Identify and correctly formulates the highest priority nursing diagnosis.Patient is A & O x 3. Pt. verbal and follows commands with encouragement. PERRLA. No sz or agitation, apparent discomfort.

Identify and correctly formulates the highest priority nursing diagnosis.Patient is A & O x 3. Pt. verbal and follows commands with encouragement. PERRLA. No sz or agitation, apparent discomfort.

BKA and L AKA, ESRD, and recurring UTIs.

Patient Profile:
WW is a 54 y/o AA male. Pt. presented to the due to suspected C4 fx, dialysis catheter infection, and possible UTI. He has a PMH of poorly controlled DM2 s/p R BKA and L AKA, ESRD, and recurring UTIs. Used to smoke 2/3 ppd but quit years ago, and used to drink a pint of ETOH per day, but quit after a stroke (unknown date – data gap). Post stroke hx of heroin and cocaine abuse. Pt has a brother and sister who help him, but lives in a nursing home for the past few years. His mother recently died of a heart attack and father’s health is unknown. Brothers also have DM2. Currently on disability, used to work as a mason water operator.
I. Subjective and Objective Data and Analysis of Data

Subjective Data Objective Data Analysis of Data

Vital Signs

Date Time Temp HR Resp BP Sa02
03/28 1500 36.5 77 16 129/59 92%
03/29 0400 37.0 88 18 156/71 100%
03/29 1400 36.0 76 12 144/66 98%
03/30 0540 36.0 78 18 145/67 98%
WW’s oral temperature consistently falls within normal limits (36.1 – 37.8 ° C), despite increased WBC count and infection. Often times with severe infection patients will experience fever, though this is not the case for WW, though many older patients may have a decreased core body temperature as their baseline (Mattson Porth, 2004).

Other Assessments

Neuro & Sensory
Patient is A & O x 3. Pt. verbal and follows commands with encouragement. PERRLA. No sz or agitation, apparent discomfort.

Skin
Dry, warm. Mucus membranes moist. Good skin mobility and turgor. Edema in left hand due to IV infiltration. Assessing the level of consciousness (LOC) continuously can give you insight into the acuity of an infection, because often the first sign of worsening infection is an alteration in LOC (Smeltzer, Bare, Hinkle, & Cheever, 2008). It is important to continually monitor WW’s LOC due to his risk of worsening infection.
Furthermore, pain medication can alter LOC, so it is important to assess baseline before medication administration (Aschenbrenner & Venable, 2009). WW is currently taking 1-2 mg of Dilaudid every 3 hours PRN and 650 mg of Percocet every 6 hours PRN for pain, so it is important to assess LOC before and after medication administration.

Examining a patient’s skin for edema can be important in assessing protein deficiency (Jarvis, 2007). WW has low levels of albumin, which can lead to edema and ascites.

Other labs/ Blood chemistry

Complete Blood Count (CBC)
3/30 3/29
WBC 14.78 H 12.59 H
RBC 3.42 L 3.38 L
Hgb 8.9 L 8.8 L
Hct 27.1 L 26.9 L
Lymph .89 L .89 L

Normal values for CBC (per JHH chart)
Hemoglobin: 13.9-16.3 g/dl
Hematocrit: 41-53%
WBC: 4.5-11.0/ L
Lymphocyte: 1.1-4.8/ L

Increased white blood cells count is an indication of infection. WW had an elevated WBC level on admission on 3/30. This level has decreased dramatically since that time and is now elevated but within normal limits, most likely due to antibiotic administration.

Low levels of lymphocytes are often seen in patients with an infection, and frequently resolve on their own (Smeltzer et al, 2008). WW is recovering from infection, so depressed lymphocyte counts are to be expected. This should be checked again if signs of infection do not clear.

Decreased red blood cells, hemoglobin and hematocrit signal anemia (Smeltzer et al, 2008). WW’s levels are significantly decreased, probably due to his end stage renal disease. It is essential that you treat anemia in patient’s in order to maximize their healing potential (Smeltzer, 2008).

RP’s values 3/30

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