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JUSTME.docx2
Virtual Patient Care Plan
The patient is a 75-84 years old white female who was admitted into the skilled nursing home care facility 3 days ago after sustaining a right medial malleolus venous stasis ulcer (VSU) while living at home. On admission, the patient reports getting tired easily with usual activities. She also complains that her legs are swollen, hurt, and easily get ulcers. Her daughter who is concern about her safety, unhealthy diet, and her inability to care for herself at home decided to bring her to the skilled nursing home care facility for close monitoring and safety. The patient has a past medical history of obesity, chronic venous insufficiency, chronic obstructive pulmonary disease (COPD), and deep vein thrombosis (DVT). She is a former smoker, and she is allergic to penicillin. The patient is full code status, and her current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown.
Assessment and Interpretation
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Assessment components |
Interpretation of findings and NANDA Diagnosis |
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A. Vital Signs · Blood Pressure: 124/82 mmHg · Heart Rate/ Pulse: 95 bpm · Respiration Rate: 19 breaths per minutes · Temperature: 97 °F (36.1 C) · SpO2 Sat: 94% · Height: 160 cm · BMI: 90 kg/ (1.6 m)2 = 35.15 · Weight: 90Kg · Pain: Patient reports no pain
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· Blood pressure: · Place of assessment: Upper left arm · Findings: within normal. · Patient pulse: · Place of assessment: right arm · Findings: strong and regular. · Temperature · Place of assessment: Tympanic of the right ear · Findings: Within normal. · BMI: Patient is overweight (BMI > 30) Diagnosis: Obesity-related to unhealthy diet as evidenced by (AEB) patient having an elevated BMI of 35.15 (Doenges et al., 2017, p. 587-584). |
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B. HEENT The Head is symmetric to the body on inspection. The face is symmetric, there is no drooping on inspection. Dry mucus membranes noted. No evidence of airway obstruction in the nasal cavity. The pupils are 4mm and react to light bilaterally.
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No evidence of abnormal findings. I was not able to palpate the skull for the shape.
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C. Neuro · Orientation: The patient is alert and oriented to time, place, and situation. · Motor: Muscle sensation and strength within normal range. · Cranial Nerves: · CNI: Not assessed, no data provided · CNII: Not assessed, no data provided · CNIII/IV/VI: Extraocular movements within normal limits · CNV: Not assessed, no data provided · CN VII: Not assessed, no data provided · CN VIII: Patient hearing is intact, patient able to hear and communicate · CNIX, X: Not assessed, no data provided · CN XI: Not assessed, no data provided · CN XII: Not assessed, no data provided |
No evidence of abnormal findings |
|
D. Cardiovascular The heart rate and rhythm are normal without evidence of murmurs. The patient presented with a history of chronic venous insufficiency, and DVT. |
Impaired peripheral tissue perfusion related to vascular dysfunction AEB by patient having a DVT and chronic venous insufficiency (Doenges et al., 2017, p.878). |
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E. Respiratory The patient's chest is moving equally. Breath sounds are clear and bilaterally equal upon auscultation. |
Impaired gas exchange related to COPD AEB the patient having elevated bicarbonate of 28mEq/L. (Doenges et al., 2017, p.357). |
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F. Gastrointestinal There is no evidence of skin discoloration on the abdomen inspection. There is a presence of normal bowel sounds to auscultation. The patient is on a regular diet with nutritional supplements. The patient has a good appetite and has been eating the majority of her meals. |
No evidence of abnormal findings |
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Genitourinary: Unable to assess, no data provided |
Unable to assess
|
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G. Integument No sign of bruises, rashes, and dehydration. The patient skin is elastic with no evidence of sweating. There is 2+ edema and brown hyperpigmentation from the knees and down on both sides. Presence of venous stasis ulcer on the right medial malleolus. The ulcer is shallow, 1 inch in width, and looks mostly pink to red with no sign of necrosis or infection. The Barden scale of predicting pressure sore risk in 16. |
· Impaired skin integrity related to venous insufficiency AEB patient having a venous stasis ulcer on the right medial malleolus (Doenges et al., 2017, p.783) · Risk for pressure injury related to +2 edema and Braden scale less than 18 (Doenges et al., 2017, p.660). |
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H. Musculoskeletal Upper and lower extremities movement and strength within normal range. The patient requires assistance with positioning in bed and assistance, and to get out of bed to the chair or ambulate. The patient has an unsteady gait and easily fatigued. |
· Impaired physical mobility related to unsteady gait AEB by the patient requires assistance to ambulate (Doenges et al., 2017, p.545). · Activity intolerance related to disease process AEB patient reports getting tired easily (Doenges et al., 2017, p.4). |
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I. Psycho/ Social The patient is a 75-84-year-old white catholic female who lives at home. The patient has a history of smoking. Per daughter reports, the patient is unable to care for self and has safety concern due to impaired mobility. Impaired mobility may prevent the patient from completing an activity of daily living (ADL). |
· Toileting self-care deficit related to impaired mobility AEB patient reports having difficulty with ambulation (Doenges et al., 2017, p.725).
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Diagnostic Data
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Laboratory data |
Results |
Normal Range |
Interpretation of abnormal results |
|
BLOOD ANALYSIS |
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Hb |
12 |
(12.0-15.5g/dL) mold |
Within normal ranges |
|
HCT |
42 |
(36-45%) mold |
Within normal ranges |
|
Platelets |
235 |
(150-400x10 9 /L) |
Within normal ranges |
|
WBC |
10.5 |
(4-11x10 9 /L) |
Within normal ranges |
|
ELECTROLYTES |
|||
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K+ |
3.9 |
(3.6-4.6mEq/L) |
Within normal ranges |
|
Na+ |
142 |
(133-143mEq/L) |
Within normal ranges |
|
Creatinine |
1.1 |
(0.8-1.4mg/dL) |
Within normal ranges |
|
Cl- |
102 |
(101-111mEq/L) |
Within normal ranges |
|
Urea Nitrogen |
16 |
(8-23mg/dL) |
Within normal ranges |
|
HCO3- |
28 |
(22-26mEq/L) |
High: The patient has a history of COPD and may be at risk for impaired gas exchange. Elevated bicarbonate of 28mEq/L is expected as the result of the body's inability to maintain adequate gas exchanges (Huether & McCance,2017, p.698). |
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HEPATIC FUNCTION |
|||
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Albumin |
3.4 |
(3.5-5.0 g/dL) |
Low: A decrease in albumin level results in a reduction of oncotic pressure and an increase in the filtration across the capillary, resulting in excess fluid buildup in the tissues leading to edema ((Huether & McCance,2017, p.929). |
|
Prealbumin |
14.7 |
(19-38mg/dL) |
Low: Prealbumin help with thyroid hormone transport which plays an important role in protein synthesis, a key element for tissue growth and tissue healing. Low prealbumin is expected and consistent with the patient's unhealthy diet and an unhealing ulcer ((Huether & McCance,2017, p.929). |
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Proteins |
6.3 |
(6-7.9g/dL) |
Within normal ranges |
|
Miscellaneous |
|||
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Glucose |
85 |
(65-140 mg/dL) |
Within normal ranges |
(Huether & McCance,2017).
Pathophysiology Flowchart
IMMOBILITY, OBESITY ADVANCED AGE
Immobility, obesity, advanced age, and congenital heart failure promote venous thrombosis and venous dysfunction
(Huether & McCance,2017, p.598)
VENOUS ENDOTHELIAL DAMAGE
Damage from trauma and intravenous medication can
create blood backflow in the extremities leading
(Huether & McCance,2017, p.599)
VENOUS REFLUX
Venous reflux increases the venous pressure known as venous hypertension High venous pressures are transmitted back to the capillaries and skin veins (Huether & McCance,2017, p.598)
VENOUS HYPERTENSION
High venous pressures are transmitted back to the capillaries and skin veins causing vessel damage and rendering them incompetent.
(Huether & McCance,2017, p.598)
HYPERCOAGULABLE STATES
Conditions such as inherited disorder, malignancy, DVT, can lead to venous dysfunction that creates blood backflow in the extremities
(Huether & McCance,2017, p.599)
INFLAMMATION
Venous hypertension, circulatory stasis, and tissue hypoxia cause an inflammatory reaction in vessel and tissues leading to fibrosclerotic remodeling of the skin and then ulceration
(Huether & McCance,2017, p.598)
EDEMA AND HYPERPIMENTATION
High venous pressures increased permeability, leakage, and deposition of hemosiderin in the skin changing its texture and elasticity
(Huether & McCance,2017, p.598)
VENOUS LEG ULCER
Circulation to lower extremity become sluggish and unable to meet metabolic demand to remove waste, provide oxygen and nutrients leading to cell death and necrosis known as VSU
(Huether & McCance,2017, p.598)
IMPAIRED MOBILITY
Edema and pain that accompanies venous ulcer often affect patient ability to perform ADLs and ambulate (Huether & McCance,2017, p.598)
PAIN
Infection can occur because of poor circulation leading to inflammatory response and pain
(Huether & McCance,2017, p.598)
Morbidity and mortality
Venous leg ulcers, formerly known as Venous stasis ulcers (VSU), are a major medical challenge. According to American Family Physician (2018), VSUs account for 80% of lower extremity ulcerations, and the overall prevalence in the United States is approximately 1 percent of the US population. The prevalence of VSU in the U.S. is approximately 600,000 annually and more common in older people (American Family Physician, 2018). The incidence of leg ulceration is increasing as a result of an increasingly aging population (American Family Physician, 2018). According to Sen et al., (2010), venous stasis ulcer is more prevalent in individuals 65 years and older. Other studies have shown that the incidence of VSUs is high in women compared to men (Sen et al., 2010). Risk factors for the development of VSUs include older age, female sex, obesity, trauma, immobility, congenital absence of veins, deep vein thrombosis (DVT), phlebitis, and factor V Leiden mutation. VSUs are a costly medical problem with a high toll on worldwide healthcare systems. In the United States, the Medicare and commercial insurance annual cost for VLU patients ascends to $18,986 and $13,653, respectively (Robles et al., 2021). The annual cost of treating venous ulcers to the US healthcare system is estimated at $2.5–3.5 billion (American Family Physician, 2018). The primary risk factors for venous ulcer development include advanced age, history of deep vein thrombosis, obesity, sedentary lifestyle, leg injury, phlebitis, and hypertension (American Family Physician, 2018).
Medications
|
Medication |
Patient’s dosage |
Drug classification |
Mechanism of action |
Specific indication for patient |
|
Multivitamin |
one tablet orally daily |
Vitamin |
Provide vitamins that are not taken through the diet, use to treat vitamin deficiencies caused by illness, pregnancy, or other disorders. side effects are allergic reaction, like rash; hives; itching; red, swollen, wheezing; tightness in the chest or throat; trouble breathing, swelling of the mouth, face, lips, tongue, or throat. (Burchum, J.et al., 2016.p.988). |
Due to the patient's age and her history of unhealthy diet, take a vitamin supplement might help strengthen bones and prevent falls. The patient is taken it to compensate for her protein deficiency which is very important to promote wound healing and blood circulation.
|
|
Zinc supplement |
one tablet orally daily |
Trace element/Metal |
Zinc is a mineral. It is called an essential trace element that improves wound healing, boosts the immune system, improving growth and health. zinc deficiency causes slow growth, loss of appetite, irritability, generalized hair loss, rough and dry skin, slow wound healing, diarrhea, and nausea (Taylor, C.et al.. Fundamentals of Nursing. 9th edition) |
To assist in patient venous stasis ulcer healing, and to help the immune system fight of bacteria that may cause potential infection. |
|
Albuterol inhaler |
360 mcg prn |
Bronchodilator |
Albuterol is a selective beta-2 agonist, a short-acting inhaled agent, that stimulates adrenergic receptors of the sympathomimetic nervous system. Results in smooth-muscle relaxation in the bronchial tree and peripheral vasculature, causing bronchodilation. Side effects include shaking, headache, nasal irritation, palpitation (Burchum, J.et al., 2016.p.926-928). |
The patient has COPD and she is wheezing. Therefore, she is using albuterol inhaler to help clear the airways where spasms may cause breathing problems. |
|
Aspirin |
81 mg orally daily |
Non-steroidal anti-inflammatory drug |
Non-selective inhibitor of cyclooxygenase, Aspirin suppresses the platelets aggregation by causing irreversible inhibition of COX-1, the enzyme that makes TXA2. Side effects can be hypertension, heart failure, renal impairment (Burchum, J.et al., 2016.p.850-865).
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As an antiplatelets, it protects against thrombotic events since the patient has a history of DVT |
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Acetaminophen |
650 mg orally every 6 hours prn |
Nonopioid analgesic, antipyretic
|
Acetaminophen relief pain and fever by helping to block prostaglandins in response to an injury or illness. It does not cause gastric ulceration, renal impairment and does not inhibit platelet aggregation. It is also associate with the toxic epidermal necrolysis (TEN) and the Stevens-Johnson Syndrome (SJS), both characterized by rashes, blistering. Overdose can cause liver damage (Burchum, J.et al., 2016.p.861 -863). |
To treat the patient mild pain comes from changing the wound dressing or cleaning the wound. |
(Burchum, J.et al., 2016).
Diagnosis
Physical diagnoses:
1. Impaired skin integrity related to inadequate nutrition AEB patient having an ulcer on the right leg (Doenges et al., 2017, p.783)
2. Impaired physical mobility related to unsteady gait AEB by the patient requires assistance to get out of bed to the chair or ambulate (Doenges et al., 2017, p.545)
Psychosocial diagnoses
1. Toileting self-care deficit related to physical limitation AEB patient requiring assistance to get out of bed or ambulate (Doenges et al., 2017, p.725)
2. Risk for loneliness related to social isolation (Doenges et al., 2017, p.527).
Plan
Physical diagnosis: Impaired skin integrity related to inadequate nutrition AEB patient having an ulcer on the right leg (Doenges et al., 2017, p.783)
|
Outcomes/Goals
|
Implementation/Nursing Interventions |
Evaluation
|
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1. Short-Term By the end of 3 days, the patient will be able to demonstrate the technique of proper wound care. |
· Educate and teach the patient to perform daily wound cleaning and dressing change. Rationale: Proper wounds care with appropriate barrier dressing is important in reducing the risk of infections and scarring while promoting healing (Doenges et al., 2017, p.787). · Instruct the patient to perform routine skin inspections by describing observed changes. Assess temperature, surface changes, texture, and contours for the sign of infection. Rationale: Systematic inspection can identify developing problems and promote early intervention, thus reducing the likelihood of progression to skin breakdown (Doenges et al., 2017, p.787). |
Unable evaluate the goal; Virtual encounter |
|
2. Short-Term By the end of 24-hour, the patient will demonstrate knowledge to reduce edema. |
· Teach the patient to elevate the lower extremities when sitting or lying on the bed to enhance venous return and reduce edema formation. Rationale: Elevating the legs help to reduce lower extremities swelling and instantly relieve pain (Doenges et al., 2017, p.789). · Teach and educate the patient about the importance of wearing anti-embolism stockings on the left leg and elastic bandages on the right leg. Rationale: Compression therapy limits swelling and excess fluid in the leg which maximizes the skin's ability to receive the oxygen needed to heal the wound (Doenges et al., 2017, p.789). |
Unable evaluate the goal; Virtual encounter |
|
3. Short-Term By the end of the shift, the patient will verbalize knowledge of proper nutrition to improve wound healing |
· Assess the patient's nutritional status including protein level for a potential source of the delayed healing process. Rationale: Malnutrition deprives the body of protein and calories required for cell growth and repair. Closely monitor albumin because a low level of less than 3.5 correlates to decreased wound healing and increased frequency of pressure ulcers (Doenges et al., 2017, p. 786). · Provide optimum nutrition including vitamin supplements (ACDE), and protein. Rationale: Balanced nutrition promotes and aids in skin and tissue healing and maintains general good health. (Doenges et al., 2017, p. 788). |
Unable to evaluate the goal; virtual encounter |
|
1. Long-term By the end of 4 weeks, the patient will be engaging in a weight loss program to promote wound healing. |
· Instruct and encourage the patient to engage in regular exercise or diet to reduce body weight and enhance circulation. Rationale: Obesity is one of the contributing and risk factors of venous ulcers. Educating the patient about the importance of weight loss is key to promote circulation and wounds (Doenges et al., 2017, p. 788). |
Unable evaluate the goal; virtual encounter |
(Doenges et al, 2017).
Psychosocial diagnoses: Risk for loneliness related to social isolation (Doenges et al., 2017, p.527).
|
Outcomes/Goals |
Implementation/Nursing Interventions |
Evaluation |
|
1. Short-Term By the end of the shift, the patient will be able to identify 3 risks factors of loneliness. |
· Assist the patient to identify feelings and situations in which she may experiencing loneliness. Rationale: Assessing contributing factors of loneliness can help determine causes of social isolation and modify those factors (Doenges et al., 2017, p.529). |
Unable evaluate the goal; virtual encounter |
|
2. Short-Term By the end of the shift, the patient will have knowledge on how to cope with her stay in the nursing home. |
· Talk to the patient about the importance of having hope and confidence in the process of her healing by encouraging her to think about things that can make her happy in the sense to reduce her anxiety during her stay. Rationale: Discussing positive health habits, including personal hygiene and exercise activity of client’s choosing will help improve her self-esteem and her motivation to achieve better outcome. Most often, older people feel so helpless and rejected when they leave their home to the nursing home. So, reorienting them, showing them empathy, love can help them be more acceptable to their new living conditions, and reduce their sense of loneliness. (Doenges et al., 2017, p.529). |
Unable evaluate the goal; virtual encounter |
|
3. Short-Term Within 2 days, the patient will be provided with resources to cope with hospitalization. |
· The nurse will determine the patient's need for socialization and identify available and potential support persons or systems. Explore methods for increasing social contact. Rationale: Assessing the need for interaction and developing a care plan accordingly will reduce the sense of isolation surrounding the illness. Methods for increasing social contact include TV, radio, videos, more frequent visitations of a family member, especially her daughter, and scheduled interaction with nurse or support staff. (Swearingen, 2016, p.81). |
Unable evaluate the goal; virtual encounter |
|
1. Long-Term By the end of 3 months patient will engage in social activities. |
· Explore the way to increase patient interest and participation in group and organization Rationale: Older people are at high risk for loneliness because they often have few opportunities to be among others or to see their relatives. Engaging them in social groups can help reduce the feeling of loneliness (Doenges et al., 2017, p.528). |
Unable evaluate; virtual encounter |
(Doenges et al, 2017; Swearingen, 2016).
References
Burchum, J. Rosenjack, Rosenthal, L. D., Jones, B. Outland, Neumiller, J. J., & Lehne, R. A. (2016). Lehne's pharmacology for nursing care. 9th edition. Elsevier/Saunders.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse's pocket guide: diagnoses,
prioritized interventions, and rationales. F.A. Davis Company.
Huether, S.E., & McCance, K.L.(2017). Understanding pathophysiology (6th ed.). Elsevier.
Lauren C., & Samina S. (2018 Apr 15). American Family Physician, Diagnosis and Treatment of Venous Ulcers, 81(8),989-996. https://www.aafp.org/afp/2010/0415/p989.html
Robles T. A.; Lev T. H.; & Ocampo C. J. (2021, Mar 21). Venous Leg Ulcer. https://www.ncbi.nlm.nih.gov/books/NBK567802/
Sen, C. K., Gordillo, G. M., Roy, S., Kirsner, R., Lambert, L., Hunt, T. K., Gottrup, F., Gurtner, G. C., & Longaker, M. T. (2018). Human skin wounds: a major and snowballing threat to public health and the economy. Wound repair and regeneration: official publication of the Wound Healing Society the European Tissue Repair Society, 17(6), 763–771. https://doi.org/10.1111/j.1524-475X.2009.00543.x
Swearingen, P. L. (2016). All-in-one care planning resource: Medical-surgical, pediatric, maternity, & psychiatric nursing care plans. (4th ed.). Mosby Elsevier.
Wound Source. (2020). Diagnosis and Pathophysiology of Venous Leg Ulcers. https://www.woundsource.com/blog/diagnosis-and-pathophysiology-venous-leg-ulcers#:~:text=The%20primary%20underlying%20mechanism%20of,ulcer%20develops%20as%20a%20consequence .
