Care Management - Care Plan Cirrhosis

Cirrhosis John Richards, 45 years old Primary Concept Nutrition Interrelated Concepts (In order of emphasis) 1. 2. 3. 4. 5. 6. 7. 8. Fluid and Electrolyte Balance Perfusion Cognition Addiction Clinical Judgment Patient Education Communication Collaboration Cirrhosis History of Present Problem: John Richards is a 45-year-old male who presents to the emergency department (ED) with abdominal pain and worsening nausea and vomiting the past three days that have not resolved. He is feeling more fatigued and has had a poor appetite the past month. He denies any ETOH (alcohol) intake the past week, but admits to episodic binge drinking on most weekends. John weighs 150 pounds (68.2 kg) and is 6'0" (BMI 17.6). You are the nurse responsible for his care. Personal/Social History: John is single, has never married, and lives alone in his own apartment. He has struggled with heroin use/abuse in the past, but has not used in the past two years. John is currently unemployed and has no health insurance. He was diagnosed with hepatitis C ten years ago but has had minimal follow-up medical care since. What data from the histories are RELEVANT and have clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Classification: Expected Outcome: *Hepatitis C–past history of Ibuprofen 600 mg PO prn for headache IV drug abuse *ETOH abuse x 25 years One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in his/her life?  Circle the PMH problem that likely started FIRST.  Underline the PMH problem(s) FOLLOWED as domino(s). Patient Care Begins: Current VS: T: 100.5 F/38.1 C (oral) P: 110 (regular) R: 20 BP: 128/88 O2 sat: 95% RA P-Q-R-S-T Pain Assessment (5th VS): Provoking/Palliative: Nothing/nothing Ache Quality: RUQ/epigastric Region/Radiation: 6/10 Severity: Continuous Timing: Orthostatic BP’s: Position: Lying Standing HR: BP: 110 128/88 132 124/80 What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Rationale: Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN: Appears uncomfortable, body tense, occasional facial grimacing Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort Pink, warm & dry,1+ pitting edema lower extremities, heart sounds regular–S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks Alert & oriented to person, place, time, and situation (x4) Abdomen distended, large–rounded–firm to touch, bowel sounds audible per auscultation in all 4 quadrants Voiding without difficulty, urine clear/light orange, loss of pubic hair Skin integrity intact, color normal for patient, sclera of eyes light yellow in color, lips and oral mucosa tacky dry, softball-sized ecchymosis on abdomen What assessment data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Rationale: Lab Results: Complete Blood Count (CBC:) WBC (4.5–11.0 mm 3) Hgb (12–16 g/dL) Platelets (150-450 x103/µl) Neutrophil % (42–72) Band forms (3–5%) Current: 12.8 10.2 98 88 3 High/Low/WNL? Previous: 9.5 11.2 122 75 0 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Basic Metabolic Panel (BMP:) Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) Glucose (70–110 mg/dL) BUN (7–25 mg/dl) Creatinine (0.6–1.2 mg/dL) Current: 135 3.5 78 38 1.5 High/Low/WNL? Previous: 138 3.8 88 25 1.1 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Clinical Significance: TREND: Improve/Worsening/Stable: Lab(s): Coags: PT/INR (0.9–1.1 nmol/L) RELEVANT Lab(s): Current: 1.5 High/Low/WNL? Previous: 1.2 Clinical Significance: TREND: Improve/Worsening/Stable: UP…worsening PT/INR: 1.5 Liver Function Test (LFT:) Albumin (3.5–5.5 g/dL) Total Bilirubin (0.1–1.0 mg/dL) Alkaline Phosphatase Current: 2.5 4.2 285 High/Low/WNL? Previous: 2.9 2.2 155 male: 38–126 U/l female: 70–230 U/l ALT (8–20 U/L) AST (8–20 U/L) Misc. Labs: Ammonia (11–35 mcg/dL) 128 124 65 85 35 28 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: ALT Normal Value: Why Relevant? Nursing Assessments/Interventions Required: Critical Value: Value: 128 Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? 2. What is the underlying cause/pathophysiology of this primary problem? Collaborative Care: Medical Management Care Provider Orders: Establish peripheral IV Rationale: Expected Outcome: NS 0.9% bolus of 1000 mL Ondansetron 4 mg IV every 4 hours PRN Orthostatic BP PRIORITY Setting: Which Orders Do You Implement First and Why? (Remember your ABCs!) Care Provider Orders: 1. Establish peripheral IV 2. NS 0.9% bolus of 1000 mL 3. Ondansetron 4 mg IV every 4 hours PRN nausea 4. Orthostatic BP Order of Priority: Rationale: Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Ondansetron 4 mg IV 4mg/2 mL vial Volume/time frame to Safely Administer: Nursing Assessment/Considerations: IV Push: Volume every 15 sec? Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (if more than one, list in order of PRIORITY) 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: 5. Expected Outcome: What body system(s) will you most thoroughly assess based on the primary/priority concern? 6. What is the worst possible/most likely complication to anticipate? 7. What nursing assessments will identify this complication EARLY if it develops? 8. What nursing interventions will you initiate if this complication develops? 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? 10. How can the nurse address these psychosocial needs? Evaluation: Six Months Later… John continues to drink ETOH on a daily basis and has not followed through with his discharge plan when he was discharged from the hospital six months ago. John is now homeless and lives in a shelter. He was brought into the ED by emergency medical services (EMS) because he was found wandering aimlessly in the neighborhood and was completely disoriented. The primary care provider in the ED orders the following labs: CBC, BMP, LFT, and INR. Current VS: Current PQRST: Provoking/Palliative: DENIES Quality: Region/Radiation: Severity: Timing: T: 99.5 F/37.5 C (oral) P: 118 (reg) R: 22 (reg) BP: 88/50 O2 sat: 94% room air Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN: Disheveled, clothing dirty, has strong body odor, appears unkempt, does not smell of ETOH Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort Jaundiced, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks Confused and disoriented to person, place, time, and situation (x4) Abdomen protuberant–distended, bowel sounds audible per auscultation in all 4 quadrants Voiding without difficulty, urine clear/orange Skin integrity intact, skin is yellow/jaundiced in color with yellow sclera 1. What clinical data is RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Rationale: RELEVANT Assessment Data: Rationale: Compare & Contrast: Last Nursing Assessment 6 Months Ago: Emphasize that the nurse should look back at previous admissions, especially admission H&P, consultation H&P, discharge summary, and labs/diagnostics as time allows. Discharge summary may be most important if time is of the essence. An essential component of clinical reasoning is TRENDING clinical data. This TREND can be established from most recent documentation in the medical record that could be hours, days or even months ago. This data is still relevant and needed to establish this trend! Last Nursing Assessment 6 Months Ago: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN: Appears uncomfortable, restless Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort Pink, warm & dry, no edema, heart sounds regular–S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks Alert & oriented to person, place, time, and situation (x4) Abdomen large–rounded–firm to touch, bowel sounds audible per auscultation in all 4 quadrants Voiding without difficulty, urine clear/light orange Skin integrity intact, color normal for patient, sclera of eyes light yellow in color, lips and oral mucosa tacky dry 2. Compare the current nursing assessment with his last assessment above. What has changed most dramatically from his last assessment six months ago that is clinically significant? 3. Has his status improved or not as expected to this point? Lab Results: Complete Blood Count (CBC:) WBC (4.5–11.0 mm 3) Hgb (12–16 g/dL) Platelets (150-450 x103/µl) Neutrophil % (42–72) Band forms (3–5%) Current: 6.9 8.9 47 68 3 High/Low/WNL? Previous: 12.8 10.2 98 88 3 What lab results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Basic Metabolic Panel (BMP:) Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) Glucose (70–110 mg/dL) BUN (7–25 mg/dl) Creatinine (0.6–1.2 mg/dL) Current: 127 2.8 74 55 1.8 High/Low/WNL? Previous: 135 3.5 78 38 1.5 RELEVANT Lab(s): Clinical Significance: Coags: PT/INR (0.9–1.1 nmol/L) RELEVANT Lab(s): Current: 2.6 TREND: Improve/Worsening/Stable: High/Low/WNL? Previous: 1.5 Clinical Significance: TREND: Improve/Worsening/Stable: Liver Function Test (LFT:) Albumin (3.5–5.5 g/dL) Total Bilirubin (0.1–1.0 mg/dL) Alkaline Phosphatase Current: 2.2 7.2 140 High/Low/WNL? Previous: 2.5 4.2 285 male: 38–126 U/l female: 70–230 U/l ALT (8–20 U/L) AST (8–20 U/L) Misc. Labs: Ammonia (11–35 mcg/dL) RELEVANT Lab(s): 59 62 128 124 78 30 Clinical Significance: TREND: Improve/Worsening/Stable: Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Why Relevant? Nursing Assessments/Interventions Required: Ammonia Value: Critical Value: 78 Medical Management: Rationale for Treatment & Expected Outcomes Care Provider Orders: Lactulose 200 g/300 mL rectal x1 NOW Rationale: Expected Outcome: Banana bag (thiamine 100 mg-folic acid 1 mgmultivitamin 10 mL) in 1000 mL of 0.9% NS over 2 hours Potassium Chloride 10 mEq IVPB (x4) each dose over 1 hour. Recheck potassium per hospital protocol Transfer to ICU 4. Does your nursing priority or plan of care need to be modified in any way after this evaluation and assessment of all clinical data including labs? 5. Based on your current evaluation, and assessment of all clinical data, what are your nursing priorities and plan of care? John is going to be admitted to ICU. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient: Situation: Name/age: BRIEF summary of primary problem: Day of admission/post-op #: Background: Primary problem/diagnosis: RELEVANT past medical history: RELEVANT background data: Assessment: Current vital signs: RELEVANT body system nursing assessment data: RELEVANT lab values: TREND of any abnormal clinical data (stable-increasing/decreasing): How have you advanced the plan of care? Patient response: INTERPRETATION of current clinical status (stable/unstable/worsening): Recommendation: Suggestions to advance plan of care: Education Priorities/Discharge Planning 1. What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem? Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? 2. What can you do to engage yourself with this patient’s experience, and show that he matters to you as a person? Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario? 2. How can I use what has been learned from this scenario to improve patient care in the future?