patient care plan.2
DESCRIPTION
Care Plan 2TRANSCRIPT
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CSU, STANISLAUS B.S.N. CLINICAL PLAN OF CARE
Student : Maggie Fabry Date of Care: 10/11/13 Room Number: 340
Patient Data Admitting Diagnosis : R humeral head fracture Age: 64 Spiritual Focus: Hindu Culture: Hindu Patient Initials: DJ Gender: F Height : 5 ft 1 in Weight: 159 lbs Admitting Date: 10/09 POD: 1 Vital Signs: T: 36.6 P: 89 R: 18 B/P: 141/78 O2 Sat: 99 Pain Scale: 9 Past Medical History: DM type 2, HTN, hyperlipidemia, nonalcoholic fatty liver disease Surgical History: R shoulder, rotator cuff surgery Diet: NPO pre-surgery, vegetarian diet post-surgery Activity: bedrest. Up with one person assist Foley: Y NG/Feeding Tube: N Advance Directives: No Drains/ Tubes: 2 L NC Code Status: Full VS Freq: Q6hr Glucose Monitoring: Y TEDs/SCDs: N Vascular Access: PCA/Epidural: N Telemetry: Y IV Site: 22 gauze IV in L forearm IV Solution: NS 1000mL Safety Considerations: Fall risk Dressing Change: N Labs to be drawn: none scheduled Scheduled Procedures: R humeral head surgery 10/10/13 Notes on pathophysiology: Type 2 diabetes: Diabetes is a problem with your body that causes blood glucose (sugar) levels to rise higher than normal. This is also called hyperglycemia. Type 2 diabetes is the most common form of diabetes. If you have type 2 diabetes your body does not use insulin properly. This is called insulin resistance. At first, your pancreas makes extra insulin to make up for it. But, over time it isn't able to keep up and can't make enough insulin to keep your blood glucose at normal levels. HTN: High blood pressure. The force of blood against artery walls is too high and can cause health problems. The more blood your heart pumps and the narrower the arteries, the higher the blood pressure
Hyperlipidemia: involves abnormally elevated levels of any or all lipids and/or lipoproteins in the blood.[1] It is the most common form of dyslipidemia (which includes any abnormal lipid levels). Lipids (fat-soluble molecules) are transported in a protein capsule. The size of that capsule, or lipoprotein, determines its density. The lipoprotein density and type of apolipoproteins it contains determines the fate of the particle and its influence on metabolism. Hyperlipidemias are divided in primary and secondary subtypes. Primary hyperlipidemia is usually due to genetic causes (such as a mutation in a receptor protein), while secondary hyperlipidemia arises due to other underlying causes such as diabetes. Lipid and lipoprotein abnormalities are common in the general population, and are regarded as a modifiable risk factor for cardiovascular disease due to their influence on atherosclerosis. In addition, some forms may predispose to acute pancreatitis.
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Nonalcoholic fatty liver diease: Non-alcoholic fatty liver disease (NAFLD) is the build up of extra fat in liver cells that is not caused by alcohol. It is normal for the liver to contain some fat. However, if more than 5% - 10% percent of the liver’s weight is fat, then it is called a fatty liver (steatosis). NAFLD tends to develop in people who are overweight or obese or have diabetes, high cholesterol or high triglycerides. Rapid weight loss and poor eating habits also may lead to NAFLD.
Lab and Diagnostic Test Data Test
type(date) Normal Range Patient Results Trend
↓↑ Rationale
(specific to pt.) Nursing Implications related to patient care &
teaching Glucose 74-118 10/09 0119: 158
10/09 0422: 135 10/10 0400: 152
↑ Monitoring blood glucose levels
because pt is a type ll diabetic. Also
monitoring because many drugs the pt is taking can alter blood
glucose levels. Levels are controlled
by insulin and glucagon.
Pt blood glucose levels are slightly above normal limits. Monitor glucose levels closely for further increases.
Administer prescribed Insulin as needed and as dictated by the sliding scale. Signs of hyperglycemia include
frequent urination, increased thirst, blurred vision and headache. Signs of hypoglycemia include confusion, abnormal behavior, vision disturbances, shakiness,
anxiety and sweating.
BUN 8-26 10/09 0119: 20 10/09 0422: 23 10/10 0400: 20
↓ Used to monitor kidney function. This
test also monitors liver function. Pt has an elevated BP and
chronic htn. This can
Pt is within normal limits. A decrease could indicate malnutrition. Could also be due to her high BP. Monitor s/s of kidney malfunction such as nausea, vomiting, or
abdominal pain. Monitor other electrolyte levels to ensure nutrition. An increase could indicate dehydration
or GI bleeding.
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Test type(date)
Normal Range Patient Results Trend ↓↑
Rationale (specific to pt.)
Nursing Implications related to patient care & teaching
cause kidney disease, so function must be monitored.
Creatinine 0.44-1.00 10/09 0119: 0.84 10/09 0422: 1.11 10/10 0400: 0.90
↓ Used to monitor kidney function/
diagnose impaired function. Pt has an
elevated BP and chronic htn can cause kidney
disease, so function must be monitored.
Pt is slightly above normal limits. Will closely monitor for changes. An increase in levels could indicate kidney
disease or dehydration. Monitor s/s such as low output, low appetite, nausea and vomiting, and persistent fatigue.
A decrease could indicate malnutrition or severe liver disease or muscle dystrophy. Monitor s/s such as
nausea, vomiting, abdominal pain or jaundice or frequent falls or waddling gait.
eGFR >60 10/09 0119: >60 10/09 0422: 49 10/10 0400: >60
↑ Used to monitor kidney function and evaluate stages of
kidney failure.
Pt is now WNL. If levels fall consistently, kidney failure could be indicated. However, antibiotic treatment can
sometimes alter labs. Use creatinine levels to confirm. Watch for s/s of kidney disease such as low output, low appetite, nausea and vomiting, and persistent fatigue.
Note that age, gender, height, race and weight can influence the glumerular filtration rate.
Sodium 136-145 10/09 0119: 130 10/09 0422: 132 10/10 0400: 136
↑ Used to monitor fluid and electrolyte
balance. This pt has DM and HTN which
can both effect sodium.
Pt levels slightly low, but slowly increasing. Watch for a decrease (hypoatremia) and s/s such as weakness,
fatigue, headache, nausea and vomiting, muscle cramps, irritability, and confusion. Low sodium levels can indicate dehydration or low sodium intake. This pt was NPO pre
surgery, so this may have caused the low levels. Pt teaching about how hydrating can prevent low sodium
levels. Potassium 3.6-5.1 10/09 0119: 4.6
10/09 0422: 5.1 10/10 0400: 4.6
↓ Used to ensure electrolyte balance. Hold meds if levels
are abnormal or nearly abnormal. This
is electrolyte is important to cardiac
function and is especially important
in patients taking diuretics or digoxin.
Pt WNL. An increase in these levels could indicate kidney disease. Monitor s/s such as low output, low
appetite, nausea and vomiting, and persistent fatigue. A decrease in levels could indicate excessive potassium
loss in the urine. This could be due to a large variety of issues such as GI disorders, renal tubular acidosis, or
hyperaldosteronism. Monitor s/s such as muscle aches, abnormal weakness, arrhythmias, diarrhea, and nausea and vomiting. Know which meds to hold if levels are not
WNL.
Chloride 101-111 10/09 0119: 99 10/09 0422: 100 10/10 0400: 105
↑ Used to monitor electrolyte balance.
Chloride follows
Pt levels slightly low. Decreased levels could indicate over hydration, CHF, vomiting, diarrhea, chronic
respiratory alkalosis, hypokalemia, or burns. Monitor for
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Test type(date)
Normal Range Patient Results Trend ↓↑
Rationale (specific to pt.)
Nursing Implications related to patient care & teaching
sodium, and water moves with both electrolytes. As a
result, chloride effects water
balance. It also helps the acid base
balance in the body. Chloride is controlled
by the kidneys, so abnormal levels can
indicate renal problems.
s/s of hypochloremia such as hyperexcitability of the nervous system and muscles, shallow breathing,
hypotension and tetany. Hyperchloremia can be indicated through s/s such as lethargy, weakness and deep
breathing. Monitor for these signs and symptoms and continue to check lab values for changes
Carbon Dioxide 22-32 10/09 0119: 23 10/09 0422: 25 10/10 0400: 25
↑ Used to monitor acid base balance in the body as well as to assist in evaluating
the pH.
Pt is WNL. Watch levels to ensure they do not increase. s/s include rapid respiration, rapid pulse rate, and SOB.
As CO2 levels increase, there could be a reduction in pt’s over all LOC. Monitor levels for any dramatic increases because it could lead to respiratory arrest. S/s of low
CO2 levels (respiratory alkalosis) include confusion, hand tremor, light headedness or nausea and vomiting.
Anion Gap 5.0-15.0 10/09 0119: 12.6 10/09 0422: 12.1 10/10 0400: 10.6
↓ Used to monitor acid base balance
Pt is WNL. An increase could indicate lactic acidosis or kidney failure. S/s would include headache, palpitations,
chest pain as well as kidney disease s/s. A decrease could indicate a low sodium blood level or bone marrow
cancer. Calcium 8.9-10.3 10/09 0119: 9.4
10/09 0422: 9.5 10/10 0400: 8.3
↓ Used to monitor parathyroid function
and calcium metabolism. Also used to monitor kidney function.
Pt is WNL. Low levels may be a result of malabsorption syndrome, hypoalbumenia, end stage kidney disease,
post thyroidectomy, hypoparathyroidism, vitamin D deficiency, inadequate intake, pancreatitis, low
phosphate, meds that block parathyroid function prevent absorption of Ca. S/s of progressing hypocalcemia would include tingling in hands, feet or lips, muscle spasms or slow uneven heart beat. An increase in levels may be caused by hyperparathyroidism, metastatic tumor to
bone, prolonged immobilization, vitamin D intoxication, lymphoma, acromegaly. Symptoms of hypercalcemia are
usually not significant, unless severe hypercalcemia results, which may cause generalized symptoms such as
GI disturbances, fatigue, and like with hypocalcemia, muscle twitching.
Total Protein 6.1-7.9 10/09 0119: 7.1 Used to diagnose, Pt WNL. A decrease in levels could indicate malnutrition.
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Test type(date)
Normal Range Patient Results Trend ↓↑
Rationale (specific to pt.)
Nursing Implications related to patient care & teaching
evaluate and monitor disorders such as liver dysfunction, impaired nutrition,
and protein-wasting states.
S/s to watch for would include weight loss, weakness or muscle fatigue, increased susceptibility to infections, or delayed healing of even small wounds. An increase in
levels could indicate dehydration or inflammatory disease. Inflammatory diseases are characterized by
episodes of inflammation that result in fever, rash or joint swelling. Will monitor lab values and use albumin and
globulin levels to confirm any abnormalities. Albumin 3.5-4.8 10/09 0119: 4.0 Just like the total
protein test, this test is used to diagnose, evaluate and monitor
disorders such as liver dysfunction, impaired nutrition,
and protein-wasting states.
Pt WNL. A decrease in levels could indicate malnutrition. S/s to watch for would include weight loss, weakness or muscle fatigue, increased susceptibility to infections, or delayed healing of even small wounds. An increase in
levels could indicate dehydration or inflammatory disease. Inflammatory diseases are characterized by
episodes of inflammation that result in fever, rash or joint swelling. Will monitor lab values and use total protein
and globulin levels to confirm any abnormalities. Globulin 2.3-3.5 10/09 0119: 3.1 Just like the total
protein test and albumin, this test is used to diagnose,
evaluate and monitor disorders such as liver dysfunction, impaired nutrition,
and protein-wasting states.
Pt WNL. A decrease in levels could indicate malnutrition. S/s to watch for would include weight loss, weakness or muscle fatigue, increased susceptibility to infections, or delayed healing of even small wounds. An increase in
levels could indicate dehydration or inflammatory disease. Inflammatory diseases are characterized by
episodes of inflammation that result in fever, rash or joint swelling. Will monitor lab values and use albumin and
total protein levels to confirm any abnormalities.
ALB/GLOB ratio 0-35 10/09 0119: 1.3 Used in the evaluation of pts that are expected to have
hepatocellular diseases
Pt WNL. An increase could indicate liver disease. Signs to watch for include loss of appetite, loss of energy,
weight loss, jaundice, or fluid retention. A decrease could indicate renal disease. S/s to watch for will include low
output, low appetite, nausea and vomiting, and persistent fatigue
Alkaline Phosphatase
38-126 10/09 0119: 66 Used to detect and monitor diseases of
the liver or bone.
Pt WNL. An increase in these levels could indicate primary cirrhosis or bone disease. S/s of cirrhosis
include loss of appetite, loss of energy, weight loss, jaundice, or fluid retention. S/s of bone disease would
include pain, weakness or tingling in the affected area. A decrease in levels could indicate malnutrition. These s/s
include weight loss, weakness or muscle fatigue, increased susceptibility to infections, or delayed healing
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Test type(date)
Normal Range Patient Results Trend ↓↑
Rationale (specific to pt.)
Nursing Implications related to patient care & teaching
of even small wounds. AST/SGOT 15-41 10/09 0119: 53 Test primarily used in
the evaluation of pts with suspected hepatocellular diseases. The amount of AST
elevation is directly related to the number of cells affected by a
disease or injury. Because this enzyme
is found in skeletal muscle and because
this pt just had a bone fracture, the test was indicated.
Pt levels above normal. This is mostly like due to her recent skeletal muscle trauma. Levels should decrease as the fracture heals. Monitor pt for healing progress and check lab value regularly to assess progression. If levels
were low, acute renal disease or diabetic ketoacidosis could be indicated.
ALT/SGPT 14-54 10/09 0119: 59 Used to identify hepatocellular
diseases of the liver or to monitor the improvement or
worsening states of these diseases
Pt levels are above normal. This could indicate cirrhosis, hepatic tumor or obstructive jaundice. A further increase could indicate hepatitis. Signs to watch for include loss of
appetite, loss of energy, weight loss, jaundice, or fluid retention. Another set of labs was not completed for this
pt. Plan to watch for these signs and symptoms and inquire about the test during my next trip to the hospital.
Bili Total 0.4-2.0 10/09 0119: 0.8 This is yet another test to evaluate liver
function.
Pt WNL. An increase in this level could indicate liver disease. S/s would include loss of appetite, loss of
energy, weight loss, jaundice, or fluid retention. Will watch for s/s and monitor pt closely.
White Blood Cell Count
4.8-10.8 10/09 0119: 14.2 10/09 0422: 15.5 10/10 0400: 9.4
↓ Used to help in the evaluation of
infection, neoplasm, allergy or
immunosuppression.
Pt was above normal levels pre-surgery, but levels have lowered since the surgery was performed. An increase
could indicate infection, dehydration, allergy or immunosuppression. S/s would include malaise or fever.
Will monitor pt for s/s of infection and will assess new labs as they come. A decrease could indicate drug
toxicity, bone marrow failure, or a dietary deficiency. S/s would include bleeding or bruising.
Red Blood Cell Count
3.80-5.40 10/09 0119: 4.13 10/09 0422: 4.04 10/10 0400: 3.33
↓ Measurement of the amount of red blood
cells in peripheral blood. Closely related
to hemoglobin and
Pt levels were WNL pre-surgery and slightly low post-op. This decrease could simply indicate blood loss due to
surgery. In general, a decrease could indicate anemia, renal disease, or bone marrow failure. S/s would depend
on the disease process being indicated. An increase
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Test type(date)
Normal Range Patient Results Trend ↓↑
Rationale (specific to pt.)
Nursing Implications related to patient care & teaching
hematocrit levels. Conducted as a routine part of a complete blood
count. Also used to check for anemia.
could indicate severe COPD of severe dehydration. S/s of increased severity of COPD include an ongoing cough that produces a lot of sputum, SOB, wheezing or chest
tightness.
Hemoglobin 11.5-15.5 10/09 0119: 12.5 10/09 0422: 12.3 10/10 0400: 10.3
↓ Used to monitor the oxygen-carrying
capacity of the blood
Pt WNL. A high number could indicate congenital heart disease, COPD, or dehydration. Symptoms of high levels
include dysfunctional cognition, dizziness, mental confusion, peripheral cyanosis, slow blood clotting times,
swelling and sudden numbness. A decrease could indicate anemia, renal disease, or bone marrow failure. Low levels are seen as pale skin, nail beds and gums,
shortness of breath, cardiac symptoms like palpitations, chest pain and aggravation of heart problems. I will
monitor labs for changes. Hematocrit 35-47 10/09 0119: 38.4
10/09 0422: 37.3 10/10 0400: 31.0
↓ This test closely reflects the
hemoglobin values. Used as a rapid,
indirect measurement of RBC number and volume, integral part
of evaluation of anemic patients.
Pt shows drop in levels post-op. This drop indicates a loss of blood during the surgery. Normally, a drop in levels could indicate anemia, renal disease, or bone
marrow failure. S/s would include constant fatigue and tiredness, pale skin, shortness of breath, hair loss,
worsening heart problems, and faster heart palpitations. An increase could indicate severe COPD or severe
dehydration or CHF.
Red Cell Distribution
Width
11.5-15.5 10/09 0119: 13.0 10/09 0422: 13.1 10/10 0400: 12.8
↓ This is an indication of the variation of
RBC size. Used to classify anemias.
Pt is within normal limits. When values are normal the anemia is said to be normochromic (hemolytic anemia).
An increase level in RDW could indicate a large variety of different kinds of anemia. S/s would include easy fatigue
and a loss of energy, SOB, dizziness and pale skin. Platelet Count
Auto 130-400 10/09 0119: 209
10/09 0422: 220 10/10 0400: 152
↓ Used to monitor platelet number in the blood. Used in this pt
to monitor risk for bleeding because they are receiving
heparin and because she is post-op.
Pt WNL. An increase could indicate anything from malignant disorder like leukemia or lymphoma to
rheumatoid arthritis. A decrease could indicate immune thrombocytopenia in which antibodies would be
destroying the body’s platelets, bleeding or infection. Monitor for s/s such as easy or excessive bruising,
superficial bleeding into the skin, or blood in urine or stools. Will monitor levels for changes and look for s/s
associated with abnormal levels Neutrophils % 42-75 10/09 0119: 83.3
10/09 0422: 78.5 ↑ Neutrophils primarily
fight acute bacterial Pt levels are high. High levels can suggest acute
bacterial infection as well as fungal infections. Levels
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Test type(date)
Normal Range Patient Results Trend ↓↑
Rationale (specific to pt.)
Nursing Implications related to patient care & teaching
10/10 0400: 84.2 infections and fungal infections. This pt
had a bone fracture and is therefore at risk for infection.
may be high due to the pt’s recent fracture and then a corrective surgery that followed. Will continue to monitor
labs to ensure that levels return to normal in a timely fashion. Pt being prescribed Ancef. Low levels could indicate sepsis or radiation therapy, aplastic anemia,
chemotherapy and influenza. Lymphocytes % 16-50 10/09 0119: 10.2
10/09 0422: 15.2 10/10 0400: 10.0
↓ Lymphocytes primarily fight chronic infection and acute viral infections. This
pt had a bone fracture and is
therefore at risk for infection.
Pt levels slightly low. Low levels can suggest immunosuppression, leukemia, sepsis, immunodeficiency
diseases, later stages of HIV infection, drug therapy (aderenocorticosteroids, antineoplastics), and radiation
therapy. S/s would depend on the disease being indicated. Elevated levels indicate chronic bacterial
infection, viral infection, lymphocytic leukemia, multiple myeloma, infectious mononucleosis, radiation, and
infectious hepatitis. Will monitor levels for improvements or for a worsening condition.
Neutrophils # 1.4-6.5 10/09 0119: 11.8 10/09 0422: 12.2 10/10 0400: 7.9
↓ Neutrophils primarily fight acute bacterial infections and fungal
infections. This pt had a bone fracture and is therefore at risk for infection.
Pt levels are high but decreasing. High levels can suggest acute bacterial infection as well as fungal
infections. Levels may be high due to the pt’s recent fracture and then a corrective surgery that followed. Will
continue to monitor labs to ensure that levels return to normal in a timely fashion. Pt being prescribed Ancef. Low levels could indicate sepsis or radiation therapy,
aplastic anemia, chemotherapy and influenza. NRBC # 0 10/09 0119: 0
10/09 0422: 0 10/10 0400: 0
This is a tool used to indicate a situation in
which a serious underlying disease could be present.
Pt at normal limit. The presence of nucleated red blood cells could indicate a variety of problems such as bone
marrow replacement, anemia, asplenia, hypoxia or extramedullary hematopoiesis.
Medication Allergies: NONE Medications
Generic & Trade Name Drug classification
(Therapeutic & Pharmacologic)
dose/Route Frequency
Action of drug and Rationale (specific to Pt)
Significant Side Effects Nursing Implications related to patient care and teaching
Atorvastatin Calcium 10mg/PO/Q48HR Inhibits HMG-CoA reductase and
cholesterol synthesis in the liver and
increases the number
Diarrhea, arthralgia, myalgia, UTI, nasopharyngitis, pain in extremity, increased liver enzymes, systemic lupus, rhabdomyolysis, rupture of
tendon, hemorrhagic cerebral infarction
May be taken at any time of the day with or without food. Monitor lipid panel 2 to 4
weeks after initiation and 2 to 4 weeks after dose adjustment. Monitor liver
function tests. Instruct pt to report s/s of
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of hepatic LDL receptors on the cell-surface to enhance
uptake and catabolism of LDL,
thus lowering plasma lipoprotein and
cholesterol levels.
Used to lower pt’s cholesterol due to her
history of hyperlipidemia.
myopathy or rhabdomyolysis such as muscle pain, tenderness, weakness, and
fever. Counsel pt to avoid excessive quantities of alcohol to reduce risk of
hepatotoxicity. Instruct pt not to consume grapefruit or grapefruit juice
with this drug. Provide pt teaching about alternate ways to lower cholesterol such as dietary changes and to incorporate
omega- 3 fatty acids regularly.
Normal Saline (NaCl 0.9%)
Electrolyte replacement; sodium salt
1,000mL/IV/Q12H PRN
Replaces sodium and chloride and
maintains levels
To help with IV patency and to
promote hydration.
Aggravation of heart failures, hypernatremia, pulmonary edema, local tenderness, tissue necrosis at injection
site, abscess
Monitor electrolytes. Teach pt to report any reverse reactions. Monitor for signs
of edema. Monitor injection site.
Normal Saline Add
Cefazolin Sodium (Ancef)
Antiinfective; cephalosporin
100mL/IVPB Two doses post-
op
Inhibits bacterial cell wall synthesis leading
to cell death.
Used to prevent infection in pt’s
fracture post-op.
Headache, dizziness, weakness, seizures, fever, chills, diarrhea,
anorexia, pain, bleeding, increased AST, ALT, bilirubin,
pseudomembranous colitis, proteinuria, increased BUN, renal failure,
nephrotoxicity, leukopenia, neutropenia, lymphocytosis, hemolytic anemia,
dyspnea, serum sickness, superinfection, Stevens-Johnson
syndrome
Assess for sensitivity to penicillin and other cephalosporins. Assess for
nephrotoxicity symptoms like increased BUN and urine output. Assess for
anaphyalxis and bleeding (ecchymosis, bleeding gums, hematuria, stool guaiac daily). Check I&O daily, blood studies (AST, ALT, CBC, Hct, LDH, asl phos, Evaluate for decreased symptoms of infection. Perform teaching on eating
yogurt or buttermilk to maintain intestinal flora/decrease diarrhea. Pt teaching
about taking medication as prescribed and about finishing entire regimen.
Instruct pt to report sore throat, bruising, bleeding or joint pain. Know that this
drug may cause diarrhea, nausea, vomiting or thrombocytopenia. After
reconstitution, shake well. Administer drug immediately after reconstitution.
Dilute reconstituted solution in 50 to 100 mL NS. Infuse drug over 30 minutes.
Losartan Potassium (Cozarr)
50mg/PO/daily Deters vasoconstriction and
Chest pain, hypotension, hypoglycemia, diarrhea, anemia, asthenia, dizziness,
Drug may be taken with or without food. Monitor BP and HR during treatment
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Angiotensin ll receptor
agonist; antihypertensive
aldosterone-secreting effects by specifically
intercepting the binding of angiotesin
ll to the AT(1) receptor.
Used to manage pt’s
hypertension.
cough, fatigue, hepatotoxicity, rhabdomyolysis, acute renal failure,
angioedema.
especially if or when dose is adjusted. Monitor renal function and electrolyte panel. Be aware that drug can cause hypoglycemia, so concurrent use with
insulin requires careful consideration. Pt should avoid activities requiring
coordination until drug effects are realized. Instruct pt to report s/s of
hypotension such as dizziness,blurry vision, confusion, weakness, fatigue or
nausea. Advise pt against sudden discontinuation of the drug. Provide pt teaching on lifestyle changes such as a diet low in salt and high in vegetables as
well as implementation of an exercise regimen. Pt should consult dr before
using potassium supplements or potassium-containing salt substitutes.
Escitalopram Oxalate (Lexapro)
Selective serotonin reuptake inhibitor;
antidepressant
10mg/PO/QAM Enhances serotonergic activity
in the CNS as a result of its inhibition of serotonin reuptake
in CNS neurons.
Used for anxiety.
Diaphoresis, abdominal pain, constipation, diarrhea, indigestion,
nausea, vomiting, xerostomia, dizziness, headache, insomnia, reduced libido, fatigue, worsening depression or
suicidal thoughts.
Monitor pt closely for clinical worsening, suicidality, or unusual changes in
behavior. Family and caregivers should be advised of the need for close
observation and communication with prescriber. Advise pt not to drink alcohol while taking medication. Use precaution when withdrawing medication. Gradual
withdraw should be used whenever possible. Monitor for s/s of resolution
which would indicate drug efficacy. Counsel pt to report s/s of serotonin
syndrome such as high fever, agitation, confusion, hallucinations, hyperreflexia, nausea, vomiting or diarrhea. Advise pt that concomitant use of aspirin, NSAIDS
or heparin can increase the risk of bleeding. May take med without regard to
meals. Docusate Sodium (Colace)
Laxative, emollient, stool
softener; anionic surfactant
40mg/PO/daily Increases water, fat penetration in
intestine; allows for easier passage of
stool.
Used to prevent
Bitter taste, throat irritation, nausea, anorexia, cramps, diarrhea, rash
Assess for the cause of constipation in the pt. Assess for therapeutic effect
(decrease in constipation, increase in BMs). Monitor pt for cramping, rectal
bleeding, nausea, vomiting. Discontinue use if these effects occur. Advise pt that med may take up to three days to soften
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constipation caused by use of analgesics
and opioids. Pt’s immobility can also cause constipation.
stools. Instruct pt not to use in the presence of abdominal pain, nausea or
vomiting. Take with a full glass of water, may be diluted in milk or juice, do not
admin within 2 hours of another laxative. Assess for abdominal distension, bowel
sounds, and usual pattern of bowel function. Advise pt to only use for short
term therapy because long term can result in electrolyte imbalances and
dependence. Pantopazole Sodium
(Protonix)
Antiulcer agents; proton-pump inhibitors
40mg/PO/daily Binds to an enzyme in the presence of acidic gastric pH,
preventing the final transport of hydrogen ions into the gastric
lumen.
Used to prevent ulcers and irritation
due to use of excessive meds at
one time. Commonly given to pts staying at
hospital.
Headache, abdominal pain, diarrhea, flatulence, hyperglycemia,
hypoglycemia, C-diff diarrhea, Stevens-Johnson syndrome
Watch for s/s of anaphylactic reaction such as rash or hives, angioedema, and
SOB. These reactions are more common when giving med IV. Assess pt routinely for epigastric or abdominal pain
and for frank or occult blood in stool, emesis, or gastric aspirate. Warn pts to report diarrhea that does not improve.
Oral tablets may be taken with or without food. If using delayed-release, swallow whole and do not split, crush or chew.
Influenza Virus Vaccine (Fluvirin)
Vaccine
0.5mL/IM/once Live attenuated influenza vaccine viruses replicate primarily in the
ciliated epithelial cells of the
nasopharyngeal mucosa to induce
immune responses (via mucosal
immunoglobulin [Ig]A, serum IgG
antibodies, and cellular immunity),
but LAIV viruses do not replicate well at
the warmer temperatures found
Stevens-Johnson syndrome, anaphylaxis, fatigue, fever, headache,
erythema at injection site or tenderness.
Inject into the deltoid muscle. EMC protocol: MAKE SURE DOCTOR HAS ORDERED VACCINE AND THAT PT
HAS SIGNED AN INFORMED CONSENT DOCUMENT! Explain
procedure to pt. Prepare medication and select an appropriately sized needle. Cleanse skin with antiseptic. Remove
needle from protector and expel any air from the syringe. Inject needle into skin at 90 degree angle. Do not aspirate with
deltoid muscle injections. Withdraw needle and activate safety device.
Massage area gently and inform pt that they may experience muscle soreness for a few days following the injection.
Advice pt to report any unusual or severe reactions following the vaccination.
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in the lower airways and lung. During the course of replication, all LAIV viral proteins would be presented
to the immune system in their native conformation and in
the context of histocompatibility
proteins.
Given to prevent this pt from getting the
influenza virus. Dextrose 50%- water
(Glutose)
Monosaccharide; carbohydrate caloric
nutritional supplement
12.5 GM/IVP PRN Prevents protein and nitrogen loss;
promotes glycogen deposition and
ketone accumulation.
Venous thrombosis, heart failure, hyperosmolar coma, pulmonary edema, hyperglycemia, hypertension, flushing.
Infuse concentrations above 10% through central vein. Do not infuse
rapidly, doing so may cause hyperglycemia and fluid shifts. Never stop infusion abruptly. Monitor infusion
site frequently to prevent irritation, tissue sloughing, necrosis, and phlebitis.
Check blood glucose at regular intervals. Monitor I&O. Monitor weight regularly
and assess patient for confusion. Teach pt how to recognize s/s of hypo and
hyperglycemia. Insulin Reg Human
(Humulin)
Pancreatic hormone; hypoglycemic
SS/SC/Q6HR
SLIDING SCALE
70-130 = 0 units 131-180 = 2 units 181-240 = 4 units 241-300 = 6 units 301-350 = 8 units 351-400 = 10 units
Promotes glucose transport and
promotes phosphorylation of
glucose in liver.
Used in this pt because she is a type
ll diabetic. Used to maintain glucose
levels throughout the day, especially after
mealtime.
Hypokalemia, sodium retention, hypoglycemia, rebound hyperglycemia, utricaria, rash, edema, lipodystrophy,
anaphylaxis.
• Perform pt teaching regarding proper subQ injection techniques if pt wishes to give their own injections. This includes teaching on proper sites for injection and rotating injection sites to prevent lipodystrophy. Monitor glucose levels frequently to assess drug efficacy and appropriateness of dosage. Monitor for s/s of hypoglycemia. These include trembling, clammy skin, palpitations (pounding or fast heart beats), anxiety, sweating, hunger, and irritability. S/s of severe hypoglycemia can include difficulty thinking, confusion, headache, seizure and coma. Monitor for s/s of hyperglycemia such as polydipsia,
13
polyphagia, polyuria, and diabetic ketoacidosis (as shown by blood and urinary ketones, metabolic acidosis, extremely elevated blood glucose level). Teach pt about life style changes that can help to control glucose levels and may help to reduce insulin intake. Perform pt teaching on tight glucose control. Maintaining tight glucose control may help pt to manage their htn and reduce other problems that can result from DM. Have another nurse verify dosage!
Diphenhydramine HCl
(Benadryl)
Ethanolamine derivative, nonselective histamine-
receptor antagonist; antihistamine, antitussive,
antiemetic, antivertigo agent, antidyskinetic
50mg/IV/Q6H PRN Acts as an antihistamine by competing with
histamine or receptor sites on effector cells.
Used for itchiness
associated with Dilaudid.
Xerostomia, dizziness, dyskinesia, somnolence, dry nasal mucosa,
pharyngeal dryness, thick sputum, anaphylaxis, photosensitivity
Administer IV at a rate not exceeding 25mg/min. Don’t give drug within 14
days of MOA inhibitors. Monitor cardiovascular status. Supervise pts
during ambulation. Advise pts to avoid alcohol and other depressants such as sedatives while taking this drug. Advise
pt to avoid activities requiring coordination until drug effects are
realized. Instruct pt that drug may cause sleepiness.
Ibuprofen 600mg/PO/Q6H PRN
Exhibits analgesic and antipyretic
activities by inhibiting prostaglandin
synthesis.
Given to this pt to reduce inflammation related to humeral
fracture.
Hypotension, rash, hypernatremia, hypoalbuminemia, hypoproteinemia,
flatulence, heartburn, nausea, vomiting, thrombocytosis, bacteremia, dizziness,
headache, elevated BUN, urinary retention, CHF, hypertension, Stevens-
Johnson syndrome, hearing loss, depression, acute renal failure, Reye’s
syndrome.
Know that NSAIDs increase the risk of serious cardiovascular thrombotic
events, MI and stroke. They can also increase the risk of GI adverse events. Medication may be given with food or
milk to reduce GI upset. Monitor for relief of pain or reduction in fever. Monitor renal and liver function tests with long term use. Advise pt to avoid use of additional NSAIDs or aspirin during therapy. Instruct pt to report s/s of
serious GI events such as bleeding, ulceration or perforation
Ondansatron HCl (Zofran)
Antiemetic; serotonin type 3 antagonist;
4mg/IV/Q6H PRN Blocks serotonin a 5-HT receptor sites in
vagal nerve terminals by disrupting CNS
chemoreceptor
Headache, fatigue, chest pain, hypotension, constipation,
bronchospasm, anaphylaxis
Monitor GI status. Auscultate bowel sounds and palpate for tenderness.
Watch for hypotension and bronchospasm. Instruct pt to
immediately report symptoms of allergic
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trigger zone.
To reduce nausea related to
administration of analgesics and other
medications.
reaction such as rash or hives. Give undiluted by direct IV and administer slowly over 2 to 5 minutes. Flush SL
before and after administration with 5mL of water. Know that drug van cause
anaphylaxis and bronchospasm. Instruct pt to report s/s of hypersensitivity
reactions such as fever, chills, rash or breathing problems. Monitor ECG in pts
with electrolyte imbalances. Acetaminophen 650mg/PO/Q4H
PRN Pain reducing ability
may be due to an inhibition of COX 2 and an elevation of
the pain threshold. It reduces fever by
inhibiting the formulation and
release of prostaglandins in the
CNS.
Used for mild pain associated with her fractured humeral bone. Prescribed
PRN in case of infection related fever post-surgery as well.
Puritus, constipation, nausea, vomiting, headache, agitation, atelectasis, liver failure, pneumonitis, Stevens Johnson
syndrome
Know that drug may cause hepatic toxicity at high doses. S/s of hepatic
toxicity include dark urine, clay-colored stools; yellowing of skin; abdominal pain;
fever or diarrhea. Monitor hepatic and renal lab values if long-term therapy is
anticipated. Advise pt that it is unsafe to take more than 4 grams of this drug in a
24 hr period. Watch for s/s of chronic poisoning such as rapid, weak pulse; dyspnea; cold, clammy extremities.
Monitor pt for s/s of allergic reaction such as rash or urticaria. Instruct pt not to use this med with alcohol. Take medication
with a full glass of water.
Pantoprazole Sodium (Protonix)
Antiulcer agents; proton-
pump inhibitors
40mg/IV/daily PRN Binds to an enzyme in the presence of acidic gastric pH,
preventing the final transport of hydrogen ions into the gastric
lumen.
Used to prevent ulcers and irritation
due to use of excessive meds at
one time. Commonly given to pts staying at
hospital.
headache, abdominal pain, diarrhea, flatulence, hyperglycemia,
hypoglycemia, C-diff diarrhea, Stevens-Johnson syndrome
IV administration should be discontinued as soon as an oral route is possible.
Flush before and after administration with either 5% Dextrose injection, 0.9%
sodium chloride injection, or Lactated ringer’s injection. Injection is NOT
compatible with midazolam and may not be compatible with products containing
zinc. Reconstitute the appropriate number of vials with 10mL of 0.9%
sodium chloride injection for each vial for a final concentration of approximately
4mg/mL. Administer IV over a period of at least 2 minutes. Watch for s/s of
anaphylactic reaction such as rash or
15
hives, angioedema, and SOB. These reactions are more common when giving
med IV. Assess pt routinely for epigastric or abdominal pain and for
frank or occult blood in stool, emesis, or gastric aspirate. Warn pts to report
diarrhea that does not improve. Monitor for injection site reactions such as
thrombophlebitis.
Heparin Sodium (Hep-Lock)
Antithrombotic; Anticoagulant
5,000 units/SC/Q8HR
Inhibits the mechanisms that
induce the clotting of blood and the
formation of stable fibrin clots at various sites in the normal
coagulation system. When heparin is combined with antithrombin lll,
thrombosis is blocked through inactivation of activated Factor X
and inhibition of prothrombin’s conversion to
thrombin. This also prevents fibrin formation from
fibrinogen during active thrombosis.
Used as a
prophylactic to prevent postoperative venous thrombosis.
Pt is inactive and Heparin will help reduce the risk of
clots.
Thrombocytopenia, increased liver aminotransferase level, hemorrhage,
hep-induced thrombocytopenia, immune sensitivity reaction, non-
traumatic spinal subdural hematoma, hyperkalemia
Draw baseline blood sample for clotting studies before starting drug. Inject deep subQ (slowly into fat layer between iliac crests in lower abdomen). Leave needle
in place for ten seconds before withdrawing. Instruct patient to report s/s
of thrombocytopenia such as easy bruising (can be in the form of petechiae
which are red, flat spots on the skin), prolonged bleeding, excessive bleeding
of the mouth while brushing teeth or flossing, black stools, dark or red urine. Instruct pt to avoid taking aspirin during
therapy unless approved by a health care professional. Check hematocrit, PTT, and platelet count frequency. Monitor potassium level in pts with diabetes or
renal disease. Urge pts to avoid activities that can cause injury. Pt should
be urged to use soft bristle toothbrush and an electric razor. Use with extreme caution in this pt because of her history
of hypertension.
Hydromorphone (Dilaudid)
Opioid agonist; opioid
0.5mg/IV/Q3H PRN
Acts primarily as an analgesic agent. It is
believed that CNS
Flushing, pruritus, sweating, constipation, nausea, vomiting, asthenia, dizziness, headache,
Hydromorphone is a potent schedule ll opioid agonist which has the highest
potential for abuse and risk of producing
16
analgesic, antitussive opioid receptors that are specific for endogenous
substances with opioid-like properties
play a role in the drug’s analgesic
effects.
This drug is prescribed PRN so
that the pt can use it for MODERATE TO
SEVERE pain related to her humeral
fracture. May be useful post-surgery
as well.
hypotension, seizure, resp depression, drug withdrawl.
resp depression. Alcohol, other opioids and CNS depressants potentiate the resp
depressant effects of hydromorphone, increasing the risk of respiratory
depression that may result in death. This drug is contraindicated for use with
Probable. Reconstitute drug immediately prior to use with 25 mL sterile water for injection to a concentration of 10mg/mL.
Administer slowly over at least 2 to 3 minutes. Assess vital signs. Assess
pain levels before and after administration. Do not give if respirations are less than 10/min. Monitor for signs of
respiratory depression. Monitor for adverse effects especially during initial
dosing. Pts should avoid activities requiring mental alertness or
coordination until drug effects are realized. Instruct pt to report
constipation, absence of pain relief, hypotension and s/s of resp depression
such as SOB, apnea and increased effort with breathing. Advise pt against sudden discontinuation of the drug. Have second
practitioner verify dosage. Hydrocodone BIT/ACE
(Norco)
5/325mg (1 tab) PO/Q4H PRN
This medication binds to opiate receptors in the CNS. It alters the
perception and response to painful
stimuli.
This will help with MILD TO
MODERATE pain after surgery and allow for healing.
Confusion, dizziness, sedation, hypotension, constipation, dyspepsia,
nausea
Know that this drug has been associated with cases of acute liver failure, at times resulting in liver failure and death. Most
injuries are the result of excess acetaminophen. Monitor liver function
tests accordingly. Assess vitals. Respiration less than 10/min; hold medication and assesses sedation,
assess pain, have second practitioner verify dosage. Advise pt that drug that
may cause drowsiness. Give with food to reduce nausea. Pts should avoid
activities requiring mental alertness or coordination until drug effects are
realized. Advise pt that med contains acetaminophen and to not take additional drugs containing acetaminophen. Advise pt to report s/s of respiratory depression
17
such as SOB, apnea and increased effort with breathing. Monitor pt for s/s of drug
overdose including nausea, vomiting, blurred vision, cool and clammy skin,
dizziness, confusion, dyspnea, respiratory depression, bradycardia, hearing loss, headache or mood or
behavior changes. Promethazine HCl (Prorex)
Laxative; Stimulant
12.5mg/IV/Q6H PRN
Completely blocks histamine H(1)
receptors without blocking the secretion
of histamine. The drug has sedative,
anti-motion sickness, antiemetic, and
anticholinergic effects but it has no
dopaminergic action due to a structural
difference with other phenothiazines.
For pt’s constipation
related to surgery and administration of
opioids.
Abdominal colic, abdominal discomfort, diarrhea, proctitis, atony of colon,
xerostomia, apnea, respiratory depression
Monitor pt for decreased abdominal pain. Monitor for BM which should take place 15-60 minutes after administration. Also monitor hydration level and mental status
during therapy. Reassess pt if rectal bleeding occurs or if no BM occurs after
laxative is given. Advise pt that drug may cause diarrhea or abdominal pain, discomfort and cramping. Instruct pt to
report rectal bleeding or failure to have a BM within 12 hrs. Drug should not be
taken for longer than 7 days. This drug must be administered IV with caution
because risk of perivascular extravasion and severe tissue damage is high. Dilute in 10 to 20 mL of NS and administer over 10 to 15 minutes. Insure patency of site
before administration. Instruct pt to immediately report any burning or pain
during or after the injection and stop administration immediately. Advise pt to avoid excessive sun exposure because drug can cause photosensitivity. Advise pt not to consume alcohol while taking
this drug.
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LA8/2011 19
Concept Mapping
Step 2. List clinical manifestations under each nursing diagnosis and other relevant data to support each diagnosis, including lab data, medications, interventions, and assessment findings. All medical & nursing interventions should be found in one or more of the boxes.
ND # 1: Acute Pain Data to support: R humeral head fracture Recent surgery for fracture (POD 1) Guarded behavior Pt reports pain Pain upon movement of R arm Prescribed pain medication
ND # 2: Risk for bleeding Data to support: Pt being administered Heparin Pt POD 1 R humeral fracture Fall risk/impaired physical mobility
ND # 3: Risk for constipation Data to support: Immobility Pt being administered opioids for pain Pt was NPO pre-surgery
ND # 4: Impaired physical mobility Data to support: Physician order of bed rest. R humeral fracture and surgery (POD 1) Pt report of pain with movement Administration of opioids (decreased awareness and coordination)
CMD: R Humeral fracture Priority Assessments: Pain! BM inquiry Vital signs and labs Pt understanding Assess injured area closely
7. Discharge Pt teaching prior Provide information about medications PT inquiry
8. Pt Education Meds Wound Care Recovery Process Pain management Immobility
ND # 5: Risk for Impaired Skin Integrity Data to support: Immobility/ Bedrest Recent fracture Recent surgery Altered nutritional state (overweight) Pt taking Heparin
ND # 6: Knowledge Deficit Data to support: Knowledge of surgery Knowledge of post-op lifestyle changes Knowledge of medications.
LA8/2011 20
Concept Mapping
Evaluate Effects of Nursing Actions- Patient Outcomes, Documentation (Done During Clinical)
1. ND/Nursing Care: Acute Pain
Nursing Actions(NIC)
• Determine if client is experiencing pain at the time of initial interview. • Assess pain level using 1-10 scale • Assess the client for pain presence routinely and frequently (when vital signs are taken, during activity, and during rest) • Ask pt to describe previous experiences with pain medications or therapy. What worked? What didn’t? • Identify pt’s comfort-function goal for pain • Prevent pain during any procedures or mobility • Administer opioids as ordered • Assess pain level, sedation level, and respiratory status at regular intervals during pain management with opioid
administration. • Assess for effectiveness of medication • Assess for constipation related to use of opioids. • Assess for adverse reactions closely and frequently and especially during the first dose. • Assess for influence of cultural beliefs on pain management and perception of pain.
Patient response: Initially, pt reported no pain and complained of numbness at the site of injury. As the nerve block worse off, pt did complain of pain and rated it at a 3/10 but noted that it was quickly increasing. Pt expressed fear of pain coming back. Pt vital signs were taken and were normal. Pt administered Norco. Assessed effectiveness of medication and reassessed pain level routinely following administration. Pt reported that Norco and Dilaudid both worked well at relieving her pain since admittance. Pt expressed her comfort-function goal as being a 1 or a 0. Pt was immobile throughout entire day, so no pre-ambulatory pain medication was needed. Vital signs were normal following administration of medications. Pt reports last BM two days prior. Pt reports no worry and claims it is only because she wasn’t allowed to eat before the surgery. Pt status was monitored closely following administration. Pt is Hindu, but expressed no hesitance about taking pain medication and communicated her pain levels often and clearly.
LA8/2011 21
2. ND/Nursing Care: Risk for Bleeding
Nursing Actions(NIC)
• Monitor for signs of bleeding in the urine, stool, sputum, vomitus. • Watch for nose bleeds, petechiae, purpura, or bruising. • Monitor laboratory values (hemoglobin, hematocrit, RBC, INR) • Implement safety precautions (Fall risk protocol, soft bristle tooth brush) • Acquire additional help when moving pt to prevent falls • Check bandaging regularly for saturation and bleeding • Check vital signs frequently and regularly (watch for low BP, elevated HR, and respiratory rate) • Before administering heparin, check APTT • Have protamine sulfate close by as a precaution for Heparin OD. • L&L bed at lowest position and put side rails up x3 before leaving room • Explain bleeding risk to pt and assess for understanding • Perform teaching on reducing risk of bleeding including elimination of risky behaviors
Patient response: no signs of bleeding visible. No bruising, petechiae or purpura visible or noted by patient. RBC high and being monitored continually and closely. All other lab values WNL. Pt successfully labeled as a fall risk pt. Pt had already brushed her teeth before my arrival, but stated that soft bristle brush was used. Pt was not ambulated throughout the entire day, so no additional help was required. Bandage monitored and checked for bleeding a saturation regularly. Vital all WNL with the exception of BP which was initially low. It was determined that the BP was low due to administrating Losartan. BP began to rise towards normal limits so no intervention was needed. No APTT was ordered. Planned to inquire as to the reasoning, but never followed through. Bed L&L each time I exited the room. Side rails up x3. Pt demonstrates good working knowledge regarding her increased risk for bleeding as well as the actions of Heparin.
3. ND/Nursing Care: Risk for constipation
Nursing Actions(NIC)
• Assess usual pattern of defecation (time of day, amount and frequency of stool, consistency of stool) • Assess for diet patterns including fiber and fluid intake
LA8/2011 22
• Review clients current medications • If client is constipated and taking medications that can cause constipation, consult a health care provider about switching
the medications • Palpate for abdominal distention • Inquire about discomfort or abdominal pain • Assess for effectiveness of laxatives • Assess for any adverse reactions of laxatives • Assess for pt’s desire to take additional laxatives to promote GI motility
Patient response: Pt reports normally producing two BMs per day. However, pt reports last BM two days prior. Pt is a vegetarian and reports eating a variety of vegetables with each meal. Pt admits to having a poor fluid intake at home. Pt is taking opioids for pain which contribute greatly to constipation. When weighing risks and benefits, keeping the pt’s pain at a low level is a priority to both the patient and the staff, so no adjustment was made to opioid prescription. However, additional laxatives were prescribed. No distention palpable. Pt reports no abdominal pain or discomfort. Pt has not yet had a BM since the beginning of her laxative therapy. Will continue to inquire about pt’s BMs. Pt reports no diarrhea or vomiting or other side effects of laxatives. Pt reports a lack of concern about constipation and claims it is because she was required not to eat proceeding the surgery.
4. ND/Nursing Care: Impaired Physical Mobility Nursing Actions(NIC)
• Screen for measures of physical function to assess strength of muscle groups • Assess for cause of impaired mobility • Monitor and record client’s ability to tolerate activity. • Before activity, treat with pain as necessary • Evaluate impact that pain has on immobility • Acquire additional help before ambulating • Consult with PT for further evaluation • Obtain any assistive devices needed for activity. • Perform ROM exercises at least twice a day • Help pt to achieve motility and start walking as soon as possible unless contraindicated.
LA8/2011 23
Patient response: Significantly decreased R hand and arm strength noted. Pt is immobile because she is recovering from her recent humeral surgery. Pt reports pain during even the slightest movement of her right arm. Planned to treat her pain before ambulating but pt did not ambulate throughout my time with her. Pain is the largest reason why this patient is immobile. She expresses fear of pain and is guarded. Planned to consult PT about starting therapy, but upon arriving, I was informed that the pt is no have a second surgery on her shoulder on 10/11. Pt is unable to perform ROM exercises with her R arm while it is still healing. Plan to start ambulating pt after her next surgery is complete.
5. ND/Nursing Care: Risk for Impaired Skin Integrity Nursing Actions(NIC)
• Monitor skin condition at least once a day for color and texture • Instruct pt to avoid harsh cleaning agents, hot water, and too frequent cleansing • Minimize exposure of the site of skin impairment to moisture, perspiration or wound drainage • Monitor condition of skin covering bony prominences • Implement prevention plan • Assess client’s nutritional status • Perform teaching to the client regarding skin assessment and ways to monitor for impending skin breakdown • Determine pt’s risk by using the Braden Scale.
Patient response: Skin integrity, color and texture appear and feel normal. Pt used warm rather than hot water while performing self cleansing as well as mild soap. Wound bandaging is tight and free of moisture or damage. Skin surrounding and covering pt’s bony prominences is without breakdown. Inquired about the need to rotate the pt’s positions regularly and was told that the brief nature of her visit was not cause for rotation. Also, pt is able to sit herself up which decreased her risk of developing any ulcers or areas of breakdown. Client electrolytes are normal which indicated good nutritional status. Pt is now eating her entire meals and is being hydrated via IV NS. Calculated pt’s Braden Scale risk at a 17 which puts her at mild risk for skin breakdown.
6. ND/Nursing Care: Knowledge Deficit Nursing Actions(NIC)
LA8/2011 24
• Consider pt’s ability and readiness to learn • Assess personal context and meaning of injury • Assess family involvement and ability to assist with learning • Perform family and pt teaching • Pt teaching about medications • Pt teaching about recovery process • Pt teaching regarding safe mobility • Pt teaching regarding proper care and maintenance of injury and bandaging • Assess for understanding.
Patient response: Pt A&O x4 and has a good ability and readiness when it comes to learning. Pt reports anxiety regarding injury because it has stopped her from caring for and seeing her four grandchildren. For her, this injury means not spending time with her family, which she reports as being a very high priority. Pt’s husband and son are both physicians. The husband was at the bed side off and on throughout the entire day and was very helpful about providing information to the client. Pt demonstrated a good knowledge of the medications she was receiving as shown by her questioning nature during administration and by her concerns about receiving Losartan when her BP was low. Pt demonstrated good knowledge about surgery dates and the process of recovery. Pt and husband were very careful while pt is adjusting positions or when moving the HOB. Planned to perform teaching about proper care and maintenance of injury, but since pt was due to have another surgery the next day, it was no longer a priority.