Running header: CRITICAL THINKING PAPER
Critical Thinking Paper
Jennifer Fisher
Grand Canyon University
NUR312
Professor Evinrude & Hemmila
November 23, 2010
Clinical Instructor: Colin
Critical Thinking Paper
Introduction
The following critical thinking paper is based off of a 76 – year – old female patient, with the initials RG. She was admitted to Banner Good Samaritan’s neurology floor on November 11, 2010. All of the plans that have been implemented in caring for her have been vital care plans that used critical thinking skills. The steps following the care for RG were to implement nursing interventions designed to attend to her acute and chronic medical history.
Biographical Data
Patient, R.G., was admitted on to pod 6 – D at Banner Good Samaritan on November 11, 2010. She was married for fifty years before her husband passed away from complications of a myocardial infarction about ten years ago. She has one son, M.G., who is in his early to mid fifties. She is a Caucasian female who was admitted to the hospital for a chief complaint of right – sided facial droop. Upon further testing it was found that R.G. was suffering from a left temporal/parietal brain tumor.
History of Present Illness
R.G. diagnosis was a left – sided temporal/parietal brain tumor. She has been an extremely active and healthy seventy – six year old patient. The only other time she has been in the hospital was to have her stent placement back in 2003. It is unclear as to the cause of her tumor or of any extenuating circumstances that would have a factor in this disease. All heart rhythms and ECGs are normal. Her laboratory values are all within a normal and acceptable ranges. There are no pressure sores located on her ankles, elbows, or other bony prominences that have constant contact with her bed. The patient is able to get out of bed and walk around as much as she can. However, her activity level is starting to noticeably decline from when she was first admitted.
Health History
Past Medical History
Her past medical history is not very extensive. She has coronary artery disease with a stent placement in 2003, osteopenia, hypertension, and hypercholesterolemia. R.G. has no history of myocardial infarction. Her colonoscopy from two to three years ago was normal. She also had a mammogram about a year ago that was normal.
Family Health History
|
GenogramKey:
= Female Living = Female Deceased
=Male Living
= Male
Deceased
Unfortunately, the patient was only able to give detailed information regarding her son and deceased spouse. She stated that both of her parents were deceased but was unable to give more information on her family history.
Psychosocial Health History
This patient has an extremely healthy social life. She is involved in her church, has many friends and family who are supportive of her, and has a very strong faith in God. She lives on her own in a small single story house. R.G. quit smoking about fifteen years ago; previously she smoked half a pack per day. Her stress relief now is to work in her garden at home.
Physical Examination
Neurological
Patient was awake and oriented times four. R.G. has no difficulty with conversations or coming up with the correct vocabulary to use when speaking. She is active with those in her surroundings and shows no signs of distress. All extra ocular movement is in tact in all directions. Photophobia is absent; gaze is conjugate. Her pupils are equal, round, and reactive to light. When asked to hold out arms and close eyes, no arm drifts were present. Strengths are equal in strength in both upper (+2) and lower extremities (+2). All extremities were able to move against gravity and against resistance. There is no deviation in her tongue. Speech is clear and evidence of facial drooping at this time. Head movement and shoulder shrug strength are strong bilaterally. Braden Scale was performed on R.G. her results are as follows:
Braden Scale
11/17 11/18
Sensory PerceptionàNo impairment 4 4
Moistureà Rarely moist 4 4
Activityà Walks occasionally 4 3
Mobility Bradenà No limitation 4 4
Nutritionà Adequate 4 3
Friction & Shear Bradenà No apparent Problem 3 3
Cardiac
No murmurs noted upon auscultation. Capillary refills are less than three seconds. No chest pain, palpitations, or peripheral edema present. Pulses are strong, equal, and present in the radius. The pedal pulses are also strong, equal, and present for this patient. EKG showed no signs of abnormalities. Her heart rate was 73 beats per minute and 128/68 for her blood pressure.
Respiratory
No cough or wheezing present in R.G. The patient’s oxygen saturation is 99% on room air, with 16 breaths per minute for her respiratory rate. No crackles were heard upon auscultation.
Gastrointestinal
The last bowel movement the patient had occurred on November 17, 2010. The patient stated it was “brown and watery (diarrhea consistency).” Patient refused to take Docusate-Senna because she did not want to have any more diarrhea. No abdominal tenderness or distention present. Her abdomen is soft, non – tender, and palpable. All four quadrants of the bowels are hyperactive upon auscultation.
Genitourinary
R.G. had no foley present until her surgery at 1500 on November 18, 2010. There was no evidence of infection present. The urine was a yellow coloring with no evidence of blood, cloudiness, or sediments. The Intake and Output record for 11/17-11/18 are as follows:
I&O for November 17, 2010 – November 18, 2010: PO intake: 1050mL NS: 525mL IVPB: 204mL Contrast amount: 11mL % of meal eaten: 300 Intake total: 1800mL Output: 3 times Balance for November 17, 2010 – November 18, 2010: 1800
Skin
Patient’s IV site is intact with no signs of infection. There is no pain, coolness to touch, redness, or signs of infiltration present. Dressing is clean, dry, and intact with a continuous infusion of normal saline plus potassium chloride at a rate of 75mL/hr occurring. Skin is dry and in need of lotion. However, there are no signs of pressure ulcers, abrasions, or evidence of abuse. Skin is frail with no tenting.
Functional Health Pattern Assessment
Health Perception/Health Management
The patient is anxious about her current health crisis, more specifically nervous about the surgical procedure being performed. She is also extremely concerned that they do not know the reason for her brain tumor. She is extremely compliant with all her treatment plans and understands the importance of being compliant with all the plans. R.G. will continue to follow plans outlined by hospital staffing. She has routine exams that she schedules with her general practitioner. Her last colonoscopy was two to three years ago and was normal. Her last mammogram was a year and had normal results as well. Safety habits are unknown. She denies the use of alcohol or illicit drugs. She has however, been smoke free for fifteen years. Every time is given medication she is able to tell what it is for and completely understands its value to her health. Patient is at risk for increased anxiety pertaining to decreased knowledge of surgery and its implications.
Values and Beliefs
R.G. believes in God; that there is a heaven and a hell. She also attends church regularly. She has a community of believers that she relies on for support and prayers. There was a Bible sitting at her bedside that she would pick ever soften to read. No at risk statements at this time can be noted at this time.
Cognitive/Perceptual
The patient wears glasses for a stigmatism. She has no hearing loss or learning disabilities. She did not state her education level, however, when giving her the morning medications she knew exactly what each medications purpose was. The major problem we encountered was her lack in education about the surgery. She did not understand the reasoning for her status of NPO, what was going to happen during the surgery, and possible outcomes from the surgery.
Nutrition/ Metabolic
R.G. has a wide range of foods that she likes, there were no particular preferences stated. She states her “nutrition and diet at home are adequate”. Did not know her normal quantity of food that was typical of her eating. She adds a lot of salt on to her foods because she cannot always taste the food. Patient is at risk for malnutrition pertaining to living on a retirement salary.
Activity/Exercise
When R.G. is at home she gets regular exercise from working in her garden, performing activities in her home (ie: cleaning, cooking, etc...), and takes daily walks in the morning time. Upon being admitted to the hospital the patient was highly active however, her activity level is starting decline rather rapidly.
Elimination
The last bowel movement the patient had occurred on November 17, 2010. The patient stated it was “brown and watery (diarrhea consistency).” Patient refused to take Docusate-Senna because she did not want to have any more diarrhea. No abdominal tenderness or distention present. Her abdomen is soft, non – tender, and palpable. All four quadrants of the bowels are hyperactive upon auscultation. R.G. had no foley present until her surgery at 1500 on November 18, 2010. There was no evidence of infection present. The urine was a yellow coloring with no evidence of blood, cloudiness, or sediments. The Intake and Output record for 11/17-11/18 are as follows:
I&O for November 17, 2010 – November 18, 2010: PO intake: 1050mL NS: 525mL IVPB: 204mL Contrast amount: 11mL % of meal eaten: 300 Intake total: 1800mL Output: 3 times Balance for November 17, 2010 – November 18, 2010: 1800. Patient at risk for
Sleep and Rest
The patient sleeps at night and takes naps during the day at the hospital. She is extremely active and aware when people are present and talking with her. She does not use any machines to help her sleep. She has no sleep pattern that she stated. No at risk statement for the patient at this time.
Role/Relationship
R.G. is a proud mother of one son (in his late fifties) and a widow for about ten or so years. She is a retired teacher with a limited income. She is a friend to many people in her church and is well connected to her neighbors. During her surgery her son, best friend, and a close neighbor were there to support her and pray for her.
Coping and Stress
The patient does not usually have increased stress when she is home. However, when she does her way of dealing/coping with her stress is to work in her garden. She is currently anxious about the surgery, the procedure, and more specifically the unknown outcomes of the surgery. Increased risk for anxiety and stress level related uncertainty of outcome of procedure and decreased knowledge of procedure
Self-Perception/Self Concept
Patient is anxious about the procedure and the outcomes. She is also anxious about what will happen with her son if the outcome is not good with the surgery. Patient is at increased risk for anxiety.
Sexuality/Reproductive
Patient is a widow, her husband died of complications from a heart attack about ten years ago. Prior to his death her sexual life with her husband was “great” according to R.G. The patient states there is no problem with not having her husband around, she misses him terribly and misses sharing the adventure with him. However, she is happy for him that God called him home.
Pathophysiology of Primary Illness
The ultimate primary diagnosis for this patient is a left – sided temporal and parietal brain tumor. Brain tumors are either benign or malignant (Government, 2010). If it is benign the tumor can typically be removed surgically because the edges are clearly defined (Government, 2010). Like any tumor though it has the ability to press on sensitive areas in the brain causing symptoms and health risks (Government, 2010). A malignant tumor is much more life threatening than the benign tumor. This type of tumor has the ability to metastasize to other areas in the body and also to take over the healthy portions of the brain tissue (Government, 2010). Types of brain tumors include: astrocytoma, brain stem glioma, ependymoma, oligodendroglioma, medulloblastoma, meningioma, schwannoma, craniopharyngioma, germ cell tumor, and pineal region tumor (Government, 2010). They are caused by sex, race, age, family history, radiation, formaldehyde, vinyl chloride, and acrylonitrile (work chemicals) (Government, 2010). Some symptoms of brain tumor are headaches, nausea and vomiting, changes in speech, vision, and hearing (Government, 2010). Also, memory problems, seizures, numbness or tingling in the arms and legs, balancing and walking problems (Government, 2010). Diagnostic tests that will be performed are CT scan, MRI, a thorough neurological exam, and physical exam (Government, 2010). The physician may also perform an angiogram, skull x-ray, spinal tap, myelogram, and possible biopsy (Government, 2010). The treatment that may be performed on the patient will depend on the type of tumor and its severity (Government, 2010). Treatment can include: surgery, radiation therapy, and chemotherapy (Government, 2010).
Interpretations
Medications
R.G. is taking a cocktail of medications in order to control her hypertension, hypercholesterolemia, and coagulation medications for her stent, anticonvulsant, and a stool softener/laxative combination. The first medication the patient is taking is Lipitor (Atorvastatin) has a lipid – lowering effect on the body (Skidmore-Roth, 2011). Its action is to “inhibits HMG-CoA reductase enzyme, which reduces cholesterol synthesis; high does lead to plaque regression” (Skidmore-Roth, 2011). This is an oral medication for R.G. Has a potential for side effects like dizziness, headache, insomnia, weakness, chest pain, peripheral edema, rhinitis, bronchitis, abdominal cramps, constipation, diarrhea, flatus, heartburn, rashes, elevated liver enzymes, and myalgia (Skidmore-Roth, 2011). With this medication monitor AST, CK, serum cholesterol and triglyceride levels, LDL and HDL levels (Skidmore-Roth, 2011). Another medication is Decadron (Dexamethasone) a corticosteroid (Skidmore-Roth, 2011). This medication’s action is to “decreases inflammation by suppression of migration of polymorphonuclear leukocytes, fibroblasts, reversal of increased capillary permeability and lysosomal stabilization” (Skidmore-Roth, 2011). Some side effects include: depression, euphoria, headache, hypertension, acne, decreased wound healing, petechiae, adrenal suppression, and osteoporosis (Skidmore-Roth, 2011). Monitor for signs of hypokalemia, CBC, WBC, electrolyte levels, bone density, and for changes in level of consciousness (Skidmore-Roth, 2011). The patient is also taking Docusate – senna (Senokot – S), a combination of docusate and senna concentrate, for a laxative and stool softener effect (Skidmore-Roth, 2011). This is typical taken at night, around bedtime however, the physician can change the administration time (Skidmore-Roth, 2011). Side effects include: black tarry stools, hives, severe stomach pain, swelling of the facial area (mouth, lips, etc…), and a feeling of chest tightening (Skidmore-Roth, 2011). R.G. is also taking Oretic (Hydrochlorothiazide) an antihypertensive and thiazide diuretic (Skidmore-Roth, 2011). This medication acts by “acting on the distal tubule and ascending limb of loop of Henle by increasing excretion of water, sodium, chloride, and potassium” (Skidmore-Roth, 2011). It is used as a way to help control the patient’s blood pressure levels. Side effects include: dizziness, drowsiness, lethargy, anorexia, cramping, nausea/vomiting, hyopkalemia, hyperglycemia, and hypercholesterolemia (Skidmore-Roth, 2011). Monitor the patient’s laboratory values, her intake and output (strictly), blood pressure, and her sodium/electrolyte values (Skidmore-Roth, 2011). Metoprolol is another medication that R.G. is taking. This is an antihypertensive, beta – blocker, and antianginal medication (Skidmore-Roth, 2011). This medication act by “lowering the blood pressure by beta – blocking effects; reduces elevated rennin plasma levels; blocks beta2 – adrenergic receptors in bronchial, vascular smooth muscle only at high doses, negative chronotropic effect” (Skidmore-Roth, 2011). Side effects include: fatigue, weakness, anxiety, blurred vision, erectile dysfunction, bronchospasm, and wheezing (Skidmore-Roth, 2011). Monitor vital signs, blood pressure, ECG, intake and output, electrolyte values, and cardiac system (very closely) (Skidmore-Roth, 2011). Watch very closely for cardiac failure due to the effects of decreasing blood pressure in the patient (Skidmore-Roth, 2011). Phenytoin (Dilatin) an antidysrhythmic, anticonvulsant is being taken by R.G. in order to prevent further seizures (Skidmore-Roth, 2011). This medication “inhibits spread of seizure activity in motor cortex by altering ion transport; increases AV conduction” (Skidmore-Roth, 2011). Side effects include: ataxia, agitation, dizziness, hypotension, diplopia, nystagmus, nausea/vomiting, rash, hypertrichosis, weakness, and leukopenia (Skidmore-Roth, 2011). Monitor for changes in level of consciousness, changes in behavior, intake and output, CBC, platelet count, renal function, and albumin levels (Skidmore-Roth, 2011). Finally R.G. is also taking Valsartan (Diovan) an antihypertensive and angiotensin II receptor antagonist (Skidmore-Roth, 2011). Its action is to “block that vasoconstrictor and aldosterone – secreting effects of angiotensin II; selectively blocks the binding of angiotensin II to the AT1 receptor found in tissues” (Skidmore-Roth, 2011). Side effects include: dizziness, anxiety, hypotension, chest pain, edema, hyperkalemia, arthralgia, back pain, and tachycardia (Skidmore-Roth, 2011). In R.G. monitor blood pressure, vital signs, electrolyte levels, intake and output, and level of consciousness (Skidmore-Roth, 2011). Also monitor the patient’s BUN, creatinine, LFTs, any facial swelling or shortness of breath (Skidmore-Roth, 2011).
Laboratory
All of R.G.’s laboratory blood values are within their normal limits. Her white blood cell count went from 7.2 to 10.8 X109/L. Her hemoglobin was 14.5g/dL to 14.8g/dL and her hematocrit was 42.4% and 43.1%. This WBC, her hematocrit, and hemoglobin levels show no indications of infections being present. They also show if a patient is anemic; highly vital to monitor if the patient is actively bleeding (Pagana, & Pagana 2006). R.G.’s red blood cell count is also within range sitting at 4.64X1012/L and 4.66X1012/L. This normal level indicates that the patient is not anemic, no signs of hemorrhage, lymphoma, or leukemia (Pagana, & Pagana 2006). The sodium (138mEq/L and 136mEq/L) and potassium (4.0mEq/L and 4.3mEq/L) are both within an acceptable range. The sodium level is important to monitor because it helps keep track of the patient’s electrolyte balances and monitor their fluids (Pagana, & Pagana 2006). The potassium is especially important to watch because it is an indicator of cardiac function and more specifically necessary for the patient since she is on hypertensive medications (Pagana, & Pagana 2006). The chloride levels are 108mEq/L and 100mEq/L. If these levels are abnormal it is indicative of an acid-base imbalance especially if the test is performed with the electrolyte levels (Pagana, & Pagana 2006). Carbon dioxide (26mEq/L and 31mEq/L) helps in evaluating electrolytes as well (Pagana, & Pagana 2006). These levels were also within normal range. BUN (19mg/dL and 24mg/dL) and creatinine (0.78mg/dL and 0.81mg/dL) levels are indicative of a well functioning liver (Pagana, & Pagana 2006). The Pro Time (13.8 sec. and 13.1 sec.), INR (1.1 and 1.0), PTT (35 sec. and 29 sec.), and the platelets (189X109/L and 189X109/L) are within normal limits for coagulation tests (Pagana, & Pagana 2006). This means that R.G.’s body is able to properly clot when necessary.
Diagnostic Tests
Truth Seeking and Analyticity
Cluster #1 and Nursing Diagnosis
- Watery and brown stool (diarrhea consistency)
- Increased levels of anxiety
- Limited financial means
- NPO status
- Increased amounts of salt added to meals
The patient is at increased risk for malnutrition pertaining to malabsorption, finances, and increased amount of salt additives.
Cluster #2 and Nursing Diagnosis
- Anxious about her current health crisis, more specifically nervous about the surgical procedure being performed
- Lack in education pertaining to the surgery and possible outcomes
- Patient not taught reasoning behind NPO status
- Unknown cause of tumor
Patient is at an increased risk for anxiety pertaining to decreased knowledge and education.
Cluster #3 and Nursing Diagnosis
- Patient’s increased age
- Frail and dry skin
- Severely decreased patient activity level
- Brown and water like stool (diarrhea appearance)
R.G. is at increased risk for skin break down pertaining to her age, skin frailty, and decreasing level of activity.
Cluster #4 and Nursing Diagnosis
- Previous seizure
- Increased anxiety levels
- Decreased level of activity
- Patient not sure of self
- Age
Patient is at an increased risk for trauma pertaining to previous seizure, anxiety levels, and her continued decreasing activity level.
Two Priority Nursing Diagnoses
The top priority nursing diagnoses is the patient’s risk for increased anxiety from nursing diagnosis #2. This is pertaining to the lack of education given to the patient concerning possible outcomes from her surgery, unknown causes of the tumor, the stress of not wanting to worry her son, and a decreased knowledge of simple medical procedures. All of these reasons have a great impact on R.G.’s anxiety levels. The second most important nursing diagnosis is diagnosis #4 her increased risk for trauma. This is due to her anxiety levels and previous seizure. It is further increased risk because of her age, decreasing level of activity and lack in confidence in herself. Following the diagnoses is #3 her increased risk of skin break - down. This is pertaining to her continual decrease in activity level, age, skin frailty and dryness, and her nutrients being consumed. The fact that age is increasing and the dryness of her skin further cause her skin to be frailer. The decreased activity level also makes her vulnerable to bed – sores and a further decrease in skin integrity. The least important of the four nursing diagnoses is her increased risk of malabsorption, nursing diagnosis #1. While it is an important and concerning diagnoses the other three diagnoses out way the diagnosis of malabsorption.
Open-mindedness
NANDA
Outcome #1
Patient will verbalize a reduction in anxiety prior to surgery (Swearingen, 2008).
Intervention A: The nurse will answer all questions regarding the patient’s procedure and other questions of the patient’s (Swearingen, 2008).
Rationale: This helps the patient to understand what is happening to them and gives them a since of knowledge and control (Swearingen, 2008).
Intervention B: The nurse will assist the patient in identifying goals focused on making decreasing anxiety and life changes (Swearingen, 2008).
Rationale: Goals help provide a direction for the patient to focus and make necessary changes (Swearingen, 2008).
Outcome #2
The patient within 1-2 hours of educating the patient on her treatment she will have a marked decrease in anxiety levels (Swearingen, 2008).
Intervention A: The nurse will teach patient how to incorporate stress management techniques (Swearingen, 2008).
Rationale: This encourages the patient to take care of self, take control of self, and thus decreases stress level (Swearingen, 2008).
Intervention B: The nurse will allow her family and support group to be in attendance of the surgery and education (Swearingen, 2008).
Rationale: By allowing this the patient’s anxiety level will decrease from having support of her family (Swearingen, 2008).
Outcome #3
Patient within 24hours of intervention and treatment her anxiety levels will be completely resolved (Swearingen, 2008).
Intervention A: The nurse will provide a calm and quiet environment for the patient prior to operation and post operation (Swearingen, 2008).
Rationale: By providing a calm and quiet environment it reduces sensory overload that contributes to her anxiety levels (Swearingen, 2008).
Intervention B: The nurse will provide support groups to help the patient (Swearingen, 2008).
Rationale: Many people benefit from the support of other people and resources (Swearingen, 2008).
NANDA
Outcome #1
Patient will exhibit no signs of oral or musculoskeletal tissue injury after seizure occurrence (Swearingen, 2008).
Intervention A: The nurse will pad the patient side rails with blankets or pillows (Swearingen, 2008).
Rationale: This action will promote safety and protect the patient from trauma or injuries that may occur (Swearingen, 2008).
Intervention B: Caution patients to lie down and push call button if they experience prodromal or aural warning (Swearingen, 2008).
Rationale: These warnings precede seizures allowing the nurse to react faster (Swearingen, 2008).
Outcome #2
The patient will verbalize knowledge of actions necessary during seizure activity (Swearingen, 2008).
Intervention A: Encourage the patient to empty mouth of dentures or foreign objects (Swearingen, 2008).
Rationale: This helps prevent choking if the seizure occurs (Swearingen, 2008).
Intervention B: The nurse will encourage the patient to wear loose clothing (not tightly fitted) (Swearingen, 2008).
Rationale: This prevents trauma and hypoxia from occurring caused by the constrictive clothing (Swearingen, 2008).
Outcome #3
The patient before being discharged will verbalize ways to prevent seizures and acknowledge ways to prevent further traumas (Swearingen, 2008).
Intervention A: The nurse will teach the patient to avoid stimulants such as caffeine and depressants such as alcohol (Swearingen, 2008).
Rationale: Depressants and stimulants increase the risk of seizures (Swearingen, 2008).
Intervention B: The nurse will encourage stress management and relaxation techniques for the patient to perform (Swearingen, 2008).
Rationale: By managing her stress levels and performing relaxation techniques the patient is able to reduce triggers for seizure (Swearingen, 2008).
Conclusion
This patient’s outcome should be one of a long life. Other than the tumor in her left temporal/parietal brain the patient is a healthy individual. Once the tumor was removed R.G. was moved to the Intensive Care Unit where she will be monitored closely. After meeting her discharge criteria the patient will be discharged and sent home (barring no complications).
References
Government. (2010). Brain tumor, Found at http://www.medicinenet.com/brain_tumor/article.htm on November 27, 2010.
Pagana, K.D., & Pagana, T.J. (2006). Mosby’s manual of diagnostic and laboratory tests. St. Louis, Missouri: Mosby Elsevier.
Skidmore-Roth, L. (24th Edition, 2011). Mosby’s nursing drug reference. St. Lousi, Missouri: Mosby Elsevier.
Swearingen, P.L. All-in-one: care planning resource. (2nd Edition, 2008) St. Lousi, Missouri: Mosby Elsevier.
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