Erickson’s Developmental Stage Related to pt. & Cite References (1) L.D. is in the stage of generativity versus stagnation which is when people reach their 40s which is also known as middle adulthood and extends to the mid 60s. In this stage middle aged adults start contributing to the next generation in caring for others; they also start engaging in meaningful work and contributing to society. Copstead & Banasik, J. L. (2013). This is also known as the generativity stage where it involves finding your life’s work by contributing. Those who do not feel like they have mastered this task will feel the stagnation stage. In this stage they feel as though they still haven’t left their meaningful mark on the world or make little interest in self-improvement and connection with others. Copstead & Banasik, J. L. (2013). L.D. views her life with generativity because she continuously speaks about her charity work. She also enjoys talking about how much she was able to help people through her yoga classes by helping them relax and leave their daily living stresses behind while in class. She also enjoys socializing with others and helping around. Even in the hospital she is always good with people and being able to cheer others up. I believe now more than ever she will continue to contribute in helping others . Patient Education (In Pt.) L.D. should continue her high protein, low fat diet as well as continue drinking fluids daily. She should completely stop smoking as it only weakens her immunize system and contributes to poor circulation and slow wound healing. L.D. should clean the area around the wound gently with mild soap and water. Do not rub the incision, allow water to flow gently over it. After your wound is healed, keep it open to the air. After dressings have been removed , wash your stump daily with mild soap and water. Do not soak it. Dry it well. Inspect your stump every day. Use a mirror if it is hard for you to see all around it , inspect for any red areas or dirt. Wear your elastic bandage all the time. Rewrap it every 2 to 4 hours. Make sure there are no creases in it. Wear your stump protector whenever you are out of bed. Always notify any changes. Discharge Planning (home needs ) Refer L.D. to her dietitian to further provide her with at home details of her dietary plan. This will involve a high protein, low saturated fats, and increased fluids. She will continue her physical and occupational therapy on a daily basis. This will allow her to fully heal as well as learn how to manage her new body part functions. L.D. and her family members will be taught about the adverse effects and medication regimen she must follow at home with the appropriate parameters to follow. Patient will be provided with transportation on a daily basis to attend all her therapeutic appointments. Medical Management/ Orders/ Medications & Allergies (2) Name Dose RT Freq. MOA RN Considerations Enoxaparin (Lovenox) 30mg SubQ Every 12 hours Enoxaparin binds and potentiates antithrombin to form a complex that irreversibly inactivates clotting factor Xa. Assess for bleeding signs and teach patient to report any bleeding, bruising, and pain. Notify if any black stools, bleeding gums, or bruising occurs. Oxycodone (Roxicodone) 10mg PO Every 4 hours PRN Act on receptors located on neural cell membranes. Assess pain level (0-10) before and after administering . Monitor respirations/vitals and report if any dizziness or slow breathing occurs. Leave call light near (risk for falls). Docusate Sodium (colace) 100mg PO Twice daily Anionic surfactant that allows water and lipids to penetrate stool. Monitor for any electrolyte imbalances and assess for abdominal distention. Notify if any rectal bleeding occurs. Make sure liquid intake is implemented. Amoxicillin (Augmentin) 125 mg PO Every 12 hours Acts on bactericidal activity by inhibition of bacterial cell wall synthesis by binding to penicillin-binding protein 1A. Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported. Assess for infection, vital signs; appearance of wound, sputum, urine, and stool;WBC) at beginning of and throughout therapy . Alprazolam (Xanax) 0.5mg PO Twice a day Benzodiazepines bind to GABA receptors in the brain and enhance GABA mediated synaptic inhibition. Assess for any suicidal ideation. Monitor vitals. Assess patient for drowsiness, light-headedness, and dizziness. Adams, M., Holland, L. N., & Urban, C. Q. (2019). Chief Complaint “ Patient presents for rehabilitation after amputation of left lower extremity as a result of osteomyelitis complaining of swelling and pain on amputated stump.” Admitting Diagnosis Sw e lling and pain . Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) L.D. is a white American female who used to be a yoga instructor. Her highest level of education is a college level degree. She enjoys socializing with the nurses as well as petting the hospitals therapy dog. L.D. is a catholic. Patient Information (1) Name: L.D. Age: 4 5 Gender: Female Code Status: Full code DPOA: No Living Will: No History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1). L.D. is a 45-year-old white American female who currently lives alone. L.D. was admitted to the E.R. after her leg became necrotic due to her previous medical history of osteomyelitis and underwent amputation of the lower left extremity . L.D. afterwards was omitted for rehabilitation complaining of swelling and pain on amputated stump. She is now being carefully treated and undergoes physical therapies to better assist her in fully healing. Medical History Osteomyelitis is inflammation and destruction of bone caused by bacteria. Copstead & Banasik, J. L. (2013). Osteomyelitis occludes local blood vessels, which cause bone necrosis and local spread of infection which can expand through the bone cortex and spread. Copstead & Banasik, J. L. (2013). Certain things such as trauma, surgery, the presence of foreign bodies, or the placement of prostheses may disrupt bony integrity and lead to the onset of bone infection. Copstead & Banasik, J. L. (2013). Osteomyelitis is an infection of the bone; these infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue. Infections can also begin in the bone itself if an injury exposes the bone to germs some of the main known factors are s mokers and people with chronic health conditions, such as diabetes or kidney failure. Copstead & Banasik, J. L. (2013). Surgical History L.D. has a surgical history of left leg amputation about a week ago as a result of her leg becoming necrotic from her previous history of osteomyelitis. Social History L.D. has a history of chronic alcoholism; it is characterized as compulsive decision making with impulse behavior and relapse. She was previously hospitalized a couple times because of her inability to control alcohol intake. She has been dealing with chronic alcoholism for about 15 years. She also smokes about 2-3 cigarettes daily, usually after her meals and occasionally in the afternoons. She has been a smoker for the past 20 years. L.D. has never used any recreational drugs. L.D. still refuses to understand her current condition and why now she has to deal with being in a wheelchair. She is still not understanding why “out of all people” how she says she had to have this condition (osteomyelitis). Although she understands that her lifestyle choices could have negatively contributed. She has no evidence of any physical, sexual, or mental abuse. She does have a history of some depression as a result of her current situation. L.D. was a yoga instructor who enjoys helping others. She also enjoys being able to socialize and not feel alone. Her main support system is her mother who usually calls her at least three times a day. Diagnostic Test/ Lab Results with dates and Normal Ranges (3) Test Norms Date Current Value WBC 5.0-10.0 8-28-19 6.2 Platelets 150-400 8-28-19 218 NA 135-145 8-28-19 131 K 3.5-5.0 8-28-19 4.0 Ca 9.0-10.5 8-28-19 8.9 Hematocrit 37-47% 8-28-19 28.4 Hemoglobin 12-16 8-28-19 12.3 BUN 7-20 8-28-19 14 Creatinine 0.5-1.1 8-28-19 0.84 Concept Map Student Name: Instructor:
PC Outcomes/Goal Monitoring vitals provides a baseline that allows quick recognition. Adequate nutrition will prevent disability that will predispose infection as well as heal surgical incision better. Good room temperature reduces microorganism on skin. Proper ROM exercises promotes tissue perfusion. Priority nursing diagnosis #2 Body image disturbed related to surgical amputation as evidence by verbal preoccupation with changed body part or function. Respiratory (7) Oxygen: Room air Cough: None Sputum: none Secretions: none Breath sounds: Clear Lung sounds: Regular SpO2: 96% Airway device: none Vital Signs (4) BP: 135/30 HR: 92 Respiratory rate: 16 SpO2: 96 % Temp: 98.2 F (Tympanic) Left radial pulse: 65bpm Inte rventions # 2 Refer patient to available resources such as prosthetic device. Do not support denial but instead focus reality and adaptation. Be honest with patient and stay in frequent contact with patient. Monitor for any suicidal ideation. Use anxiety reducing techniques as often as needed. Collaborate with psychiatric nurse regarding care as needed. Refer patient to occupational and physical therapy once a day. Monitor for pain every 2 hours. Assessment/ Evaluation #1 The patient met the goal of the nursing interventions. The patient reported feeling less pain and more eager with her physical exercises. Patient attended physical therapy twice a day. Patient performed all her range of motion exercises while in bed and even attempted them on her own with adequate rest periods. Patient used her wheelchair and took a stroll to the nursing station for 15 minutes. She looked stronger and was enjoying her new diet plan. Patient only took one dose of her PRN pain dose. A ssessment/ Evaluation #2 The patient met the nursing intervention goals. Patient was eager to know more about her prosthetic use and asked for more information. Patient was told of her limitations and how she would be able to manage a normal life. Patient looked at her amputated leg with more of an understanding as well as attended her psychiatric nurse. Patient attended a social group and communicated/socialized more outside of her room. Patient used deep breathing techniques when she felt anxious. She attended all her physical and occupational therapies. Patient received her usual dose of alprazolam and was monitored for any adverse reactions, but none were reported. PC Evaluation Plan The patient met the goal of the nursing intervention. The patient increased her fluid, vitamin C, iron, and nutrition intake. Patient was turned every 2 hours as well as maintained a proper room temperature. Patients dressing was changed this morning and the swelling was reduced and no drainage shown. The proper sterile technique was implemented while changing her dressing. Patient reported less swelling on her legs and a pain level of 4 from her previous 8. She performed her deep breathing and coughing techniques as well as proper hygiene amongst the faculty, patient, and visitors. Patients skin tone and extremities were assessed for proper circulation. PC Interventions Monitor vitals every 4 hours. Maintain adequate nutrition and fluid and electrolyte balance such as increased vitamin C, sufficient iron, and 2400-2600 mL of fluid daily. Monitor the administration of antibiotic for any side effects. Maintain neutral temperature environment. Turn patient every 2 hours. Cough and deep breathing exercise every 2 hours. Use sterile techniques when changing dressings. Good hand hygiene and teach patient how to care for their own hygiene as well. Psychosocial (14) Language barrier: None Understands directions: Yes Level of Education: College Mood/Affect: Cooperative/low mood Alcohol use: Yes Tobacco use: Yes (2 cigarettes/day) Support: Mother Stressors: Condition Cardiovascular (6) Devices (pacemaker): No Capillary refill: <3 secs Peripheral Edema: Edema: Present on RLE & LUE non-pitting Peripheral Heart sounds: S1, S2, normal Pulses: Present except on LLE amputation. Endocrine (13) Thyroid Disease: None Estrogen use: None Testosterone use: None Steroid Use: None Misc. (Ht/Wt) Weight: 125.27lbs Height: 5’8 GU (10) Urinary Symptoms: None Urine color: Yellow Urinary Catheter: No Urinary Elimination: voiding w/o difficulty Urine odor: Normal Last Void: 8/30/19 1:40pm GI (9) Bowel Sounds: All hypoactive Abdomen: Distended Last BM: 8/30/19, 1:30pm Stool: Semisoft Color: Brown Ostomy: No Incontinence: No Rest/ Exercise (11) Activity: Mobility Aids: Wheelchair Functional level: Independent Sleep patterns: Uninterrupted ROM: limited on LLE Fall risk: High risk Neurological (5) Pain: 9 (0-10 scale) PEERLA: 4mm Brisk Oriented: Alert & Oriented X4 Glasgow Coma Scale: 15 Senses: normal (all 5) Behavior/Emotional: Cooperative Outcome/Goal #1 Patient will improve mobility and independence within three days by assisting physical therapy daily. Priority nursing diagnosis #1 Impaired physical mobility related to left lower extremity amputation as evidence by wheelchair assistive device.
Nutrition/Hydration (8) Diet: High protein and fiber Feeding Method: Self Nausea: No Vomiting: No Skin turgor: Normal Weight: No change Aspiration Risk: None
Outcome/Goal #2 Patient will verbalize accepting body image of left extremity in two weeks, by demonstrating a positive attitude.
Integumentary (12) Skin: Intact c ool and moist Risk for falls: High risk Skin Color: Pink no cyanosis Lesions: None Skin turgor: Good skin turgor
Potential Complications/ at risk for At risk for infection related to surgical procedure on left lower extremity as evidence by increased red dened swelling at surgical site. Interventions #1 Educate the patient on the proper use of assistive device. Provide progressive mobilization as much as patient tolerates. Schedule physical therapy twice a day and increase mobilization. Perform Range of motion exercises every two hours. Maintain a high protein diet/adequate nutrition. Implement measures to prevent falls such as low position of bed, call light near, wearing nonskid shoes/socks. If in pain give pain medication before any physical movement
