MIAMI DADE COLLEGE - MEDICAL CENTER CAMPUS - SCHOOL OF NURSING NUR 1025L: Fundamentals Nursing Clinical Students Name:

Francisco J Ortiz Date: _07/15/13_ Clients Initials: ____ IH ___ Admission Date: _04/01/2013 Age: 91yr DOB: ______08/28/1921_____ Sex: Male X Female Race/Ethnicity: WHITE/______________ Support System: _____son _________________________________________________________ Religion: _Catholic MEDICAL HISTORY ALLERGIES: _NKA_ Admitting Medical Diagnosis (es): DMII; Fracture of humerus; dementia; hypertension; lipoid metabolic disorder, iron deficiency; anemia Chief Complaint: abnormal lab History of Present Illness: Pt is a 91 yr old female history from nursing home history of GI bleeding. Pt was sent back to the hospital because of low HH Past Medical History (include past surgical history): Significant hypertension ,Dementia, asthma, DMII and hyperlipidemia; No alcohol abuse, no drug abuse Clients (Parents)Understanding of Illness: patient has dementia and cannot recollect information given Stage of Development: Erickson Ego Integrity vs. Despair _ Freud: According to Freud, the genital stage lasts throughout adulthood. He believed the goal is to develop a balance between all areas of life. Piaget _ Formal Operational ____ Special Developmental Considerations: N/A Height: 162.56 cm Weight: 50 kg Placement in Growth Chart: _N/A Immunizations: Patient refused flu vaccine

VITAL SIGNS Time Taken: ______1000_________ Activity: ______________ Position: ____wheel chair__________ 1

T_36.4 P96 R 19 BP _129/68 Baseline (Normal Age for Age): T_ 36.137.8 P_60 -100 R_12-20_ BP 120/80 _

NUTRITION Diet: REGULAR Food Preferences:_EXTRA SYRUP IN BREAKFAST, COFFEE AFTER LUNCH, COOKIE AFTER DINNER Nutritional Requirements: (Cal/Kg/Day): 2100 CAL/KG/DAY Total Calories per Day: _1900___________ Fluid Requirements (Ml/Kg/Day): __________________________________ ________________Total Fluids per Day: _______________________________ Special Treatments: ____________N/A Medications at Home:_N/A___________________________________________________________________________________________ __________________________________________________________________________________________________________________

Medication(s) Worksheet NAME CLASSIFICATI ON Prilosec DOSE/ROUTE/FREQUE NCY SAFE RANGE 20mg daily by mouth MECHANISM OF ACTION Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen. INDICATIONS NURSING CONSIDERATIONS AND PATIENT EDUCATION CNS: A Assess patient dizziness, routinely for drowsiness, epigastricor fatigue, abdominal pain and headache, frank or occult blood weakness. in the stool, emesis, CV: chest or gastric aspirate. pain. GI: abdominal Monitor CBC with pain, acid differential regurgitatio periodically during n, therapy. constipation, diarrhea, flatu- lence, nausea, vomiting. Derm: itching, rash. Misc: allergic reactions. SIDE EFFECTS

GERD/maintena nce of healing in erosive esopha- gitis. Duodenal ulcers (with or without anti-infec- tives for Helicobacter pylori). Shortterm treatment of active benign gastric ulcer. Pathologic hypersecretory conditions, including Zollinger-Ellison syndrome. Reduction of risk of GI bleeding in critically ill patients.

Norvasc

10mg 1 tab PO

Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in in- hibition of excitationcontraction coupling and subsequent contraction.

Indications:Alone or with other agents in the management of hypertension, angina pectoris, and vasospastic (Prinzmetals) angina.

CNS: headache, dizziness, fatigue. CV: peripheral edema, angina, bradycardia, hypotension , palpitations. GI: gingival hyperplasia, nausea. Derm: flushing. CNS:
NEUROLEPTIC MALIGNANT SYNDROME, SUICIDAL THOUGHTS,

Monitor blood pressure and pulse before therapy, during dose titration, and periodically during therapy. Monitor ECG periodically duing prolonged therapy.

Celexa

10mg 1 tab PO

Selectively inhibits the reuptake of serotonin in the CNS.

Depression.

apathy, confusion, drowsiness, insomnia, weakness, agitation, amnesia, anxiety.

Assess for suicidal tendencies, especially during early therapy and dose changes. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and may minimize dry mouth. If dry mouth persists for more than 2 wk, consult health care professional regarding use of saliva substitute

Namenda

10mg 1 tab PO

Binds to CNS N-methyl-Daspartate (NMDA) receptor sites, preventing binding of glutamate, an excitatory neurotransm itter.

Moderate to severe Alzheimers dementia.

CNS: dizziness, fatigue, headache, sedation. CV: hypertensio n. Derm: rash. GI: weight gain. GU: urinary frequency. Hemat: anemia.

Assess cognitive function (memory, attention, reasoning, language, ability to perform simple tasks) periodically during therapy.

Amaryl

4mg 1 tab PO (with breakfast)

Lower blood glucose by stimulating the release of insulin from the pancreas and increasing the sensitivity to insulin at receptor sites. May also decrease hepatic glucose production.

Control of blood glucose in type 2 diabetes mellitus when diet therapy fails. Require some pancreatic function.

CNS: dizziness, drowsiness, headache, weakness. GI: constipation , cramps, diarrhea, druginduced hepatitis, heartburn, q appetite, nausea, vomit- ing. Derm: photosensiti vity, rashes.

Observe for signs and symptoms of hypoglycemic reactions (sweating, hunger, weakness, dizziness, tremor, tachycardia, anxiety).

Zestril

10mg 1 tab PO

ACE inhibitors block the conversion of angiotensin I to the vasoconstric tor angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandi ns. ACE inhibitors also q plasma renin levels and p aldosterone levels. Net result is systemic vasodilation.

Alone or with other agents in the management of hypertension.

CNS: dizziness, drowsiness, fatigue, headache, insomnia, vertigo, weakness. Resp: cough, dyspnea. CV: hypotension, chest pain, edema, tachycardia. Endo: hyperuricem ia

Hypertension: Monitor bloodpressure and pulse frequently during initial dose adjustment and periodically during therapy. Notify health care professional of significant changes.

Ferrous sulfate

65mg tab with breakfast

An essential mineral found in hemoglobin, myo- globin, and many enzymes. Enters the bloodstream and is transported to the organs of the reticuloendoth elial system (liver, spleen, bone marrow), where it is separated out and becomes part of iron stores.

Prevention/treat ment of irondeficiency anemia

CNS: IM, IV SEIZURES, dizziness, headache, syn- cope. CV: IM, IV hypotension , hypertensio n, tachycardia. GI: nausea; PO, constipation, dark stools, diarrhea, epigastric pain, GI bleeding;

Assess nutritional status and dietary history to determine possible cause of anemia and need for patient teaching. Assess bowel function for constipation or diarrhea. Notify health care professional and use appropriate nursing measures should these oc- cur.

Zocor

20mg 1 tab PO nightly

Inhibit an enzyme, 3hydroxy-3methylglutar yl-coenzyme A (HMG-CoA) reductase, which is respon- sible for catalyzing an early step in the synthesis of cholesterol.

Adjunctive management of primary hypercholesterolemia and mixed dyslipidemias.

CNS: dizziness, headache, insomnia, weakness. CV: chest pain, peripheral edema. EENT: rhinitis; lovastatin, blurred vision. Resp: bronchitis.

Obtain a dietary history, especially with regard to fat consumption.

Aspirin

81mg daily PO

Inhibits the synthesis of prostaglandi ns that may serve as mediators of pain and fever, primarily in the CNS. Has no significant antiinflammator y properties or GI toxicity.

Mild pain. Fever.

GI:

HEPATIC FAILURE, HEPATOTOXICITY

(overdose). GU: renal failure (high doses/chroni c use). Hemat: neutropenia, pancytopeni a, leukopenia. Derm: rash, urticaria.

Assess overall health status and alcohol usage before administering acetaminophen. Patients who are malnourished or chronically abuse alcohol are at higher risk of developing hepatotoxicity with chronic use of usual doses of this drug. Assess amount, frequency, and type of drugs taken in patients self-medicating, especially with OTC drugs. Prolonged use of acetaminophen increases the risk of adverse renal effects. For short-term use, combined doses of acetaminophen and salicylates should not exceed the recommended dose of either drug given alone.

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PATHOPHYSIOLOGY-BRIEF TEXTBOOK PICTURE WITH CLIENT COMPARISON Definition, Etiology, Incidence, Pathophysiology, Diagnostic tests, Signs & symptoms, Medical treatments Textbook Pathology- Incidence of anemia reflect the presence of bone marrow failure or excessive loss of red blood cells or both. Bone marrow failure can occur due to nutritional deficiencies, toxic exposures, tumor, or mostly due to unknown causes. Red blood cells can be lost through hemorrhage or hemolysis (destruction) in the latter case, the problem can be caused by the effects of red blood cells that do not correspond to the resistance of normal red blood cells or due to several factors outside the red blood cells that causes red blood cell destruction. Red blood cell lysis (dissolution) occurs mainly in the phagocytic system or in the reticuloendothelial system, especially in the liver and spleen. As a byproduct of this Client Patient has lab levels indicative of Low Iron anemia

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process the bilirubin that is formed in phagocytes will enter the bloodstream. Any increase in red blood cell destruction (hemolysis) immediately reflected by increasing plasma bilirubin (normal concentration of 1 mg / dl or less; levels of 1.5 mg / dl result in jaundice in the sclera. Anemia is a blood disease characterized less low levels of hemoglobin (Hb) and red blood cells (erythrocytes). The function of the blood is carrying food and oxygen to all organs of the body. If the supply is less, then the intake of oxygen will be less. As a result, can inhibit the work of the vital organs, the brain One. The brain consists of 2.5 billion bioneuron cells. If capacity is lacking, then the brain will be like computer memory is weak, slow catch. And if it is damaged, can not be repaired (Sjaifoellah, 1998). Classification- Anemias can be classified by cytometric schemes (i.e., those that depend on cell size and hemoglobincontent parameters, such as MCV and MCHC), erythrokinetic schemes (those that take into account the rates of rbc production and destruction), and biochemical/molecular schemes (those that consider the etiology of the anemia at the molecular level. Etiology- The most common cause of anemia is deficiency of nutrients required for the synthesis of red blood cells, such as iron, vitamin B12 and folic acid. The rest is the result of a variety of conditions such as hemorrhage, genetic abnormalities, chronic disease, drug toxicity, and so on. Statistics 7% of children aged 1-2 had anemia in the US 1999-2000 (MMWR, NCHS, CDC) 12% of women aged 12-49 had anemia in the US 19992000 (MMWR, NCHS, CDC) 174,600 nursing home residents had anemia in the US 1999 (National Nursing Home Survey, NCHS, CDC) 10.7% of nursing home residents had anemia in the US 1999 (National Nursing Home Survey, NCHS, CDC)

Patient anemias related to poor nutrition

Patient lies within the range of those 23% of females having anemia

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 3.4 million cases in the US (Mayo Clinic) 1.3% of population self-reported having anemia in Australia 2001 (ABS 2001 National Health Survey, Australias Health 2004, AIHW) 0.3% of male population self-reported having anemia in Australia 2001 (ABS 2001 National Health Survey, Australias Health 2004, AIHW) 2.3% of female population self-reported having anemia in Australia 2001 (ABS 2001 National Health Survey, Australias Health 2004, AIHW) 217,000 women self-reported having anemia in Australia 2001 (ABS 2001 National Health Survey, Australias Health 2004, AIHW)

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DIAGNOSTIC TESTS Test (i.e. X-Ray, MRI, EEG, EKG) N/A RESULTS Date, Result, Significance

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Laboratory values CHEMISTRY PROFILE NORMAL VALUES CLIENTS VALUES DATE D A T E DATE HEMOTOL OGY NORMAL VALUES DATE CLIENTS VALUES DA TE DATE

SODIUM POTASSIUM CHLORIDE CO2 CALCIUM GLUCOSE BUN CREATININE

135-145 Meq/L 3.5- 5.1 mEq/L 98-108 mEq/L 19-34 8.2-10.3 mg/dL 70-105 mg/dL 7-25 mg/ Dl 0.6-1.2 mg/dL

142 5/10/13 4.5 5/10/13 109 5/10/13 23.0 5/10/13 7.7 5/10/13 110 (H)** 5/10/13 36 (H)** 5/10/13 1.1 5/10/13

WBC RBC HGB HCT MCV MCH MCHC PLATELETS DIFFEREN TIAL NEUTROPHI LS SEGMENTS BANDS 16

3.8-10.8 K/uL 3.80-5.20 11.815.4g/dl 41-50 79.494.8fL

4.82 5/10/13 2.06*L 5/10/13 12.1 5/10/13 38*L 5/10/13 90.7 5/10/13

25.6-32.2 pg 11.515.0%

27.8 5/10/13 16.6 5/10/13

PHOSPHORUS CHOLESTERO L TOTAL 6.4-8.9 PROTEIN g/dL ALBUMIN 3.5-5.0 g/dL ALBUMIN/GLO BULIN RATIO

6.4 5/10/13 3.48 5/10/13 2.97 5/10/13

AST (SGOT) ALT (SGPT) TOTAL BILIRUBIN AMYLASE LIPASE

13-39 U/L 7-52 U/L 0.3-1.0 mg/dL

23 5/10/13 15 5/10/13

LYMPHOCYT ES EOSINOPHIL S BASOPHILS MONOCYTE S COAGULATION STUDIES

SODIUM POTASSIUM CHLORIDE CO2 CALCIUM GLUCOSE BUN

135-145 Meq/L 3.5- 5.5 mEq/L 98-108 mEq/L 19-34 8.2-10.3 mg/dL 70-105 mg/dL 7-25 mg/ Dl CBC Hgb

142 5/10/13 4.5 5/10/13 109 5/10/13 23.0 5/10/13 7.7 5/10/13 110 (H)** 5/10/13 36 (H)** 5/10/13

PTT WBC RBC HGB HCT MCV MCH MCHC BMP

3.8-10.8 K/uL 3.80-5.20 11.8-15.4g/dl

4.82 5/10/13 2.06*L 5/10/13 12.1 5/10/13 38*L 5/10/13 90.7 5/10/13

27.8 5/10/13

Na Plts K+

Cl

BUN Glucose Creatinine 17

WBC Hct

HCO3

URINALYSIS COLOR YELLOW APPEARANCE CLEAR SP. GRAVITY 1.010 PH GLUCOSE KETONE OCCULT BLOOD PROTEIN BILRUBIN UROBILINOGEN NITRITE LEUCOCYTE CAST WBC RBC CRYSTALS SQUAMOUSCEL LS/ EPITHELIAL CELLS Relate the clinical significance of abnormal lab values above: 4.8 NORMA L NEGATI VE NEGATI VE NEGATI VE NORMA L NEGATI VE NEGATI VE TEST TEST URINE CULTURE

MISCELLANEOUS NORMAL CLIENTS VALUES VALUES DATE DATE DATE PENDI 07/17/1 NG 3

GLUCOSE(HIGH)- INDICATIONS:- Symptoms of elevated glucose levels include abdominal pain, fatigue, muscle cramps, nausea, vomiting, polyuria, and thirst. Possible interventions include sub- cutaneous or IV injection of insulin with continuous glucose 18

monitoring. BUN(HIGH)- INDICATIONS:-A patient with a grossly elevated BUN may have signs and symptoms including acidemia, agitation, confusion, fatigue, nausea, vomiting, and coma. Possible interventions include treatment of the cause, administration of intravenous bicarbonate, a low-protein diet, hemodialysis, and caution with respect to prescribing and continuing nephrotoxic medications.

RBC(LOW)- INDICATIONS:-Low RBC count leads to anemia. Anemia can be caused by blood loss, decreased blood cell production, increased blood cell destruction, or hemodilution. HCT (LOW)- INDICATIONS:- High Hct leads to polycythemia. Polycythemia can be caused by dehydration, decreased oxygen levels in the body, and an overproduction of RBCs by the bone marrow. Dehydration from diuretic use, vomiting, diarrhea, excessive sweating, severe burns, or decreased fluid intake decreases the plasma component of whole blood, thereby increasing the ratio of RBCs to plasma, and leads to a higher than nor- mal Hct. Causes of decreased oxygen include smoking, exposure to carbon monoxide, high altitude, and chronic lung disease, which leads to a mild hemoconcentration of blood

Head to Toe Assessment General Appearance: The pt is resting comfortably in no acute distress. No weight loss or gain. No fever Head & Hair: Norm cephalic and atraumatic Face: Norm cephalic and atraumatic Eyes: Norm cephalic and atraumatic Ears: Norm cephalic and atraumatic Nose: Turbinates bright red and swollen, mucous pink, no swelling Lips/Mouth/Throat: No cracking/ lesions on lips, mouth is clean and free from debris, mild breath odor. 19

Neck: Chest/Breast: Clear to palpation and auscultation lateral chest is larger than anterior/posterior diameter. Lungs: Clear to auscultation; no abnormal sounds heard. Heart: Normal rhythm sounds heart at the fine precordial points. Abdomen/Kidneys: Normal bowel sounds, no masses, lumps, or tenderness found. Genitalia (Internal Exam Deferred): N/A Rectum (Internal Exam Deferred): N/A Extremities: No edema clubbing or cyanosis Back: no deformities R.O.M.: Limited range of motion. Patient is in the wheelchair bound. Document findings on next page

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Plan of Care Priority Nursing Diagnosis: Nursing Diagnosis: Imbalanced Nutrition Less Than Body Requirements Risk Nursing Diagnosis: Risk of Enhance tissue perfusion Supporting Data: Patient reports of decreased exercise or activity tolerance Subjective: Patient states I am tired Objective: patient labs show abnormal lab levels after analysis Expected Outcome (Goals) Long Term: Provide patient nutritional/fluid needs to avoid further complication before discharge. Short Term: After 1hr disease process/prognosis and therapeutic regimen will be understood by patient. Nursing Interventions Nursing Actions Monitor vital signs: Auscultate breath sounds, heart rate and rhythm, respirations q 4 hours. Scientific Principle and/or Rationale Respiratory system may become decompensated. Tachycardia and changes in blood pressure may be present because of pain, anxiety and reduced cardiac output. Indicators of level of hydration and adequacy of circulating Evaluation BP is 129/68 Lung sounds are clear to auscultation, respiratory rate is between 20 to 24 breaths per minute and pulse is at 96 Modification of Plan of Care

Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes q

Mucous membrane are moist, capillary refill is less than 2 seconds and 22

If skin turgor +2 call doctor for order of IV fluids for hydration.

4 hours.

volume. Identifies deficiencies in RBC components affecting oxygen transport and treatment needs/response to therapy.

skin turgor has increased Pt labs will show improvement if other treatments are working e.g. iron supplement

Monitor laboratory studies, e.g., Hb/Hct and RBC count, arterial blood gases (ABGs).

Note changes in balance, gait disturbance, and muscle weakness.

May indicate Patient showed signs of neurological changes improved muscle associated with strength after consuming vitamin B12 deficiency, meals affecting client safety and increasing risk of injury.

Elevate head of bed, as tolerated.

Enhances lung Pt tolerated head rest at expansion to maximize 45 degrees and 90 oxygenation for degress cellular uptake. Note: May be contraindicated if hypotension is present. Promotes adequate rest, maintains energy level, and alleviates strain on the cardiac and respiratory systems.

May have to be discontinued if hypotension is present or noted

Assist client to prioritize ADLs and desired activities. Alternate rest periods with activity periods.

The patient Change environment to verbalizes understanding where pt will have of priority learning needs.

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Review nutritional history, Identifies deficiencies including food preferences. and suggests possible interventions. Note: Daily meal diary over period of time may be necessary to identify anemia related to nutrient deficiencies such as no meat in diet iron and vitamin B12 deficiency, or few leafy vegetables in diet folic acid deficiency.

Patient tolerated ambulating from chair to bed after a short rest

Encourage questions before and after each teaching.

Questions facilitate open communication between patient and health care professionals, and allow verification of understanding of given information and the opportunity to correct misconceptions When oral lesions are present, pain may restrict type of foods client can tolerate.

The patient asked questions regarding her regimen, diet and concerns when injecting herself.

Suggest bland diet, low in roughage, avoiding hot, spicy, or very acidic foods, as indicated

Pt ate puree food that was tolerate for consumption

Ask doctor if TPN is a possible suggestion for I/O

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Encourage or assist with good oral hygiene before and after meals; use softbristled toothbrush for gentle brushing. Provide dilute, alcohol-free mouthwash if oral mucosa is ulcerated.

Enhances appetite and Pt demostrated use of oral intake. Diminishes oral hygiene after I bacterial growth, performed task minimizing possibility of infection. Special mouth-care techniques may be needed if tissue is fragile, ulcerated, or bleeding and pain is severe

Review individuals target blood glucose levels as soon as possible.

Although this range varies per person, the ideal range for the adult diabetic is considered to be 80 to 120 mg/dL. (Doenges pg 418)

Patient understood that their normal blood sugar levels are between 70 to 100 milligrams per deciliter.

Monitor laboratory studies, such as Hgb/Hct, blood urea nitrogen (BUN), prealbumin and albumin, protein, transferrin, serum iron, vitamin B12, folic acid, TIBC, and serum

Aids in establishing dietary plan to meet individual needs. Evaluates effectiveness of treatment regimen, including dietary sources of needed

Pt BUN level became stable after treatment

If level are still low after treatment consult with doctor for other treatment

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electrolytes.

nutrients.

Review clients dietary Identifies deficits and program; compare with deviations from recent intake before end of therapeutic plan, which shift. may precipitate unstable glucose and uncontrolled hyperglycemia. (Doenges pg 412) Identifies deficiencies in RBC components affecting oxygen transport and treatment needs/response to therapy.

The patient complies with the new way of teaching nutritional intake and insulin pattern.

Monitor laboratory studies, e.g., Hb/Hct and RBC count, arterial blood gases (ABGs).

CARE PLAN RUBRIC Student: ___________________________________ Date: ______________________ 26

CATEGORIES SUBJECTIVE DATA (Relevant and timely and quoted from patient) OBJECTIVE DATA (Includes vital signs, physical assessment findings, diagnostic tests and procedures, relevant medications, etc.) NURSING DIAGNOSIS (NANDA, R/T, AEB) GOAL (Condition, Time Frame, Parameters, and must be realistic) INTERVENTIONS AND RATIONALES (Assess, Assist, and Teach) EVALUATION OF CARE PLAN (Evaluate each nursing action for effectiveness) MODIFICATION OF CARE PLAN (Modify patient care plan based on patients response to interventions)

POSSIBL E POINTS 10

YOUR POINTS

COMMENTS

10

20

20

20

10

10

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*TOTAL SCORE: *Student must obtain score of > 77% in order to obtain a grade of S on the weekly care plan. Reviewed with student: ______________________________ Signature Date: ___________________

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