitor for bleeding and s/s of hypoxia (HR,
BP, RR, cyanosis, etc.)
Hemoglobin may decline after the
▪ Maintain adequate hydration
10.8 g/dL (13.5 to 17.5): Low age of 90 (Meiner & Yeager, 2019).
▪ Monitor trends overtime and report
The patient is 92.
significant changes to provider
Htc
RBC
PLT
Updated 5/29/18 Rev EC 10/18
35.3% (39-52): Low
Hematocrit may decline after the age
of 90 (Meiner & Yeager, 2019). The
patient is 92.
3.24 M/uL (4.4-5.9): Low
Since the patient has an infection of
the bone, there may be a decrease
in hematopoietic tissue in the
marrow of the long bones. This can
lead to a delay in the production of
RBCs (Meiner & Yeager, 2019).
314 k/uL (150-440)
N/A
▪ Monitor for bleeding and s/s of hypoxia (HR,
BP, RR, cyanosis, etc.)
▪ Maintain adequate hydration
▪ Monitor trends overtime and report
significant changes to provide
▪ Monitor for bleeding and s/s of hypoxia (HR,
BP, RR, cyanosis, etc.)
▪ Maintain adequate hydration
▪ Monitor for venous thrombosis
▪ Monitor trends overtime and report
significant changes to provider
▪ Monitor for ecchymosis and bruising.
▪ Monitor for bleeding and ensure IV insertion
sites are not hemorrhaging.
▪ Maintain adequate manual pressure on
bleeding areas.
3
▪ Monitor trends overtime and report
significant changes to provider
Albumin
2.8 g/dL (3.4 to 5.4), Low
Diagnostic Test
MRI of L foot with
contrast
Impression Statement
Large soft tissue defect in heel.
Unstageable ulcer.
Albumin levels decrease with age,
and are associated with chronic
diseases (Meiner & Yeager, 2019).
Diagnostics Test
Rationale for Abnormal
Osteomyelitis
▪ Monitor nutritional status, and ensure
adequate protein intake
▪ Assess for drug toxicity, as low albumin can
lead to toxicity with protein bound drugs
▪ Monitor trends overtime and report
significant changes to provider
Relevant Nursing Care
▪ Assess circulation, sensation, and motor
ability in left foot.
▪ Elevate heel to remove pressure.
▪ Educate about signs and symptoms of
systemic infection.
MEDICATION LIST: INCLUDE SCHEDULED AND PRN MEDS
Name of
Drug
(Brand &
Generic)
Class &
Mechanism of
Action
apixaban
(Eliquis)
Ther. Class:
Anticoagulants
(Davis, n.d.).
Pharm. Class:
factor xa inhibitor
Up to 5 mg PO BID
Dose/ Route/ Frequency
IV Meds (if applicable):
*mLs of diluent/type of diluent
*Length of infusion:
*IV rate mL/Hr:
5 mg PO q BID
80–325 mg PO q day
81 mg PO q daily
Safe Dosage Range
(Med Book &
Calculate Your
Patient's Safe Range)
Side Effects
Prevention of DVT
due to reduced
mobility.
Bleeding, hypersensitivity
reaction (anaphylaxis)
▪ Assess for signs of bleeding
and hemorrhage (bleeding
gums; nosebleed; unusual
bruising; black, tarry stools;
hematuria; fall in hematocrit
or BP)
▪ Assess for DVT and stroke
▪ Explain purpose and method
of administration of
medication. Inform that they
may bruise easily and bleed
longer than usual.
Prevention of MI
Dyspepsia, epigastric distress,
nausea, GI bleeding,
hypersensitivity reactions
(anaphylaxis)
▪ Assess pain severity and
characteristic
▪ Assess fever and associated
signs (tachycardia,
diaphoresis, chills)
▪ Monitor hepatic function
MOA: Acts as
selective factor X
inhibitor that
blocks the active
site of factor Xa,
inactivating the
cascade of
coagulation.
aspirin
(Acurprin)
Ther. Class:
antipyretic,
nonopiod
analgesic
Pharm. Class:
salicylates
Updated 5/29/18 Rev EC 10/18
RN
Responsibilities/Assessments
Reason
4
▪ Monitor for signs of bleeding:
PTT, HTC, Hgb, RBC
(Davis, n.d.)
MOA: Decreases
platelet
aggregation.
Produces
analgesia/
inflammation/
fever by inhibiting
prostaglandins
(Davis, n.d.).
vancomycin
(Vancocin)
Ther. Class: antiinfective
500 mg q 6 hrs or 1 g q
12 hrs up to 4 g/day
300 mg in NaCl 0.9% 100 ml IVPB
q 12 hrs
Osteomyelitis of L
heel
Hypotension, rash, ototoxicity,
N/V, nephrotoxicity, phlebitis,
back and neck pain, anaphylaxis,
chills, fever, red man syndrome
▪ Assess for infection (V/S,
wound appearance, sputum,
urine, stool, WBCs)
▪ Monitor IV site as it may be
irritating to the tissues
▪ Monitor BP throughout
infusion
▪ Monitor for I/Os. Cloudy
urine may indicate
neprotoxicity.
Variable depending on
brand directions/
manufacturer
1 tablet PO daily
Nutritional deficiency
Urine discoloration (vitamin B)
• Educate patient that urine
may change color
• Educated that best source
for vitamins is nutritious
foods from different food
groups
Pharm. Class:
N/A
MOA: Binds to
bacterial cell wall
causing cellular
death.
Multivitamins
Therapeutic:
Vitamins
Pharmacologic:
N/A
(Davis, n.d.)
MOA: Acts as
coenzymes or
catalysts in
metabolic
processes.
Fulmer SPICES: An Overall Assessment Tool for Older Adults
ASSESSMENT
Sleep Disorders
YES/NO and Explanation
No; the patient reports she gets an average of 10 hours of sleep per night. Denied waking up in the middle of
the night or having a difficult time falling asleep.
Problems with Eating or Feeding
No; the patient reports eating 100% of meals. States that her appetite is good. No swallowing problems or
aspiration of food or liquids.
Incontinence
Yes; the patient has functional incontinence due to her limited mobility. The patient wears a diaper; if she is
unable to receive assistance for toileting then she will use her diaper.
Confusion
Updated 5/29/18 Rev EC 10/18
Yes; the patient was able to engage in conversation, but later in the day she was “sundowning” and was not
aware that she lives in a skilled nursing facility.
5
Evidence of Falls
Skin Breakdown
No; she has no recent history of falls but does have a history of falls. Since she has limited mobility she is at
less of a risk for falls.
Yes; she has an open ulcer on her left heel. No pressure ulcers noted to other areas of her body and bony
prominences.
*See https://consultgeri.org/try-this/general-assessment
Communication
Other Geriatric Specific Interventions (Age >65)
Specific Issues Identified
The patient communicates her needs effectively and can maintain longer conversations. Some confusion
was present in the afternoon. Patient needs to be re-oriented to her surroundings periodically.
Physiological and Psychological Age
Changes
Patient is severely limited with her mobility due to her left heel ulcer. Her positions should be changed q 2
hours to avoid pressure injuries. She was dehydrated prior to discharge, so encouraging and reminding
about fluid intake is important even when not thirsty.
Pain
She reports pain to her left heel. Heel should remain elevated and she should be assessed for pain
frequently.
Functional Status, including ADLS, IADLs
and mobility.
Patient can sit but cannot ambulate. She needs assistance with toileting, but her upper extremities allow
her to conduct some ADLs such as brushing her teeth, combing her hair, and washing her face. She
needs assistance with bathing as well.
Evidence of Elder Abuse?
No evidence of elder abuse. No bruising present and the patient responded that she feels safe in her
skilled nursing facility.
Discharge Planning, including home
environment and social supports
The patient will be discharged to a skilled nursing facility with an IV line in place to finish her antibiotic
treatment. She has little family in Los Angeles, but has a personal aid that helps her daily.
Gerontological Competency
Updated 5/29/18 Rev EC 10/18
6
Nursing Plan of Care
Nursing Diagnosis
-3 physical, one
psychosocial NANDA dx
-Limit to one “at risk”
NANDA
-For R/T do not use medical
dx
-For AEB, use objective and
subjective data
Goal
What is it you want the
patient to accomplish,
or what do you want to
have happen?
Objective(s)
Measurable with
time frame
Interventions
-What are you going to do
to meet the goals?
-Must have at least 3
interventions per NANDA
-Include assessments,
interventions, pt. teaching,
referrals, discharge
planning, etc.
-Individualize this to your
patient & be specific.
Scientific Rational
Why are you doing
this for this patient?
MUST include
citations.
Evaluation
First, were
goals/objectives met,
not met or partially
met? Second, what
was the patient’s
response to your
interventions?
1. Deficient fluid volume r/t
insufficient fluid intake AEB:
poor skin turgor with tenting,
BP: 96/56, dry mucous
membranes, pt. states, “I am
very thirsty.”
The patient will achieve
an adequate fluid
volume status.
By the end of the
12-hour shift, the
patient will attain a
systolic BP > 100
mmHg.
1. Monitor VS (pulse,
respirations, BP) q 1
hour until adequate
fluid volume achieved.
1. Deficient fluid
volume results in
tachycardia,
tachypnea, and
hypotension
(Ackley et al.,
2020).
1. Objective met; VS
were taken q 1
hours. VS before
fluid bolus were
BP: 96/56, HR:
84, RR: 20, O2
sat: 95%, T: 98.5.
2. For those with
mild to moderate
fluid deficits, 0.9%
saline can be
used as fluid
replacement
(Ackley et al.,
2020).
2. Objective met;
fluid bolus led to
systolic BP > 100
mmHg. Pt.
tolerated fluid
bolus well.
2. Administer 500 mL
NaCl 0.9% fluid bolus
IV at rate of 500mL/hr.
3. Provide patient
teaching about her
susceptibility to
dehydration due to her
advanced age.
Encourage her to
regularly consume
liquids even when not
thirsty.
Updated 5/29/18 Rev EC 10/18
3. Strategies to
improve fluid
intake in the
elderly include
reminders about
drinking fluids and
encouraging small
amounts of fluid
throughout the
day (Ackley et al.,
2020).
3. Objective partially
met; at time of
teaching pt.
began
“sundowning” and
became
confused.
Teaching had to
be repeated
several times.
7
2. Impaired tissue integrity
r/t infectious process AEB:
necrotic/eschar tissue at L
heel, 6/10 aching pain at L
heel, localized
edema/redness/heat to L
heel, pt. states, “Ouch! My
foot hurts.”
The patient will
maintain an appropriate
wound healing process
(e.g., decrease in size
of wound).
By the end of the
12-hour shift, the
patient will be
provided the
prescribed
treatment
measures for L
heel wound
(protective boot,
antibiotics, pt.
teaching).
1. Assess L heel area for
s/s of worsening
infection (pain,
redness, swelling,
purulent drainage,
heat.).
2. Administer vancomycin
300 mg IVPB q 12
hours.
3. Provide client teaching
on skin and wound
assessments and how
to monitor for
symptoms of infection
and appropriate
healing.
3. Frail elderly syndrome r/t
immobility and social
isolation AEB: pt. states, “I
can’t walk”, ”I live alone,” L
heel wound, age: 92 y.o.,
sex: female, hx of falls.
The patient will perform
activities of daily living
as safely and
independently as
possible.
By the end of the
12-hour shift, the
client will eat,
transfer to a chair,
and toilet with
minimal to no
assistance.
1. Assess the pt.’s degree
of frailty with the Frailty
Index.
2. Encourage and assist
client with activities of
daily living.
3. Discharge the client
with referrals for an
interdisciplinary care
team including physical
therapy.
Updated 5/29/18 Rev EC 10/18
1. An assessment of
ulcers should
include changes
in sensation, a
detailed pain
assessment, and
signs of inection
(Ackley et al.,
2020).
2. Vancomycin is an
anti-infective that
is indicated for
osteomyelitis
infections (Davis,
n.d.).
3. Early assessment
and interventions
of tissue integrity
can aid in
preventing more
serious issues
from developing
(Ackley et al.,
2020).
1. Validated tools
such as the Frailty
Index has
accurate
predicative
reliability and can
help identify frail
older adults
(Ackley et al.,
2020).
2. Elderly client who
remain sedentary
have deteriorating
mobility levels
1. Objective met; L
heel was
assessed during
the shift and
found to be
edematous, red,
and swollen but
with no drainage.
Lower extremity
pedal pulses were
weak.
2. Objective met;
patient received
prescribed dose
of vancomycin.
Pt. tolerated
medication well;
no N/V or rash
noted.
3. Objective not met;
the patient did not
understand the
teaching. Pt. has
limited mobility
and cannot
inspect feet.
1. Objective met; the
pt. was identified
as very frail
according the
Frailty Index
(hypothetical).
2. Objective met: the
client ate
independently,
needed
assistance in
transferring to the
chair and some
8
4.Decreased diversional
activity engagement r/t
impaired mobility,
insufficient opportunities for
diversional activities AEB:
pt. states “I can’t walk or do
anything,” “I don’t have any
family,” prolonged
hospitalization per pt. chart.
The patient will engage
in personally satisfying
recreational activities.
Updated 5/29/18 Rev EC 10/18
By the end of the
12-hour shift, the
client will identify
two diversional
activities she can
comfortably engage
in.
1. Assess the pt.’s motor
skills, hand dexterity,
and vision.
2. Encourage the client to
share feelings about
their interests,
environment, or lack of
opportunities for
recreation. Identify
appropriate activities
that the client can
engage in within their
situation.
3. Refer to occupational
therapy.
(Ackley et al.,
2020).
assistance with
toileting.
3. Care for the frail
elder adult should
not only focus on
medical problems,
but also on
supporting the
client to be
independent
(Ackley at al.,
2020).
1. Diversional
activities need to
be individualized
to the pt.’s
abilities (Ackley et
al., 2020).
2. Sharing feelings
about once’s
perceived sense
of loss can be
therapeutic
(Ackley et al.,
2020).
3. Occupational
therapists assist
clients in
accessing and
conducting
recreational
activities (Ackley
et al., 2020).
3. Objective met;
physical therapy
assessed the
client and
demonstrated
exercises she can
do on her own
(hypothetical).
1. Objective met; the
pt. was found to
have good hand
dexterity, but poor
vision.
2. Objective met; the
pt. shared how
she used to be a
dancer but can’t
do that anymore.
She identified
knitting and board
games as two
activities she
would enjoy
(hypothetical).
3. Objective met; the
patient was
referred to
occupational
therapy at her
SNF
(hypothetical).
9
References:
Ackley, B., Ladwig, G., Makic, M., Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12
ed.). Elsevier.
Davis F. A. (n.d.). Davis’s Drug Guide. https://www.drugguide.com/ddo/
McCance, K. L., & In Huether, S
