You are assigned to care for a 84 year female, Doris Jones, in Good Samaritan Rehabilitative and Nursing Facility. She was admitted 3 days ago from the hospital for strengthening and rehabilitation. Due advancing dementia she will be for long term care placement after rehabilitative therapy to maximum functional status.
While reviewing the chart you find the following information:
Admission Date: January 31, 20XX
Primary Diagnosis: Left hip fracture with surgical repair, 2 weeks post-op. Fell at home.
Past Medical history: CVA, HTN, vascular dementia, osteoarthritis, cholecystectomy, GERD, deconditioning. Admitted from home, were she lived alone into hospital.
Allergies: PCN, Demerol, Shell fish
She has advanced directives in the record, her Responsible party is her daughter, and she is a DNR.
In the nurses notes from yesterday you find the following information: Resident Base line VS: T-98.7 oral, P-96 regular, R- 22 regular, BP-110/72 POx 94% on room air pain scale -7/10. Last set of vital signs: Today, 0700 T- 98.8 oral, P-84 R-16 BP- 126/88, POx 93% on room air. She is complaining of pain and frequently asks for pain medication even though it is ordered only TID. She is reluctant to move, and remains in bed most of the time without moving. She is refusing to go to Physical therapy, and does not participate in ADLs.
Last night Mrs. Jones became confused in the middle of the night and attempted to get out of bed over the side rails by herself stating she had “go to the bathroom.” She was disoriented to person, place and time, she thought she was at her own home. Mrs. Jones was noted to be incontinent of urine when nurse found her climbing over side rails.
Functional assessment reveals: requires assistance with turning and positioning, on turning schedule. Requires being set up for ADLs and encouraged to participate but refuses involvement. Her weight on admission: 154 lbs. Diet: Soft with ground meat, give 1 can Jevity 1.2 – 1 can if consumes less than 50%, tolerates diet well. She has a PEG tube. She complains that the pain medication not working. She is on safety precautions. She has a prior history of being continent of both bowel and bladder at home. States she has trouble with constipation at home sometimes.
Treatments include: VS Q shift, Turn and reposition q2hour, Physical therapy with weight bearing as tolerated for strengthening and walker ambulation. Wound to left hip surgical incision healing without signs of infection, staples already removed, incision approximated and open to air.
Today: While working with Mrs. Jones you complete a physical assessment and document the following note.
Date/Time: X/X/XX ; XX:XXpm
Vital Signs/Pain/Pulse Ox: T-98.1 oral, P-60, regular, R- 12 regular, B/P 124/82, Rt. arm, semi-fowlers, Pulse Ox
94% on room air, Patient complains of pain in the left hip, 9/10, describes it as a sharp pain, worse with movement,
nothing helps it.
Cognition (Neurological) / Psychosocial (mood) / Sensory (vision & hearing): Alert & oriented to person only; noted
forgetfulness, PERRLA. Pupils 4mm, able to read newspaper and wall clock with glasses, responsive
to commands at moderate conversational tones. Face symmetrical, Able to communicate needs verbally. Speaks English.
Mode is depressed, states she is ‘hopeless’.
Perfusion (Cardiac): S1and S2 regular at APETM landmarks.
Apical pulse 62 and regular. Pulses: temporal +2, carotid +3, brachial +2, radial +2, femoral +1
Popliteal +1, Posterior tibial +1 and dorsalis pedis +2, All pulses equal bilaterally; Capillary refill 2 sec in both upper and
lower extremities, no edema noted
Oxygenation(Respiratory): Breath sounds clear in all lobes, anterior and posterior; Moderate chest expansion, equal
bilaterally. No cough or shortness of breath, O2 at 2l/min per NC
Nutrition (GI/Abdomen): Abdomen soft, round and non-tender with palpation; Bowel Sounds audible and sluggish in 4
quadrants, PEG tube 18fr, upper left quadrant, no redness, drainage or edema noted at site, Placement verified, Residual
5ml of greenish gastric contents , Tolerates diet well; eating 50% of breakfast and lunch, No noted change in weight.
Elimination: Patient incontinent of bowel and bladder, Last BM 2 days ago, large formed and brown; Normal pattern is
BM q2 days, Urinates 5-6 times per day, dark yellow in color, no odor noted;
Mobility (Musculo-Skeletal): Moves all extremities however, weak in lower extremities and requires assistance
Transfer with the assist of 2 person, Uses wheelchair for mobility propelled by nurse; refusing walker when not in PT, able
to support self in sitting position Requires complete assistance with all ADLs due to non-participation;
Responds appropriately when extremities are touched. Observed in PT to ambulate 10 steps with walker with extensive
assist and step by step cueing. Refused PT after lunch. No history of falls since admission; noted climbing OOB last HS
. without requesting assistance.
Protection (Integumentary): . Oral Mucous membranes pink and moist, has full set of dentures; nasal passage clear; Skin
turgor 1 sec; Skin evenly pigmented , red area on sacrum, 3cmx4cm, non-blanching, Mepilex dressing to sacrum ordered
Perineal area with excoriation noted, calmoseptime ointment ordered every shift and PRN.
Incision to left hip 12 cm, no redness, drainage, odor or edema noted, pink incision line appears to be healing well.
Nutrition: Nutrition: Ht: ___64__ Wt:_153____ BMI: ___26_____ BMI- overweight Low risk for disease,
Braden Scale: 11, High risk
Fall Risk: 17, High risk
Signature: Emma Nurse, Student Nurse MTC
Metabolic Panel Feb. 2, 20XX, 0600
Glucose 114* (74-106)
Sodium 142 (136-145)
Potassium 4.2 (3.5-5)
Chloride 106 (98-106)
CO2 23 (23-30)
Anion Gap 7* (8-16)
BUN 23* (10-20)
Creat 1.3* ((0.5-1.2)
Calcium 8.7* (9-10.5)
GFR 41* (60 or higher)
CBC Feb. 2, 20XX, 0600 Feb. 3, 20XX, 0600 Normal range
WBC 7.7 8.8 (5-10)
RBC 4.9 4.1* (4.2-5.4)
Hgb 9.3* 9.0* (12-16)
Hct 28.7* 28.2* (37-47)
MCV 85.2 84.9 (80-96)
MCH 27.2 27.1 (27-31)
MCHC 29.8* 29.4* (33-36)
RDW 14.3 14.2 (11.5-14.5)
Platelet 170,200 170,100 (150,000-400,000)
Urinalysis Feb. 2, 20XX, 1430 Normal
Appearance: clear clear
Color: dark amber* amber yellow
Odor: none aromatic
pH: 5.5 4.6-8
Protein 6mg/dl 0-8
Specific gravity 1.005 1.005-1.030
Glucose negative none
Ketones negative none
Bilirubin negative none
Nitrates negative none
Cast positive* none
WBC none none
RBC none none
Medication Administration Record
February 20XX 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Hydrocodone 5 mg/acetaminophen 325 mg
TID 09 TM TM EN
13 TM TM
17 RG RG
Multi vitamin tablet
1tablet- PO daily 09 TM TM EN
Amlodipine 10 mg tab
Norvasc 10 mg tab
1tablet- PO daily 09 TM TM EN
Metoprolol, 50 mg tab
Lopressor 50 mg tab
1 tablet- PO daily 09 TM TM EN
Micro K 10meq cap
1- PO daily 09 TM TM EN
Mepilex dressing to sacrum after cleaning with carra-klenz 7-3 TM TM EN
Calmoseptime ointment to areas of excoriation q shift 7-3 TM TM EN
3-11 KG KG KG
11-7 NN NN NN
Oxycodone 5mg tab
Oxycontin 5mg tab
1-PO q3hour for pain PRN P NN NN NN
R NN NN NN
N RJ RJ
Diet-soft with ground meats
Jevity 1.2, one can if consumes less than 50% meal 8 TM TM
12 TM TM
18 KG KG
60cc PO PRN constipation P
Acetaminophen 325mg tab
Tylenol 325mg tab
2- PO PRN for fever P
Alleriges: PCN, Demerol, Shell fish
Name: Doris Jones Doctor: Peter Smith
Date Time Drug Dose/Route Reason Initials Time Effectiveness Initials
2/1/XX 0130 Oxycontin 5 mg PO Complaints of pain NN 0215 Patient denies effective NN
2/1/XX 0500 Oxycontin 5 mg PO Complaints of pain NN 0530 Patient denies effective NN
2/1/XX 2100 Oxycontin 5 mg PO Complaints of pain RJ 2130 Patient denies effective KG
2/2/XX 0115 Oxycontin 5 mg PO Complaints of pain NN 0145 Patient denies effective NN
2/2/XX 0430 Oxycontin 5 mg PO Complaints of pain NN 0500 Patient denies effective NN
2/2/XX 2130 Oxycontin 5 mg PO Complaints of pain RJ 2200 Patient denies effective RJ
2/3/XX 0100 Oxycontin 5 mg PO Complaints of pain NN 0145 Patient denies effective NN
2/3/XX 0445 Oxycontin 5 mg PO Complaints of pain NN 0515 Patient denies effective NN
Alleriges: PCN, Demerol, Shell fish
Name: Doris Jones Doctor: Dr. B. E. Well
Nursing Concept Map
Category 4 3 2 1 Points Earned
Priority Assessment Correct medical diagnosis and 10 or more specific priority assessments Correct medical diagnosis and 6 to 9 specific priority assessment Correct Medical Diagnosis and 3 to 5 specific priority assessments Incorrect medical diagnosis & 1 or 2 priority assessment
Problem 1 Correct #1 with 10 assessment data with results Correct #1 with 6 to 9 assessment data with results Correct #1 with 3 to 5 assessment data with results or incorrect # 1 Incorrect # 1 or no assessment results
Problem 2 Correct #2 with 10 assessment data with results Correct #2 with 6 to 9 assessment data with results Correct #2 with 3 to 5 assessment data with results or incorrect # 2 Incorrect # 2 or no assessment results
Outcome Correctly written outcome/goal Missing either the time frame or not measurable Missing the time frame and not measurable Inappropriate outcome/goal
Nursing Interventions with rationales 8 interventions with 1 or 2 assessment interventions 5 to 8 interventions with more than 2 assessment interventions Less than 5 interventions with 2 or more assessment interventions 3 or less interventions or more than 2 assessment -type interventions and missing rationales
Evaluation Properly patient responses for each interventions and progress toward outcome/goal Patient responses are not properly evaluated with progress toward goal evaluated Either interventions or progress toward goal evaluation No evaluation written
Possible Points 24