DOMINICAN COLLEGEDIVISION OF NURSING

NR 223

Student: Samantha Miller Date: 11/5/2014___

Room #: 250 Patient's Initials: S.F. Age: 93/ Female ___

RR: 18bpm Temp: 97 degree F O2 sat: 89% BP: 110/60mm/Hg_

Current Diagnoses: Other and unspecified Hyperlipidemia, Depressive Disorder NEC, Dementia CCE with Behavioral Disturbances, Cerebral Thrombosis with Infarct, Essential Hypertension, Insomnia Unspecified, Delusional Disorder

Medical Diagnosis and Definition of Medical Diagnosis:Failure to Thrive r/t depressionDefinition: Subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf

Activity Level: Willingness to thrive: 3= Sometimes demonstrated Diet: Regular solids. Thin liquids with s/a by mouth. Regular

Current Treatments: (Define)1. Pain assessment 3 times per day.2. Weights: Monthly weights 1 time per day every 5th month during the day.3. Alarm: Bed alarm in place. Check placement and function 3 times per day(day,

evening, night)4. Alarm: Chair alarm in place.5. Assess: Skin and foot evaluation 1 time every Monday evening.6. Apply to sacral area topical 3 times per day during day, evening, night.

Laboratory and/or Diagnostic Tests:

Clinical Report:Glucose: 105 HI

Test Result Abnormal Reference Units Previous Result

Date

Glucose 105 HI 70-99 mg/dL 115 HI 06/02/2014Sodium 141 133-145 mmo1/L 141 06/02/2014Potassium 4.4 3.3-5.3 mmo1/L 4.6 06/02/2014Chloride 103 96-108 mm01/L 101 06/02/2014CO2 27 22-29 mmo1/L 26 06/02/2014BUN 19 8-23 mg/dL 21 06/02/2014

Creatinine 0.75 0.60-1.30 mg/dL 0.86 06/02/2014e-GFR 72 >60 mL/ min 62 06/02/2014e-GFR, African American

87 >60 mL, min 75 06/02/2014

BUN/Creat Ratio

25.3 10.0-28.0 24.4 06/02/2014

Calcium 9.0 8.6-10.4 mg/dL 9.3 06/02/2014

Current Medications

Name(generic & brand name)

Classification Dosage Action Side Effects and Contraindications

Nursing Implications

Senna (Sennosides)

Laxative PO 2 tablets, 5 mL of granules or 10 to 15 mL of syrup, usually at bedtime (max, 15 mL twice daily of syrup).

PR 1 suppository at bedtime; may repeat in 2 h.

Directly acts on intestinal mucosa by altering water and electrolyte secretion, inducing peristalsis and defecation.

Nausea, vomiting, or other symptoms of appendicitis; acute surgical abdomen; fecal impaction; intestinal obstruction; undiagnosed abdominal pain

Administer at bedtime on empty stomach.

Shake liquid solution before administering.

Dissolve granules before administering.

Give oral dosages with full glass of water or juice.

Administer suppository with patient lying on left side.

Fluticasone propionate (FLONASE)

Respiratory inhalant combination

Inhalation 1 inhalation (250/50) twice daily (morning and evening, approximately 12 h apart)

Inhibits multiple cell types (eg, mast cells) and mediator production or secretion (eg, histamine) involved in the asthmatic response.

Primary treatment of status asthmatics or other acute episodes of asthma or COPD in which intensive measures are required; hypersensitivity to any component of the product; severe hypersensitivity to milk proteins (Advair Diskus).

Prime aerosol inhalation before using the first time by releasing 4 test sprays into the air away from face, shaking canister well for 5 sec before each spray.

If inhaler has not been used for more than 4 wk or if it is dropped, prime inhaler again by shaking well before each spray and releasing 2 test sprays away from the face.

Shake inhaler well for 5

sec before use.

Simvastatin(Zocor)

Antihyperlipidemic

Usual dosage range: 5 to 40 mg orally once a day in the evening.Patients with CHD or at high risk of CHD:Initial dose: 10 to 20 mg orally once a day in the evening started simultaneously with diet and exercise.Patients at high risk for a CHD event due to existing CHD, diabetes, peripheral vascular disease, history of stroke or other cerebrovascular disease:Initial dose: 40 mg orally once a day in the evening

Inhibits HMG-CoA reductase enzyme, which reduces cholesterol synthesis

Pregnancy (X), breastfeeding, hypersensitivity, active hepatic diseaseSide effects: CNS: Headache, cognitive impairmentGI: Nausea, constipation, diarrhea, dyspepsia, flatus, abdominal pain, liver dysfunction, pancreatitis, hyperglycemiaINTEG: Rash, pruritusMS: Muscle cramps, myalgia, myositis, myopathyRESP: Upper respiratory tract infection

Assessment History: Allergy to

simvastatin, fungal byproducts; impaired hepatic function; pregnancy; lactation

Physical: Orientation, affect; liver evaluation, abdominal examination; lipid studies, liver function tests

Interventions Ensure that patient has

tried a cholesterol-lowering diet regimen for 3–6 mo before beginning therapy.

Give in the evening; highest rates of cholesterol synthesis are between midnight and 5 AM.

Advise patient that this drug cannot be taken during pregnancy; advise patient to use barrier contraceptives.

Arrange for regular follow-up during long-term therapy. Consider

reducing dose if cholesterol falls below target.

Teaching points

Take drug in the evening. Do not drink grapefruit juice while using this drug.

Have periodic blood tests. This drug cannot be taken

during pregnancy; using barrier contraceptives is recommended.

You may experience these side effects: Nausea (eat frequent small meals); headache, muscle and joint aches and pains (may lessen); sensitivity to light (use a suncreen and wear protective clothing).

Report severe GI upset, changes in vision, unusual bleeding or bruising, dark urine or light-colored stools, fever, muscle pain, or soreness.

LOZENGES

Oral anesthetic

Allow 1 lozenge (10-15 mg) to dissolve slowly in mouth; may repeat

Ester local anesthetic blocks both the initiation

Numbness of the mouth or throat.Severe allergic reactions

Assessment (Pre-administration):VS, monitor for dyspnea, weakness, tachycardia.

(Benzocaine-Menthol)

every 2 hours as needed.

and conduction of nerve impulses by decreasing the neuronal membrane’s permeability to sodium ions, which results in inhibition of depolarization with resultant blockage of conduction.

(rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue).

Why hold or not give this med?S/S of hypersensitivity

Evaluation:Check after giving.

Improvement of throat irritation.

CLOPIDOGREL (Plavix)

Platelet aggregation inhibitor

Recent MI, stroke, peripheral arterial disease, TIA: Adult:PO 75 mg/day with/without aspirin.Acute coronary syndrome: PO loading dose 300 mg then 75.

Inhibits ADP-induced platelet aggregation

Hypersensitivity, active bleedingSide effects: CNS: Headache, dizziness, depression, syncope, hypoesthesia, neuralgia, confusion, hallucinationsCV: Edema, hypertension, chest painHEMA: Epistaxis, purpura

Assessment & Drug Effects

Carefully monitor for and immediately report S&S of GI bleeding, especially when coadministered with NSAIDs, aspirin, heparin, or warfarin.

Lab tests: Periodic platelet count and lipid profile.

Evaluate patients with unexplained fever or infection for myelotoxicity.

Patient & Family Education

Report promptly any unusual bleeding (e.g.,

black, tarry stools). Avoid chronic aspirin or

NSAID use unless approved by physician.

Do not breast feed while taking this drug.

Dominican CollegeDivision of Nursing

Nursing Care Plan

Student: _Samantha Miller_________________________ Client's Initials: S.F.____________ Date: 11/5/2014_____________

ASSESSMENT NURSING DIAGNOSIS

GOALS & OUTCOME CRITERIA

NURSING ACTIONS RATIONALE EVALUATION

Subjective Data:1. “It feels like a prison in here”2. “I don’t like it here”3. “I don’t want any friends”

Objective Data:1. Slumps in her wheelchair2. Does not speak unless spoken to3. Does not want to participate in any activities4. Seems to be in pain at times.

P: The patient is sad and does not want to participate in any activities or have any friends.

E: This patient was in the Holocaust and is having problems in her new environment, saying “it feels like a prison in here” is probably saying she is having flashbacks of the Holocaust being here in the nursing home. She does not want to be monitored all the time, she wants to

Goal:1. Get patient not to slouch so much by having them be more active.

1. Teach alternative coping strategies such as physical activity.

1. EBN: As the number of minutes of exercise increased, hopelessness decreased in prison inmates (Cashin, Potter, & Butler, 2008). EB: In college students, physical activity each week was associated with decreased feelings of hopelessness (Taliaferro, Rienzo, & Pigg,

be free.S: The fact that she slouches, does not speak, and does not participate in activities shows that she is depressed.

2. Patient will verbalize importance of communicating with others.

3. Patient will be free of any pain which will give the patient the will to be more active and be in a good mood.

2. Educate patient on the importance of communicating with others.

3. Assess for pain and respond with appropriate measures for pain relief.

2008).

2. EBN: Accurate information allows the redefining and transforming of hope (Duggleby & Wright, 2005; Duggleby, Williams, & Wright, 2009). EB: Educational interventions may decrease hopelessness related to the threat of breast cancer in young women (Fry & Prentice-Dunn, 2006).

3. EB: Pain that interferes with mood and enjoyment in life results in feelings of hopelessness for clients with

Outcome Criteria: Decision-Making, Hope, Mood Equilibrium, Good Nutritional StatusHas a presence of Hope as evidenced by the following indicators: Expresses expectation of a positive time spent in the home/Expresses faith/Expresses will to participate.

advanced cancer (Mystakidou et al, 2007b).