NURSING CARE PREPARATION

Student Name: Elizabeth B. Archibald Date of Care: 10/17/2017

Unit/Room Number: Med/Surg Date of Admission: 10/11/2017

Age: 85 y/o Ethnic/Cultural Preferences: Caucasion
Gender: Female Allergies: No known allergies
Eriksons Developmental Level: Code Status: Full Code
Ego Integrity vs. Despair

Chief Complaint/Primary Diagnosis: Myelopathy S/P Cervical Stenosis Secondary Fracture

Surgical repair: Fusion Laminectomy

Co-morbidities: HTN, anxiety, constipation, previous MI, osteoporosis, neuropathy, radiculopathy, spondylosis/stenosis (cervical),
torticollis, facet joint syndrome, previous bilateral knee replacements, previous reverse total right shoulder replacement.

Discharge Plan: Patient will be here for 4 weeks for physical and occupational therapy

Integrated Pathophysiology

Patient present for fusion laminectomy performed 10/11/2017. Patient history revealed that patient has had cervical spinal
problems for a long time due to cervical spondylosis (age related wear and tear of vertebral discs), which led to cervical stenosis-
spinal compression was causing diminished conscious proprioception, and therefore, injuries. These falls, and injuries lead to a
fractured vertebra. A laminectomy was performed on C1 and C2, and a fusion was performed to C3 and C4. The lamina is a portion
of the posterior vertebrae that can cause spinal cord compression. This lamina was removed, increasing space, and taking pressure
off spinal cord. C3 and C4 were fused, meaning that they were welded together, to ensure healing, and resulting in 1 vertebrae
instead of 2. Patient has suffered neuropathy prior to surgery due to impingement on nerves, radiculopathy due to damage of nerve
root, and torticollis (head turned to one side) due to painful spasms. Patient is in a swing bed for PT, OT, and ST. She is doing well
with self-feeding, but is not able to ambulate, or perform self-care.

Data Collection
Diet (Type): Regular, but fed upright and supervised. IV (Fluid type, rate, access type): None
I&O (MD order/Nursing Order/Frequency): None CBG (Yes/No, frequency): No
Fall Risk/Safety Precautions (Yes/No): Yes Activity (What is ordered): Only to sit up for 30 minutes at a
time.
Wound Care (Yes/No): Yes Oxygen (Yes/No, Delivery method, how much): No
Drains (Yes/No, Type): No Last BM: This AM @ 10AM, brown, formed, large balls, easy to
pass.
Other Tubes: None

ASSESSMENTS

Integumentary: Head and Neck:

Skin is pink, not dull, warm, and is well hydrated/moist.
There is no skin tenting present.
There is a large bruise to right and left wrist on the palm side
due to rough handling during surgery (per patient).
CRT is < 3 seconds, and MM are moist/pink
Patient is high risk on the Braden Scale
Patient has two small stage 1 bed sores to sacral region that are
being treated with a protective barrier cream.
Hair is thick, scalp is clean and pink.
Cervical surgery was performed, and patient is in a C-collar.
Could not palpate/auscultate carotid or check cervical LNs, due
to C-collar
Eyes- PERRLA.
Face symmetrical, patient has a calm expression.

Patient does not have any masses

Ear/Nose/Throat: Thorax/Lungs:

Mouth: moist, pink, and all natural teeth present. Lungs CTA bilateral, anterior and posterior.
Patient can swallow, but is at risk for aspiration due to recent Room air.
cervical surgery and neuro deficits. Anterior/lateral angle= 2:1

Cardiac: Musculoskeletal:

Peripheral pulses all 2+ and easily palpated. ROM to legs equal and active.
No extra heart sounds, or murmurs auscultated ROM to right arm equal and active.
(patient states that she has an S3 heart sound that comes and ROM to left arm diminished due to full rotator cuff tear.
goes, but it was not heard today) Patient has strong and equal hand grips, and lifts feet without
CRT < 3 seconds impingement.
No edema present Patient is on bedrest, but can sit up for 30 minutes at a time
No JVD observed PRN.
Patient has paresthesia to hands.
Patient is not to ambulate without assistance, and a walker.

Genitourinary: Gastrointestinal:

Patient is functional incontinent. Patient has been constipated and is on Colace.

She can hold her feces and urine, but cannot get to the bed side
commode by herself, and therefore, relies on briefs until a CNA
or RN can assist.
Urine is clear, and voiding is not painful. I&Os are not ordered
by MD.
This morning she had solid, brown stool in the bedside
commode.
Normoperistaltic bowel sounds all 4 quadrants.
No abdominal pain with palpation.

Neurological: Other (Include vital signs, weight):

Patient has neuro deficits due to spinal injury. T: 98.1

Patient has paresthesia in hands, has trouble talking, and gets P: 62 BPM
dizzy when standing. R: 16 BPM
BP: 193/73
All fields of vision intact. SPO2: 98& RA
Weight: 124 #
Pain: 3/10 r/t headache
 CURRENT MEDICATIONS

Generic & Classification Dose/Route/ Onset/Peak Intended Action One adverse reactions One nursing Implications for this
Trade Name Rate if IV client
Therapeutic: anti- 0.2 MG PO O: 30-60 mins Decrease BP drowsiness Assess for edema
Clonidine/ hypertensives Q12H P: 1- 3hours
Catapres Pharmacologic: (tablet)
adrenergic
(centrally acting)

Lisinopril/ Therapeutic: 40 MG PO QD O: 1hr Decrease BP Cough Observe for signs of cough associated
Zestril antihypertensive in AM with allergic reaction
Pharmacologic: ACE (tablet) P: 6hr
inhibitors

Therapeutic: 240 MG PO QD Onset: 30min Eliminate angina Hypotension Assess BP four times per day
Diltiazem/ antianginals, anti- in AM
Cardizem arrhythmic (class (capsule) Peak: 23hr
IV), anti-
hypertensive
Pharmacologic:
calcium channel
blockers

Therapeutic: 100 MG PO BID O: 12 72 hr Facilitate diarrhea Investigate types of stool passage,

Docusate/ laxatives (capsule) passage of stool and if it is an easy defecation.
Colace Pharmacologic: P: unknown
stool softeners

Therapeutic: 600 MG PO BID O: Unknown Essential for Hypercalcemia Monitor electrolytes as ordered by
Calcium mineral and (tablet) P: Unknown bone formation doctor
Carbonate electrolyte
replacements/suppl
ements
 DIAGNOSTIC TESTING
Date Other Interpretation as related to
Normal
(PT, PTT, INR, ABGs, Results Pathophysiology cite reference & pg #
Range
Cultures, etc)
10/12/2017 Quantiferon Gold TB Negative Pending results

DAR NURSING PROGRESS NOTE

10/17/17 @ 0930
Diagnosis: Nutritional deficiency, less than body requirements R/T inability to feed self, post-surgery AEB patient unable to lift eating
utensil from plate to mouth.
Action: Nursing student chopped up food, described what was on plate, and fed patient as desired.
Result: Patient ate a cup of grits, one full pancake, and a full cup of pears.
E.B. Archibald, student RN

10/17/17 @ 1100
Diagnosis: Disturbed body image R/T inability to wash self, and perform basic care AEB patient complaining that she feels dirty.
Action: Nursing student changed patient brief and provided perineal care, gave patient a bed bath, washed hair with shampoo cap,
and brushed her teeth.
Result: Patient felt very good after care, and took a long nap.
E.B. Archibald, student RN

Date: 10/17/17
Time: 1300
Diagnosis: Readiness for enhanced self-care r/t previous trauma AEB patient sharing information with student
nurse regarding sexual abuse as a child.
Action: Patient shared with student nurse that she was raped as a child on her way to school. This discussion
came about because of the #metoo discussion on the news. The patient thinks that people should be aware
that sexual harassment happens more often than people would like to admit.
Response: Student nurse showed emotional support, by hugging patient and being open to discussion if
needed.
Signature: Liz, student RN
PATIENT CARE PLAN

Patient Information:
Recent spinal surgery, neurological deficits, risk for aspiration weakness, risk for falls, skin ulcers, pain

Problem #1 Risk for aspiration R/T recent cervical spinal surgery AEB by hospital protocol that any surgeries that can lead to
neurological deficits need to be put on aspiration precautions.
Desired Outcome: Patient will not aspirate any fluid of solid food during my shift
Nursing Interventions Client Response to Intervention
1. Patient will sit at a 90-degree angle when eating or drinking, atleast 3 1. Patient did very well assisting the nurses when she was
times per day. pulled up in bed to have her head elevated.

2. Patient will take small bites and take breaks in between bites. 2. Patient likes to eat fast so that her food does not get
Breaks will last for at least 30 seconds. cold. Patient needs to slow down.

3. Assess patient carefully when eating for inadequate swallowing, or 3. Patient has done well with swallowing and completely
food pocketing at every meal/snack time, or when patient is drinking. emptying mouth.

Evaluation:
Patient is doing very well at preventing aspiration. She is chewing and swallowing well. She is on aspiration precautions as a
standard hospital protocol that all patients with neurological deficits will be placed on these precautions.

Problem #2 Risk for falls R/T surgery AEB patient being very weak, and unable to support her body weight for extended periods on
time
Desired Outcome: Patient will not have any falls during my shift.
Nursing Interventions Client Response to Intervention
1. Patient will be ambulated with a gate belt anytime she gets up out of 1. Patient was nervous about falling, and so she liked the
bed. added security of the gate belt.

2. Patient will not get up on her own without a CNA or RN present. If 2. Patient did very well at using her call light.
she needs someone she will use her call light.

3. Patient will wear non-slip footwear 24/7. 3. Patient gets cold very easily, and likes the added
warmth that the socks bring.
Evaluation:
Interventions were successful. Patient did not slip or fall during shift. Patient did get weak and was shaky when getting back into
bed from bedside commode, but she did not fall.

Problem #3 Risk for impaired skin integrity R/T bed rest AEB small stage 1 decubitus ulcer formation on sacral region.
Desired Outcome: Patient will not show any increased redness during my shift.
Nursing Interventions Client Response to Intervention
1. Keep briefs dry, change brief every 1-2 hours. 1. Patient did well at telling us when she needed to void
or defecate.
2. Use protective barrier cream every time briefs are changed- at least 2. This occurred three times during my shift. Redness did
every 1-2 hours. not increase.

3. Reposition patient every 1 hour. 3. Patient was a wonderful at helping to turn, and
reposition.
Evaluation:
I successfully kept patient dry, and kept protective barrier cream applied. Patient was repositioned every hour, and did well helping.
Problem #4 Acute pain r/t surgery AEB patient complaining of headache every 4 hours and stating it is a 4/10.
Desired Outcome: Patients pain will be decreased from 4/10 to 1/10 2 hours post interventions.
Nursing Interventions Client Response to Intervention
1. Administer Tylenol as directed Q4H PRN. 1. Patient did well at taking Tylenol PRN.

2. Apply warm or cool wash rag (client preference) to head for 10 2. Patient enjoyed a warm wash rag, because she stated it
minutes. was soothing, and because she gets cold easily.

3. Use distraction to keep head pain away. 3. Patient liked to talk about family, and her dogs.

Evaluation:
Patients pain was a 4/10 first thing in the AM, and then decreased to 0/10 after an hour. Successful pain management.

Problem #5 Anxiety R/T hospitalization AEB patient stating that she feels overwhelmed with lack of control over her life.
Desired Outcome: Patient will not feel anxious within 1-2 hours post interventions.
Nursing Interventions Client Response to Intervention
1. Use relaxing massage to calm patient at least once during shift. 1. Patient has her owner personal lotion that I rubbed on
her feet. It made her relax well.
2. Allow patient to do as much self-care as possible to encourage 2. Patient likes to feed herself. She fed herself her whole
independence. lunch.

3. Encourage family to visit, and use humor to bring cheer into 3. RN Mary was very good for patient, because she has a
patients situation. very funny sense of humor. Patients spouse came to visit
and this lifted patients mood.
Evaluation:
Patient seemed to be in good spirits when I left for the day. Her family was present, and she thanked me for her care.

Problem #6 Alterations in comfort R/T being on bedrest AEB patients declined status in mobility.
Desired Outcome: Patient will feed more comfortable in setting to rest adequately by mid shift.
Nursing Interventions Client Response to Intervention
1. Decorate room with patients things so that she feels at home 1. Patient has he own personal home blankets, a picture,
and her cell phone at her bedside.
2. Patient was given a bed bath to ensure comfort. 2. Patient was very grateful and stated that she felt so
much better.
3. Ensure privacy by keeping door closed or curtain drawn. 3. Patient does not like when people walk down the
hallway and can see in her room.
Evaluation:
Huge improvements made in making patient feel comfortable. High quality care given.