patient profile instructor copy robin ritter
TRANSCRIPT
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
ROBIN RITTER
PATIENT SUMMARY Admitted with Total Hip Replacement (THA) - post-op day #3. Patient has a history of angina and requires
sublingual nitroglycerin. Colace is ordered but no BM since before surgery. Also requires administration of subQ heparin and clarification of pain medication.
LEARNING GOALS
• Identification of additional information required from report
• Correct dosage calculation• Correct administration of subQ, sublingual and
PO medications• Documentation of medication administration• Effective SBAR communication with prescriber
• Identification of priority nursing assessments for patient with angina and THA
• Interpretation of lab results for postoperative patient receiving heparin
• Creation of appropriate 5-minute nursing care plan for patient with angina and THA
• How to complete medication error report if needed
PATIENT PROFILEINSTRUCTOR COPY
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterInstructor Copy
• Heparin 50,000 units/5 mL• Heparin 10,000 units/10 mL (Distractor)• Colace 100 mg tablets• Nitroglycerin sublingual spray• Nitroglycerin sublingual tablets (Distractor)• Oxycodone 5 mg/Acetaminophen 325 mg tablets
(controlled substance - count)
• SubQ syringes• Medication cups• Alcohol wipes• Injection training pad
Medications Required: Additional Supplies Needed:
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Medications Required:
Additional Supplies Needed:
SKU MEDICATION / ITEM QUANTITY PRICE
PM087803 Practi-Heparin™ 10,000 USP/10 mL (1,000 U/mL) 10 $59.95 / Box of 40
PM087804 Practi-Heparin™ 50,000 USP/5 mL (10,000 U/mL) 10 $62.95 / Box of 40
PM117805 Practi-Docusate™ Oral Medication 10 $14.95 / Box of 48
PM127805 Practi-Nitroglycerin Spray™ 1 $39.95 / Box of 5
PM117834 Practi-Nitroglycerin™ Oral Med 1 $24.95 / Box of 5
PM117814 Practi-Oxycodone & Acetaminophen™ Oral Medication 10 $14.95 / Box of 48
SKU MEDICATION / ITEM QUANTITY PRICEMED051026 3 mL Luer Lok Syringe with Safety Needle 10 $14.95 / Box of 50
MED051460 3 mL Luer Lok Syringe with Safety Needle 10 $19.29 / Box of 50
MED111001 3 mL Syringe with Blunt Vial Access Cannula 10 $37.49 / Roll of 100
MS081023 Plastic Medicine Cups 10 $1.76 / Box of 100
MED081072 Alcohol Prep Pads 30 $18.50 / Box of 2,000
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterInstructor Copy
2
TODAY’S LAB RESULTSWBC 10.4
RBC 4.8
HGB 7.2
HCT 38.1
PLT 358,000
RBS 66
Na+ 135
Cl- 97
K+ 3.5
• Allergies: Plavix, Restoril• Admitted with THA (total hip replacement)• Post-op day #3• Medical history: stable angina• VS: T 99.8 - P 88 - RR 22 - BP 102/64 -
pulse ox 91%• Lung sounds diminished bilaterally• No BM since before
surgery• Patient just asked
for medication to relieve angina chest pain
Patient Health & History
Additional Optional Supplies:
SKU MEDICATION / ITEM QUANTITY PRICEMS153901 SLS Small Injection Trainer 1 $19.95 / Each
DATE TIME PATIENT NAME # ON HAND # USED # LEFT SIGNATURE
Controlled Substance Count Sheet:
MEDICATION:
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterInstructor Copy
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Medication Specifications:
HEPARIN 5,000 UNITS SUBQ BID | Dosage Time: 0900, 1700DRUG CLASS: AnticoagulantREASON WHY PRESCRIBED FOR THIS PATIENT: Prevent postoperative DVT
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:1. Monitor platelet count for HIT - assess for signs of bleeding2. Do not administer other medications that affect clotting3. Do not rub the injection site after administration - bruising at injection sites common
SHOULD IT BE ADMINISTERED AS WRITTEN? YESRATIONALE: Prevent DVT
COLACE 100 MG PO BID | Dosage Time: 0900, 1700DRUG CLASS: Stool softenerREASON WHY PRESCRIBED FOR THIS PATIENT: Immobility and pain medications cause constipation
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:1. Stool softener only, not a laxative - do not confuse with Dulcolax 2. Take with a full glass of water or juice3. Encourage dietary fiber -teach patient to avoid Valsalva maneuver
SHOULD IT BE ADMINISTERED AS WRITTEN? YESRATIONALE: No BM since before surgery, laxative needed as well
NITROGLYCERIN SUBLINGUAL SPRAY - 2 SPRAYS Q 5 MINUTES | Dosage Time: PRN UP TO 3 TIMES PRN CHEST PAIN **LAST DOSE: NOT PREVIOUSLY GIVEN
DRUG CLASS: Antianginal vasodilatorREASON WHY PRESCRIBED FOR THIS PATIENT: Relieve angina chest pain
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:1. Have patient raise the tongue and spray underneath2. May be repeated Q 5 minutes x 2 —> if still not relief call Rapid Response3. Monitor heart rate & BP - can cause headache (relieve with acetaminophen)
SHOULD IT BE ADMINISTERED AS WRITTEN? YESRATIONALE: Patient requests medication to relieve angina pain
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterInstructor Copy
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ADDITIONAL INFORMATIONWhat additional information is needed from the shift report?• IV access?• Activity order? How tolerated? PT consulted?• Diet? • Trend of CBC? • Oxygen ordered? Spirometer? Any SOB? Lung sounds? Cough/deep breathe?• SOB with activity? (anemia)• Type & cross done? Blood on hold? • Incision appearance? Drain?
Interpretation of lab results? • Elevated WBC - possible infection, probable inflammation after surgery, need to look at diff• Low hgb/hct/rbc - blood loss after surgery• Pulse ox - probable atelectasis
What are the key nursing assessments?• Chest pain - quality, onset, etc. • Lung sounds (diminished —> atelectasis)• Incision appearance• Activity tolerance, especially with anemia• Abdomen (constipation)
SBAR communication with physician:• Angina (if not relieved with NTG)• Oxygen (titrate to keep pulse ox > 95-98%)• Order for spirometer (if facility requires order)• Laxative order in addition to Colace• Change subQ heparin order to Q 12 hours• Clarify pain level for Oxycodone PRN (consider Tylenol for mild pain
OXYCODONE 5 MG/ACETAMINOPHEN MG 1 TABLET PO Q | Dosage Time: PRN 4 HOURS PRN PAIN **LAST DOSE: 5 HOURS AGO
DRUG CLASS: Combination narcotic pain medication with prostaglandin inhibitorREASON WHY PRESCRIBED FOR THIS PATIENT: Postoperative pain relief
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:1. Prescribed acetaminophen dosage is less than 4 gram/day - OK2. No anti-inflammatory effects - will not affect blood clotting times 3. Watch for respiratory suppression4. Causes constipation
SHOULD IT BE ADMINISTERED AS WRITTEN? NORATIONALE: Clarify dosage with prescriber
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterInstructor Copy
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5-MINUTE NURSING CARE PLAN
Problem #1: Impaired tissue perfusion R/T coronary blood vessel blockage AEB patient report of angina pain
Goals: Relief of chest pain within 15 minutes
Interventions:1. Assess quality and severity of chest pain2. Administer nitroglycerin sublingual spray as ordered3. Assess precipitating factors for pain
Evaluation of goal (met/not met):To be done at the end of the shift
5-MINUTE NURSING CARE PLAN
Problem #2: Constipation R/T immobility, narcotic pain medications AEB no BM since before surgery
Goal: BM today
Interventions:1. Obtain order for and administer laxative2. Teach patient to avoid Valsalva maneuver3. Teach patient to increase dietary fiber and fluid intake
Evaluation of goal (met/not met):To be done at the end of the shift
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterInstructor Copy
MEDICATION ERROR REPORTPatient Name: Physician: Date of Error: / / Time of error: Date of report: / /
Physician Notified? □ Yes □ NoIf Yes: Name: Date: / / Time:If No: Explain:
Nursing Supervisor Notified: □ Yes □ NoIf Yes: Name: Date: / / Time:If No: Explain:
Family/Responsible party notified: □ Yes □ NoIf Yes: Name: Date: / / Time:If No: Explain:
Pharmacy Notified: □ Yes □ NoIf Yes: Name: Date: / / Time:If No: Explain:
Medications Involved:Description of Error (Include medication name, dose, route, and time(s) administered) Care provided and outcome of patient:
Type of Error:□ Wrong drug□ Wrong dose□ Wrong dosage form□ Wrong documentation□ Wrong time□ Wrong route□ Other:
Reason for Error:□ Transcription error□ Misread order□ Miscalculated dose□ Incorrectly measured dose□ Pharmacy error□ Failure to identify patient□ Other:
Actions to prevent recurrence:
Signature / Title: Date:
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7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
ROBIN RITTER
PATIENT PROFILESTUDENT COPY
PATIENT SUMMARY Admitted with Total Hip Replacement (THA) - post-op day #3. Patient has a history of angina and requires sublingual
nitroglycerin. Colace is ordered but no BM since before surgery. Also requires administrationof subQ heparin and clarification of pain medication.
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterStudent Copy
1
• Allergies: Plavix, Restoril• 66 year-old admitted with THA
(total hip replacement)• Post-op day #3• Medical history: stable angina• VS: T 99.8 - P 88 - RR 22 - BP
102/64 - pulse ox 91%• Lung sounds diminished bilaterally• No BM since before surgery• Patient just asked for medication to
relieve angina chest pain
Patient Health & History
TODAY’S LAB RESULTSWBC 10.4
RBC 4.8
HGB 7.2
HCT 38.1
PLT 358,000
RBS 66
Na+ 135
Cl- 97
K+ 3.5
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
DAILY PATIENT WORKSHEETRoom
Name
Admitting Diagnosis Doctor
Allergies Admission Date Code Status
Diet Isolation Activity
Medical History Assessment Findings Diagnostic Test
Medications NaClK+CaMgPhosBUN CreatRBSCO2
WBCRBCHGBHCTPLTPTINRPTT
Vitals
TPRBPPOX
Intake Output Skin & Wounds
Pain Last BM Staff RN
PATIENT PROFILE - Robin RitterStudent Copy
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7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
Medication Specifications:
HEPARIN 5,000 UNITS SUBQ BID | Dosage Time: 0900, 1700DRUG CLASS:
REASON WHY PRESCRIBED FOR THIS PATIENT:
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:
1.
2.
SHOULD IT BE ADMINISTERED AS WRITTEN?
RATIONALE:
COLACE 100 MG PO BID | Dosage Time: 0900, 1700DRUG CLASS:
REASON WHY PRESCRIBED FOR THIS PATIENT:
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:
1.
2.
SHOULD IT BE ADMINISTERED AS WRITTEN?
RATIONALE:
PATIENT PROFILE - Robin RitterStudent Copy
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7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
NITROGLYCERIN SUBLINGUAL SPRAY - 2 SPRAYS Q 5 MINUTES | Dosage Time: PRN UP TO 3 TIMES PRN CHEST PAIN *LAST DOSE: NOT PREVIOUSLY GIVEN
DRUG CLASS:
REASON WHY PRESCRIBED FOR THIS PATIENT:
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:
1.
2.
SHOULD IT BE ADMINISTERED AS WRITTEN?
RATIONALE:
PATIENT PROFILE - Robin RitterStudent Copy
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OXYCODONE 5 MG/ACETAMINOPHEN MG 1 TABLET PO Q | Dosage Time: PRN 4 HOURS PRN PAIN *LAST DOSE: 5 HOURS AGO
DRUG CLASS:
REASON WHY PRESCRIBED FOR THIS PATIENT:
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:
1.
2.
SHOULD IT BE ADMINISTERED AS WRITTEN?
RATIONALE:
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Chris CrawleyInstructor Copy
5-MINUTE NURSING CARE PLAN
Problem #1:
Goal:
Interventions:
1.
2.
3.
Evaluation of Goal (met/not met):
5-MINUTE NURSING CARE PLAN
Problem #2:
Goal:
Interventions:
1.
2.
3.
Evaluation of Goal (met/not met):
PATIENT PROFILE - Robin RitterStudent Copy
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