CASE Study Assessment & Reasoning PDF

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Assessment & Reasoning Integumentary System

Peter Dahlberg, 68 years old

Suggested Integumentary Nursing Assessment Skills to Be Demonstrated: -

Inspect head and scalp for color, hair distribution, lesions, and hair texture Inspect scalp for infestations Inspect and palpate skin for texture, moisture, and temperature Pinch skin folds over clavicle to check skin turgor and mobility Note body hair distribution on legs Assess any wounds or lesions (Note: color, shape, configuration, size, location, and distribution) Inspect for edema Inspect nails of feet and hands (Note: shape, contour, consistency, and color) Check for clubbing Check cap refill Inspect skin on posterior surfaces Check blanching on any reddened areas/bruising/vascularity Note appearance of IV sites

• • •

Role play or go through the interview/body assessment process – student to student or as a group. Review the case study as an application exercise in small groups or together as a class. Depending on your program some of this content in the case study may not have been taught. Do not let that prevent you from utilizing this case study! Instead, use it to promote learning by having students identify what they do not yet know and provide guidance to where they can find the information in the textbook or on the internet to address knowledge gaps. This is educational best practice and another way to scaffold knowledge!

Make Learning Active!

Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Present Problem: Peter Dahlberg is a 68-year-old Caucasian male with heart failure, atrial fibrillation, diabetes type 2, and an open left foot ulcer + for MRSA. Mr. Dahlberg came to the emergency department (ED) with reports of increased pain in the left foot, chills, fever of 101.5 F/38.6 C and increasing weakness over the past two days. His wife who is a retired nurse noticed an increase in redness of the surrounding skin and swelling of his foot around the chronic left foot ulcer. His left great toe is black with an open stage III ulcer, measuring 1x1 cm, on the top of his left foot. Surrounding tissue is bright red and extends from his left foot to his lower left leg. A CT of his left foot confirmed osteomyelitis in the left great toe. He is scheduled to have his left great toe amputated in surgery tomorrow. He is admitted to the med/surg floor from the ED, and you are the nurse responsible for his care. What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential)

RELEVANT Data from Present Problem:

Clinical Significance:

Pt is pos for MRSA Pt has significant infection Pt S/S: Pain in L foot,chills,fever 101.5 Pt S/S indicate worsening infection, spreading upward into L F, increasing weakness, surr. tissue leg. bright red ext to LL leg.

What is the RELATIONSHIP between your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Class: Mechanism of Action (own words): Heart failure Warfarin 5 mg PO daily Anticoagulant Blood Thinner, decreases clotting Atrial fibrillation

Lisinopril 20 mg PO daily

Diabetes type 2-diet controlled (no drugs listed)

Furosemide 40 mg PO daily

ACE Inhibitor

Used to lower HBP

Diuretic

Reduces excessive fluid retention

Patient Care Begins: Current VS: T: 101.5 F/38.6 C (oral) P: 98 (irregular) R: 22 (regular) BP: 148/90 O2 sat: 94% room air

P-Q-R-S-T Pain Assessment: Provoking/Palliative: Quality: Region/Radiation: Severity: Timing:

Movement Dull ache Left foot 7/10 Continuous

What vital signs are abnormal? What is the reason (pathophysiology) for these findings? (Reduction of Risk Potential/Health Promotion and Maintenance)

Abnormal VS:

slight fever 101.5 pulse 98 (irregular) respirs 22 BP 148/90 02 SAT 94%

Clinical Significance:

sign of infection pulse rate is high and irregular suggesting heart disease/ heart failure fast respirs indicate respiratory distress, difficulty breathing hypertention suggests heart disease low 02 suggests low oxygen level in Bl, Hypoxemia, may be caused by the heart being unable to pump sufficiently suggesting heart disease/ failure.

Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Current Assessment: GENERAL SURVEY:

Alert, pleasant, in no acute distress, dress appropriate for the season, hygiene and grooming normally for age and gender, calm, body relaxed, no grimacing appears to be resting comfortably. Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. Pink, warm & dry, left foot has a moderate amount of nonpitting edema, heart sounds irregular with no abnormal beats, pulses right leg anterior pedal and posterior post-tibial 2+ and brisk cap refill. Left leg popliteal pulse thready 1+ and lower left leg has sluggish cap refill of 1-2 seconds. Abdomen round, soft, and nontender. BS + in all four quadrants Voiding without difficulty, urine clear/yellow Left great toe is black with an open stage III ulcer 1x1 cm on the top of his left foot with no odor or drainage. Surrounding tissue is warm, bright red, tender to gentle palpation and extends from his left foot to his lower left leg, skin turgor elastic, no tenting present.

NEUROLOGICAL: HEENT:

RESPIRATORY: CARDIAC:

ABDOMEN: GU: INTEGUMENTARY:

What assessment findings are abnormal? What is the reason (pathophysiology) for these findings? (Reduction of Risk Potential/Health Promotion & Maintenance)

RELEVANT Assessment Data:

moderate nonpitting edema L foot irreg ht sounds (no abnorm beats) L leg popliteal pulse thready/1+ LL foot sluggish cap refill L great toe black L great toe open stg III ulcer 1x1cm

Clinical Significance:

Edema/excess fluid retention likely due to pt diagn heart failure indicates a ht murmer, valve not closing properly causing regurg indicates low bloodflow to LL leg & foot indicates slow/inadequate Bl circulation in LL foot indicates death of tissue/ Gangrene due to lack of Bl flow,may be a combined result of insufficient circulation & Diabetes open ulcer due to poor Bl flow which prevents healing & infection

Lab Results: Current: Last Adm.:

WBC 20.2 10.8

Complete Blood Count (CBC) HGB PLTs 10.2 285 10.0 296

% Neuts 92 68

Bands 2 0

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

WBC 20.2 HGB 10.2 % Neuts 92 Bands 2

Indicates increased prod of WBCs indicates low level of Hemoglobin in Bl indicates infection low bands indicate inability to fight infection

Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved.

worsening minimal improvement worsening minimal improvement

Current: Last Adm.:

Basic Metabolic Panel (BMP) K Gluc. 4.0 254 3.9 225

Na 138 137

Creat. 1.8 1.4

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Gluc 254 Creatinine

extremely high high

worsening worsening

Put it All Together and Think Like a Nurse! 1. Interpreting relevant clinical data, what is the primary problem? What body system(s) will you assess most thoroughly based on the primary/priority concern?

Problem: Poor Bl flow to LL leg/foot & heart failure & MRSA 2.

Pathophysiology of Problem in OWN Words:

Priority Body System:

Pt has inadequate circulation/ Bl flow to LL Leg/foot likely as the result of Circulatory heart not pumping Bl sufficiently to lower extremities. Diabetes also contributes to tissue death from lack of Bl supply to tissue. Pt also has a severe infection (MRSA) resistent to antibiotic treatments, very serious. Infection may spread throughout the body via the blood circulation.

Which specific nursing assessments for this body system are most important? Validate successful completion of each nursing assessment on a manikin (if available) identified with peer or faculty initials.

PRIORITY Nursing Assessments: Monitor VITALS (pulses on ALL extremeties & FEVER/temp. Cardiovascular (heart rate & heart sounds)

Rationale: Due to pt diagn heart failure

Validate Student Performance: (I have performed assessments in class last fall.)

3. What is the current nursing priority and plan of care?

Nursing PRIORITY: PRIORITY Nursing Interventions:

Circulation & Infection Rationale:

Monitor pt closely. All vitals. Pt has been diagn w/ ht failure, diabetes & Monitor signs of infection spreading MRSA. (redness moving up LL leg) Admin. prescribed meds Ensure adequate fluids

Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Expected Outcome: Pt's condition will improve, overcome infection and continue treatment for heart failure and Diabetes.

4. State the rationale and expected outcomes for the medical plan of care. Medical Management: Rationale: Contact Precautions Pt in isolation due to MRSA (contagious) Piperacillin-tazobactam 3.375 g over 4 hours IVPB

Penicillin antibiotic to treat infection

Blood glucose every 4 hours Monitor Bl Glucose level w/sliding scale

Expected Outcome:

Prevent MRSA contact spread Pt will overcome infection

Pt Bl Glucose will lower to manageable level

Hydromorphone 0.3-0.5 mg every 2 hours PRN pain

Keep pt comfortable/ pain level to minimum

Pt will be comfortable

Acetaminophen 650 mg PO every 4 hours PRN for temp. >101 F/38.3 C

Lower body Temp/ control fever

Fever will subside

Evaluation: Sixty Minutes Later… Students construct the remainder of a case study by determining what they would notice if client condition improves or deteriorates (faculty decide) Evaluate the response of your patient to nursing and medical interventions during your shift. All physician orders have been implemented that are listed under client management.

Current VS: T: 98.6 P: 70 R:16 BP: 120/80 O2 sat: 98 Current Assessment: GENERAL APPEARANCE: RESP:

Most Recent: T: 101.5 F/38.6 C (oral) P: 98 (irregular) R: 22 (regular) BP: 148/90 O2 sat: 94% room air

Current PQRST: Provoking/Palliative: Quality: Region/Radiation: Severity: Timing:

***PT IMPROVES***

Outward appearence normal, no signs of distress. PPt: Taking Rx Diabetic meds and has modified diet/exercise.

Respirs normal rt, good lung sounds

CARDIAC:

Normal HR, still has murmer but circulation imprv.

NEURO:

Pt Al&OR x3, 5/5 muscle stregnth, no signs stroke, PERRLA

GI:

Active bowel sounds in all 4 quads Voiding regularly

GU: INTEGUMENTARY:

L Great toe was amputated, surrounding tissue has healed well, no redness or signs of infection.

Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved.

1.

What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data:

Clinical Significance:

TREND: Improve/Worsening/Stable:

Pt BP, HR, Temp, Respirs & O2 Sat are all within therapeutic range.

Pt appears to have recovered well.

RELEVANT Assessment Data:

Clinical Significance:

Improved

TREND: Improve/Worsening/Stable:

Pt appears and states he is feeling much better and is following Physician's orders for Rx meds, Pt states he has modified his diet and began walking.

These changes are significant in improving Pt's overall health.

Improved

2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified after this evaluation assessment? (Management of Care, Physiological Adaptation)

Evaluation of Current Status: Pt status has greatly improved.

Modifications to Current Plan of Care: Pt will maintain recommendations. No current adjustments necessary.

3. What did you learn that you can apply to future patients you care for? Reflect on your current strengths and weaknesses this case study identified. What is your plan to make any weakness a future strength?

What Did You Learn? Through this case study I realized that even Pts with serious health issues may recover well and with the right medical interventions and lifestyle changes, they can improve their health significantly. What could have been done better? Really no idea...open to suggestions!

What did you do well in this case study? I did a lot of research, and it was very interesting!! I also made use of medical abbreviations.

What is your plan to make any weakness a future strength?

Always learn, and always improve.

Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved....