MANAGEMENT

Course Project:

MANAGEMENT OF THE NURSING HOME RESIDENT

Ruth Geide

ASSESSMENT:Current Complaint: FK presents today for a routine exam, to review her lab results, to review her current medications and dosages, and to obtain prescription refills. She desires a flu shot today. She has no acute complaints about her health or living arrangements at this time.

History of Present Illness: This lady was diagnosed with HTN and obesity approximately 20 years ago. She was diagnosed with DM Type 2, hyperlipidemia, and osteoarthritis about 15 years ago. She was treated for CHF 7 years ago. She has recently developed hypothyroidism and anxiety. We are currently working with her on controlling these chronic diseases with medications and lifestyle changes.

Review of Systems:

General: Denies weakness, fevers, weight loss or gain.Integument: Denies itching, rash, bruising, or lesions. Unaware of any bites-or stings.

HEENT: Right cataract; Occasional trouble hearing; mild seasonal allergies.

Cardiac: Occasional dependent pedal edema; denies palpitations or chest pain; MI 20 years ago.Respiratory: Denies cough, SOB, dyspnea, wheezing, or asthmatic symptoms.

Neurology: No history of TIAs, strokes or seizures. Occasional dysesthesias of lower extremities.

GI: Denies difficulty swallowing, reflux or changes in appetite.Occasionalconstipation.

Psych: Denies episodes of depression or suicide ideations: Son reports no mental status or personality changes. She reports taking Ativan 0.5mg BID “to take the edge off my nerves and help me sleep at night”. 

Hematology: No history of bleeding tendency, excessive bruising, or lymph gland enlargement.

Endocrine: Feels she is doing all she can to control her blood sugar levels by dieting and taking her medication as prescribed. Denies feeling jittery or fatigued due to thyroid dysfunction.

Musculoskeletal: Denies muscle aches or pains. Reports arthritic pain involving the back and knees. Denies fractures due to falls.

GU: Denies incontinence, frequency, urgency or pain on urination.

Past Medical History: Denies smoking, alcohol, and prescription or illegal drug abuse.Denies allergies to food or medication.Surgeries: Right total knee arthroplasty 2005; Prior C-sections x2. Neuro: (5/08) Carotid U/S & stress perfusion scan: <50% carotid artery disease in left internal carotid; right carotids clear. Patient had complained of dizziness and head ache of unknown origin.Ophthalmology: (4/09) Vision 20/40 with bifocals, age-related cataracts, proliferative diabetic retinopathy, hyperopia, presbyopia, & astigmatism.Dental: (5/09) Partial plates fit securely, no gum disease noted, fillings aresecure.Nephrology consult: (06/06) Crt 1.9, GFR 49.9 due to diabetic nephropathy.Cardiology 🙁 5/08) Stress Test: abnormal R wave progression, normal perfusion. EKG showed incomplete RBB from old anteroseptal MI; Echo showed normal LV function and normal valve function, EF 70%. Patient had complained of clammy skin and chest pain that was eased with NTG.Integumentary: (10/08) Removed benign fibroepithelial papilloma from abdomen.Bone Density: (03/09) Osteopenia of the left hip (-1.3 T score); Femur neck (-2.3); Ward’s score (-2.4); Lumbar spine/L1 (-1.6); Total T score of the spine (-0.2).Colonoscopy: (09/08) Mucosal lining appears pale pink and is without inflammation. There are no masses that appear abnormal.Mammogram: (10/08) Fibroglandular and fibrofatty with scattered benign and vascular and secretory calcifications in both breasts.

Current Medications:  Ativan 0.5mg 1 PO BID as needed for anxiety #60 1 refillNovolin 70/30 Pen Fill 100 unit/m1Cartridge units sq as directed #120 ml, 1 refill Actos 15mg 1 PO, once daily in the am, #90 1 refill Diovan HCT 160-25mg 1 PO once daily in the am, for HTN #90, 1 refillMetoprolol Tartrate 50mg 1 PO BID, #180, 1 refill Lasix 40mg, 1 PO once daily in the am, #90, 1 refillPotassium Chloride 10 meq Cap ER, 1 PO BID after meals with full glass of water, #180, 1 refill Vytorin 10-40mg 1 PO once daily in the evening #90, 1 refill Levoxyl 25 mcg 1 PO once daily in the am, #30, 2 refills

Social History: This patient is a retired homemaker, widow of ten years, mother of two grown sons and two daughters in-law. She is a grandmother of six grandchildren. The family all lives in Piedmont, SC. Her parents, brother, and both sisters are all deceased.

Family Apgar: Patient scored 10/10. Son scored 10/10. The patient is satisfied and grateful to her family for all their emotional and physical support. The patient considers her children and grandchildren as “close knit” and feels they are open to sharing problems and concerns with each other. Her daughters in-law include her in on church functions, community activities and all family holidays. The patient feels loved and admired by her children and grandchildren. “I always get a hug when I need it.”

Comprehensive Physical Exam:

General Survey:

Vital signs: 97°F; 64 reg.; 18 shallow & non-labored; 126/74 left arm; Height: 62 inches; Weight: 269.4 lbs. (122.45 kg); BMI: 42.44. FK is a well nourished and alert Caucasian female in no acute distress.

Integument: Warm, dry of flesh tone. No lesions, rashes, moles or dry areas noted. No bruising or discolorations noted.

HEENT: Hair healthy, scalp free of lesions; Eyes clear, red reflex noted, PERRLA. Patient wears bifocals full time. TMs clear, shiny, gray. Small amount of golden cerumen in external auditory canal. Hearing adequate at a conversational tone. Nasal mucosa pale pink, no drainage noted, septum intact. Denies sinus pain on palpation. Neck supple, no lymphadenopathy. Thyroid soft, normal size, no nodules noted on palpation. Pharynx pink and without exudate. Oral mucosa pink, free of lesions, and well hydrated.

Cardiac: S1 & S2 without murmurs, gallops, rubs. No carotid bruits. Peripheral pulses 2+. 1+ pitting. dependent edema to both ankles.

Respiratory: Clear to upper lobes and decreased to bases bilat., no respiratory distress noted.

Neuro: Cranial nerves 11-XII grossly intact. Diminished pain and sensation to both feet to light and firmtouch with monofilament.

GI: Abdomen soft, non-tender. (+) bowel sounds to all quads. No hepatosplenomegaly noted. Two small anal hemorrhoids noted on rectal exam. Stool smear collected for occult blood. OB (-).

Psych: Affect appropriate, smiles and laughs frequently. Pleasantly cooperative during the examination.

Hematology: Fasting labs as follows for 09/09 compared to last visit of 06/09.Cholesterol 09/09:143 06/09: 150Triglycerides 165 190HDL 32 35LDL 78 77CK 26 22Glucose 151 126HgA1C 7.0%7.0%BUN/Crt 24/ 1.7 32/1.8Potassium 4.0 3.7Calcium 10.0 10.1ALT 14 14TSH 3.8 4.5Stool OBNeg. Neg.U/A Protein 1+; Ketones 1+ Protein 1+; Ketones 2+GFR 47 49.4

Endocrine: DM 2, Metabolic Syndrome, and corrected hypothyroidism as per labs.

Musculoskeletal: Able to move all extremities. Shoulders have somewhat limited ROM due to arthritic changes to the joints. Gait steady without assistive device, but somewhat limited ROM due to arthritic changes in hip, knee, and ankle joints.

GU: Previous pelvic exam (06/09) showed cervical atrophy with no changes to vaginal vault.

Functional Assessment:Katz Index: Score of 5. Patient is independent with ADLs except needs help bathing, requires some assistance into and out of shower, needs minimal helpwith dressing self.MMSE: Score of 25 /30. Patient has decreased odds of dementia, is normal for a high school education, and shows no cognitive impairment.Geriatric Depression Scale: Score of 2. Patient is not at risk for depression.Tinetti Score for balance (13/16); for gait (10/12); Total Score (23/28) Patient is at moderate risk for falls.

Risk Factors Assessment:Medical/Family History: Father had DM and died of lung cancer; Mother had HTN, CAD and died of a CVA; Brother had HTN, CAD and died of MI at 44 y/o; Sister had DM, HTN, CAD and died of MI at 62 y/o;Sister had DM, HTN and died in a MVA at 58 y/o.

Medical/Personal: DM2 places her at risk for blindness, renal failure, stroke, MI, infections, amputations, foot ulcers, depression, and obesity.

Physical: Osteoarthritis, osteoporosis, lower extremity dysesthesias, neuropathy, and a sedentary lifestyle place her at risk for greater weight gain, falls, and fractures.

EVALUATION OF PATIENT:

Pathophysiology of DM 2: A type of metabolic disorder characterized by resistance of the receptors to the action of insulin, an impairment of the beta-cells to produce adequate insulin, and failure of the liver to inhibit the production of glucagon. The result is hyperglycemia that causes an increase in visceral fat, hyperlipidemia, CAD, and hypertension. Metabolic syndrome is another aspect of diabetes mellitus. Female patients present with waist circumference of >35 inches, blood pressure >130/85, triglycerides >150, LDL <150, HDL <50, fasting serum glucose >100, and may have elevated serum insulin levels.

Pathophysiology of CHF:  Heart failure is the diminished ability of the ventricle to fill and/or eject blood. The ventricle’s muscle wall is weakened over time by sustained hypertension (increased after load) or by a myocardial infarction (decreased contractility). The myocardium is unable to contract adequately to. pump blood out of the heart chambers (increased preload, S3) and becomes congested with blood. Fluid from the congested heart is trapped in the lungs (crackles) and causes shortness of breath on exertion and at rest.

Pathophysiology of HTN:  Hypertension is higher than normal pressures inside the arteries that damage the endothelium lining. Primary hypertension has an unknown cause, but is frequently associated with a family history of cardiac disease, stress, smoking, and obesity. Prolonged arterial pressures of >140/80 changes the thickness of the blood vessels and increases  atherosclerosis. These vascular changes eventually permanently damage the brain, eyes, kidneys, and heart tissues. Prolonged damage to these tissues is responsible for stroke, retinopathy, renal failure, and myocardial infarction.

Pharmacotherapeutic Evaluation:Drug Name Rationale Cost Analysis Interactions Side Effects Toxic WarningAtivan Anxiety Inexpensive Barbiturates, Drowsiness, Seizures, $4 List MAOls, blurred vision, hallucinations, Psychotropics, muscle tremors, acute Narcotics, weakness, skin tubularAntidepressants rash necrosisActos Hypoglycemic 30 tabs/$148 Isoniazid, Rhinitis, Confusion, DM Type 2 Not on $4 List Diuretics, CCBs, headache, tachycardia, Steroids, Lopid, weight gain, ,tremors, Phenothiazines, muscle pain, sweating, Synthroid, tooth blurred vision Dilantin, Versedproblems comaDiovan HCT Hypertension 30 tabs/$102 Barbiturates, Back pain, Tachy or Not on $4 List diuretics, ASA, headache, Bradycardia, NSAIDS, rash, sore fainting, rapid Narcotics, throat, drywt. gain, Muscle cough, fatigue, jaundice, Relaxants, Oral stomach pain,, seizures hypoglycemicsstuffy nose Metoprolol Hypertension Inexpensive Digoxin, Impotence, Irreg. heart $4 ListCatapres, insomnia, rate, fainting,Lamisil, Paxil, fatigue, short of breath, Insulin, CCBs, anxietyjaundice, diuretics depressionLasix Diuretic 30 tabs/ $26 Lithium, Headache, Irreg. heart Not on $4 List Digoxin, numbness or rate, muscle Steroids, tingly feeling, pain, skin rash, Edecrin, dietdizziness, hearing loss, pills, Mycins, blurred vision jaundice, ASA, Edecrin decreased urinary outputKCL Supplement Inexpensive Digoxin, Mild diarrhea, Irreg. heart $4 List Quinidine, tingling in rate, muscle Bronchodilators, hands or feet, weakness, tarry ACEIs, Diuretics mild dyspepsiastools, coffee ground emesisVytorin Lipid Lowering 30 tabs/$125- Ketoconozole, Headache,Mylagia, $150 Mycins, GI symptoms myopathy, Not on $4 List Grapefruit juice, rhabdomyolysisNiacin, Digoxin,  Cyclosporine, oral anticoags Levoxyl Thyroid 30 tabs/ $17 Lithium, Mild hair lossInsomnia, Hormone Not on $4 list amiodarone, fever, antidepressants, nervousness, calciumweight changes supplements, iron supplements, antacids Novolin 70/30 Hypoglycemic Pens:Albuterol, Hypoglycemia: Insulin Allergy: 10ml Vial/ $57 Catapres, headache, skin rash, 15ml Vial/Box Reserpine, Beta- hunger, wheezing, SOB, $107-$150 Blockers drowsiness, tachycardiablurred vision, tremors.

 Fiscal Evaluation: Receives husband’s Social Security benefits monthly._ Receives Medicare Part B. Sons supplement income to provide adequate care.

DIAGNOSIS:1. DM 2 w/ complications 250.912. HTN, benign 401.13. Heart Failure, congestive 428.04. Hyperlipidemia, mixed 272.25. Hypothyroidism, unspec. 244.96. Anxiety state, unspec. 300.07. Osteoarthritis, unspec. 715.908. Obesity, NOS 278.00

MANAGEMENT PLAN:

Diabetes: Management of her diabetes centers on glycemic control in order to prevent problems or to delay complications.> Annual eye exams by ophthalmologist to follow progression of diabetic retinopathy.> Assess GFR and albuminuria every three months to assess progression of diabetic nephropathy. Protein restriction when GFR begins-to fall below 70m1/min.Collect U/A and microalbumin specimens at each three month visit.Refer to nephrologist when GFR <70 ml/min and serum creatinine is > 2.0 mg/dl.> Hyperlipidemia goals for females: LDL < 100, HDLs > 55, Triglycerides <150.Collect lipid panel at each three month visit.

Behavioral interventions to reinforce at each routine visit:Weight loss by observing a low fat diet that limits cheese, animal fats and added butter. Increasing exercise goal to walking 30 mins. three times a week inside the facility. Goal for weight loss is a BMI of <40.Suggest a supplement of omea-3 fatty acid/fish oil.Patient must take Vytorin daily. Need- to assess CK & ALT levels every 3 mos. while on Vytorin. ^ Glycemic goals: fasting blood glucose >75, < 100, A1C < 7%.Collect fasting serum glucose level at each three month visit.Weight loss by observing and ADA diet plan that consists of complex carbohydrates, proteins, and vegetables.Monitoring of blood glucose three times a day before meals. Keep diary of all results. Review signs and symptoms of hyperglycemia and hypoglycemia with the patient.Arrange for purchase of diabetes identification bracelet.Plan to order supplies of insulin pens and blood glucose strips.^ Neuropathy requires no treatment except foot care assessment for ulcer prevention. Education on how to perform daily foot inspection by using a mirror to view her feet. Educate nursing staff on routine diabetic foot assessment protocols.Teaching points to include how to avoid foot injury or infection by: not walking barefooted, wearing well fitting shoes, wearing clean loose-fitting socks, applying daily moisturizer. ^ Annual flu shot.

Hypertension: Management of cardiovascular disease centers on effective control of blood pressure.^ Check blood pressure at each visit and in-between visits if symptomatic. Goal is to keep blood pressure <130/80.^ Assess lungs for crackles; assess heart for S3 and S4; assess carotids and abdomen for bruits at each routine visit.> Behavioral interventions to include in each three month visit:Weight loss by observing ADA and low fat dietary recommendations as above. Goal of BMI <40. DASH diet: 7-8 servings of whole grains daily; 4-5 serving of vegetables daily; 2-3 servings of dairy foods daily; 1-2 servings of lean protein daily; 4-5 servings of nuts, seeds, legumes a week. 2.4 g/ 1 tsp of sodium per day.Exercise recommendations as above for weight loss and stress reduction.> Labs to include BNP and CBC to assess electrolyte status at each three month visit.^ Continue the use of diuretics and metropolol (hx of MI) to control blood pressure and CHF.

Hypothyroidism: Management of a low thyroid condition centers on the patient’s compliance with daily medication and recognition of signs and symptoms of hyperthyroidism.^ Check TSH levels every three months during routine office visits.> Stress the importance of taking Levoxyl daily every morning.> Educate her to recognize signs and symptoms of hyperthyroidism in-between visits as medication dosage may need to be adjusted: appetite changes, nervousness, insomnia, weight loss, hair loss, dry skin, increased sweating, increased blood pressure, and heart palpitations.

Osteoarthritis/Osteoporosis:  Management of arthritis includes management of pain, joint health and flexibility by reducing weight and preventing further injury to joints.> Limit use of NSAIDs due to medication interaction with Diovan and Lasix. Rather, promote use of heat therapy to joints and elastic knee orthoses to manage pain and support joints.> Recommend stretching and mild weight bearing exercises daily to promote joint health and to reduce weight.> Recommend well-fitting shoes to prevent falls and fractures.> Bone density scan recommended every year to assess osteoporosis progression in hips.> Encourage intake of calcium and vitamin D rich foods and supplements.