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Patient Information: Patient's Initials: L. G. C. Room #: 466 …

- - - - Risk Factors: (Mayo Clinic, 2018)
        Genetics
        Family lifestyle
        Inactivity
        Unhealthy diet
        Medical problems
        Certain medications: antidepressants, anti-seizure medications, diabetes medications, antipsychotic medications, steroids, & beta blockers
        Social and economic issues
        Advanced age
        Pregnancy
        Smoking
        Lack of sleep
        
        Obesity: “Obesity is an excessively high amount of body fat or adipose tissue (Lewis, pg 874, 2017).” Obesity results in an abnormal increase in the accumulation of fat cells. There is an increase in adipocytes (hyperplasia) and an increase in their size (hypertrophy). Obesity can have primary causes which include the excessive intake of calories over energy expenditure needs, or secondary causes such as congenital anomalies, chromosomal anomalies, metabolic problems, CNS lesions/disorders, or drugs. Health risks associated with obesity include cardiovascular problems, diabetes mellitus, gastrointestinal and liver problems, respiratory and sleep problems, musculoskeletal problems, cancer, metabolic syndrome, and psychosocial problems* such as depression and/or social withdrawal.
        How the patient got into this state: The patient’s obesity could have been caused by a variety of factors including PCOS or excessive caloric intake. #
      - Risk Factors: (Mayo Clinic, 2018)
        Advanced age
        Race: African Americans
        Family history
        Being overweight or obese
        Physical inactivity
        Tobacco use
        Too much salt in diet
        Too little potassium in diet
        Too little vit D in diet
        Alcohol use
        Stress
        Certain chronic conditions: kidney disease, diabetes, sleep apnea
        
        Benign Essential Hypertension: Hypertension, or high blood pressure, is defined by having a blood pressure over 140/90 (Lewis, pg 684, 2017), and can result from either primary or secondary causes. Primary hypertension is an elevated blood pressure without an identified cause, and it accounts for 90-95% of all HTN cases. Contributing factors to primary hypertension include advanced age, alcohol intake, tobacco use, diabetes mellitus, elevated serum lipids, excess dietary sodium intake, gender (young to middle-aged men & older women), family history, obesity, African American ethnicity, sedentary lifestyle, socioeconomic status, and stress. The pathophysiology of primary hypertension is as follows. Blood pressure rises with any increases in cardiac output or systemic vascular resistance. The hemodynamic hallmark of hypertension is persistently increased SVR. In regards to insulin resistance and hyperinsulinemia as contributing factors to HTN, high insulin levels stimulate SNS activity and impair nitrous oxide-mediated vasodilation. Other effects of hyperinsulinemia include vascular hypertrophy and increased renal sodium reabsorption. Secondary hypertension is an elevated BP with an identified cause such as cirrhosis, coarctation or congenital narrowing of the aorta, endocrine disorders, renal disease, or sleep apnea.
        How the patient got into this state: The patient’s benign essential hypertension could be attributed to her DM II, positive family history (dad), obesity, low SES, and stress. # #
      - Risk Factors: (Mayo Clinic, 2018)
        Weight
        Fat distribution
        Inactivity
        Family history
        Race: African Americans, Hispanics, American Indians, & Asian-Americans
        Advanced age
        Prediabetes
        Gestational diabetes
        Polycystic ovarian syndrome
        
        Diabetes Mellitus II: “Diabetes mellitus is a chronic multisystem disease characterized by hyperglycemia related to abnormal insulin production, impaired insulin utilization, or both (Lewis, pg 1120-1142, 2017).” DM is a major contributor to heart disease and stroke. The causes of diabetes are thought to be a combination of genetic, autoimmune, and environmental factors. Normally, insulin is produced by beta cells in the islets of Langerhans in the pancreas and is continuously released into the bloodstream in small increments, with increased release with food ingestion. Insulin lowers blood glucose levels and keeps a normal range between 70-110 mg/dL. Insulin promotes glucose transport from the bloodstream into the cell, where cells utilize glucose to make energy. Liver and muscle cells store excess glucose as glycogen, which can be released and utilized in times of low glucose levels. Type II diabetes mellitus, or adult-onset diabetes, has many risk factors including obesity, advanced age, and familiar history. Type 2 DM is characterized by inadequate insulin secretion and insulin resistance. The body either does not produce enough insulin or does not use it effectively, or both. Genetic mutations can lead to insulin resistance, a condition in which the body does not respond to insulin due to unresponsive or insufficient insulin receptors. This results in hyperglycemia because cellular glucose uptake is impeded. Clinical manifestations of DM type II include polyuria, polydipsia, polyphagia, fatigue, recurrent infections, recurrent vaginal yeast or candida infections, prolonged wound healing, and visual changes.
        How the patient got into this state: The patient’s DM II could have been caused by a variety of factors, including obesity, familiar history (dad), poor diet, and PCOS.
        # #
      - Risk Factors: (Mayo Clinic, 2018)
        A diet lacking in certain vitamins
        Intestinal disorders: Crohn's & celiac disease
        Menstruation
        Pregnancy
        Chronic conditions: cancer, kidney failure
        Family history
        Other: certain infections, blood diseases, autoimmune disorders, alcoholism, exposure to toxic chemicals, use of some medications
        Advanced age
        
        Anemia: Anemia is a deficiency in erythrocytes, the quantity/quality of hemoglobin, and/or the volume of packed RBCs (hematocrit) (Lewis, pg 606, 2017). Due to the ability of RBCs to transport oxygen, anemia can lead to tissue hypoxia. Anemia can result from primary hematologic problems or as a secondary consequence from some other disease process. Causes of anemia include decreases in RBC production, defective DNA synthesis, decreased numbers of RBC precursors, blood loss, increased RBC destruction, and from acquired extrinsic factors such as physical destruction, antibodies, or infectious agents.
        How the patient got into this state: The patient’s anemia could have been caused by a diet lacking in vitamins, menstruation, or HTN. The chart did not specify what type of anemia the patient has, and the patient was unsure. # #
      - Risk Factors: (Mayo Clinic, 2018)
        Injury
        Weakened immune system
        Skin conditions
        Lymphedema
        History of cellulitis
        IV drug use
        Obesity
        
        Cellulitis/Right foot infection/Non-Healing Wound: Cellulitis is an inflammation of the subcutaneous tissues (Lewis, pg 414, 2017). It can be a secondary complication or a primary infection. The infection often follows a break in the skin, from which causative agents such as staphylococcus aureus or streptococci are allowed access to the tissue. Clinical manifestations of cellulitis include tenderness and erythematous and edematous areas with diffuse borders. Chills, malaise, and fever may also be present. Treatment includes moist heat, immobilization, elevation, and/or systemic antibiotic therapy. Factors that delay wound healing include nutritional deficiencies, inadequate blood supply, corticosteroid drugs, infection, smoking, mechanical friction, advanced age, obesity, diabetes mellitus, poor general health, and anemia (Lewis, pg 168, 2017). Obesity decreases blood supply to fatty tissues and DM decreases collagen synthesis, delays capillary growth, impairs phagocytosis as a result of hyperglycemia, and reduces the supply of oxygen and nutrients secondary to vascular disease. Poor general health delays wound healing due to a generalized absence of factors necessary to promote wound healing. Anemia delays wound healing because of an inadequate oxygen supply to tissues.
        How the patient got into this state: After the patient’s initial injury (hitting her foot on the bed), her DM II, obesity, poor general health, and anemia contributed to her delayed wound healing, which is what brought her into the hospital to begin with.
      - Risk Factors: (Mayo Clinic, 2018)
        Obesity
        Diabetes
        
        Vulvar Abscess: “An abscess is an enclosed collection of liquefied tissues (pus) that results from the body’s defensive reaction to foreign material (Polsdorfer, 2015).” There are 2 types of abscesses, septic and sterile, with septic being the most common. Septic abscesses can occur anywhere on the body and are a response to an invading pathogen. In response, WBCs gather at the infected site and produce enzymes that attack and digest the pathogen, resulting in the production of pus. The most common causative agent of an abscess is Staphylococcus aureus.
        How the patient got into this state: The patient could have done something (scratch) to produce a breakage in the skin on her vulva, allowing a pathogen access into the tissue. The immunosuppressive nature of the patient’s DM II may have also contributed to the development of an abscess. # #
      - Risk Factors: (Mayo Clinic, 2018)
        Family history
        Diabetes
        Irregular periods
        
        PCOS: Polycystic ovary syndrome is a disorder that includes ovulatory dysfunction, polycystic ovaries, and hyperandrogenism (Lewis, pg 1255, 2017). It most frequently occurs in women under 30. The etiology of this disorder is unknown, but it is thought to be due to the ovaries producing estrogen and excess testosterone, but not progesterone. As a consequence to the hormonal imbalance, the patient does not ovulate, and multiple fluid-filled cysts develop from maturate ovarian follicles. Manifestations of PCOS include irregular menstrual periods, amenorrhea, hirsutism, and obesity (80% of women). If PCOS is left untreated, cardiovascular disease and abnormal insulin resistance with DM II may develop. # #
      - Risk Factors: (Mayo Clinic, 2018)
        Personality: timid, negative, avoidant
        Genetics
        Traumatic experiences
        
        Anxiety: Anxiety is a common symptom of depression, affecting 60-90% of patients with depression (Halter, pg 257, 2014). Again, just like with depression, there is no clear pathophysiology, but there is a plethora of research trying to determine the cause. Several studies have shown that there is a genetic basis to anxiety disorder. The amygdala plays a role by alerting the brain to the presence of danger, which brings about fear and anxiety. Neurotransmitter imbalances in epinephrine, norepinephrine, dopamine, serotonin, and GABA also have been shown to contribute to the development of anxiety. # #
      - Risk Factors: (Halter, pg 253, 2014)
        Prior episode
        Family history
        Ineffective coping
        Female gender
        Medical co-morbidity
        Low SES
        Current/history of substance abuse
        Early childhood trauma
        Lack of social support
        Stressful life events
        Postpartum period
        
        Depression: Numerous studies have shown that genetics play a part in the development of depressive disorders. Evidence also supports that CNS neurotransmitter abnormalities including abnormal levels of serotonin, norepinephrine, dopamine, acetylcholine, and GABA may cause depression. Decreases in serotonin can result in sleep disturbances, decreased appetite, low sex drive, poor impulse control, and irritability. A deficiency in norepinephrine can result in apathy, reduced responsiveness, or slowed psychomotor activity. Norepinephrine, serotonin, and acetylcholine play an important role in stress regulation, and stressful life events may deplete neurotransmitter stores, resulting in an inability to deal with stress. There are also theories that suggest that abnormal levels of sex hormones (estrogen and testosterone) may also play a role in the development of depression. Basically, there is no clear pathophysiology of depression, but there is a plethora of research trying to determine the cause. # #
- - - - Intervention: Nurse will observe patient for and report signs of infection such as redness, warmth, discharge, and increased body temperature.
        Rationale: A change in mental status, fever, shaking, chills, and hypotension are indicators of sepsis (Ackley et al., 2017).
      - Intervention: Nurse will note and report lab values including WBCs w/ differential, serum protein, serum albumin, and cultures.
        Rationale: An increase in immature bands indicates infection, and a neutropenic patient with a fever is a medical emergency. Obtaining cultures allows the healthcare professional to determine the type of antibiotic therapy (Ackley et al., 2017).
      - Intervention: Nurse will educate patient on signs and symptoms of infection to report.
        Rationale: Earlier identification is associated with a better prognosis (Ackley et al., 2017).
      - Intervention: Nurse will provide wound care as appropriate to patient’s wound type and stage of healing, as ordered.
        Rationale: Appropriate wound care helps to prevent infection (Ackley et al., 2017).
  - - - Intervention: Prior to activity, the nurse will treat pain will pharmacological or nonpharmacological methods.
        Rationale: Pain limits mobility (Ackley et al., 2017).
      - Intervention: Before activity begins, nurse will obtain any assistive devices needed for activity, such as a gait belt, walker, cane, crutches, or a wheelchair, and provide patient education on their use.
        Rationale: Assistive devices can help increase mobility (Ackley et al., 2017).
      - Intervention: Nurse will monitor and record the patient’s ability to tolerate activity and use all four extremities, noting pulse rate, blood pressure, dyspnea, and skin color before and after activity.
        Rationale: The use of reliable and valid screening procedures helps determine activity tolerance and whether the patient can advance to and tolerate more demanding physical tasks (Ackley et al., 2017).
      - Intervention: Nurse will aid patient in increasing independence in ADLs with the use of encouragement in self-efficacy and discouragement in helplessness.
        Rationale: Providing unnecessary assistance with transfers and bathing may promote dependence and a loss of mobility (Ackley et al., 2017).
  - - - Intervention; Nurse will assess the patient’s nutritional status.
        Rationale: Optimizing nutritional intake, including calories, fatty acids, protein, and vitamins, is needed to promote wound healing. If the nurse can identify the patient’s deficits, they can alter the patient’s diet and give supplements in order to correct these deficits (Ackley et al., 2017).
      - Intervention: Nurse will provide wound care as appropriate to patient’s wound type and stage of healing, as ordered.
        Rationale: The selection of wound dressings and cleansing is based on different wound types in different stages of healing (Ackley et al., 2017).
      - Intervention: Nurse will not position the patient on the site of skin impairment and reposition and transfer the patient with care to protect against adverse effects of external mechanical forces such as pressure, friction, and shear.
        Rationale: This prevents exacerbation of current breaches in skin integrity and prevents the development of new breaches (Ackley et al., 2017).
      - Intervention: Nurse will determine the extent of the skin impairment using a classification system.
        Rationale: Rating the skin injury will give the nurse a baseline for comparison in order to determine an improvement or worsening in skin integrity (Ackley et al., 2017).