Adult Case Study

Validation Case Study I
NUCO 4430: Transition and Validation Seminar I
October 26, 2010
Kimberely S. Strickland
University of Virginia

One: The most obvious symptom of a compound fracture is the bone protruding through the patient’s skin. Other indications of this type of fracture are edema at the site, pain and tenderness, false motion, and extremity deformity (Nettina, 2006). Another sign is bleeding at the site. Because the bone has burst through muscle, blood vessels, subcutaneous tissue, and skin to make contact with the outside world, these would be damaged as well. Nerve damage is also certain and the clinician can expect to see parasthesia as a result.

As swelling continues, the nurse should look for the classic signs of ischemia: pain, pallor, pulselessness, paralysis, parasthesia, and poikilothermia (Acute limb ischemia, 2006). After only six hours, irreversible changes can occur if ischemia is left untreated (2006). The nurse should also be on alert for signs of shock. Bones are extremely vascular and an injury such as this can lead to loss of large amounts of blood both outside and inside the body. Anxiety, vertigo, shallow breathing, increasing heart rate, clammy skin, unconsciousness, and decreased urine output are all signs of shock.

Because Mr. Vasquez is a smoker, his risk of infection is more than twice that of a non –smoker (Castillo, Bosse, MacKenzie, & Patterson, 2005). His rib fractures will discourage him from deep breathing and could lead to pneumonia. Another serious complication of a fracture is an embolism and the nurse should be alert at all times for respiratory distress, mental status changes, and fever (Nettina, 2006). Decreased mobility is also a potential complication with any fracture of the lower extremities.

To diagnose a compound fracture, the physician would certainly order an X-ray and CT scan of the left leg and ribs. The nurse should also expect a complete blood count, basic metabolic panel, PT/INR, arterial blood gas, cardiac enzyme series, serum albumin, liver function tests, BUN, creatinine and a urine analysis and culture. The patient will also be typed and cross-matched for a possible blood transfusion. The physician would likely order an angiography to assess the extent of blood vessel damage. Because of the soft tissue injuries associated with this fracture, an MRI would probably be ordered as well. She should also expect telemetry and pulse oximetry monitoring. Because Mr. Vasquez has a dry, hacking cough, night sweats, and fatigue, the nurse should expect the chest X-ray to indicate tuberculosis. If this is the case, the patient shall be placed on airborne isolation.

Prior to surgery, the nurse wants to ensure that the patient understands his N.P.O. status to prevent any risk of aspiration during surgery. She should also view all the lab results and alert the doctor to any abnormalities. If her facility requires a pre-operative checklist for the patient, this should be completed and vital signs should be obtained. The patient should be frequently assessed for any signs of complications or change in condition. Urine output should be monitored for any change in color that might indicate hematuria. Pain should be monitored and treated as ordered by the physician. The nurse should also continue to monitor for any blood loss. If a bandage was applied in the emergency department, she must check it frequently for shadowing or saturation.

Also, the nurse needs to talk to the patient and his family and ensure that all their questions have been answered. If the nurse can answer any lingering questions, she must do so. However, if the patient or his family has questions outside her scope of practice, she should alert the physician so that these can be addressed prior to surgery.

After the patient returns from surgery, the nurse should obtain a set of vital signs and perform an assessment immediately. Respiratory function should be closely monitored for any changes, and the patient’s pain must be kept under control. Compartment syndrome and thromboembolism are two serious complications that can develop from this type of injury, and the nurse should be alert to any signs of either condition. Neurological changes such as poor capillary refill, paralysis, pain, tightness, and pulselessness can signal impending compartment syndrome (Nettina, 2006). The physician will likely order anticoagulants to decrease the risk of thromboembolism, but the nurse should monitor the patient closely for calf pain or tenderness, unilateral leg edema, skin warmth and redness, and a fever greater than 100.4 degrees Fahrenheit (Collins, 2009). The area around the fracture area should be monitored for any changes.

Two: Mr. Vasquez is an underweight male with body mass index of 19.9 (Centers for Disease Control, n.d.). His family doesn’t eat a lot of meat and relies on beans for most of their protein. The family eats a variety of vegetables and Mrs. Vasquez bakes fresh bread daily. Mr. Vasquez also drinks three beers every day.

Part of any nutritional history includes diet information which is stated above. During the diet history, the nurse should also ask if the patient has any financial difficulty obtaining food. Mr. Vasquez had stated that the family can’t afford a lot of meat and that the family’s primary source of protein is beans. This is a concern because Mr. Vasquez may not be getting enough protein as well as the recommended daily allowance of vitamins and minerals. Other[KH1] s subjects the interviewer would include are the number of restaurant meals in a given period (including fast food); likes, dislikes, and cravings; food storage and preparation; and diet choices. During this part of the assessment, the nurse should also ask about any gastrointestinal-related health changes in the past year (Forsyth, 2005). For example, questions about nausea, vomiting, and diarrhea; weight loss and gain; swallowing difficulties; and appetite changes would be asked during this part of the patient interview (2005).

The physical assessment is a head-to-toe account of a patient’s nutritional status. This process relies on both subjective data from the patient and objective data from the nurse (Lutz & Przytulski, 2006). She should begin with his overall general appearance. Is he sluggish or peppy? Does he appear obese or thin? Are his hair and nails brittle and thin or healthy and thick? Has he had any vision changes? Do his corneas appear hardened or do his conjunctiva appear pink? Does his mouth appear dry and cracked? Are sores inside? Does the tongue appear normal or swollen? Are all the patient’s teeth intact? Are any caries visible? Does the patient have headaches? Do any areas of his head and neck appear swollen? Is the patient having heart palpitations or problems with the peripheral vasculature (Estes, 2006)? Is his abdomen tender? Has he had any nausea, vomiting, or diarrhea? Have his bowel habits changed (Forsyth, 2005)? Does she detect any ascites? Has the patient had any musculoskeletal issues (2005)? How is his muscle tone? Is he agitated or irritable? Has he experienced any numbness? Is his speech slurred? How are his coordination and gait? When the nurse answers all of the above questions, she will have a good idea of the patient’s physical status. As an example of the worst case scenario, the nurse has assessed the patient and found him to have brittle hair and nails. This could be due to a lack of vitamins and minerals or something as serious as kidney disease. Vision changes could be attributed to age or to diabetes. Mouth sores may be caused by a broken tooth. Dental caries may be the result of too little calcium or too many sweets. Headaches may be the result of too many diet sodas sweetened with aspartame. Swollen cheeks might be due to enlarged glands or goiter. Heart palpitations could be caused by too much caffeine. Changes in appetite may be caused by depression. Changes in bowel habits might be a warning sign of malnutrition. Musculoskeletal changes may be solved by correcting vitamin and mineral deficiencies. Agitation and irritability could be caused by one of hundreds of ailments.
Anthropometrics are the measurements of the human body. These measurements include height, weight, and body proportions (Lutz & Przytulski, 2006). The nurse would begin by taking the patient’s height and weight. She would then calculate the body mass index and assess whether the patient’s measurements are normal. Next, she would calculate the waist/hip ratio. This is obtained by measuring the narrowest point of the waist and the widest point of the hips. The number is calculated by dividing the waist by the hip (2006). Abnormal measurements are linked to obesity (2006). The skinfold thickness test determines body fat reserves and nutrition status (Estes, 2006). Using calipers, the nurse measures the subcutaneous fat between the patient’s acromion process and the olecranon process on his tricep (2006). Since most of the body’s fat is in the subcutaneous tissue, this is a very reliable indicator of body fat (Lutz & Przytulski, 2006). Last, the mid-arm circumference is used to obtain information on skeletal muscle mass. The patient flexes his arm at the elbow and the nurse measures the circumference halfway between the two processes mentioned above (2006). The number is then put into a mathematical formula to determine the range into which the patient falls. Abnormal results may be indicative of kwashikor (protein malnutrition) or marasmus (protein-calorie malnutrition) or a mixture of the two (Estes, 2006).

Mr. Vasquez should complete a three-day diet history (2006). The nurse should obtain the times of his meals and snacks as well as the content to establish a clear picture of his eating habits. Portion size information would also be helpful since he is underweight.
Labs ordered in conjunction with the nutritional assessment and diet history would be:
· White blood count (5,000-10,000 / mm3)
· Glucose (70-100 mg / dL)
· BUN (Blood urea nitrogen) (7-20 mg / dL)
· Creatinine (0.6-1.2 mg / dL)
· Sodium (135-145 mEq / L)
· Potassium (3.5 – 5.0 mEq / L)
· Phosphate (2.4-4.1 mg / dL)
· Magnesium (1.7-2.2 mg / dL)
· Calcium (8.5-10.2 mg / dL)
· Chloride (98-106 mEq / L)
· Albumin (3.4-5.4 g / dL)
· Prealbumin (15-35 mg / dL)
· Folic Acid (2.7-17.0 ng / mL)
· Vitamin B12 (200-900 pg / mL)
· Vitamin D (30.0-74.0 ng / mL)

The values listed are the desired level for each blood test (Forsyth, 2005). The physician might also order a twenty-four hour urine test.

Three: Mr. Vasquez has four nursing diagnoses:
· Pain, Acute, related to leg wound and recent surgery;
· Nutrition: Imbalanced, Less than Body Requirements related to inadequate caloric and protein intake;
· Risk for Constipation, related to immobility, diet changes, and pain medication administration; and
· Risk for Falls, related to leg injury, pain medication administration, and unfamiliar environment.

These four diagnoses will be discussed below.

Nursing Diagnosis: Pain, Acute, related to leg wound and recent surgery

Major Suggested Optional
Nursing Outcomes Interventions Interventions Interventions

Pain Control-1605 Medication Simple Guided Surveillance
Management Imagery -monitor patient
-administer -assist patient to for signs of pain
Uses analgesics as pain medicines use his imagination
recommended as ordered to redirect his attention -Monitor behavior
160505 away from his pain patterns

-Monitor for signs -Plan with patient an -Monitor vital signs,
and symptoms of appropriate time to do as appropriate
drug toxicity guided imagery

-Determine the
patient’s know-
ledge about
medication

Patient-Controlled Teaching: Individual Animal-Assisted
Reports uncon- Anesthesia (PCA) -teach patient about Therapy
trolled symptoms Assistance pharmacological -contact volunteer
to health pro- -teach patient how methods of pain services about
fessional to use the PCA relief putting patient on
160507 their rounds

Rating:
1 Never demonstrated
2 Rarely demonstrated
3 Sometimes demonstrated
4 Often demonstrated
5 Consistently demonstrated

Pain Level-2102 Analgesic Admini- Positioning Music Therapy
stration -Premedicate patient -Determine the
-Determine pain before moving as patient’s interest
location, charac- appropriate in music
teristics, quality,
Length of pain and severity before -Position in proper -Inform the patient
episodes 210204 medicating patient body alignment as to the purpose of
the music
Restlessness 210208 -Check history for -Immobilize or support experience
drug allergies the affected body part, as
appropriate -Assist the patient
Agitation 210222 -Determine analgesic in assuming a
selection based on comfortable
type and severity of position
pain

Rating:
1 Severe
2 Substantial
3 Moderate
4 Mild
5 None

Nursing Diagnosis: Nutrition: Imbalanced, Less than Body Requirements related to inadequate caloric and protein intake
Major Suggested Optional
Nursing Outcomes Interventions Interventions Interventions
Appetite-1014 Nutrition Therapy Nutrition Management Weight Gain Assistance
-select nutritional -encourage calorie intake -discuss possible causes
Desire to eat 101401 supplements, as appropriate for body type of low body weight
appropriate and lifestyle

-Monitor food -Inquire if patient has any -Provide a variety of
Food intake 101406 ingested and cal- food allergies high-calorie nutritious
culate daily caloric foods from which to
intake, as appro- choose
priate
Rating:
1 Severely
Compromised
2 Substantially
Compromised
3 Moderately
Compromised
4 Mildly
Compromised
5 Not Compromised

Nutrient intake 101407

Nutritional Status: Nutritional Monitoring Teaching: Prescribed Diet Sustenance Support
Nutrient Intake-1009 -Monitor skin turgor, -Explain the purpose of -Determine adequacy
as appropriate the diet of patient’s financial situation
Caloric Intake -Weigh patient at -Appraise patient’s
100901 specified intervals current knowledge about -Determine adequacy
prescribed diet of food supplies in
Protein Intake -Monitor albumin, home
100902 total protein, hemo- -Provide written meal
globin, and hemato- plans, as appropriate -Discuss financial aid
crit levels support with the patient
Rating:
1 Not Adequate
2 Slightly Adequate
3 Moderately
Adequate
4 Substantially Adequate
5 Totally Adequate


Nursing Diagnosis: Risk for Constipation, related to immobility, diet changes, and pain medication administration

Major Suggested Optional
Nursing Outcomes Interventions Interventions Interventions

Bowel Elimination- Constipation / Nutritional Medication Adminis-
0501 Impaction Manage- Monitoring tration: Oral
ment

-Monitor for signs -Monitor energy -Follow the five rights of
Elimination and symptoms of level, malaise, medication administration
pattern 050101 constipation fatigue, and
weakness -Note patient’s medical
-Monitor bowel history and history of
sounds -Monitor for allergies
Passage of stool nausea and
without aids -Monitor bowel move- vomiting
050121 ments, including
frequency, consistency,
shape, volume, and
color, as appropriate

Rating:
1 Severely
2 Substantially
Compromised
3 Moderately
Compromised
4 Mildly
Compromised
5 Not Compromised


Self-Care: Toileting Self-Care Assistance: Exercise Therapy: Anxiety Reduction
0310 Toileting Ambulation
-Consider the culture -Dress patient in non- -Use a calm,
of the patient when restrictive clothing reassuring approach
Positions self on promoting self-care
toilet or commode activities -Provide low-height bed, -Clearly state
031005 as appropriate expectations for
-Provide privacy patient’s behavior
during elimination -Consult physical therapist
Gets to toilet between about ambulation plan, as -Explain all
urge and passage of -Remove essential needed procedures,
urine 031014 clothing to allow for including sensations
elimination -Assist patient to transfer, likely to be
Gets to toilet between if needed experienced during
urge and evacuation of the procedure
stool 031015

Rating:
1 Severely
Compromised
2 Substantially
Compromised
3 Moderately
Compromised
4 Mildly
Compromised
5 Not Compromised



Nursing Diagnosis: Risk for Falls, related to leg injury, pain medication administration, and unfamiliar environment
Major Suggested Optional
Nursing Outcomes Interventions Interventions Interventions

Balance-0202 Fall Prevention Environmental Vital Signs Monitoring
Management: Safety

Maintains balance -Identify behaviors -Identify safety needs -Monitor blood pressure,
while standing on and factors that of the patient, based pulse, temperature, and
one foot 020209 affect risk of falls on level of physical respiratory status, as
and cognitive function appropriate
-Monitor gait, and past history of
balance, and behavior -Note trends and wide
Maintains balance fatigue level fluctuations in blood
while walking with ambulation -Modify the environment pressure
020203 to minimize hazards
-Assist unsteady and risk -Monitor lung sounds
Rating: individual with
1 Severely ambulation -Provide adaptive devices -Monitor pulse oximetry
Compromised to increase the safety of
2 Substantially -Place mechanical the environment
Compromised bed in lowest
3 Moderately position
Compromised
4 Mildly
Compromised
5 Not Compromised


Coordinated Body Mechanics Self-Care Assistance Medication Management
Movement Promotion
0212 -Determine patient’s -Assist patient in -Facilitate changes in
commitment to accepting dependency medication with physician,
learning and using needs as appropriate
correct posture

Control of -Instruct patient -Provide desired -Monitor for non-
movement about need for personal articles therapeutic drug
021205 correct posture (e.g., deodorant, reactions
to prevent fatigue, toothbrush, and
strain,or injury bath soap)

-Assist to avoid -Encourage -Determine the patient’s sitting in the same independence but knowledge about
position for intervene when patient medication
prolonged periods is unable to perform
Rating:
1 Severely
Compromised
2 Substantially
Compromised
3 Moderately
Compromised
4 Mildly
Compromised
5 Not Compromised


Four: The Hemovac drainage system is a type of closed drainage system in which blood and exudate are gently sucked out of the patient’s wound and into the reservoir. Removing the exudates serves several purposes. Edema is reduced as are the risk for infection and skin breakdown (Wolters Kluwer / Lippincott Williams & Wilkins, n.d.). Emptying the reservoir every four to six hours ensures optimum suction and reduces strain on the sutures (n.d.). When emptying the drain, the nurse should maintain clean technique and be sure to compress the device fully when she is finished. This will ensure that the system remains closed and continues the gentle suction on the wound. This type of system is commonly seen with orthopedic and abdominal surgeries (n.d.).

Five: The purpose of a blood transfusion is to replenish blood products that a patient has lost through hemorrhage or is lacking because of an illness. For example, a patient involved in a life-threatening car accident has lost a lot of blood and is rushed to the hospital. Lab tests reveal that his hemoglobin is 7.5 gm / dL. The physician would most likely order at least one unit of packed red blood cells to replace some of what the patient has lost. In other cases, illness keeps the hemoglobin level low enough to warrant a unit of packed red blood cells, usually below 8.0 gm / dL. Patients with anemia sometimes find themselves on the receiving end of a bag of blood. Red blood cells carry oxygen in the blood. Anemic patients with low hemoglobin don’t have enough red blood cells to carry the oxygen to their tissues and may need a transfusion to help their blood do its job. Other patients with thrombocytopenia may receive platelets. The normal platelet count is 150,000-450,000 per deciliter. Patients with this disorder have less than 150,000 platelets per deciliter.

Fresh frozen plasma is administered when the patient’s stable plasma coagulation factors are decreased (Forsyth, 2008). The patient may have an allergic reaction with this type of transfusion. Albumin is also administered to patients occasionally to treat shock, trauma, infection, electrolyte imbalances, and hypoproteinamia (2008).

Another less common types of blood transfusion is granulocytes (white blood cells) which is given to patients with very low white blood counts to help them fight infection. Some donors prefer to bank their own blood and this is called an autologous blood transfusion.
Before any patient gets the first drop of blood, a physician’s order must be on the chart and the patient will sign a blood consent form. Then the lab will type and cross-match his blood for compatibility. This usually takes approximately one to two hours. Before the patient’s nurse initiates the transfusion, two nurses must verify the patient’s name, his date of birth, his corporate identification number, and his blood bank number. Four identifiers are always checked at the bedside for patient safety. If any identifier does not match, the blood is returned to the lab immediately.

Although most blood in the United States is safe for transfusions, reactions do occur. If a reaction occurs, the nurse should immediately stop the transfusion and obtain a set of vital signs before notifying the patient’s physician. Depending on the type of reaction, the physician may elect to stop the transfusion or continue. If the transfusion if halted, the blood, saline bag, and all tubing is then hand delivered to the lab along with the slip that accompanied the blood. The nurse should complete the reaction portion of the slip and place one copy on the chart (one copy goes to the lab).

One reaction that can occur is an acute lung injury. The patient will suddenly become short of breath, have chills, decreased blood pressure, and increased temperature (Novant, 2010). Hypoxia results and oxygen should be titrated to keep saturation greater than ninety-two percent (2010). Another type of reaction is an acute hemolytic or febrile non-hemolytic reaction. In this reaction, the blood pressure drops, but the heart rate and respirations increase (2010). The patient’s immune system is attacking the transfused cells. The patient may experience “severe flank or back pain”, hemoglobin in the urine, “shock, nausea, chills, (and) burning at the infusion site” (2010). Other times, a patient may experience increased temperature, chills, increased heart rate and systolic blood pressure changes which are indicative of bacterial contamination (2010). If a patient is having an allergic reaction, he is likely flushed, itching, and breaking out in hives (2010). In all the above reactions, the physician should be notified at once.
Six: The first priority is to apply oxygen at two liters nasal cannula and bring the saturation above ninety-two percent. After assessing the patient’s heart and lung sounds, the nurse should immediately administer nitroglycerin and morphine for the chest pain while notifying her charge nurse to order the following stat: an ABG (arterial blood gas), twelve-lead EKG, and a cardiac enzyme series. Most units have standing protocols for chest pain and enlisting the help of the charge nurse will increase the efficiency of care as well as improving the odds of a better outcome for the patient.

The doctor should also be notified, and the charge nurse can assist by paging him to the nurse’s phone. The nurse should expect a diagnosis of a pulmonary embolism (PE). Mr. Vasquez had two classic signs of a PE: unexplained shortness of breath and chest pain.
Most of the time, a PE begins as a blood clot deep in the leg veins. This is a condition known as deep vein thrombosis (DVT) (NIH, n.d.). The clot then breaks off from the vein and travels to the lungs where it blocks an artery (n.d.). A PE is not uncommon after orthopedic surgery and can be fatal if left untreated.

The patient’s doctor will most likely order an ultrasound of the left leg. He may also order a CT scan. An angiogram, D-dimer, and chest X-ray are also likely (NIH, n.d.).

The physician will probably order a regimen of heparin and Coumadin. The patient will most likely be placed on a heparin drip. The physician can choose either low-dose protocol or high-dose protocol for the drip. In either case, an unfractionated heparin blood test is drawn every six hours until the patient’s result is therapeutic. After two consecutive therapeutic results, the lab is checked every morning per protocol. The other medication, Coumadin, is given orally in conjunction with heparin. A daily PT / INR lab test is checked while the patient is on Coumadin. The physician decides whether to continue or stop the Coumadin based on the daily results.

Seven: Heparin is administered intravenously (IV) for Mr. Vasquez. This drug may be administered IV or subcutaneously (SC). Heparin has three uses. First, it is used to prevent and treat a PE (Weinstock et al, 2006). Second, heparin is used on surgery patients post-operatively to prevent clot formation(2006). Third, heparin is also used to diagnose disseminated intravascular coagulation (DIC) which is a disorder that leads to small clot formation within the vessels (2006). Fourth, heparin is also used as a flush to maintain patency of heparin locks (2006).

The most important nursing consideration when administering heparin is to ensure that the patient does not have an allergy to the drug. The nurse should also check the patient’s lab work, particularly the partial thromboplastin time (aPTT) (2006). If the patient is on IV heparin, the physician will also be checking his unfractionated heparin level every six hours until two therapeutic results are achieved. According to Weinstock et al (2006), heparin is incompatible with many drugs and the nurse should check with the pharmacy to ensure that no compatibility issues exist. Heparin can also cause many allergic reactions, ranging from alopecia to uticaria (2006). The nurse should not give heparin intramuscularly (IM) because doing so can cause “hematoma, irritation, and pain” (2006). For safety purposes, the nurse should keep a drug book close because of all the contraindications, adverse reactions, and nursing considerations associated with this drug.

Coumadin is administered orally and IV but not SC. This drug is used to prevent and treat PE, recurrent myocardial infarction, patients with heart valve replacements, and venous thrombosis (Weinstock et al, 2006). In the simplest explanation possible, Coumadin works by inhibiting the vitamin-K dependent clotting factors produced by the liver. This explains why part of the patient teaching includes no green leafy vegetables because they are loaded with vitamin K. This would serve as an antidote to the drug.

Coumadin has more drug interactions listed than heparin (Weinstock et al, 2006). Any patient with bleeding tendencies should not take Coumadin. The patient should not smoke or drink alcohol with this drug because they will alter the affects (2006).
Like heparin, the nurse should avoid IM injections because they produce the same side effects (Weinstock et al, 2006). Since this drug has as many safety considerations as heparin if not more, the nurse should keep the drug book close and pharmacy on speed dial.

Heparin
Coumadin
Routes
IV or SC
IV or Oral
Uses
Prevent / treat PE; prevent clot formation on post-op patients; diagnose DIC; heparin lock flush
Prevent / treat PE, MI; heart valve replacement, venous thrombosis
Mechanism of Action
Prevents the conversion of prothrombin to thrombin which is needed for the conversion of fibrinogen to fibrin; without fibrin, clots are unable to form (Weinstock et al, 2006)
Inhibits vitamin-K dependent clotting factors from forming in the liver
Contraindications
Heparin hypersensitivity; uncon-
trolled bleeding; severe thrombo-
cytopenia
Bleeding or bleeding tendencies; cerebral aneurysm; severe hepatic or renal disease
Drug Interactions
(see drug book for full details)
Antihistamines, digoxin, NSAIDS, platelet aggregation inhibitors, nitroglycerin (IV), thrombolytics
Acetaminophen, beta blockers, corticosteroids, barbiturates, vitamin C, vitamin K
Adverse Reactions
(see drug book for full details)
Fever, angina, hematuria, dyspnea, anaphylaxis, pain, nausea, vomiting
Intracranial hemorrhage, weakness, epistaxis, hepatitis, nausea, vomiting
Nursing Considerations
(see drug book for full details)
Use cautiously in alcoholics; avoid IM route; keep protamine sulfate on hand to use as an antidote
Monitor INR (daily in acute setting); avoid IM injections
Patient Teaching
(see drug book for full details)
Explain that heparin can’t be taken orally; advise patients to avoid NSAIDS and carry appropriate medical identification
Avoid green leafy vegetable; patient should avoid activities that could lead to trauma
(Weinstock et al, 2006)


Eight: In Winston-Salem, North Carolina, Mr. Vasquez has many resources available to him. The first of these begins before he is ever released from the hospital. The case worker, “Alice,” works tirelessly to ensure that each patient receives any resources for which they qualify. Alice would use the monies available in the social worker fund to help Mr. Vasquez obtain a month’s supply of his medicines to take home with him when he is discharged from the hospital. She would also set up home health services, home physical therapy, occupational therapy in the home, and oxygen therapy as prescribed by the patient’s physician. These services are available to everyone, not just immigrants and non-citizens. All of the above would be set up prior to discharge.

Many organizations offer services for Hispanics only but most have their doors open to all. The Hispanic League of the Triad is a non-profit organization that promotes awareness of Hispanic culture but also offers translation services at health clinics (First Line, 2008). The Second Harvest Food Bank of Northwest NC aims to decrease hunger and contributes food to 350 agencies across the region (2008). Although the agency does not provide direct service to individuals, it may be a starting point for Mr. Vasquez and his family to enrich their pantry. The nurse should also refer the family to the Forsyth County Department of Social Services for family and children’s Medicaid as well as food and nutrition services. The agency also has a Low Income Energy Assistance Program to help with heating bills. The Experiment in Self-Reliance provides financial services and counseling to low-income families who want to improve their living conditions and station in life.

Crisis Control Ministry is an excellent resource for low-income families. They provide emergency assistance with “rent/mortgage, utilities and fuel, food, and prescription medications” (First Line, 2008). The agency charges no fees and only requires that the recipients be residents of Forsyth County (2008).

Upon discharge, the patient will receive information about the above agencies. If he does not receive a flyer about each agency, he will at least receive a phone number. He will also receive three sheets minimum per policy:
· Physician’s Medical Patient Discharge Instructions
o Contains patient’s diagnosis, diet, activity level, referrals, wound management instructions, follow-up appointments and tests
· Nurse’s Medical Patient Discharge Instructions
o States that patient received information on the physician’s form as well as drug teaching (below); information regarding vaccinations, personal belongings, patient teaching, tobacco cessation, discharge destination and medications can be found on this sheet
· Patient Discharge Medication List
o Gives the patient a complete list of medications, including his home and hospital medications; which ones to stop and which ones to continue; new medications are also included on this sheet as are the times for the next dose of each medication
In addition to the information about the agencies and the facility’s three discharge sheets, the nurse should also individualize the discharge package for this patient a bit more. He will be discharged on crutches so that information needs to go home with him. Splint care will be sent as well. Wound care will be performed by the home health nurse, at least for a while. She will then determine what type of teaching is necessary after her work comes to an end.
Coumadin teaching is necessary. The patient will most likely be discharged on Lovenox, another anticoagulant, and the manufacturer provides a teaching kit with a DVD, booklet, and a needle box. Teaching will be completed before the patient is discharged. Optimally, the patient will be able to self-administer the SC Lovenox injections prior to discharge. Materials will be provided in Spanish whenever possible.



References

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First Line (2008). Directory of community resources for Forsyth County. Winston-Salem, NC: Forsyth County Public Library.

Forsyth Medical Center (2005). Patient admission history. Retrieved October 2, 2010 from employee intranet.

Forsyth Medical Center (2005). Laboratory data. Retrieved October 2, 2010 from employee intranet.[KH9]

Lutz, C. & Przytulski, K (2006). Nutrition & diet therapy: Evidence-based applications (4th ed.). Philadelphia, PA: F.A. Davis Company.

Johnson, M., Bulechek, G., Butcher, H., Dochterman, J. M., Maas, M., Moorhead, S., & Swanson, E. (Eds.). (2006). NANDA, NOC, and NIC linkages (2nd ed.). St. Louis, MO: Mosby Elsevier.

Moorhead, S., Johnson, M., Maas, M.L., & Swanson, E. (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis, MO: Mosby Elsevier.

Nettina, S. M. (2006). Lippincott manual of nursing practice (8th ed.). Ambler, PA: Lippincott Williams & Wilkins.

Novant Health (2010). Blood and blood product administration. Retrived October 2, 2010 from employee intranet.

National Institute of Health (NIH) (n.d.). Pulmonary embolism. Retrieved October 21, 2010 from [KH10] http://www.nhlbi.nih.gov/health/dci/Diseases/pe/pe_causes.html

Weinstock, D., Bryant, J., Cray, J., Dodds, K.D., Harold, C.E., Lyons, D. Priff, N., & Shaw, M. (2006). Nurse’s drug handbook (5th ed.). Hicksville, NY: Blanchard & Loeb.
Wolters Kluwer / Lippincott Williams & Wilkins (n.d.).[KH11]

Closed wound drain management (JP or Hemovac). Retrieved October 21, 2010 from http://procedures.lww.com/lnp/view.do?pId=39341&s=p&fromSearch=true&searchQuery=hemovac



Pass
Kimberely, your case study was well written, complete and accurate! you Passed!!! thanks, carollynn






APA / Writing – This was more of a content paper, with writing reviewed mainly for basics and less focus to grammar/style. Overall, your paper was very good and I did like that table on nursing dxes. The SNL paper will be reviewed more for formal writing and APA and the following will need to be done correctly in your SNL paper in order to pass the SNL paper.
· Margins, spacing, font – margins on all sides must be 1 inch.
· Quality of references – not great. You need to use more credible nursing journals. See the reference page for comments.
· Reference list and citations – several minor errors, but you need to fine-tune these for the SNL paper.
I was impressed with your decision to put the nursing dxes in a table – that was neat. As you know, the APA format for that table was wrong. (That is why we encouraged no tables in the document, but only as attachments.) For this paper, this will be OK; but, if you use tables in the SNL paper, they will need to be APA driven. Again, I liked the concept!!!! Kathy




[KH1]Other

[KH2]?

[KH3]Where was this source used?

[KH4]Where was this source used?

[KH5]Why the month?

[KH6]Not how journals are cited – should be just year.

[KH7]Not a quality journal

[KH8]Not a quality source

[KH9]In text – how do you know which 2005 source you are citing?

[KH10]Where was this cited?

[KH11]Publishers don’t go here or in the citation