Care of a Group
Bluegrass Community and Technical College
Critical Criteria #1: Assessment and Prioritizing Patient Care
Client # 1 is a 71 year old female who was hospitalized on 1/23/13 with an admitting diagnosis of hyperglycemia, weakness and dehydration. This client has history of underlying lung cancer with metastasis to bone and was recently diagnosed with metastasis to the brain. Other history includes Hypertension, Hypothyroidism, Mitral Valve regurgitation and COPD. Chemotherapy has been put on hold and she is currently getting radiation to the head. Client’s family reports her being more dependent over the last two weeks. She was found with acute kidney/injury ...view middle of the document...
Skin tear noted to right upper forearm. Client turned q2 hours. No other skin lesions or breakdown found. F/C drained 180ml clear amber urine; no pain or bladder tenderness reported.
Priority diagnoses for this client are 1) Risk for ineffective airway clearance r/t nonproductive cough, and abnormal breath sounds 2) Risk for infection r/t retained secretions, poor nutrition, chronic disease, impaired pulmonary defense system secondary assoc with COPD, skin tear, indwelling Foley catheter, lumen port access, and decreased immune system due to steroids. 3) Risk for Aspiration
Client #2 is a 74 year old male who was hospitalized on 1/25/13 with an admitting diagnosis of chest pain. He presented to the emergency room with c/o pressure like pain chest pain that wasn’t relieved with nitroglycerin. Client denies any shortness of breath or nausea. Pain improved after being placed on oxygen. Client’s past medical history includes Hypertension, CAD, GERD/Hiatal Hernia, Hx of acute renal Failure in 2010, chronic thrombocytopenia and anemia. Past surgeries are Cardiac Triple Bypass, 3 Cardiac Stents, Back surgery, and Tumor/cyst removal form right groin. He is allergic to penicillin’s. Client is on contact precautions r/t to having acinetobactor infection and is receiving a cardiac diet. CXR pending at this time for possible pneumonia in left lower lobe. Client on continuous telemetry monitoring and awaiting results of serial cardiac enzymes also. His vitals are stable (T:98.1, P:69, BP:150/71; RR:18; O2:98% per RA).
Upon assessment, client is sitting up in chair waiting for breakfast. He is alert and oriented X3. Client is hard of hearing. He is not wearing any oxygen at this time. Lungs are clear bilaterally. Abdomen is soft and non-distended. Positive BS heard in all four quadrants. He has no skin breakdown and scuds on bilateral extremities. Currently he has a 20 gauge IV located in LFA saline locked. Site is without redness or edema and dressing is dry and intact. Client voids in urinal, urine clear and yellow. No complaints of pain reported at that time.
Priority nursing diagnoses for this client is 1) Acute pain R/T myocardial ischemia 2) Risk for infection R/T inadequate primary defenses AEB: Leukemia.
Client # 3 is a pleasant 61 year old female who was hospitalized on 1/24/13 with an admitting diagnosis of Chest Pain, Vertigo and anxiety. Client presented to the ER with nausea and lightheadedness. He was sent from his cardiologist’s apt. because he felt like he was going to pass out. He was noted to be Atrial Fibrillation and therefore was kept for further evaluation and treatment. MRI was completed showing maxillary sinusitis. Patient was started on antibiotic therapy and soon after developed diarrhea. His wife recently passed away and night nurse explained that his loss has caused him a lot of anxiety. His chart indicates she his past medical history includes hypertension, pancreatitis and lumbago with previous surgeries...