renal tele patient-3

California State University, Stanislaus

School of Nursing

N4810 Adult Health Nursing II Clinical

3 units

DIRECTIONS FOR COMPLETING THE CLINICAL PLAN OF CARE

The Clinical Preparation Form is considered homework in which the student prepares to give nursing care by first reviewing pertinent aspects of patient care specific to the patient selected during the clinical expe-rience. The worksheet must be completed prior to the beginning of the clinical learning experience.There are a number of sections to this worksheet and each section is to be completed. The following are the directions for completing the worksheet. If you have any questions about completing the worksheet or regarding instructor comments on you work, please contact your clinical instructor as soon as possible. Submit electronically, unless specified otherwise by your clinical instructor.

Student/Date: Include your full name and the date of the clinical experience

Patient Initials/Medical Record Number/Ethnic or Cultural Background: Do not use the name of the patient, use only the patient's initials and medical record number. Don't forget to include information about your patient's cultural background.

Admission Date: Identify the date of admission to the hospital.

Admitting Diagnosis: Identify the admitting diagnoses of the patient.

Other Diagnosis/Surgical Procedures: Look on the H&P, the admitting note, the nursing history and the operative note. If applicable identify all medical diagnosis and surgical procedures done currently or in the past.

Allergies: Note specific allergies. If none, write "none" or NKDA"

Diet: Identify the specific diet for patient

Intake and Output (I & O): Indicate if the patient is on I & O includes all pts. receiving IV therapy

IV: Indicate the type and location of IV, type of solution and the rate per hour.

Invasive Tubes: Indicate any invasive tubes that are present.

Pertinent Laboratory & Diagnostic Information: Identify the date of the lab work, low or high values accompanied by arrows up or down to demonstrate the trend.

Medications: Identify the name of the drug, both generic and trade, mechanism of action, side effects, rationale, and nursing implication and patient teaching. This should be done for every medication the patient is receiving. Use your drug book.

Patient Care Plan: Review the pt. care plan for accuracy and thoroughness. Make any changes you feel are appropriate. For example, add a problem which you feel needs to be included. Describe the expected outcome and the appropriate nursing interventions.

N4810 Clinical Paperwork Rev 11/6/13

CSU, STANISLAUS B.S.N.CLINICAL PLAN OF CARE

Patient Data

Student: Kaylee Blankenship Date of Care: 3/12/15-3/13/15 Room Number: 4721-A Code Status: FULL

Pt. Initials D.R. Gender: Female Age: 88 Height: 5’ Weight: 50.1 kg (110 lbs) BMI: 21 Spirituality: Protestant Ethnicity: Caucasian

Admitting Diagnosis: HypoglycemiaVital Signs: Temp 97.7 F (36.5 C) HR 110 RR 18 B/P 159/65 O2 Sat 95 Pain Scale & Scale Type 0 out of 10History related to this admission: type II DM w/o mention of complicationPast Medical History: HTN essential. Abnormal heart sounds, motion sickness, type II DM w/o mention of complication, arthropathy unspecified, cervcalgia, GERD, hyperlipidemiaAdmit Date: 3/9/15 POD: : Ø Surgical History & Date: shoulder surgery-left side (2008), left knee replacement (2000), appendectomy (1945), tonsil removal (less than 12 yr), extracap cataract removal w/IOL (9/2009) MD(s): Ahire

Diet: soft diet w/ 1:1 feeder Activity: ambulate with assist Foley: indwelling single lumen cath (3/9/15) Feeding Tube & Rate : Ø Advance Directive: Yes ________ No X Drains/ Tubes: Ø Isolation: Ø VS Freq: q4hr per unit protocol Glucose Monitoring: yes (AC and HS) DVT Prophylaxis: SCD’s Vascular Access: PCA/Epidural: Ø Telemetry & Rhythm: 5-lead (sinus tachycardia-

most of the time) IV Site: right forearm IV Solution & Rate: NaCl 0.9% 75 ml/hr Safety Considerations: fall precautions, aspiration, confusion, restraints Restraints: side rails up, vest/jacket, soft bilateral wrist restraints on 3/11/15. Had no restraints and just a sitter 3/12/15-3/13/15 Dressing Changes & Frequency: Ø Labs for day of clinical: BMP w/ GFR routine daily, Mg routine daily am, Mg routine after replacement prn, K routine after replacement prn, CBC with auto differential routine dailyScheduled Procedures: Echocardiogram 3/13/15

Procedures done this admission: Ø Oxygen: room air Respiratory Treatment: Ø Vent Settings: Ø Allergies: NKDA Advanced Hemodynamic Monitoring & Values: Ø

IV Drips Medications Dosage & Rate: Ø _________________________ ________________________ ________________________ __________________________ ________________________


Notes on PathophysiologyMedication

Generic & Trade Name Dose, Route, Frequency

Mechanism of ActionClassification

Patient-Specific Rationale Nursing Considerations(Assessment implications, side effects, reasons to hold

med, administration rate, etc…)Acetaminophen (Tylenol)

650 mg PO q4hr prn

Analgesic, antipryretic;synthetic nonopioid p-aminophenol derivative

Action: Pain reduction may result from inhibition of prostaglandin synthesis in CNS, with subsequent blockage of pain impulses. Fever reduction may result from vasodilation and increased peripheral blood flow in hypothalamus.

For mild pain 1-3 or temp above 38 degrees C as indicated on MAR. Pt has arthropathy which can sometimes casue mild aches and pains.

Side effects: Pruritis, constipation, nausea, vomiting, insomnia, agitation, atelectasis, Stevens-Johnson syndrome, toxic epidermal necrolysis, pneumonitis, thrombocytopenia, hemolytic anemia, neutropenia, leukopenia, pancytopenia, hepatotoxicity, hypoglycemic coma

Considerations:-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 for hepatic and renal lab values.-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.-Monitor for effectiveness through fever reduction or pain reduction.-Advise pt that it is unsafe to take more than 4 grams of acetaminophen in a 24-hr period.-Instruct pt not to use this med with alcohol.-Perform teaching on the presence of acetaminophen in other medications. Instruct pt to take medication with a full glass of water.

Ascorbic acid (vitamin C)

1,000 mg PO daily

Vitamin C-water soluble vitamin

Action: wound healing collagen synthesis, antioxidant, carbohydrate metabolism

Dietary supplement for deficiency. Side effects: headache, fatigue, diarrhea, anorexia, heartburn, cramps, polyuria, urine acidification, oxalate/urate renal stones, dysuria, hemolytic anemia

Considerations:-Assess I&O ratio, urine pH, ascorbic acid levels, nutritional status, and for thrombophlebitis.-Teach pt necessary foods to include in diet (i.e. citrus fruits) and do not exceed prescribed dose.

Aspirin

81 mg tab PO chewable daily with breakfast

Analgesic; NSAID

- Action: A potent inhibitor of both prostaglandin synthesis and platelet aggregation than its other salicylic derivatives due to the acetyl group on the aspirin molecule, which inactivates cyclooxygenase via acetylation.

Decreases platelet aggregation (blood thinner), which is what the patient needs in order to help prevent blood clots. Pt also has history of HTN.

Side effects: Gastrointestinal ulcer, bleeding, age related macular degeneration, tinnitus, bronchospasm, angioedema, Reye’s syndrome

Considerations:-Take medication with a full glass of water (8 ounces or more) or food.-Monitor CBC, chemistry profile, BP, fecal occult blood test, LFTs.


-Instruct pt to report s/s of bleeding or GI distress.- Pt may take with food or milk.-Instruct pt to avoid alcohol during therapy.

Bisacodyl (Dulcolax)

10 mg suppository daily prn

Laxative; Stimulant

Action: Acts directly in the intestines by increasing motor activity; thought to irritate colonic intramural plexus

Ordered prn to prevent constipation due to pt’s limited mobility (intermittently on restraints due to decreased LOC)

Side effects: Abdominal colic, abdominal discomfort, diarrhea, proctitis with suppository use, atony of colon.

Considerations:-After administration, retain medication for about fifteen to twenty minutes.-Monitor for signs of effectiveness such as decreased abdominal discomfort and pain and a BM within 15 to 60 minutes.-Reassess pt if recta, bleeding or no BM occurs after 12 hours.- Perform ot teaching about how drug can cause diarrhea or abdominal pain, discomfort, and cramping.-Pts should not take med for more than 7 days unless approved by a health care professional.-PR administration: explain procedure to pt, ensure pt privacy, position pt into sim’s position , apply clean gloves, and insert medication gently through anus and past the internal sphincter and against the rectal wall. While inserting the medication, tell pt to take slow deep breaths through the mouth and to relax the anal sphincter.

Calcium carbonate/vitamin D (caltrate 600+D)

600 mg/400 Unit 2tab PO daily

Anatacid; calcium supplement

Action: Reduces total acid load in GI tract, elevates gastric pH to reduce pepsin activity, strengthens gastric mucosal barrier, and increases esophageal sphincter tone.

This is used to help with the pt’s GERD to reduce acidity level of GI secretions. Vitamin-D is also for a supplement. This might be because many patients are being found to be vitamin D deficient so it is precautionary in a way.

Side effects: Headache, irritability, weakness, nausea, constipation, flatulence, rebound hyperacidity

Considerations: -Know that drug may cause an increase in calcium levels and may cause a decrease in phosphate levels.-Record the amount and consistency of stools, and manage constipation with laxatives or stool softeners. Monitor calcium levels, especially in pts with mild renal impairment.-Calcium should be 8.5-10.5, urine calcium should be 150 mg/day-Watch for evidence of hypercalcemia such as nausea, vomiting, headache, confusion and anorexia.-Perform teaching with patient against taking in an indiscriminant routine and against switching antacids without the prescriber’s advice. Urge pt to notify prescriber about s/s of GI bleeding such as tarry stools, or coffee-ground vomitus.

Clopidogrel (Plavix)

75 mg PO daily

Platelet aggregation inhibitor

Action: Inhibits ADP-induced platelet aggregation. This is for her peripheral arterial disease, which

Helps reduce the pt’s future risk of stroke since she has HTN and a history of abnormal heart sounds.

Side effects: Headache edema, hypertension, chest pain, constipation, GI bleeding, pancreatitis, hepatic failure, hypercholestremia, UTI, fatigue, bronchospasm, dyspnea, bronchitis


works as an anticoagulant. Considerations:-Assess for pt for thrombotic/thrombocytic purpura: fever thrombocytopenia, neurolytic anemia-Symptoms of stroke or MI during treatment-Hepatic studies: AST/ALT bilirubin, creat-Blood studies: CBC, differential, HCt, Hgb, PT, cholesterol.-Teach pt that blood work will be necessary during treatment. Teach pt to report any unusual bleeding/bruising and to take the medication with food to minimize GI upset. Report diarrhea, skin rash, subQ bleeding, chills, fever, or sore throat. Inform pt to tell all health care providers that he/she is using this medication.

Dextrose (GLUTOSE)

15 g oral gel prn

Action: raises blood glucose levels. For patients experiencing acute hypoglycemia. Provides a source of water and carbohydrates. The simple carbohydrate may minimize liver glycogen depletion and provide protein-sparing action.

For blood glucose of 45-69 mg/dL or greater if patient is symptomatic, if patient conscious and able to chew.This is ordered in case the patient becomes hypoglycemic again like she was on admission.

Side effects: Hyperglycemia, hyperosmolarity, cerebral hemorrhage, cerebral ischemia, pulmonary edema

Considerations:-Assess: I&O (make sure patient is receiving adequate hydration and electrolyte balance)-Check electrolytes and blood and urine glucose-Shake well before using

30 g oral gel prn “ ” For blood glucose less than 45 mg/dL, if patient conscious and unable to chew

-Same as above

“ ”

Dextrose 50%

12.5 g IV inj prn

Action: Prevents protein and nitrogen loss; promotes glycogen deposition and ketone accumulation. acute hypoglycemia

For blood glucose of 45-69 mg/dL or greater if patient is symptomatic. If patient has an IV and unable to swallow.This is ordered in case the patient becomes hypoglycemic again like she was on admission.

Side effects: Venous thrombosis, heart failure, hyperosmolar coma, pulmonary edema, hyperglycemia, hypertension, flushing

Considerations:-Administer bolus over 5-10 mins-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.-Assess: electrolytes and calorie count-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. And blood glucose monitoring procedures.

25 g IV inj prn For blood glucose less than 45 mg/dL. If patient has an IV and unable to swallow.

-Same as above

-Administer IV bolus over 5-10 minsSame as above

Glucagon (Glucagen Hypokit) Action: Induces liver glycogen For blood glucose of 45-69 mg/dL or Side effects: Hypotension, hyperglycemia


1 mg IM inj prnbreakdown and glucose release, relaxes GI smooth muscle. Raises blood glucose levels. For patients experiencing acute hypoglycemia.

greater if patient is symptomatic. If unable to obtain IV access and unable to swallow.

Considerations:-Monitor: blood glucose levels and level of consciousness.-Teach: Be familiar with technique for administration in case of emergency, seek medical assistance if no response is seen within 15 mins of glucagon injection, once response has occurred patient should be given oral carbohydrate. This will restore liver glycogen and avoid recurrence of hypoglycemia,

Same as above “ ” For blood glucose less than 45 mg/dl. If unable to obtain IV access and unable to swallow.

“ ”

Glucose Chew tab

16 g Chew tab PO prn

Action: raises blood glucose levels. For patients experiencing acute hypoglycemia.

For blood glucose of 45-69 mg/dL or greater if patient is symptomatic.If patient is conscious and able to swallow.

-Do not swallow whole.-May administer 4 oz of juice INSTEAD of glucose tabs.

32 g Chew tab PO prn “ ” For blood glucose less than 45 mg/dL.If patient is conscious and able to swallow.

-Do not swallow whole.-May administer 8 oz of juice INSTEAD of glucose tabs.

Heparin5,000 units subQ q12hr

Anticoagulant, antithrombotic

-Action: Prevents conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing inhibitory effects of antithrombin III

For prevention of DVT due to patient’s limited mobility due to restraints ordered because of the pt’s altered LOC.

Side effects: Fever, chills, headache, hematuria, hemorrhage, thrombocytopenia, anemia, rash, delayed transient alopecia, hematoma, cutaneous necrosis, hyperkalemia, hypoaldosteronism, anaphylaxis

Considerations:-Assess: bleeding, hemorrhage, blood studies (Hct, occult blood in stools) q3 months, PTT, platelet count, hypersensitivity (rash, chills, itching).-Teach: product may be held during active bleeding. Use soft bristle toothbrush to avoid bleeding gums, carry emergency ID, report to prescriber any signs of bleeding or hypersensitivity

Hydralazine (apresoline)

10 mg IV inj q6hr prn

Antihypertensive, direct-acting peripheral vasodilator

Action: Vasodilates arteriolar smooth muscle by direct relaxation; reduction in blood pressure with reflex increases heart rate, stroke volume, cardiac output

Ordered to lower pt’s BP because she has HTN. Acts as a vasodilator thus reducing pressure within the vessels, lowering BP. This medication is more of an immediate actor since it is IV rather than a slower acting PO medication (which she also has ordered).

Side effects: Peripheral neuritis, depression, fever, chills, palpitations, reflex tachycardia, shock, angina. Rebound hypertension, orthostatic hypotension, constipation, urinary retention, leukopenia, anemia, thrombocytopenia, nasal congestion, muscle cramps, flushing, edema, dyspnea.

Considerations:-For IV administration: each 10 mg over 1 minute-DBP> 95-SBP>165-Assess: cardiac status, electrolytes (K, Na, Cl, CO2,


CBC, glucose. Weight daily, edema, crackles, dyspnea, orthopnea. IV site for extravasation. Mental status,-Teach: to take with food, avoid OTC preps. Notify prescriber if chest pain, severe fatigue, fever, muscle or joint painRise slowly

Insulin lispro human (Humalog KWIKPEN)

Inj Pen 1-6 units subQ tid 30 mins before meals

Antidiabetic, pancreatic hormone; modified structures of endogenous human insulin

Action: Decreases blood glucose by transport of glucose into cells and the conversion of glucose to glycogen, indirectly increases blood pyruvate and lactate, decreases phosphate and potassium.

This is used to lower the patient’s glucose level due to her Type 2 DM (use sliding scale)

Side effects: Blurred vision, dry mouth, flushing, lipodystrophy, lipohypertrophy, swelling, hypoglycemia, rebound hyperglycemia, peripheral edema

Considerations:-Sensitive regimen-Don’t hold if NPO-Give the following correction insulin in addition to any nutritional insulin.-For blood glucose:70-200 mg/dL: 0 units201-250 mg/dL: 2 units251-300 mg/dL: 3 units301-350 mg/dL: 4 units351-400 mg/dL: 5 unitsGreater than 400 mg/dL, draw serum blood glucose, administer 6 units and notify prescriber-Assess: fasting blood glucose, A1c, urine ketones, hypoglycemic reaction (sweating, weakness, dizziness, confusion, headache, rapid weak pulse, fatigue, tachycardia, slurred speech, staggering gait, acetone breath, hunger-Teach: keep insulin equipment available at all times (carry a glucagon kit, candy or lump of sugar), does not sure diabetes, carry emergency ID as diabetic, recognize hypoglycemia reactions (headache, tremors, fatigue, weakness) and hyperglycemia (frequent urination, thirst, fatigue, hunger). Symptoms of ketoacidosis (polyuria, dry mouth, increased BP, acetone breath, Kussmaul

Magnesium Hydroxide (Milk of Magnesia)

30 ml oral suspension PO daily prn

Mineral; Antacid

Action: Increases osmotic gradient in small intestine, which draws water into intestines and causes distention. These effects simulate peristalsis and bowel evacuation.

This is ordered prn in order to prevent constipation as a result of the patient’s limited mobility form restraints.

Side effects: Confusion, decreased reflexes, dizziness, syncope, paralysis, hypothermia, hypotension, arrhythmias, circulatory collapse, nausea, vomiting, cramps, flatulence, anorexia, hypermagnesemia, hypocalcemia, muscle weakness, diaphoresis, allergic reaction

Considerations:-Shake well before using-Follow dose with full glass of water.-Assess for the cause of constipation. Perform pt teaching about adverse reactions. Know that this medication may delay absorption of other drugs. Instruct


pt that prolonged use of this medication can lead to laxative dependence. Perform teaching on how a healthy diet and regular exercise can reduce the need for laxatives. Monitor electrolyte and liver function tests while administering this medication. Monitor I&O. Continue to monitor for medication effectiveness by assessing the abdomen (looks, listen, feel) and asking the pt regularly about BMs.

Magnesium Sulfate

2g in water in 50 ml IVPB (premix) prn

Electrolyte, anticonvulsant, saline laxative, antacid

Action: Increases osmotic pressure, draws fluid into the colon, neutralizes HCl

For electrolyte replacement. The pt’s Mg level has been intermittently low which could possibly be due to malnutrition caused decreased food intake because of confusion and being placed on restraints.

Side effects: muscle weakness, sweating. Confusion flaccid paralysis, hypothermia, hypotension, heart block, circulatory collapse, vasodilation, diarrhea, prolonged bleeding time, electrolyte, fluid imbalances, respiratory depression/paralysis

Considerations:-Mg between 1.5-1.8 mg/dL-Refrigerate-Watch patient for s/s of magnesium toxicity: thirst, confusion, decrease in reflexes, I&O ration, check for decrease in urinary output-Teach pt the reason for administration and expected results.

“ ”

3g in dextrose 5% 100 ml IVPB prn

“ ” “ ” -Mg between 1.2-1.4 mg/dL-Refrigerate

“ ”

4g in sterile water 100 mL

“ ” “ ” Mg between 0.9-1.1 mg/dL

Metoprolol tartrate (Lopressor)

50 mg tab PO bid

Beta-adrenergic blocker; cardiovascular agent

Action: Selective activity on beta-1 adrenoreceptors located mainly in cardiac muscles. At higher doses, it may inhibit beta-2 adrenoreceptors of bronchial and vascular smooth muscles. Possible mechanisms of antihypertension effects include: competitive antagonism of catecholamines at peripheral and cardiac adrenergic receptors, a central effect leading to reduced sympathetic outflow, and suppression of rennin activity.

Given to this pt to lower her BP because she has a history of HTN. However, this medication ended up being d/c because her heart rate would drop rapidly after administration and then sky rocket again in the 100’s after the medication wore off. The doctor’s suspected sick sinus syndrome (SSS) as the cause.

Side effects: Bronchospasm, bradyarrhythmia, heart block, heart failure, hypotension, constipation, diarrhea, nausea, dizziness, headache, depression, dyspnea.

Considerations:-Hold for systolic blood pressure less than 90 or heart rate less than 60Instruct pt to take with or immediately following meals. Swallow tab whole with glass of water.-Monitor BP regularly and especially near the end of the dosing interval to confirm 24-hr hypertension control.-Monitor BP, HR and ECG in early treatment to assess for MI. Regularly monitor HR and rhythm during therapy.-Teach pt to avoid of activities requiring coordination until drug effects are realized. Advise pt to report s/s of cardiac failure such as pulmonary edema, dyspnea,


cyanosis, peripheral edema, hepatomegaly. Be aware that durg may mask s/s of hypoglycemia. Advise pt to take ER tabs after meals.-DO NOT ABRUPTLY STOP TAKING MED. The dosage should be gradually reduced over a period of 1 to 2 weeks.

Potassium chloride

10 mEq in sterile water 100ml IVPB premix daily prn

Electrolyte/mineral replacement; potassium

-Action: Needed for the adequate transmission of nerve impulses and cardiac contraction, renal function, intracellular ion maintenance

In case of hypokalemia The patient’s levels were actually high on admission, but then remained WNL the following days. This must have been ordered as a precaution on the doctor’s part due to pt’s age and possible malnutrition resulting from decreased/altered LOC.

Side effects: Confusion, bradycardia, cardiac depression, dysrhthymias, and arrest, pain, diarrhea, ulceration of small bowel, oliguria, cold extremities

Considerations:->3.5 NO replacement-Potassium 3.1-3.4-administer KCL 10 mEq in 100 mL sterile water over 1 to 2 hours.-Potassium 3.0 or below administer KCL 10 mEq in 100 mL sterile water over 1 hour in 4 divided doses. If patient is NPO or not able to tolerate PO-<2.9 KCl 10mEq in 100 ml steril water over 1-4 hrs plus coadminister 40 mEq po dose-Document each KCl replacement does seperatley on eMAR-Use peripheral or central line-Notify physician if >80 mEq of KCl/ 24hr is administered-Administer ½ dose if creatinine less than or equal to 2.0-Assess hyperkalemia, potassium level, hydration status, I& ratio, cardiac status-Teach pt to add potassium rich food to their diet, avoid OTC, report hyperkalemia/hypokalemia symptoms (lethargy, confusion, decreased output), dissolve powder or tablet completely,

Potassium chloride CR (KCOR-CON, KDUR)

10-40 mEq PO daily prn

Mineral and electrolyte replacement; supplement

-Action: Maintain acid-base balance, isotonicity, and electrophysiologic balance of the cell, activator in many enzymatic reactions, transmission of nerve impulses, contraction of cardiac, skeletal and smooth muscle.

Same as above (just in PO form) Side effects: Arrhythmias, heart block, cardiac arrest, hyperkalemia, respiratory paralysis

Considerations:Potassium replacement scale:3.5-4.0= 20 mEq KCl po once3.0-3.4= 40 mEq KCl po onceless than or equal to 2.9= 40 mEq po once with 40 mEq IV-Administer ½ dose if creatinine less than or equal to 2.0-Don’t crush/ chew and take with foodDocument each KCl replacement does separately on eMAR-Monitor vital signs and ECG. Do not administer drug if apical pulse or BP is low. Particular caution must be used in the administration of K-Dur to this pt because she has a first degree heart block and potassium supplements


can cause heart block. Monitor renal function and check BUN and creatinine labs often. Pay careful attention to potassium lab values and monitor daily. DO NOT ADMINISTER MED IF POTASSIUM LEVELS ARE GREATER THAN NORMAL. Educate pt on ways to consume potassium through their diet by eating leafy greens, avocado, bananas, potatoes, and beans.

Pravastatin (pravachol)

80 mg tab po daily

Antilipemic; HMG-CoA reductase enzyme

Action: Inhibits HMG-CoA reductase enzyme which reduces cholesterol synthesis

For patient’s history of hyperlipidemia. It helps reduce the levels of LDL and triglycerides in the blood, while increasing the levels of HDL’s.

Side effects: fatigue, chest pain, constipation, diarrhea, abdominal pain, heartburn, hepatic dysfunction, pancreatitis, hepatitis, renal failure, myalgia, rhinitis, cough

Considerations:-Assess fasting lipid profile (LDL, HDL, triglycerides), hepatic studies (AST, ALT, LFT’s may increase), renal studies (BUN, I&O ratio, creatnine), rhabdomyolysis (muscle tenderness and pain).-Teach that blood work will be necessary during treatment. Teach patient to report blurred vision, sever GI symptoms, muscle pain, weakness, and fever. Pt should follow low cholesterol diet and an exercise program

Risperidone (Risperdal)

0.25 mg tab po daily

AntipsychoticBenzisoxazole derivative

Action: Unknown; May mediate through both dopamine and serotonin antagonism.

Used to treat patient’s confusion and altered LOC. It was working for the first couple of days, however, the doctor d/c it because it was causing pauses in the patient’s cardiac rhythm.

-Side effects: EPS, dystonia, tardive dyskinesia, insomnia, drowsiness, seizures, neuroleptic malignant syndrome, suicidal ideation, orthostatic hypotension, tachycardia, heart failure, constipation, jaundice, weight gain, hyperprolactinemia, neutropenia, upper respiratory infection

Considerations:-Assess for suicidal thoughts/behaviors. Make sure the patient swallowed the medication-Assess I&O, bilirubin, CBC, hepatic studies, urinalysis, affect, orientation, LOC, reflexes, and sleep pattern.-Monitor pt’s B/P for s/s of dizziness, faintness, palpitations, tachycardia, EPS, and neuroleptic malignant syndrome. Assess for constipation, urinary retention, weight gain, hyperglycemia, and metabolic changes.

-Teach the pt that orthostatic hypotension may occur; avoid hot tubs, abrupt withdrawal from medication, OTC

preparations, and hazardous activities. Teach the pt to comply with medications and to notify the prescriber

immediately if suicidal thoughts/behaviors occur.

LABS Normal Range(Fill in

Hospital Norms)

RESULT 1(3/9/15 @

0949)

RESULT 2(3/10/15 @0427)

RESULT 3(3/11/15 @

0347)

RESULT 4(3/13/15 @0415)

Reason for abnormal lab values r/t diagnosis & nursing implications


CBC WBC 4.0-11.0 K/uL 5.7 7.0 7.3 6.5 WNL RBC 4.40-6.0 M/uL 4.07 3.61 3.76 3.36 This patient’s levels have

been trending down since admission. This may be due to a dietary deficiency or renal disease caused by the pt’s type 2 DM or age. However, since this number has been trending down since admission possibly indicating bleeding is taking place. The pt should be monitored for s/s of hemorrhage including abdominal pain/swelling, light-headedness, large area of deeply purple skin (ecchymosis), increased HR, decreased BP.

Hemoglobin 13.5-18.0 g/dL

12.4 11.1 11.6 10.5 This patient’s levels have been trending down since admission. May indicate bleeding. The pt should be monitored for s/s of hemorrhage including abdominal pain/swelling, light-headedness, large area of deeply purple skin (ecchymosis), increased HR, decreased BP.

Hematocrit 40-52% 37.8 33.5 34.9 31.2 This patient’s levels have been trending down since admission. May indicate bleeding. The pt should be monitored for s/s of hemorrhage including abdominal pain/swelling, light-headedness, large area of deeply purple skin (ecchymosis), increased HR, decreased BP.

CHEMISTRYSodium 136-145

mmol/L135 139 140 140 Pt was slightly low on

admission; however, during her hospital stay


she had remained WNL. Monitor for s/s of worsening hyponatremia such as N/V, headache, confusion, loss of energy, restlessness, muscle weakness/spasms, or cramps, seizures, coma, and signs of heart failure. Continue with IV fluids and monitor pt’s I&O.

Potassium 3.5-5.1 mmol/L

5.4 4.0 3.5 4.4 WNL

Chloride 98-107mmol/l 101 103 106 107 WNLGlucose 70-99mg/dl 228 187 190 165 The initial lab value was

high, which is due to measures that were taken on admission to replace her glucose level when they found out that she was hypoglycemic. The pt’s glucose level remained higher than normal since she has type 2 DM. It was managed with insulin lispro on a sliding scale. Pt’s blood sugar levels should continue to be monitored (AC/HS). Monitor for s/s of hypoglycemia including confusion, abnormal behavior, vision disturbances, shakiness, anxiety and sweating. Monitor for s/s of hyperglycemia including frequent urination, increased thirst, blurred vision and headache.

Calcium 8.2-10.2 9.5 9.6 8.8 8.7 WNLMagnesium 1.8-2.4mg/dl 1.1 1.8 These levels were lower

than expected. This may be due to malnutrition since the patient has been on restraints and not eating as much as usual


or it could be due to renal disease. Some medications can become toxic to the kidneys causing damage. Replacement should be initiated according to MAR scale. Monitor patient for s/s of hypomagnesmia including abnormal eye movements, convulsions, fatigue, muscle cramps/spasms, muscle weakness, and numbness.

LIVER PANELAST 0-37 U/L 49 39 This could be high due to

an acute liver injury. The pt was admitted for hypoglycemia, possibly from taking too much insulin which has the potential to cause hepatic injury.

ALT 0-60 U/L 26 26 WNLKIDNEY PANELBUN 12-20 mg/dl 22 28 19 22 The patient’s levels were

slightly high which indicates that she just isn’t getting good perfusion possibly verging on ARF. Pt. may also be dehydrated after being in restraints and little intake. Her age also plays a factor in proper renal function. Monitor patient’s I&O.

Creatnine 1.4-1.78 ml/sec

1.41 1.45 0.94 0.96 Pt’s level fluctuated between WNL. This could be decreased due to acute renal failure from hypoglycemia (overdose of insulin). I could also be slightly low since the patient it older. As one ages, creatnine levels


decrease. Monitor patient’s I&O.

GFR >=60 33 32 54 53 The patient’s levels are lower than expected. 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. Creatnine should be monitored in congruence with this value in order to evaluate kidney function.

UA collection typeUrine glucose Negative >500 This elevated level is due

to her type 2 DM., so the pt is experiencing glycosuria Since the pt came in with hypoglycemia they were quickly trying to correct this which is probably why we see so much in the urine. She is being loaded up with glucose so a lot is getting excreted through the urine. Monitor for s/s of hypoglycemia including confusion, abnormal behavior, vision disturbances, shakiness, anxiety and sweating. Monitor for s/s of hyperglycemia including frequent urination, increased thirst, blurred vision and headache.

Urine Protein Negative 30 Proteinuria is typically an indicator of renal disease. It could also be high due to the patient’s diabetic complications with hypoglycemia.


DIAGNOSTIC DATA

TEST RESULTSECG: 5 lead Sinus tachycardia (most of the time)X ray: chest (due to SOB) Aorta atherosclerotic, cardiac silhouette

enlarged, heavy mitral valve calcification. Chronic bronchial thickening.

MRI (for altered LOC) No acute brain process. Old right frontal lobe infarct. Microvascular changes.

CT: brain w/o contrast (for altered LOC) Small old basal ganglia lacunar infarcts. Mild cortical atrophy and chronic small vessel ischemia changes. No acute intracranial process.

CT: cervical spine (for altered LOC and neck pain)

Moderate to severe multilevel degenerative disc and facet changes greatest at C5-6. 2mm anterior subluxation C7 on T1 probably related to facet degenerative changes.


Concept Mapping Student Name: _____________

Student Name: _________________________

N4810 Clinical Paperwork Rev11/06/13

7. Risk for InjuryData to Support: -Confused-Previously on restraints-Multiple medications-Pt has a foley and a running IV (risk for tripping)-Generalized weaknessInterventions: -Fall protocol-Aspiration protocol-Pt has a sitter-SCD’s applied-BS monitored and adjusted with medication (to avoid hypo/hyperglycemia)-

1. Acute ConfusionData to Support:-Hypoglycemia can cause confusion, however, it has persisted even though her glucose levels are now within range-Patient Frequently only A&Ox2 or less-Pt verbalized a need to have to pay for her lunch using a “lunch card” when there is no lunch card sin the hospital.-Pt had a sitter due to her confusionInterventions:-Continually assess patient LOC and orientation-Perform an accurate mental status exam -Assess blood sugar (to make sure mental status isn’t due to a separate physiological alteration)-Reorient pt as necessary-Keep patient calm and relaxed-Assist with ADL’s. Use simple directions-Pt was on Risperidal to help with confusion, but was taken off because it was causing pauses in her EKG

4. Anxiety: Data to Support: Pt. confused -Previously on restraints-Verbalizes fear about “paying for lunch” says she “sees her husband”-Keeps trying to get in and out of bed-Fidgets and very restless-Pt thinks she has things to do and places to be that aren’t real.Interventions:-Ativan was prescribed but only as a single dose on admission. May need new medication.-Explain procedures. Use step-by-step directions-Reassure patient as appropriate. Use relaxation techniques and therapeutic communication.-Encourage family participation (she seemed to really relax when family was present)- Pt’s behavior needs to be discussed with doctor.

Chief Medical Diagnosis: HypoglycemiaPriority Assessments: LOC: she has been confused since admittanceVS: pt is on medications that have affected her HR and BPEKG: pt is on renal tele with frequently irregular heart rhythmI&O: pt has been on restraints and her some of her electrolyte levels have been off-Glucose levels: uncontrolled type 2 DM-Skin integrity: Pt was on restraints and often immobile

3. Imbalanced Nutrition: less than body requiresData to Support: -Pt. came in with hypoglycemia, which could have been due to diet-Pt intake is limited, was on restraints-Pt rarely drinks fluids unless told to.-Confusion-Low Mg level (1.1)-Pt lost 10 lbs since admittanceInterventions: -Monitor I&O-Encourage fluids and food intake-1:1 feeder (sitter)-Pt reoriented frequently-Mg replaced- Calcium carbonate/vitamin D (caltrate 600+D) and Ascorbic acid (vitamin C) administered

2. Decreased Cardiac OutputData to Support: -Hx: abnormal heart sounds and HTN- EKG showed tachycardia and some arrhythmias -Pt went for an echocardiogram on 3/13/15 at 1300. I wasn’t able to get her Ejection Fraction-Clammy mottled skin-HR: 110, SpO2: 95%, BP: 159/65-RBC: 3.36, Hgb: 10.5, Hct: 31.2Interventions:-Assess heart sounds, rate, and rhythm. Assess lung sounds (monitor for s/s of HF)-Monitor VS and EKG-Monitor I &O-Administer O2 as needed-Apply SCD’s -Echocardiogram scheduled-Monitor lab values (CBC, Na, and Creatnine)

6. Risk for unstable glucose levelData to Support: -Pt admitted for hypoglycemia-Blood glucose monitoring AC/HS-Pt on sliding scale for insulin lispro-Inadequate intake r/t restraints and confusion-ConfusionInterventions:-Monitor blood glucose AC/HS-Evaluate A1C for control over previous 2-3 months-Administer insulin according to sliding scale.-Monitor I&O-Monitor for s/s of hypo/hyperglycemia-Assess for cognitive changes that may have led to admission for hypoglycemia

5. Risk for bleedingData to Support: -Pt fell prior to admission-Pt receiving heparin 5,000 units subQ and aspirin-RBC: 3.36 (trending down)-Hgb: 10.5 (trending down)-Hct: 31.2(trending down)-Ecchymotic skin on armsInterventions: -Monitor lab values (CBC, INR, PT, PTT)-Monitor VS-Monitor medications for bleeding risks-Assess for s/s of bleeding (abdominal pain/swelling, absent/decreased bowel sounds, light-headedness, large area of deeply purple skin (ecchymosis), increased HR, decreased BP

Problem Evaluation

Problem # Evaluation of Patient Response

1Pt fluctuated frequently between A&O x4 to A&Ox2 or less. When she was on Risperidal she was much more alert and oriented, however, it was causing frequent pauses in her heart rhythm, so the doctor d/c the medication. Since the medication was d/c the patient became much more confused and the sitter became frightened that she was hallucinating because of what she was saying. The patient also kept trying to sit up and get out of bed, not realizing her own weakness/confusion. I went in to the room and took like 15 minutes to sit and talk with the patient, reorient her, use therapeutic communication, reassured her as appropriate, and repositioned her so that she was comfortable and relaxed. The patient seemed to respond well to this, because during the rest of the shift she seemed a lot calmer and the sitter wasn’t as worried. Family visits were encouraged, because when they were present the pt seemed to be much more relaxed and oriented. A quiet and reduced stimulus environment was provided in order to keep the pt relaxed. The pt may be experiencing some dementia, which was exacerbated by the episode of hypoglycemia. I made sure I explained everything I was doing to the patient and gave her simple step-by-step directions. The pt seemed much more calm when I explained what I was doing.

2The pt was frequently tachycardic since her metoprolol was held. The doctor held the medication because every time it was administered the patient’s HR would drop to the 50’s and then after it wore off, would shoot back up into the 100’s. So, the doctor suspected the pt had sick sinus syndrome (SSS). The patient’s BP remained slightly high as did her HR, but there was no medication prescribed yet to manage her HR appropriately. The pt didn’t experience any adverse effects from these changes. SCD’s were applied and O2 wasn’t needed. She was scheduled for an echocardiogram later on the second day, which may provide some answers on the status of the heart and help make a plan for how to treat the client in the future (may need a pacemaker).

3Since the pt was on restraints and because she is confused, her intake diminished slightly. So, now that she is out of restraints I really encourage her to eat and drink fluids regularly. The pt seemed to respond well to this encouragement. A 1:1 feeder was ordered, this was a way to closely monitor the pt’s intake. Her Mg was replaced and there was no s/s of hypo/hypermagnesmia while I was caring for her. Supplements were administered. All electrolytes were WNL except for Mg, which was replaced.

4The pt responded really well to the relaxation techniques and therapeutic communication that I used. As mentioned previously I went in to the room and took like 15 minutes to sit and talk with the patient, reorient her, use therapeutic communication, reassured her as appropriate, and repositioned her so that she was comfortable and relaxed. The patient seemed to respond well to this, because during the rest of the shift she seemed a lot calmer and the sitter wasn’t as worried. Family visits were encouraged, because when they were present the pt seemed to be much more relaxed and oriented. Since the patient didn’t have anything in her MAR for anxiety, her behavior should be discussed with the doctor in order to see if something should be prescribed to help calm the patient. This would also help limit her risk for injury, because she might not keep trying to get in and out of bed so frequently due to agitation/confusion.

5The patient has not shown and s/s of bleeding besides her lab values, which is a good sign. Her MRI,X-ray, and CT all were negative for any signs of bleeding. Her bowel sounds were active, stomach was non-distended and without pain. Her arms were ecchymotic but that could mostly be attributed to age and thin skin. The pt should just continue to be monitored for s/s of bleeding


and for any further decrease in her lab values (RBC, Hgb, Hct).

6The patient responded well to all interventions because her glucose remained relatively stable since admission. Her blood glucose level was medicated with insulin according to a sliding scale. The pt seemed to understand the need to monitor her blood glucose levels. The pt’s confusion is what may have to led to her admission for hypoglycemia, so before discharge this should be addressed.

7The pt remained free from injury since her admission. Fall and aspiration precautions were taken in order to prevent injury. The pt was very confused, which also put her at risk for injury. She was frequently reoriented and a quiet environment was provided in order to help with orientation/confusion. The sitter was an added precaution to prevent injury as well.


Student Clinical Self-AppraisalEXAMPLE

Weekly (turn in with Care Plan/Map)

Student: Kaylee Blankenship Course N4810_____ Instructor: Sherri BrownInstructions: Please evaluate your performance during clinical today using the following concepts:

Client Advocate Professional Demeanor FlexibleCritical Thinking Communication/rapport Coordinator of CareSelf-Initiated Technical skills Team PlayerProfessional Accountability Organized EducatorLeadership Well-prepared Ability to PrioritizeNursing Process Comprehensive Assessment Knowledgeable

Areas of Strength Today: 3/13/15

Self-Initiated/Leadership: This week I felt like I did a lot of the pt’s coordinated care on my own. I was able to bring things to the nurses attention that she did not recognize.

Ability to Prioritize: I used more of my time management skills this week and became more organized. One of my patient’s was on an insulin drip so I had to really pay attention to my timing to make sure that the blood sugars were on time.

Communication/rapport: I felt like I built rapport with both patients. They looked forward to seeing me the next day and felt comfortable asking me questions. I was able to use therapeutic communication with the pt with altered LOC. She was becoming agitated and I was able to get her to relax without medication.

Well-prepared: I felt really prepared this week. I made sure I got a thorough history on each pt and came prepared to take care of each pt’s needs.

Knowledgeable: I knew quite a bit about each patient’s diagnosis already, but I did learn a lot about documentation and critical thinking.

Areas Needing Growth-Include plan of improvement

Leadership: I think I still need work on my leadership skills. As a student nurse I am not also super confident in my skills and knowledge level yet, but I am definitely making progress.

Technical skills: I could perfect my skills a little more. I am not always 100% on the steps of every procedure, but that is why I check the policy and procedures.

Critical thinking: I am always working to improve my critical thinking skills. I am not always able to connect all of the dots as far as labs, medications, diagnosis and s/s are concerned. Each clinical experience helps to hone these skills though.

Instructor Comments:I am so excited for you to move on out of the program You are an incredible student nurse and I love seeing you grow. Your leadership skills will improve as you move out of nursing school. It is hard to grow in this area in school. I love how you attacked your labs this time. You often gave a couple of reasons why lab could be altered and one was always correct. Nice job!!!!


Student’s Name: Kaylee Blankenship Pt’s Initials: D.R. Date: 3/13/15

Atrial rhythm: Regular or Irregular Ventricular rhythm: Regular or Irregular

Atrial Rate: 60 bpm Ventricular rate: 80 bpm

PR interval: 0.12 seconds QRS interval: 0.08 seconds

QT interval: 0.4 seconds

Is AV conduction normal? (Y/N)______________ If not, why is it abnormal? sinus node isn’t firing correctly resulting in occasional junctional beats

P wave normal? (Y/N) Not every QRS has a p-wave

QRS complex normal? (Y/N) 0.08 seconds

Are all of the QRS complexes the same? (Y/N) ___________________

Are there premature beats? (Y/N) __________ , Atrial or ventricular

Interpretation of rhythm:

2 junctional beats present (4 th and 8 th complex )

Potential hemodynamic consequences of this rhythm and interventions for this rhythm:

Pt should be monitored for any further EKG abnormalities. Pt also has SSS, which can cause quick fluctuations in EKG rhythms. Pt had medications, such as metoprolol and risperidone due to the adverse side effects they were having on her heart rate and rhythm. No interventions are needed at this time just closely monitor for any changes in current status.


sherri brown, 03/31/15,

Agree good job

Student Name: Kaylee Blankenship Date: 3/20/15 Clinical Instructor: Sherri Brown_

Instructions: Attach a copy of this form to the back of each of you Clinical Plan of Care/Maps for grading purposes.

Grading Rubric:1. Patient Data includes: 20 points possible ____20_

a. Health historyb. All blanks and/or issues are addressed

2. Each medication includes: 20 points possible ___20__a. Nameb. Rationalec. Side effectsd. Nursing implications-specific to this patient

3. Lab Diagnostics 10 points possible _10____a. Testb. Resultsc. Implications & Teaching

4. Problem Identification includes 20 points possible __20___a. Correctly lists individualized needsb. Correctly identifies problemsc. Problems are prioritized and numbered, each problem in priority of importance d. Map includes at least five physiological problems, discharge planning and patient educatione. Each problem includes:

i. Nursing diagnosisii. Data to supportiii. Medicationiv. Nursing treatment (interventions)

5. Planned interventions includes 10 points possible _10____a. Interventions appropriateb. Correctly prioritizes interventionsc. Assessments performedd. Communicatione. Patient teachingf. Discharge planning

6. Evaluation of Interventions includes 10 points possible ____10_a. Evaluates physical interventionsb. Evaluates teaching

7. a. Priority Assessments are appropriate to diagnoses 10 points possible ___10_b. Clinical Paperwork is complete


Total Points ____100_________/100 = ____%


renal tele patient-3

Documents

patient care plan

clinical instructor

nursing care

patient intake

patient teaching

clinical learning experience

nursing history

admission date