Nrn220 SUBJECTIVE HPI: is a with so insulin-dependent type 2 diabetes

Posted: March 13th, 2024

-Reflection & Evaluation (with specific learning objectives/SLOs listed that were achieved during your clinical rotation and how you met them)

-SBAR (upload & attach an actual image of the SBAR you created and used at the bedside. Do NOT re-write or type it to make it look nice for our sake, please, but it must be legible.)
____________________________________________________________________________________
-Critical Thinking Questions:
1. Primary reason for admission
2. What is the pathophysiology of the patient’s main diagnosis/diagnoses?
3. Priority Nursing Diagnosis Statement (in 4-part statement if an actual problem, or a 3-part statement if “risk for”)

4. Realistic Complications
(What can go wrong & lead to serious issues and/or death) 5. Key Assessments
(To prevent the complications & related to main issues currently)
6. Nursing interventions
Pharmacological
(dependent) and Non-Pharm (independent)

7. What transitional care and planning is needed for this patient?
____________________________________________________________________________________
-Physical assessment by body system *(written as if you were giving a verbal report at handoff) **(Include ordered goals for any titratable medications being used and what the current dose is at the time of your assessment)
1. NEURO
2. CARDIAC: insert an ECG strip & YOUR INTERPRETATION (rate/rhythm, PRI, QRS, & QT)
3. RESPIRATORY
4. GI/NUTRITION/DIET
5. GU
6. SKIN/MS
7. LINES
8. INFUSIONS
9. EQUIPMENT/DEVICES
10. PSYCHOSOCIAL

-Lab and diagnostics [pt implications (Why is this important for the patient?), nursing implications (How should nursing respond?)]

Relevant Lab or Panel
(Listing normal parameters is optional) Trend Patient Implications
(Why is this important to your patient specifically?) Nursing Implications
(How will this change your nursing care?)

Diagnostic Test Summarized Result(s) Patient Implications
(Why is this important to your patient specifically?) Nursing Implications
(How will this change your nursing care?)

-One focused nurse’s note

-Medications: (For scheduled medications, use the med sheets on the pages below and fill them out at the bedside to the best of your ability. For continuous and titratable infusions, use the table on this page.)

Infusion Drug Titration Orders Why is this needed?

Nrn220
SUBJECTIVE HPI: is a with so insulin-dependent type 2 diabetes, diabetic neuropathy s/p right BKA due to infection, Atrial Fibrillation not Eliquis (patient preference due to frequent falls), Essential Hypertension, severe persistent asthma w/ cosinophilia, chronic bronchitis/bronchiolitis, Chronic Sinusitis s/p Sinus Surgery and Hyperlipidemia. Patient was sent in to Eisenhower Health on for neurological procedure. Patient uses a walker at baseline and reports having a fall in November after which he started having progressive weakness in the left lower and upper extremities. Symptoms have progressed to the point where patient has been wheelchair bound for the past 10 days. Patient also reports weakness in the upper extremities and drops objects frequently due to this weakness. MRI cervical spine done in February shows multilevel multifactorial cervical spondylosis causing multilevel neural foraminal narrowing ranging from mild to severe. There is also spinal canal stenosis, marked at C7-T1 and moderate to marked at C3-C4 and C6-C7. MRI of the thoracic spine shows moderate discogenic/degenerative changes at T6-T7 and T7-T8. We regards to his severe asthma, patient reports a history of frequent mucus plugging with recurrent bronchoscopy to relieve the plugging. Patient was started on dupilumab every 2 weeks starting about a year ago with great improvement of his asthma. Patient also uses budesonide and arformoterol and nebulizers at home. He denies any asthma exacerbations or symptoms of mucus plugging since starting dupilumab. He also denies use of his albuterol inhaler since starting this medication. Regarding his diabetes, patient reports monitoring his glucose at home with BG ranging from 100-110. He takes metformin and 20 units of Lantus.

On arrival, patient was hemodynamically stable on room air. CT of the cervical spine shows no acute cervical spine fracture or trauma with multifactorialcervical degenerative changes. MRI was ordered and patient was admitted for optimization severe asthma in preparation for cervical spine procedure.
REVIEW OF SYSTEMS: Constitutional: Negative for activity change, appetite change, fatigue and fever. inorrhea, sore throat, trouble swallowing and voice change. RENT: Negative for congestion, hearing loss, rh Eyes: Negative for photophobia and visual disturbance. of breath and wheezing. Respiratory: Negative for apnea, chest tightness, shortness Cardiovascular: Negative for chest pain and palpitations. Gastrointestinal: Negative for abdominal distention, abdominal pain, constipation, diarrhea, nausea and vomiting.

Allergies: Pollen extracts Treatment T- ..• Admission Dx: Cervical Myelopathy (Cms/Hcc) Primary Problem: Cervical myelopathy (CMS/HCC) Past Medical History: t • Asthma : .,.. • BPH (benign prostatic hyperplasia) Av.,. • Chronic sinusitis ILI • Diabetes mellitus (CMS/HCC) fin’` 1rr. • Foot drop, left • Foot drop, right foot -7- . …..,…zik, ‘pp, • History of atrial fibrillation • Hypercholesteremia • Hypertension • Uses walker 455- 6 Treatment Team Sticky Notes 1S:DO — \ % 1 2, /cpSli vir tywiP i kg GS • 6 2._ ci c\ BACKGROUND Last transfer: 3/11/2024 7:34 PM MAIN OR Diet: NPO Diet __ Safety/Alerts: High fall risk 1,..<4 r 4z) n am , Prior Living Arrangements: Past and Future Surgeries 1\1?0 5.1,, d,,,, s('")C Past Procedures (3/8/2024 to Today) Date Time Procedures Status 03/11/2024 1200 CERVICAL THREE TO CERVICAL Completed roy\Tecr6G,nePLA 3 ) FOUR, CERVICAL SIX TO or 1 'RC ci i 61- irk cCK. CERVICAL SEVEN, CERVICAL Discharged SEVEN TO THORACIC ONE (00 aCCAVAP n ANTERIOR CERVICAL SV, '''/-) IlYa 0 Hi- . DISCECTOMY FUSION 1%0 PM Ut fir( 124/11.4 ( 1D uMo co, i kie,„,) INSTRUMENTATION (0, / ,-) 2./.1 cr 0 qi o 0 s-c-I-on we, ), 1 z____ Q ASSESSMENT Last Vitals: BP: 151/85 (03/12 0630) Heart Rate: 55 (03/12 0734) Resp: 19 (03/12 0734) Temp: 36.3 °C (97.4 °F) (03/12 0000) SpO2: 100 % (03/12 0734) Weight: 90.9 kg (200 lb 6.4 oz) (03/11 1053) Resp Rate Setting: 18 Tidal Volume (mL): 450 mL PEEP/CPAP/EPAP (cmH2O): 5 cm H2O Fi02 (%): 40 % Last Blood Glucose: POCT - 229 mg/dL (H) 3/12/2024: 6:30 AM Lab Draw - 245 mg/dL (H) 3/12/2024: 5:03 AM Last Lactate: No result in last 36 hrs ,$).40 6 `I Do Na K CI BUN Cr WBC HGB HCT PLTCT aPTT INR 139 mmol/L 4.0 mmol/L 111 mmol/L (H) 33 mg/dL (H) 1.1 mg/dL 10.0 K/uL 9.6 g/dL (L) 28.3 % (L) 244.0 K/uL No result in last 36 hrs No result in last 36 AM Lines/Drains/Airways Skin Risk/Wounds/Pressure Injuries: Peripheral IV 03/08/24 Left Antecubital (Active) Braden Score <=13: High Risk; Daily 0700 2 RN (4 Eyes on Skin) Assessment required Peripheral IV 03/08/24 Anterior; Right Forearm (Active) Surgical 03/11/24 Cervical Anterior Other (Comment) ______________________ Comprehensive Nursing Care for Patients with Cervical Myelopathy

Cervical myelopathy, a condition characterized by compression of the spinal cord in the neck region, necessitates comprehensive nursing care to address various aspects of the patient’s well-being. This article delves into the crucial elements of nursing management for individuals with cervical myelopathy, encompassing assessment, interventions, and transitional care planning.

Pathophysiology and Nursing Diagnosis

Cervical myelopathy arises from the narrowing of the spinal canal, often due to degenerative conditions such as cervical spondylosis, disc herniation, or ossification of the posterior longitudinal ligament (OPLL) (Badhiwala et al., 2015). The compression exerted on the spinal cord can lead to various neurological deficits, including weakness, numbness, balance issues, and loss of fine motor skills. A priority nursing diagnosis for a patient with cervical myelopathy could be “Impaired Physical Mobility related to spinal cord compression, as evidenced by progressive weakness in the extremities and loss of ambulatory function.”

Potential Complications and Key Assessments

Realistic complications associated with cervical myelopathy include respiratory compromise, aspiration pneumonia, deep vein thrombosis (DVT), pressure injuries, and increased risk of falls (Kalsi-Ryan et al., 2019). Key assessments to prevent these complications include frequent respiratory assessments, monitoring swallowing ability, assessing skin integrity and implementing appropriate pressure relief measures, and evaluating gait and balance while promoting safe mobility.

Nursing Interventions

Nursing interventions for patients with cervical myelopathy encompass both pharmacological and non-pharmacological approaches. Pharmacological interventions may include analgesics for pain management, corticosteroids to reduce inflammation, and anticoagulants for DVT prophylaxis (Karadimas et al., 2015). Non-pharmacological interventions involve promoting safe mobility through the use of assistive devices, implementing fall precautions, providing respiratory support (e.g., incentive spirometry, suctioning), facilitating proper positioning and skin care, and ensuring adequate nutrition and hydration.

Transitional Care and Planning

Transitional care and planning for patients with cervical myelopathy involve a multidisciplinary approach to ensure a smooth transition from acute care to rehabilitation or community settings. Collaboration with physical and occupational therapists is crucial for developing individualized rehabilitation plans and optimizing functional outcomes (Bowers et al., 2017). Discharge planning should address home modifications, assistive device procurement, caregiver education, and coordination with community resources for ongoing support.

In conclusion, comprehensive nursing care for patients with cervical myelopathy encompasses a multifaceted approach, addressing the patient’s physical, functional, and psychosocial needs. Through meticulous assessment, evidence-based interventions, and collaborative transitional care planning, nurses play a vital role in optimizing outcomes and improving the quality of life for individuals affected by this debilitating condition.

Badhiwala, J. H., Ahuja, C. S., & Akbar, M. A. (2015). Cervical spondylotic myelopathy: etiology, diagnosis, and surgical techniques. Journal of Spine Surgery, 1(1), 5–10. https://doi.org/10.3978/j.issn.2414-4630.2015.06.01

Kalsi-Ryan, S., Singh, J. M., Massicotte, E. M., Arnold, P. M., Brodke, D. S., Norvell, D. C., Hermsmeyer, J. T., & Fehlings, M. G. (2019). Ancillary outcome measures for assessment of individuals with cervical spondylotic myelopathy. Spine, 44(22S), S112–S123. https://doi.org/10.1097/BRS.0000000000003330

Karadimas, S. K., Erwin, W. M., Ely, C. G., Dettori, J. R., & Fehlings, M. G. (2015). Pathophysiology and natural history of cervical spondylotic myelopathy. Spine, 40(22S), S30–S36. https://doi.org/10.1097/BRS.0000000000001186

Bowers, C. A., Kundu, B., Ropper, A. E., Morse, L. R., Marra, A., Kalsi-Ryan, S., Massicotte, E. M., Hitzig, S. L., Kotter, M., & Fehlings, M. G. (2017). Rehabilitation after cervical myelopathy surgery: A systematic review. Global Spine Journal, 7(6), 590–603. https://doi.org/10.1177/2192568217701089

Fehlings, M. G., Brodke, D. S., Norvell, D. C., & Dettori, J. R. (2015). The evidence for intraoperative neurophysiological monitoring in spine surgery: does it make a difference?. Spine, 40(17), 1319–1330. https://doi.org/10.1097/BRS.0000000000001008