Running head: interdisciplinary care 1 Essay

Running head: interdisciplinary care 1

interdisciplinary care 16

RUA Paper: Interdisciplinary Care

NR341 Complex Adult Health

Chamberlain College of Nursing

Christine Hermann

Spring Session

February 10, 2019

RUA Paper: Interdisciplinary Care

On Sunday, February 10, 2019 I was able to take on the role of a nurse on a telemetry unit and took care of R.W at St. James Hospital. When first seeing this patient I was a little nervous to dive right in and get to know him better but as the day went on I was becoming more confident. Although I took on the role of being his nurse, I was assigned a registered nurse named Tami whom I followed throughout the day and helped care for her patients. After we received report from Manny, the night shift nurse, we began looking up our patient’s medications, labs, and any new orders that may have been put in or not given in report that morning. With report taken and looking up R.W, I came to the realization that he appears to have multiple things going on with him but with his congestive heart failure, he comes to the hospital frequently due to these exacerbations that occur. When it comes to the heart, I seem to be very fascinated by all the different things that could go on and how it affects different parts of the body. Throughout the day, I was very confident that he would be able to go home as soon as there was less fluid in his legs. After reviewing my patient’s chart, I went to do my thorough assessment which consisted of inspection, auscultating lungs, stomach, and heart, palpating the abdomen and legs, and percussing if needed. The thorough assessment is as follows below.

Background Information and Demographics

The patient’s care began on February 9, 2019. Patient is a male with the initials R.W. He was born on November 4, 1956 which makes him 63 years old. Patient is currently single and does not have a current employer. His ethnicity is white and non-Hispanic/Latino. He speaks English and has allergies to latex and clonazepam. He was admitted to the telemetry unit presenting as full code with an admitting diagnosis of congestive heart failure exacerbation. While being admitted, he stated that he was feeling fatigued and his legs were swollen and tender to touch. R.W. stated that before the events leading up to this visit, he was noticing that his legs were swelling, feeling more fatigued than normal, and that it was a bit more difficult to breath while he was at home. At that time, he called an ambulance and they brought him here. Patient states that he has never smoked or done drugs and was never a huge drinker only drank socially. He currently lives at home with his sister and her husband on the second floor of their house.

When talking about family history he only stated that his mother had diabetes and his father had prostate issues. He also stated that they both had hypertension as they got older. There are multiple diseases and disorder that make up this gentleman’s past medical history which consists of anxiety, asthma, anemia, bipolar 1, benign prostatic hyperplasia, chronic obstructive pulmonary disease, depression, diabetes, left ventricular systolic dysfunction, peptic ulcer disease, seizures, major depressive disorder, pacemaker, and polio as a child. In the past, he has had three surgeries consisting of tonsillectomy, back surgery, and a benign cyst that was removed.

Assessment Findings

Upon my focused assessment, I first started with his vital signs which were within normal limits for this patient. His blood pressure was 149/90, temperature was 98 orally, pulse was 88, respirations were 18, and oxygen saturation was 95%. Patient stated that he was in no pain at the time. When the patient arrived to the floor he weighed 88.6 kilograms and when he was weighed that day, he was 88.5 kilograms therefore he had no significant weight gain or loss. R.W. had a recent electrocardiogram showed that he was AV paced with sinus arrhythmia. He was very accommodating and willing to work with me during the assessment. He was able to follow all commands and was able to answer all my questions appropriately. He was oriented x4 to person, place, date, and who the current president was. R.W. was a very pleasant man who seemed to be smiling and loved to talk about his life as a pianist. His skin appeared to be cool and dry but his lower extremities appeared to very fluid overloaded. While examining his legs and feet, it appeared that his skin had some scabs on the top of his feet and scratch marks on his shins. There was no drainage noted. When examining him, his head appeared to be normocephalic with some balding, eyes had no drainage, sclera was white, and conjunctiva was pink. There was no hearing loss or impairment noted along with no skin breakdown behind the ears. His neck appeared to be within normal limits with patent airway, no masses, and no deviation.

As I continued my focused assessment down to the lungs I noticed that he was not using any accessory muscles to breath but when I was auscultating, I was able to hear fine crackles at the base of his lungs but no wheezing at inspiration. I then asked if he was feeling short of breath and he stated that he was not at this time. Although he does not feel short of breath now, he states that he cannot lay flat, that he has to always be sitting up. He did state that he wears two liters of oxygen at home after he goes up and down the stairs. This is due to his fluid overload and his congestive heart failure. While I was auscultating his lungs, I was able to also listen to his heart and S1 and S2 were noted with no signs of a murmur. Since he came in for congestive heart failure, I made sure I listened to his apical pulse for a full minute. I also noted that since the floor I was on was a telemetry unit, he was wearing a heart monitor and had a continuous pulse oximetry. R.W. had no lesions, scars, and contour was appropriate for his ethnicity when inspecting the abdomen. Upon auscultation of the abdomen, I asked when his last bowel movement was and he stated that it was early this morning on February 10th and it appeared to be brown and hard. When palpating, it was soft, nontender, no masses, and no signs of bladder distention. Patient has no issues urinating although he claims it takes him a while to begin. R.W. can move all extremities without any complications but has +4 pitting edema bilaterally from his thighs down to his feet but states that he is not experiencing any pain other than when palpating them. Overall, patient was very pleasant and helpful throughout my focused assessment.

Laboratory and Diagnostic Tests

Date

Lab Test

Results

Normal

Comments

2/10/19

WBC

7.6

4.8-10.8

This value is within normal range. This plays a role in letting us know there are no signs of infection within the body.

2/10/19

RBC

3.86L

4.2-5.4

This value is low due to the patient being anemic.

2/10/19

Hgb

12.3

12-16

This value is within normal range. Hemoglobin is the protein within the red blood cells.

2/10/19

Hct

37.4

37-47

This value is within normal range. Contains mostly of total blood volume within red blood cells.

2/10/19

Platelet

245

150-400

This value is within normal limits. This means that these small fragments are interrupting the clotting factor.

2/10/19

BUN

15

10-20

This value is within normal range. This means that the patients kidneys are functioning appropriately.

2/10/19

Creatinine

1.1

0.6-1.2

This is within normal range. A BUN test helps reveal if there is a problem with the kidneys or liver.

2/10/19

Glucose

188H

70-110

This value is higher than the recommended value. This may be due to stress or is not making the correct amount of insulin.

2/10/19

Sodium

139

136-147

This value is within normal range. It helps maintain normal blood pressure and regulates the body’s fluid balance.

2/10/19

Potassium

3.6L

3.7-5.1

This value is not within the normal limits. This means that the heart may not be pumping effectively and should be fixed as soon as possible.

2/10/19

Magnesium

1.8

1.5-2.5

This value is within normal limits. This is important for the maintenance of the heart and nervous system.

2/10/19

CO2

29.3

20-32

This value is within normal range. It can be affected by the kidney’s and lung function.

2/10/19

Protein

6.1

6-8.3

The value is within normal range. If low, it can affect the growth, development, and health of the cells and body.

2/10/19

Brain Natriuretic Peptide

72.7

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