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Age: 93
Sex: Female
Patients Past Medical History: Diabetes mellitus, A-Fib, Senile dementia, Thyroid Disease
NURS-240
Drug
Classification
Dose
Frequency
Parameters to
be checked
prior to
administration
Patient safety:
when to hold
the medication &
follow up required
Side effects
of the
medication
and required
follow up
Patient
Teaching
Anticoagulant
5,000
Units
Q 8 Hours
Prevention of
thrombus
formation
INR, PTT, PT
Hold if
uncontrolled
bleeding or open
wounds, severe
thrombocytopenia
, hypersensitivity
Drug
induced
hepatitis,
alopecia,
bleeding,
HIT, anemia
Aspirin EC
tablet
Salicylates
81 mg
Daily
Prophylaxis of
TIA and MI
Last dose
Hypersensitivity,
bleeding disorders
or thrombocytopenia
Tinnitus, GI
bleeding,
dyspepsia,
nausea,
abdominal
pain,
anorexia,
increased
bleeding
time
Insulin Regular
(HumuLIN R,
NovoLIN R)
Antidiabetics,
hormones
pancreatics
1 unit
TID AC
Control of
hyperglycemia
Last Dose
Glucose Level
hypoglycemia,
allergy or
hypersensitivity
Hypoglycem
ia, erythema,
pruritis,
swelling
Report any
symptoms of
unusual
bleeding or
bruising to
HCP
immediately.
Carry an ID
card with this
information
at all times.
Take with a
full glass of
water and to
remain in an
upright
position for
15-30 mins
after
administratio
n.
Report
tinnitus,
unusual
bleeding of
gums;
bruising;
black tarry
stools; or
fever lasting
longer than 3
days
Teach proper
technique for
administratio
n
Teach patient
that insulin
treats
hyperglycemi
a but does
not cure
diabetes.
Therapy will
be long term
S/S of
hypoglycemi
a and what to
do if they
NURS-240
Acetaminophe
n (Tylenol)
Antipyretic,
nonopioid
analgesics
650m
g
Q 4Hour
PRN
Last dose
Pain level
Hypersensitivity,
hepatic
impairment/
active liver
disease
Hepatotoxici
ty (in High
Doses),
Increased
liver
enzymes,
renal failure,
neutropenia
occur
Take exactly
as directed
Avoid
Alcohol
Can alter
blood
glucose
monitoring
results
II.
Pathophysiology:
Atrial Fibrillation (AF) is the most common type of arrhythmia. The dysrhythmia may
begin and end spontaneously or may be persistent. It is characterized by total disorganization of
atrial electrical activity due to multiple ectopic foci resulting in loss of effective atrial contraction.
Causing the atria to contract very fast or irregularly. In AF, blood pools in the atria and doesnt
completely pump into the ventricles causing the chambers to not work together as they should. AF
results in a decreased cardiac output because of ineffective contractions and/or rapid ventricular
response. Clots form because of the stasis of blood (a clot can form/pass to the brain and cause a
stroke or dislodge to another place in the body). Structural Heart Disease is the underlying cause
in many cases of AF however; the cause in healthy normal hearts is less well understood.
Lewis,Dirksen,Heitkemper,Bucher,&Camera.(2011).Medical
SurgicalNursing(8thed.).St.Louis,
MO:Elsevier.
Page827
III.
Etiology of the condition (underline the etiologies that relate to your patient):
Known risk factors for AF include age, male sex, valvular heart disease, hypertension, and
diabetes. Most often AF is associated with an underlying structural heart disease such as valvular
problems, heart failure, coronary artery diseases, congentital heart disease, cardiomyopathy, and
septal defects. AF can be secondary to reversible causes and treatment of the underlying disease
usually gets rid of the arrhythmia. Some of the most common causes are alcohol intake, infectious
state, heart attack, hyperthyroidism, and pulmonary embolism.
Lewis,Dirksen,Heitkemper,Bucher,&Camera.(2011).Medical
SurgicalNursing(8thed.).St.Louis,
MO:Elsevier.
NURS-240
Page 827
IV.
Lewis,Dirksen,Heitkemper,Bucher,&Camera.(2011).Medical
SurgicalNursing(8thed.).St.Louis,
MO:Elsevier.
Page827
V.
Medical Treatment:
The goals of treatment include a lowered heart rate, prevention of cerebral events,
and conversion to sinus rhythm, if possible. Drugs used for rate control include
calcium channel blockers, Beta-adrenergic blockers, Digoxin, and dronedarone. For
some patients, pharmacological or electrical conversion back to sinus rhythm may
be a consideration. For a patient in AF longer than 48 hours, anticoagulation therapy
with Warfarin is needed for 3 weeks before cardioversion and for 4 weeks after a
successful cardioversion. Anticoagulation therapy is needed because the
cardioversion can cause clots to dislodge and can place the patient at risk for stroke.
If it is found that no clots are present, anticoagulation therapy is not needed before
the cardioversion.
Lewis,Dirksen,Heitkemper,Bucher,&Camera.(2011).Medical
SurgicalNursing(8thed.).St.Louis,
MO:Elsevier.
Page 827
VI.
Nursing Management:
NURS-240
VII.
Date
of
the
test
Results of
the lab or
diagnostic
test
Normal
Values of
the lab or
diagnostic
test
WBC
RBC
9/18
9/18
6.52
3.42
4.0-11.0
F 3.8-5.1
Hemoglobi
n
9/18
10.3
F 11.715.5
Hematocrit
9/18
30.2
F 35%47%
Sodium
Potassium
Chloride
CO2
Glucose
9/19
9/19
9/19
9/19
9/19
140
4.0
100.4
32
177
135-145
3.5-5.0
95-105
32-48
70-99
NURS-240
Analysis of
the results:
normal,
abnormal,
elevated or
decreased;
Explain the
reason for
any
deviations
from the
norm
Normal
LOW can
be from
hemorrhage,
dietary
insufficiency,
chronic
illness,
hydration
status
LOW -can be
from
hemorrhage,
dietary
insufficiency,
chronic
illness,
hydration
status
LOW- can be
from
hemorrhage,
dietary
insufficiency,
chronic
illness,
hydration
status
Normal
Normal
Normal
Normal
HIGH diet
Current
medications
which may
affect the
results, of
any
(explain
how)
Nursing
Actions
related to
the results
None
Increase
fluids to
hydrate,
evaluate
vitamin or
mineral
deficiency
None
Increase
fluids to
hydrate,
evaluate
vitamin or
mineral
deficiency
None
Increase
fluids to
hydrate,
evaluate
vitamin or
mineral
deficiency
Salicylates
Level taken
controlled
DM (before
insulin
therapy)
Creatinine
Calcium
9/19
9/19
0.5
8.2
0.6-1.3
8.6-10.2
Normal
LOW
Albumin
9/18
2.1
3-5
LOW
Magnesium
9/18
1.6
1.5-2.5
Normal
(acute
toxicity) Aspirin
before or
after meal?
Monitor
diet,
administer
Insulin
Aspirin,
Heparin,
Occurs with
low albumin
levels,
assess
nutrition and
assess for
vitamin D
deficiency
Hepatotoxic Assess for
drugs
malnutrition
, over
hydration,
third space
losses
Pagana,K.D.,&Pagana,T.J.(2010).ManualofDiagnosticand
LaboratoryTests(4thed.).St.
Louis,MO:Mosby.
VIII.
Discharge Planning
NURS-240
IX.
Client Teaching
Medications
MED Chart
Diet
Enteral Feeding 40mL/hr with a 100mL flush every 6 hours
Activity
o Total Assist
o Passive ROM
o Turn in bed q 2hr
X.
Treatments
Patient is DNR, no heroic measures to be performed. Palliative care only.
Anticoagulants for prevent blood clots, Aspirin to prevent MI, Insulin to control DM,
acetaminophen PRN for pain
Safety
Call light in reach, side rails up, HOB up, bed low, brake on, Aspiration Precautions
Growth & Development
Patients age: 93
According to Erikson: Stage: Integrity
Crisis: Despair
A. Describe your patients ability to achieve their growth and developmental tasks.
a. The patient is total assist and bedridden. The patient is unable to communicate
well. She can follow simple commands and answer yes or no questions
however; she does not speak otherwise and only moans. The patient needs total
assistance with ADLs such as bathing, oral care, changing, etc. The patient has
a Foley catheter and does not get up to use the bathroom and she had a G tube
running continuously at 40 mL/hr. The patient is frail and has a very weak left
NURS-240
side due to a CVA. She also has an altered mental status, she is oriented to
herself but not to time/place.
B. How is this ability affected by the underlying disease process and/or the current
admission?
Patient was admitted to ED due to a fall at the nursing home where she lives. Nurses
at the long term care facility reported a change in LOC one day after the fall and patient
was sent to ED. Daughter reports that the patient normally communicates and talks
well, however, the patient is unable to communicate well and can only use simple
words such as yes or no. Patient can follow simple commands but is only oriented to
self, not place or time. The patients ability to perform ADLs is impaired due to old age
(muscle weakness), recent stroke (left side impaired), and altered mental status.
Daughter reported to her knowledge that the patient was not on any anticoagulation
medication for her A-Fib. This underlying condition could have possibly caused blood
clots that could have caused her recent stroke.
C. List nursing actions to assist your client in meeting their growth and developmental
needs.
Keep patient and family members/nursing staff at long term care facility educated
on the medication the patient is prescribe to make sure she takes it properly when being
discharged and to ensure understanding of why the medication is being taken.
Keep patient informed on a heart healthy diet (if PO again) and ensure that she and
family members understand why it is important to keep up on a healthy diet.
Assist the patient in ROM exercises to help with the contractures associated with
recent stroke to help recovery, prolong life, and increase independence if possible.
It seems the patient has a relatively good relationship with her children and family
based on the information provided from her children and the way in which he daughter
speaks fondly of her mother. The patient will be able to reach Integrity over Despair as
long as her relationship with her children remains strong; the patient is likely to feel
satisfied with what she will leave behind for her family. It is hard to make an inference
on this matter since the patient was not able to communicate well in order to provide a
good insight on her life overall.
NURS-240
XI.
List in priority order all relevant nursing diagnoses for your patient. Include NANDA
diagnosis, etiology, and supporting data. Identify in order the top three priority diagnoses.
Assessment Data:
Nursing Diagnosis
Nursing Actions
Rationale
Evaluation
(According to NANDA)
NURS-240
1. Monitor
patients
blood
pressure
closely and
monitor for
need of
medication to
regulate
high/low
pressure if
needed.
2. Monitor
patients vital
signs and
keep patient
on constant
heart
monitor.
3. Correct
electrolyte
imbalance
4. Draw
patients INR
and PT time
per MD
order,
administer
Heparin per
order/ if
needed.
1. Patients blood
pressure keeps
fluctuating
from
hypotensive to
hypertensive. It
would not be
therapeutic to
give the patient
a calcium
channel blocker
etc. If the
patients blood
pressure is
stable.
However,
should the
patient need an
anti
hypertensive,
constant
monitoring of
blood pressure
can ensure a
quicker
response,
should there be
a change in
condition.
2. It is important
to monitor vital
1. Patients
pressure
remained
normal li
througho
clinical d
(110/58 a
2. Patients
signs wer
normal li
during cl
day, exce
HR woul
fluctuate
80s-120
3. Patient r
continuo
enteral fe
(Glucern
40ml/hr w
100ml NS
every 6 h
4. Patients
PT time l
not avail
the MAR
review, r
were still
pending.
5. Patient w
5. Assess need
for a Social
work consult
for education
on programs
available for
medication
cost
6. If needed, an
echocardiogr
am can be
performed in
order to rule
out the
presence of
clots in the
atria.
NURS-240
unable to
commun
well, thes
should be
discussed
patients
daughter
possibly
staff from
term car
6. Patient is
and no h
measures
be perfor
this patie
Cardiove
will not b
performe
provide patients
with
information for
appropriate
resources to
help people who
cannot afford
their
medications.
This is to ensure
compliance to
the medication
regimen and
prevent
noncompliance
due to financial
issues before
they even occur.
6. If there are no
clots present in
the atria,
anticoagulation
therapy is not
required before
cardioversion
therapy (if
needed). Also, if
clots are found
this allows the
medical staff to
prepare/caution
for increased
risk of stroke
Expected Outcome:
NURS-240
LTG:
Patient or family
member will
verbalize 2 ways to
help ensure
medication
compliance and 5
ways to help prevent
falls at home before
discharge.
Evaluate each
expected outcome:
NURS-240
Assessment Data:
Nursing Diagnosis
Nursing Actions
Rationale
Evalua
(According to NANDA)
Evaluate
nursing a
1. Palpate radial,
carotid, femoral,
and dorsalis pedis
pulses, noting rate,
amplitude and
symmetry.
Document.
NURS-240
1. All p
present
on left
extrem
noted w
than th
extrem
This m
2. Auscultate heart 2. Specific dysrhythmias are
due to l
sounds, noting
more clearly detected audibly
movem
rate, rhythm,
than by palpation. Hearing
the left
presence of extra
extra heartbeats or dropped
Passive
heartbeats, and
beats helps identify
exercise
dropped beats.
dysrhythmias in an
perform
unmonitored client.
help inc
3. Administer
blood f
supplemental
3. This increases the amount of the extr
oxygen, as
oxygen available for myocardial Nurse o
indicated
uptake, reducing irritability
made a
caused by hypoxia.
4. Monitor
2. Patie
laboratory studies, 4. Electrolyte imbalances, such
chronic
especially
as potassium, magnesium, and
Dysryh
electrolytes. And
calcium adversely affect cardiac already
use therapeutic
rhythm and contractility. Also,
identifi
measures to
Hypoalbuminemia is often
before
correct
associated with anemia.
to hear
imbalances.
(Potassium imbalance is the
howeve
number one cause of AF)
listenin
5. Provide calm
heart so
and quiet
5. This reduced stimulation and always
environment
release of stress-related
import
catecholamine, which can cause listen fo
or aggravate dysrhythmias and murmu
vasoconstriction, increasing
irregula
myocardial workload.
3. Patie
oxygen
nasal ca
Oxygen
checked
occasio
make s
was bei
admini
properl
HOB k
least 30
to ease
breathi
for asp
precaut
4. Patie
receivin
enteral
of Gluc
40mL/h
100mL
every 6
continu
monito
values a
adjust f
approp
5. Patie
TV on i
on a low
volume
low, wi
patient
cracked
door w
mostly
keep ou
hallway
howeve
closed a
way so
patient
closely
monito
she cou
commu
well. P
was app
in a cal
manner
she wou
be start
Expected Outcome:
NURS-240
STG:
Heart rate and
rhythm converted
back to sinus
rhythm to sustain
adequate cardiac
output and tissue
perfusion within 48
hours.
LTG:
Achievement of
activity level
sufficient for basic
self-care before
discharge.
Evaluate each
expected outcome:
LTG:
Goal not met,
Patient has not been
considered for
discharge at this
point. Patient is total
assist and on enteral
feedings.
Doenges,M.E.,Moorhouse,M.F.,&Murr,A.C.(2014).Guidelines
forIndividualingClientCare
AcrosstheLifeSpan:NursingCarePlans(9thed.).
Philadelphia:DavisCompany.
Pages9293
Lewis,Dirksen,Heitkemper,Bucher,&Camera.(2011).Medical
SurgicalNursing(8thed.).St.Louis,
MO:Elsevier.
NURS-240
NURS-240