NURS 101L: Case Study #12- Meningitis

Student

Date

Instructor

Course

Patient Initial

S.M.

Unit/ Room#

Med Surg 6 room 621 A

DOB

12/1/1950

Code Status

Full Code

Height/Weight

6’1” 200lbs

Allergies

Penicillin, Ceftriaxone and Morphine

Temp  (C/F Site)

Pulse  (Site) 

Respiration

Pulse Ox (O2 Sat)

Blood Pressure

Pain Scale 1-10

102.3 Oral

115 RA

25

89%

80/54

0/10

History of Present Illness including Admission Diagnosis &

Chief Complaint (normal & abnormal) supported with Evidence Based Citations

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations

Diagnosis: Sepsis, COPD exacerbation, Pneumonia

Chief Complaint: S.M. states that over the course of the last week his CPAP machine at home has not been helping him while he sleeps. He reports increases SOB and increased difficulty breathing while sleeping. S.M. states that while he has been trying to sleep, he has had to use more pillows to prop him up as his CPAP machine isn’t working like it used to. S.M states that he has been coughing more and more and feels like he can’t get enough breath into his lungs, he feels like he has to gulp air more frequently. S.M states that at home his cough has gotten worse and he now has yellow phlegm that is coming up. S.M. states that he has had a fever for several days and he has been taking Tylenol around the clock to try and bring the fever down. Prior to coming into the ER S.M. states that he was getting more and more dizzy and weak and when he couldn’t stand up to use the restroom upon waking up this morning, he finally called 911. 

Rationale: COPD is what_____________________ (citation) People with COPD are more susceptible to pneumonia because _______________(citation). Pneumonia can contribute to a sepsis diagnosis how __________ (citation). Sepsis does what to the body _____ (citation)

Neuro: 

• Pupils PERRLA- PERRLA means ____ (Citation)

This indicates _____ (citation)

• A&O x3 with mild moments of confusion
• Confusion means _____ (citation)

Cardiac:

• Heart sounds WNL 
  • If pneumonia advanced, you would hear ____ (citation)

Respiratory: 

• Crackles on auscultation 
  • Crackles indicate _____ because ______ (citation)

GI:

• Bowel sounds heard in all four quadrants
  • If there are normal bowel sounds this means _____ (citation)
• No distention
  • If there was distention it could mean (correlate to CPAP)        (citation)
• No pain on palpation
  • If there was pain in palpation it would mean (correlate to CPAP)

       (citation)

GU: 

• Pt has no urinary retention
  • Explain normal urinary function (citation)
  • If there was retention it would mean _____ (correlate it to sepsis diagnosis) (citation)

Skin: 

• Intact
• Diaphoretic
  • explain diaphoresis in sepsis (citation)
• Pale
  • Explain pale skin in sepsis (citation)

Pulse: 

• Radial 1+
• Femoral 1+
• Pedal 1+
  • Explain why his pulses are diminished (citation)

Strength

• Weak BUE, BLE
  • Explain why he is weak (citation)

Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),

include dates and rationales supported with Evidence Based Citations

Past Medical & Surgical History,

Pathophysiology of medical diagnoses

(include dates, if not found state so)

Supported with Evidence Based Citations

Chest X-Ray: Chest X-ray showed infiltrates on bilateral lower lobes, bullae, flattened diaphragm

• Rationale explaining what infiltrates are, what is there diagnostic significance
• Rationale explaining what bullae is and diagnostic significance
• Rationale explaining why a flattened diaphragm is significant

Blood Culture- Gram positive bacteria

• Significance of gram positive bacteria, what this means (citation)

Sputum Culture- Gram positive bacteria

• What this means and significance (citation)

• Hypertension- Diagnosed on: _____ pathophysiology of hypertension, citation
• Diabetes mellitus- Diagnosed on: ______ pathophysiology of DM and what this means (citation)
• Hyperlipidemia- Diagnosed on: ______ pathophysiology and citation
• Hiatal Hernia, unrepaired- Diagnosed on: ____  pathophysiology and citation
• TIA- Diagnosed on: ________ pathophysiology, citation

Erikson’s Developmental Stage with Rationale

And supported by Evidence Based Citations

Socioeconomic/Cultural/Spiritual Orientation 

& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations

Ego Integrity Vs Despair 

• Ego Integrity: Definition, (citation)
• Despair- Definition (citation)
• SM is in __(your opinion)__. I believe S.M. is in ______ because he does _____ or says _____. His behavior models _____ which I believe supports the stage _____. 
• Rationale: People who are in _____ stage do ______. They say ______. Their behavior is _______. 

S.M. is a 69 year old Scottish/Welsh male. He has 5 children, 3 sons and 2 daughters. 2 of his sons and both of his daughters are lawyers and are working toward partnership in his firm. His third son is a cardiothoracic surgeon. He has 6 grandchildren all of whom he has paid for to attend private school stating that ‘Education is a portal to a better life’. 

SM has donated money through the years to several children’s scholarship funds ensuring that other children who grew up in the poor neighborhood of Queens where he grew up would have a good shot at higher education. 

He was raised in the Presbyterian church although he has not practiced any religion since he was 18. When his grandmother died after having cancer, SMs wife states that he refused to go to church because his grandmother was a ‘god fearing woman’ and died a painful death. His wife states that SM had remarked several times through his life that if such a good woman died in such a harsh way, then there really must not be a god, or at least a loving god. 

S.M. has been a lawyer since he was 25 practicing in criminal defense. He has his own law firm with 5 other partners below him. Per SM family, he was going to retire this year and his son was going to take over the firm. 

SM has several investments and has always been active in the stock market, his family reports that the stock market was a game to him, and he would prefer to read Wall Street Journal when they went to Las Vegas stating that was all the gambling that he had to do. He owns his own home on Mulholland and the family reports that he has several investment properties. 

Psychosocial Concerns: 

• Pts who have prolonged stays in ICU are at higher risk of suicidal ideation, SM is very independent, there is concern that he may have thoughts of self harm because of prolonged ICU stay (citation)
• Pts who are active at home and who are suddenly debilitated fall into great depression because they are not able to regain their initial level of independence. SM is at risk of developing depression. Rationale (citation)
• Pts who retire with ill health are susceptible to a rapid decline in health and have higher probability to be noncompliant with medications. (citations)

Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each

 (“At Risk for…” nursing dx)

Inter-professional Consults,  Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale

supported with Evidence Based Citations

At risk for loneliness r/t limited visitor contact in the ICU.

• Collaborate with staff to ensure visitors are rotated frequently
• Teach patient to use hospital HIPPA secure webcam chats for family contact
• Teach family to use hospital compliant web chats to ensure confidentiality when chatting with patient.

At risk for impaired skin integrity r/t need for constant use of CPAP mask 

• Assess for skin reddening q2hr
• Teach patient to report feelings of burning or pain related to mask wear
• Collaborate with nursing staff to ensure barrier creams used under mask. 

Consults

• Dietary: Carbohydrate controlled diet to ensure blood sugar stays within normal ranges during hospitalization. (rationale, citation)

• PT: Range of Motion exercises while immobile in bed in ICU (rationale, Citation)

• Social Worker: Locate insurance approved Home Health company to ensure patient does not have to go to skilled nursing facility per patient’s requests (rationale, citation)

• RT: Ensure patient is aware of how to eat with mask without aspiration (rationale, citation)

Discharge Referral

• Home Health Company: rationale and citation
• Oxygen supply Company: rationale and citation

Orders

• Levaquin 500mg q8h IV: rationale and citation
• Constant CPAP: rationale and citation
• Carbohydrate controlled diet: rationale and citation
• CBC and Lactate qam: rationale and citation
• Continuous Cardiac monitoring: rationale and citation
• Blood glucose qHS and AC: rationale and citation
• ABG qAm: rationale and citation
• VBG qam: rationale and citation
• Sliding scale insulin before meals: rationale and citation

Priority Nursing Diagnosis

(at least 2)

Written in three part statement

Planning

(outcome/goal)

Measureable goal during your shift

(at least 1 per Nursing diagnosis)

Prioritized Independent and collaborative nursing interventions;  include further assessment, intervention and teaching

(at least 4 per goal)

Rationale Each must be 

supported with Evidence Based Citations

Evaluation

Goal Met, Partially Met,

 or Not Met

& Explanation

Nursing Diagnosis

Measurable goal

Intervention 1

Rationale, citation

Met

Intervention 2

Rationale, citation

Intervention 3

Rationale, citation

Intervention 4

Rationale, citation

Nursing Diagnosis

Measurable goal

Intervention 1

Rationale, citation

Met

Intervention 2

Rationale, Citation

Intervention 3

Rationale, Citation

Intervention 4

Rationale, Citation

Medications (with APA citations

Class/Purpose

Route

Frequency

Dose (& range)

If out of range, why?

Mechanism of action 

Onset of action

Common side effects

Nursing considerations

specific to this patient

Brand name, Generic name 

(citation)

Class/Purpose

(citation)

Route

Frequency

Dose

Mechanism/Onset (citation)

Side Effects
(citation)

Considerations (citation)