Patients Hospital Chart Review - Report Example

Running Head: NURSING PROCESS PAPER Nursing Process Paper Nursing Process Paper The following informationregarding this patient was taken from the patient’s hospital chart as well as a personal interview conducted. The patient is an 89 year old male admitted to the ICU on March 25th, 2008 with congestive heart failure. Currently he is being monitored and evaluated by the staff and no follow up surgeries have been scheduled. The patient chief complaints were of a sudden onset of shaking rigors and tremors beginning about 2 p.m. on the day he was admitted. He is also febrile but has shown no symptoms of angina and has denied having any chest pains or any orthopnea. He is showing some signs of vascular edema but he denies any syncope or near syncope, and does appear to be mostly alert and responsive to his surroundings and to questions. Upon review of the history and during an interview with the patient it was found that prior to this episode he was unable to walk more than fifteen minutes at a time before becoming fatigued and short of breath. The patient has undergone some recent previous surgeries in the past two years, one for the removal of a benign polyp from his colon after the observation of blood in his stool. This may have also been a side effect of Plavix. He had also fractured his ankle in a slip an fall and now has a pin in place there. He has a prior history of congestive heart failure and coronary heart disease, he is easily fatigued and has some signs of arterial fibrillation. He has also received two stents put in place in order to allow better blood flow to his heart and lungs. Upon questioning the patient about his circumstances he states that he would like to go home as soon as possible. He is married and his wife is in stable health, although she is near to his age as well. He also has other family supports in place to help him around the house should it be necessary as well as community and other social supports. He complains about not being able to go to church, he is a devout Christian, but the chaplain has visited him quite often and he finds some solace in that, but being in ICU he has limited visitation times. The patient’s general health is poor and he has become quite inactive over the past year stating that he used to go for walks with his wife but now cannot keep up with her at all. He has had several colds, which were “hard to shake,” and he sounds congested and seems to have an active cough presently. His family history further reveals that his father died of congestive heart failure and that his mother died of renal failure, but both were in advanced ages. The patient while alert seems to have some minor confusion about how long he has been hospitalized and what is being done to help him, although this may be normal under the circumstances. He says that he feels frustrated and isolated and that he is not allowed to see his wife often enough. While his general affect is somewhat alert and bright he falls into moments of despair talking about death and that his father died of a heart condition as well. Furthermore, overall he seemed quite oriented to his environment and very responsive during the course of the interview. For most of this interview the patient was in bed with his head and shoulders raised on pillows. He fidgeted quite a bit to stay comfortable and was constantly playing with his oxygen tubes, arranging them over his ears and moving them about in his nose in an effort to feel more comfortable. Before recently being hospitalized the patient reported that he used to have a “pretty good appetite,” but over the past six-months or so he has not been able to eat as much as he used to. He has also lost, by his estimations, ten or fifteen pounds over that period. He seems to have no inherent food intolerance and although he states that his appetite is good to start with, after eating a few bites he often feel full or even a little nauseous. He does have a lower denture plate that he comments on having some difficulty with and he often takes it out while eating. When asked if he can chew his food well without it he simply replies, “I manage.” There may be a possibility that he is not digesting his food well because of this situation. His skin overall seems slightly yellowish in presentation with several age spots apparent on his hands and some on his neck. There is also the presence of a reddish blotchy rash over his arms and hands that may be the result of his febrile condition. There are no open wounds or other disfigurements apparent and when asked the patient says that he has some moles on his lower back that the doctors said they would remove at some point. After being hospitalized, the patient complains of abdominal pain, some nausea and vomiting as well as diarrhea. He also complains of painful and frequent urination and has hematuria present. As indicated earlier the patient is experiencing a great deal of muscular weakness and fatigue and also complains of chronic back pain. He also exhibits vascular edema, headaches, dysrrhythmia, and shortness of breath. This certainly places him in the fall risk category as well as possible future placement in a long term car facility when discharged from the hospital. Lab tests, CK (U/L), have revealed an acute myocardial infarction and cerebrovascular incident. Other tests, Alk phos, AST and ALT, are high and likely indicate liver disease such as cancer of the liver or cirrhosis. This may be related to the patient skin color and jaundiced condition. Also there are indications that the patient is anemic and suffering from blood loss through urinary and GI tract. Prior to hospitalization the patient remembers having some difficulty falling and staying asleep for long periods of time. He admits to waking early and needing less sleep than he used to, but now he states that he feels very tired and fatigued almost all the of time. He states also that he does awaken very easily and now that he is in the ICU he finds it almost impossible to get more than a few minutes of sleep at a time. However the staff notes that when they have checked on him he appears to be sleeping for at least an hour or more in one period during the course of the night. The patient’s chart indicates that he is awake and alert most of the time during the day and has no episodes of displacement or confusion other than possible misperceptions of time. The mini-mental evaluation records that he does have some short term memory loss but can solve simple problems and remember most lists and is aware of his surroundings. However, there is a tendency to melancholia and hints of depression at times, not unusual considering his failing health and hospitalization. Although the patient complains of pain, especially headaches and lower back pain, his tolerance for pain seems to be normal. When moving in the bed or trying to walk, he has some trouble from fatigue more than from pain tolerance levels. Further examination of the patient’s history also reveals a, lumbar disc dz. Possibly causing the lower back pain. Currently the patient requires plenty of bed rest with some range of motion exercises to help keep his muscles from contracting The patient does wear glasses for reading as well as distance vision, although his visual acuity appears normal while wearing them. He does not wear a hearing aid or seem to have any difficulty hearing. Although during the course of the interview he did ask for repetition of a question or comment occasionally. He appears to enjoy talking and speaks English as his primary language. The only difficulty for him seemed to be his energy levels, which seem to fall after about a half-hour or so of conversation. When I asked the patient how he was feeling aside from his physical ailments he said an interesting thing. “You know, in my mind I still feel like I am twenty years old, but when I go to walk or do anything I realize that I’m not.” He says that he wishes he could still walk with his wife around the block at least, but that he has not been able to do that for quite some time. When his wife has to help him up to go upstairs or to go to the bathroom it really angers him and he admits to being a bit short tempered with her at times. But he says that, “It’s okay ‘cause she give it right back to me calling me and old so and so, and then I laugh.” His seems to have a valuable relationship both physically and psychologically in his marriage. Prior to this current hospitalization the patient has been living at home with his wife. He has children who offer some natural support as well as visiting nurse services and other care giving agencies that assist he and his wife with medical needs and chores around the house. He has been retired for over twenty years, but tried to keep active after retirement. He says at that time they had purchased a recreational vehicle and traveled around the country for a while, but they both got homesick after at time. They are members of their local church and he had kept active along with his wife with different functions in the church until his heart problems. However, they are both still a fixture in their community and their neighbors children call them grandma and grandpa. This patient would be in Erickson’s ninths stage of development, (Late 80s and beyond) Very Old Age. The primary psychosocial crisis at this stage is integrity versus despair. The patient needs to return to a feeling of accomplishment and completeness in order to feel that his life has been, and can continue to be worthwhile for as long as he is alive. “In Stage nine, a person’s autonomy, independence, and control are challenged; as a consequence self-esteem and confidence weaken.” (Hakim & Wegmann, 2002, p.161) One of the mental exercises I would recommend for this patient, after he has sufficiently recovered from his physical ailments, would be to conduct a life review process. This process involves the emotional processing of a lifetime of events from the patient’s past. This is an autobiographical retrieval process focused primarily on bringing up specific events that an older adult might not have reviewed or remembered o his or her own without the use of this process. Studies have shown that older adults who used this autobiographical memory process enhanced their overall mood state and showed marked decreased in depressive symptoms and a reduction in feelings of hopelessness. This eventually lead to an improvement in the satisfaction that they fell for life as a whole. (Serrano, Latorre, Gatz, and Montanes, 2004). I believe this patient, and others in his condition would benefit greatly from this process. References Hakim, H. & Wegmann, D. (Fall 2002) A comparative evaluation of the perceptions of health of elders of different multicultural backgrounds. Journal of Community Health Nursing;, Vol. 19 Issue 3, p161, 11p Serrano, J.P. ,Latorre J.M., Gatz M., Montanes, M.J. (June, 2004) Life review therapy using autobiographical retrieval practice for older adults with depressive symptomatology. Psychology and Aging. Vol. 19 (2) J pp. 272-277. Read More