TCC Nursing Program NURS 2543 Nursing Promotion for Quality of Life

Hospice Patient/Family Data Sheet

1. Past Medical History and reason for Hospice care

2. Family/Caregiver Structure

3. Describe Environment

TCC Nursing Program NURS 2543 Nursing Promotion for Quality of Life Functional Health PatternsSubjective and Objective Data Health Perception Health Management: The client was admitted and is maintained on hospice due to the current diagnosis of rectal cancer which is terminal. Patient is a 75 y/o African American female. The client also has a diagnosis of dementia. The patient youngest daughter is her live in primary caregiver. The primary caregiver takes the patients to all of her appointments in addition to ensuring that the patient gets her medications as ordered. The patients caregiver stated that healthcare providers have done as expected and she is currently happy with the level of care her mother receives. Nutrition Metabolic: Pt. caregiver states pt.s appetite is poor to fair. He patient stated that she does not have any problems with chewing or swallowing. The patient does wear dentures and did not have them in her mouth during the assessment. Mucous membranes are pink, moist and intact. Patient has recently been suffering from nausea but vomiting has not presented itself at this time. Patients caregiver states that the patient has lost at total of 7 pounds in the last 30 days. Oral temperature 97.9 degrees Fahrenheit. Skin was warm and dry with yellow undertones. Skin was intact, no open sores noted. Heels of both feet were spongy but intact. Patient takes Megace as an appetite stimulant. Activity-Exercise: Patient can move around fairly easy with mild assistant when first getting out of bed in the morning. Patient does not smoke, and has mild shortness of breath on exertion, patient states that it was tolerable and that she was not experiencing any shortness of breath at this time. Patient has a congestive heart failure; pt. states that she is not currently having cardiac pain nor has she experienced any recently. Lungs were CTA; respiratory rate of 18 breaths per minute visually, no cough present at this time. Apical heart rate 86 beats per minute and was irregular in rate and rhythm. Edema present in lower extremities bilaterally and was not pitting. Lower extremities were warm and dry Cognitive Perceptual: pt. has PERRLA, was oriented to person and place, patient does not use hearing air or glasses, wears dentures, hearing is slightly diminished. Patient denies having pain; patient does not reveal any consciousness of memory changes but caregiver states that there have been moderate memory changes in the last 6 months. Patient demonstrated awareness of body parts. Education level was not addressed.

Self-Perception -Self-Concept: Questions about the patients self and abilities were not answered by the patient for lack of time. Illness has affected the patients physical mobility and the ability to participate in once meaningful interactions. The patient is limited to contact with the youngest daughter with occasional visits from her other 7 children. The patient is no longer to independently shop for herself or prepare her own meals. The patient was relaxed and lying in bed, unguarded behavior. Unable to assess geriatric depression using standard measuring the tool due to the lack of time. Role Relationship: The patient who is a mother of 8 grown children is now being cared for by her youngest child. The youngest child is now the primary caregiver. Patient was a homemaker. The patient is no longer available to do things as independently as she did before the beginning of the disease process and she is unable to live by or care for herself. The daughter seemed distant while hospice was with the patient; she answered questions but appeared to be very tired. I visualized no interaction between the daughter and the patient.

with patches of hair present. Pedal pulses were present and palpable. Blood pressure 193/89. Capillary refill less than 3 second in upper and lower extremities. Negative Holmans sign, strength in upper and lower extremities was equal bilaterally. Patient uses a rolling walker outside of the home. Patients caregiver states that the patient easily tires when completing simple tasks and naps frequently. Elimination (urinary/bowel): Patient stated that she has problems urinating with a major complaint of pain in her lower back and some hesitancy as well as a decrease in the amount of urine she passes. Functional incontinence with bowel and bladder. Caregiver states that the patient does not drink much because she is not thirsty. Last BM 9/18/12 which was soft, semi formed and dark brown. Patient does not take any stool softeners or laxatives because she states that most of her stools are soft or liquid. Abdomen was soft and non-tender, bowel sounds were active in all quadrants, no pain or discomfort upon palpation, no bulges or masses felt. Care giver states the use of briefs at night and during the day due to the functional incontinence. Sleep-Rest: Patient has no specific sleep patterns due to the variance because of daytime sleepiness and frequent naps. Caregiver states that the patient lays down beginning at 10pm and rises from bed around 10am. Main factors that influence sleep are frequent daytime napping and diarrhea during the night. Upon my assessment of the patient is visibly clear that she was tired, eyes were swollen with dark circles underneath and was frequently yawning. Patients attention span was short. Sexuality-Reproductive: Patient is and presents herself as a female, she wears make up and wears dress clothes specific to a woman. Patient gets yearly mammograms. All others sexual/reproductive patterns were not addressed.

Coping-Stress-Tolerance: Patient denies any use of alcohol or illegal drugs. Support systems consist of children not all of which participate in her care. Lack of eye contact. Patient had a bright affect. Patient denies having anxiety. No specific coping mechanisms or stressors noted.

Value-Belief: Patients home was decorated with religious items, a picture of the last supper, a picture of Jesus, crosses, a crucifix on the wall in the bedroom and a bible on the bedside table. Patient has a DNR. Questions regarding specific religious beliefs were not asked due to the lack of time.

TCC Nursing Program NURS 2453 Nursing Promotion for Quality of Life Hospice Medication List Med/Route, Frequency, Dosage Normal Dose Range 1) Classification, 2) Action 3) Reason Rxd for THIS Client 1) Nursing Precautions 2) Common Side Effects, 3) Nursing Implications Clients Response to Medication

Date Started

TCC Nursing Program NURS 2453 Nursing Promotion for Quality of Life

Working Copy
Nursing Diagnosis Knowledge deficient Supporting Data Key learning need (Hospice) Management of hypertension history of non-compliance Meds Meds Nursing Diagnosis Risk for caregiver role Strain (daughter) Supporting Data

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Nursing Diagnosis Ineffective health maintenance Supporting Data

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Client/Family 75 y/o African American female with a Hospice diagnosis of rectal cancer. Daughter is primary caregiver Reason for Needing Hospice: Rectal Cancer Key Assessments:

Nursing Diagnosis Chronic confusion Supporting Data

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Nursing Diagnosis Risk for electrolyte imbalance Supporting Data

Nursing Diagnosis: risk for ineffective GI tissue perfusion Supporting Data

Nursing Diagnosis: decreased cardiac tissue perfusion Supporting Data

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TCC Nursing Program NURS 2453-Nursing Promotion for Quality of Life Teaching Plan Nursing Diagnosis Goal ____________________________________________________________________________________ Content Reference: ____________________________________________________________________________ Learner Objectives Caregiver will demonstrate understanding of the teaching content by verbalizing what blood pressure is, why compliance to the medication regime is necessary and potential complications to not complying with medication regime. Met Content 1. Provide the numeric value of the patient's BP and explain what it means (e.g., high, low, normal, borderline). Encourage patient to monitor BP at home and instruct the patient to call health care provider if BP exceeds high or low limits set by health care provider. Normal BP <120 and <80 Prehypertension 120-139 or 8089 Hypertension, stage 1 140-159 or 90-99 Hypertension, stage 2 160 or 100 (Lewis, Sharon. Medical-Surgical Nursing (with Media), 8th Edition. Mosby p. 741). 2. Inform the patient that hypertension is usually asymptomatic and symptoms (e.g., nosebleeds) do not reliably indicate BP levels. 3. Explain the potential dangers of uncontrolled hypertension. The most common complications of hypertension are target organ diseases occurring in the heart (hypertensive heart disease), brain (cerebrovascular disease), peripheral vasculature (peripheral vascular disease), kidneys (nephrosclerosis), and eyes (retinal damage) (Lewis, Sharon. Medical-Surgical Nursing (with Media), 8th Edition. Mosby p. 743). 4. Caution the patient not to stop Clonidine abruptly because withdrawal may cause a severe hypertensive reaction. Sudden discontinuation may cause withdrawal syndrome including rebound hypertension, tachycardia, headache, tremors, apprehension, and sweating. Teaching Strategy I would provide the caregiver verbal instruction as well as provide her with supplemental information in handout form if needed. I would use open ended questions and therapeutic communication.

TCC Nursing Program NURS 2453 Nursing Promotion for Quality of Life Evaluation of the Teaching

The chief learner in this teaching plan is the daughter who is the primary caregiver. Client has poor health management due to non-compliance with hypertension medication regime, I believe due to a knowledge deficit. I did not identify any readiness to learn from the caregiver but she did act surprised when the blood pressure maintains a range in the 190s systolic and in the 90s diastolic. Teaching would be held in an intimate and non-threatening part of the common such as the family room. In this instance I would choose not to include the patient in the teaching lesson simply due to the fact that the caregiver provides the daily medication to the patient. I would sit across from the caregiver and maintain non-threatening eye contact. I would include basic information regarding hypertension; material would be at a 6th grade level or less. First I would assess the knowledge of the caregiver on hypertension; judging by what she did or did not know I would tell her that blood pressure is the force exerted by the blood against the walls of the blood vessel. I would educate the caregiver that hypertension is more aggressive in African Americans and results in more severe end-organ damage. (Lewis, 2011) I would inform her that hypertension is known as the silent killer because it commonly presents with no signs and symptoms and that while the patient states she is fine she still needs to continue taking the prescribed medications. I would educate the caregiver to not to stop drugs abruptly because withdrawal may cause a severe hypertensive reaction (rebound hypertension). (Lewis, 2011) After the caregiver teaching was complete and throughout the teaching I would evaluate the caregivers understanding of the information given. I would evaluate caregivers understanding by

having her repeat the information learned. I would ask her if she understood the information given and I would ask her if she had any questions or concerns. (Lewis, 2011)

Lewis, S. (2011). Medical Surgical Nursing. St. Louis: Elsevier Mosby.

TCC Nursing Program NURS 2453 Nursing Promotion for Quality of Life

Grading Criteria for Hospice Teaching Project Student

Possible Points Earned Points

ID#

Date

22

28

30

14

6 Total 100

Assessment A. Provides a comprehensive patient history and describes the client clearly. (4) B. Systematically organizes comprehensive data using functional health patterns. (4) C. Completes and documents pertinent focused assessment data relevant to clients medical condition. (4) D. Provides research about clients acute/chronic conditions and treatment, including end-of-life considerations. (4) E. Documents research of indications for and effects of prescribed medications. (4) F. Describe laboratory and diagnostic work, including significance of abnormal results. (2) Diagnosis A. Clusters data from functional health patterns (4) B. Applies appropriate nursing diagnoses. (4) C. Prioritizes client problems (4) D. Chooses priority learning need (4) E. Selects NANDA-approved nursing diagnosis and etiology related to learning need (6) F. Teaching need is appropriate for the client (6) Planning A. Develops an overall learner goal. (6) B. Develops measurable learner-centered objectives. (6) C. Specific content is outlined and referenced. (6) D. Teaching strategies are selective and appropriate to the content and the learner. (6) E. Learning activity is directly related to clients interests, resources, and daily living patterns. (6) Implementation/Evaluation Process Evaluation A. Addresses client behaviors indicating readiness to learn (2) B. Physical/psychological barriers to learning are identified (2) C. The environment during teaching is described, include who is present (2) D. Learner reactions to presentation of content are identified, including questions, comments, and nonverbal behaviors (2) E. The level of achievement of each stated learner objective is evaluated (2) F. Addresses overall progress toward stated goal. (2) G. Describes changes student would make if experience were repeated (2) Form and Format A. References cited using APA format (3) B. Grammar and spelling correct, document is legible (3)