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CSU, STANISLAUS B.S.N.

CLINICAL PLAN OF CARE


Student: Maggie Fabry

Date of Care: 09-19-13

Room Number: 325

Patient Data
Admitting Diagnosis: Acute chronic alcohol intox
Age: 47
Spiritual Focus: None
Culture: Caucasian
Patient Initials: PM
Gender: F
Height: 5 2
Weight: 109 lbs
Admitting Date: 9/17/13
POD: NA
Vital Signs: T: 36.8
P: 74
R : 18
B/P: 148/88
O2 Sat: 96
Pain Scale: 0
Past Medical History: Asthma, COPD, bronchitis, anxiety, arthritis, alcoholism, fibromyalgia, smoking pack/day
Surgical History: bilateral hip replacement, cataract
Diet: Regular
Activity: Progressive gait; ambulates with assistance
Advance Directives: No
Drains/ Tubes: N
Code Status: DNAR
VS Freq: Q6H
Glucose Monitoring: N
Vascular Access:
IV Site: peripheral IV L antecubital space, 22 gauze
IV Solution: SL
Dressing Changes: N Labs to be drawn: N Scheduled Procedures: N

Foley: N

NG/Feeding Tube: N

TEDs/SCDs: N
PCA/Epidural: N
Telemetry: Y
Safety Considerations: Fall risk; latex precautions

Notes on pathophysiology:
Alcohol dependency: If you continue to abuse alcohol, it can lead to alcohol dependence. Alcohol dependence is also called alcoholism. You are physically or
mentally addicted to alcohol. You have a strong need, or craving, to drink. Alcoholism is a long-term (chronic) disease. It's not a weakness or a lack of willpower. Like
many other diseases, it has a course that can be predicted, has known symptoms, and is influenced by your genes and your life situation.
Asthma: Chronic lung disease that inflames and narrows the airways. Asthma causes recurring periods of wheezing, chest tightness, shortness of breath, and
coughing. The coughing often occurs at night or early in the morning. People who have asthma have inflamed airways. This makes them swollen and very sensitive.
They tend to react strongly to certain inhaled substances. When the airways react, the muscles around them tighten. This narrows the airways, causing less air to
flow into the lungs. The swelling also can worsen, making the airways even narrower. Cells in the airways might make more mucus than usual. Mucus is a sticky, thick
liquid that can further narrow the airways. This chain reaction can result in asthma symptoms. Symptoms can happen each time the airways are inflamed.
http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/
COPD: progressive disease that makes it hard to breath over time. Symptoms include coughing that produces large amounts of mucus, wheezing, shortness of
breath, chest tightness. Cigarette smoking is number one cause. The airways and air sacs lose their elastic quality. The walls between many of the air sacs are
destroyed. The walls of the airways become thick and inflamed. The airways make more mucus than usual, which can clog them. This makes gas exchange
impaired. COPD consists of emphysema and chronic bronchitis. http://www.nhlbi.nih.gov/health/health-topics/topics/copd/
Bronchiitis: the lining of the airways is constantly irritated and inflamed. This causes the lining to thicken. Lots of thick mucus forms in the airways, making it hard to
breathe.

Anxiety: characterized by excessive, exaggerated anxiety and worry about everyday life events with no obvious reasons for worry. People with symptoms of
generalized anxiety disorder tend to always expect disaster and can't stop worrying about health, money, family, work, or school. In people with anxiety, the worry is
often unrealistic or out of proportion for the situation. Daily life becomes a constant state of worry, fear, and dread. Eventually, the anxiety so dominates the person's
thinking that it interferes with daily functioning, including work, school, social activities, and relationships. http://www.webmd.com/anxiety-panic/guide/generalizedanxiety-disorder
Arthritis: Arthritis is inflammation of one or more of your joints. The main symptoms of arthritis are joint pain and stiffness, which typically worsen with age. The two
most common types of arthritis are osteoarthritis and rheumatoid arthritis. Osteoarthritis is usually just caused by the normal wear and tear of life.

Fibromyalgia: Fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Researchers
believe that fibromyalgia amplifies painful sensations by affecting the way your brain processes pain signals. Symptoms sometimes begin after a physical trauma,
surgery, infection or significant psychological stress. In other cases, symptoms gradually accumulate over time with no single triggering event.
http://www.mayoclinic.com/health/fibromyalgia/DS00079/DSECTION=treatments-and-drugs

Lab and Diagnostic Test Data


Test
type(date)

Normal Range

Patient Results

Glucose

74-118

120

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &


teaching

Monitoring blood
glucose levels that
could be altered due

Pt blood glucose levels are ever so slightly above normal


limits. Monitor glucose levels closely for further increases.
Signs of hyperglycemia include frequent urination,

Test
type(date)

Normal Range

Patient Results

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &


teaching

to meds the pt is
taking.

increased thirst, blurred vision and headache. Signs of


hypoglycemia include confusion, abnormal behavior,
vision disturbances, shakiness, anxiety and sweating.
Pt has below normal levels. This decrease could indicate
malnutrition associated with this pts alcoholism and
withdrawal. Could also be due to her high BP. Monitor
s/s of kidney malfunction such as nausea, vomiting, or
abdominal pain. Monitor other electrolyte levels to
ensure nutrition.

BUN

8-26

Used to monitor
kidney function. Pt
has an elevated BP
and chronic htn can
cause kidney
disease, so function
must be monitored.
Used to monitor
kidney function. Pt
has an elevated BP
and chronic htn can
cause kidney
disease, so function
must be monitored.
Used to monitor
kidney function and
the stage of kidney
failure.

Creatinine

0.44-1.00

0.65

eGFR

>=60

>60

Sodium

136-145

135

Used to monitor fluid


and electrolyte
balance.

Potassium

3.6-5.1

3.7

Used to ensure
electrolyte balance.
Pt came in for a
detox so nutritional
status and hydration
could be
compromised. Hold
meds if levels are
abnormal or nearly
abnormal. Also, pH
imbalance can effect
K levels. Since this pt
is a smoker, pH

Pt is WNL. An increase in levels could indicate kidney


disease or dehydration. Monitor s/s such as low output,
low appetite, nausea and vomiting, and persistent fatigue.
A decrease could indicate malnutrition or severe liver
disease or muscle dystrophy. Monitor s/s such as
nausea, vomiting, abdominal pain or jaundice or frequent
falls or waddling gait.
Pt is WNL. If levels fall below 60, kidney failure could be
indicated. Use creatinine levels to confirm. Watch for s/s
of kidney disease such as low output, low appetite,
nausea and vomiting, and persistent fatigue. Note that
age, gender, height, race and weight can influence the
glumerular filtration rate.
Pt levels slightly low. Watch for a decrease (hypoatremia)
and s/s such as weakness, fatigue, headache, nausea
and vomiting, muscle cramps, irritability, and confusion.
Low sodium levels can indicate dehydration. Pt teaching
about how hydrating can prevent low sodium levels.
Pt WNL. An increase in these levels could indicate
kidney disease. Monitor s/s such as low output, low
appetite, nausea and vomiting, and persistent fatigue. A
decrease in levels could indicate excessive potassium
loss in the urine. This could be due to a large variety of
issues such as GI disorders, renal tubular acidosis, or
hyperaldosteronism. Monitor s/s such as muscle aches,
abnormal weakness, arrhythmias, diarrhea, and nausea
and vomiting.

Test
type(date)

Normal Range

Patient Results

Chloride

101-111

99

Carbon Dioxide

22-32

26

Anion Gap

5.0-15.0

13.7

Calcium

8.9-10.3

8.2

WBC Count

4.8-10.8

7.2

Trend

Rationale
(specific to pt.)
levels as well as K
levels must be
monitored.
Used to monitor
electrolyte balance.
Chloride follows
sodium, and water
moves with both
electrolytes. As a
result, chloride
effects water
balance. It also helps
the acid base
balance in the body.
Chloride is controlled
by the kidneys, so
abnormal levels can
indicate renal
problems.
Used to monitor acid
base balance in the
body as well as to
assist in evaluating
the pH. This pt has
COPD, monitoring for
CO2 retention.
Used to monitor acid
base balance.

Used to monitor
parathyroid function
and calcium
metabolism. Also
used to monitor
kidney function.
Used to help in the
evaluation of
infection, neoplasm,
allergy or

Nursing Implications related to patient care &


teaching

Pt slightly below normal limits. Monitor for s/s of


hypochloremia such as hyperexcitability of the nervous
system and muscles, shallow breathing, hypotension and
tetany. Hyperchloremia can be indicated through s/s such
as lethargy, weakness and deep breathing. Monitor for
these signs and symptoms and continue to check lab
values for changes

Pt is WNL. Watch levels to ensure they do not increase.


s/s include rapid respiration, rapid pulse rate, and SOB.
As CO2 levels increase, there could be a reduction in pts
over all LOC. Monitor levels for any dramatic increases
because it could lead to respiratory arrest. S/s of low
CO2 levels (respiratory alkalosis) include confusion, hand
tremor, light headedness or nausea and vomiting.
Pt is WNL. An increase could indicate lactic acidosis or
kidney failure. S/s would include headache, palpitations,
chest pain as well as kidney disease s/s. A decrease
could indicate a low sodium blood level or bone marrow
cancer.
Pt slightly below normal limits. S/s of progressing
hypocalcemia would include tingling in hands, feet or lips,
muscle spasms or slow uneven heart beat. Watch for
these symptoms and continue to monitor labs. A calcium
supplement may be needed is levels continue to decline.
Pt WNL. A decrease could indicate drug toxicity, bone
marrow failure, or a dietary deficiency. S/s would include
bleeding or bruising. An increase could indicate infection
or dehydration. S/s would include malaise or fever. Will

Test
type(date)

Normal Range

Patient Results

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &


teaching

immunosuppression.
This pt is a smoker
and an alcoholic so a
test to spot an
infection or a low
immune system is
necessary.
Closely related to
hemoglobin and
hematocrit levels.
Conducted as a
routine part of a
complete blood
count. Also used to
check for anemia.
Used to monitor the
oxygen-carrying
capacity of the blood.
In this pt, used to
monitor the severity
of her COPD.

monitor pt for s/s of infection and will assess new labs as


they come.

RBC Count

3.80-5.40

3.86

Hemoglobin

11.5-15.5

13.0

Hematocrit

35-47

38.6

This test closely


reflects the
hemoglobin values.
Used to further
evaluate the pts
COPD status.

Red Cell
Distribution
Width

11.5-15.5

15.6

Platelet Count
Auto

130-400

233

This is an indication
of the variation of
RBC size. Used to
indicate a condition
called amisocytosis.
Used to monitor
platelet number in the
blood. Used in this pt
to monitor risk for
bleeding.

Pt levels WNL. A decrease could indicate anemia, renal


disease, or bone marrow failure. S/s would depend on
the disease process being indicated. An increase could
indicate severe COPD of severe dehydration. S/s of
increased severity of COPD include an ongoing cough
that produces a lot of sputum, SOB, wheezing or chest
tightness.
Pt WNL. An increase could indicate severe COPD. S/s
would include severe SOB upon little activity, a cough
that wont go away, and possibly mucous being coughed
up. A decrease could indicate anemia, renal disease, or
bone marrow failure. S/s would depend on the disease
process being indicated. I will monitor labs for an
increase which would indicate an escalation in the pts
COPD.
Pt WNL. A drop in levels could indicate anemia, renal
disease, or bone marrow failure. S/s would depend on
the disease process being indicated. An increase could
indicate severe COPD or severe dehydration. S/s of
increased severity of COPD include an ongoing cough
that produces a lot of sputum, SOB, wheezing or chest
tightness.
Pt is very slightly above normal limits. An increase level
in RCDW could indicate a large variety of different kinds
of anemia. S/s would include easy fatigue and a loss of
energy, SOB, dizziness and pale skin.
Pt WNL. An increase could indicate anything from
malignant disorder like leukemia or lymphoma to
rheumatoid arthritis. A decrease could indicate immune
thrombocytopenia in which antibodies would be
destroying the bodys platelets. Monitor for s/s such as
easy or excessive bruising, superficial bleeding into the

Test
type(date)

Normal Range

Patient Results

NRBC#

0.0

Total Protein

6.1-7.9

6.5

Albumin

3.5-4.8

3.9

Globulin

2.3-3.5

2.6

Trend

Rationale
(specific to pt.)
This is a tool used to
indicate a situation in
which a serious
underlying disease
could be present.
Used to diagnose,
evaluate and monitor
disorders such as
liver dysfunction,
impaired nutrition,
and protein-wasting
states. For this pt it
is most likely being
used to monitor her
nutrition and to check
for impairment.
Just like the total
protein test, this test
is used to diagnose,
evaluate and monitor
disorders such as
liver dysfunction,
impaired nutrition,
and protein-wasting
states. For this pt it
is most likely being
used to monitor her
nutrition and to check
for impairment.
Just like the total
protein test and
albumin, this test is
used to diagnose,
evaluate and monitor
disorders such as
liver dysfunction,
impaired nutrition,
and protein-wasting
states. For this pt it

Nursing Implications related to patient care &


teaching
skin, or blood in urine or stools. Will monitor levels for
changes and look for s/s associated with abnormal levels.
Pt at normal limit. The presence of nucleated red blood
cells could indicate a variety of problems such as bone
marrow replacement, anemia, asplenia, hypoxia or
extramedullary hematopoiesis.
Pt WNL. A decrease in levels could indicate malnutrition.
S/s to watch for would include weight loss, weakness or
muscle fatigue, increased susceptibility to infections, or
delayed healing of even small wounds. An increase in
levels could indicate dehydration or inflammatory
disease. Inflammatory diseases are characterized by
episodes of inflammation that result in fever, rash or joint
swelling. Will monitor lab values and use albumin and
globulin levels to confirm any abnormalities.
Pt WNL. A decrease in levels could indicate malnutrition.
S/s to watch for would include weight loss, weakness or
muscle fatigue, increased susceptibility to infections, or
delayed healing of even small wounds. An increase in
levels could indicate dehydration or inflammatory
disease. Inflammatory diseases are characterized by
episodes of inflammation that result in fever, rash or joint
swelling. Will monitor lab values and use total protein
and globulin levels to confirm any abnormalities.

Pt WNL. A decrease in levels could indicate malnutrition.


S/s to watch for would include weight loss, weakness or
muscle fatigue, increased susceptibility to infections, or
delayed healing of even small wounds. An increase in
levels could indicate dehydration or inflammatory
disease. Inflammatory diseases are characterized by
episodes of inflammation that result in fever, rash or joint
swelling. Will monitor lab values and use albumin and
total protein levels to confirm any abnormalities.

Test
type(date)

Normal Range

Patient Results

ALB/SGOT

15-41

124

AST/GLOB ratio

0-35

1.5

Alkaline
phosphatase

38-126

64

ALT/SGPT

14-54

71

Bili Total

0.4-2.0

1.5

Trend

Rationale
(specific to pt.)
is most likely being
used to monitor her
nutrition and to check
for impairment.
Used in the
evaluation of pts that
are expected to have
hepatocellular
diseases such as this
pt who abuses
alcohol use regularly.
Used in the
evaluation of pts that
are expected to have
hepatocellular
diseases such as this
pt who abuses
alcohol use regularly.
Used to detect and
monitor diseases of
the liver or bone.

Used to identify
hepatocellular
diseases of the liver
or to monitor the
improvement or
worsening states of
these diseases.
Because this pt is an
alcoholic, liver
function must be
monitored for
damage.
This is yet another

Nursing Implications related to patient care &


teaching

Pt levels are significantly above normal. This increase


could indicate liver disease. Signs to watch for include
loss of appetite, loss of energy, weight loss, jaundice, or
fluid retention. Another set of labs was not completed for
this pt. This leads me to believe that these levels might
be expected from a pt who is admitted for detox. Plan to
watch for these signs and symptoms and inquire about
the test during my next trip to the hospital.
Pt WNL. An increase could indicate liver disease. Signs
to watch for include loss of appetite, loss of energy,
weight loss, jaundice, or fluid retention. A decrease could
indicate renal disease. S/s to watch for will include low
output, low appetite, nausea and vomiting, and persistent
fatigue.
Pt WNL. An increase in these levels could indicate
primary cirrhosis or bone disease. S/s of cirrhosis
include loss of appetite, loss of energy, weight loss,
jaundice, or fluid retention. S/s of bone disease would
include pain, weakness or tingling in the affected area. A
decrease in levels could indicate malnutrition. These s/s
include weight loss, weakness or muscle fatigue,
increased susceptibility to infections, or delayed healing
of even small wounds.
Pt levels are significantly above normal. This could
indicate cirrhosis, hepatic tumor or obstructive jaundice.
A further increase could indicate hepatitis. Signs to watch
for include loss of appetite, loss of energy, weight loss,
jaundice, or fluid retention. Another set of labs was not
completed for this pt. This leads me to believe that these
levels might be expected from a pt who is admitted for
detox. Plan to watch for these signs and symptoms and
inquire about the test during my next trip to the hospital.

Pt WNL. An increase in this level could indicate liver

Test
type(date)

Normal Range

Patient Results

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &


teaching

test to evaluate liver


function.

disease. S/s would include loss of appetite, loss of


energy, weight loss, jaundice, or fluid retention. Will
watch for s/s and monitor pt closely.

Medication Allergies: Penicillin, Latex


Medications
Generic & Trade Name
Drug classification
(Therapeutic &
Pharmacologic)
Thiamine HCL (Biamine)

dose/Route
Frequency

Action of drug
and Rationale
(specific to Pt)

Significant Side Effects

Nursing Implications related to


patient care and teaching

100mg/PO/daily

Water-soluble
vitamin; combines
with adenosine
triphosphate and
thiamine
diphosphokinase to
form thiamine
pyrophosphate, a
coenzyme essential
for normal growth
and aerobic
metabolism, nerve
impulse transmission,
and acetylcholine
synthesis.

Cyanosis, pulmonary edema, GI tract


hemorrhage, cardiovascular collapse,
angioedema, anaphylactic shock, death

Instruct pt to watch for signs and


symptoms of serious allergic reaction
which can include rash, itching or
swelling, severe dizziness, or trouble
breathing. Instruct pt to not crush or
chew enteric-coated tablets. Upon
discharge, perform pt teaching about
food that are rich in thiamine. These
foods include yeast, pork, beef, liver,
wheat and other whole grains, nutrientadded breakfast cereals, fresh
vegetables, especially peas and dried
beans.

Bronchospasm, bradyarrhythmia, heart


block, heart failure, hypotension,
constipation, diarrhea, nausea,
dizziness, headache, depression,
dyspnea.

Instruct 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

Vit B1; Water Soluble

Metoprolol Tartrate
(Lopressor)
Beta-adrenergic blocker;
cardiovascular agent

50 mg/PO/BID

Used to prevent
Wernicke syndrome
which involves a
deficiency of thiamine
which most often
results from
alcoholism. Given to
this patient for her
alcohol abuse and
dependence.
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.

Folic Acid (Folvite)

1 mg/PO/daily

Vit B Complex group; watersoluble vitamin

Amlodipine (Norvasc)
Calcium Channel blocker;
dihydropyridine

5mg/PO/daily

Given to this pt to
lower her BP which
was high on
admission and
steadily high
throughout visit.
Stimulates production
of red and white
blood cells and
platelets in some
megaloblastic
anemias.
Given to this patient
because folate
deficiency is
accelerated by
alcohol consumption
Blocks the
transmembrane influx
of calcium ions into
cardiac and vascular
smooth muscles. It

control. Monitor BP, HR and ECG in


early treatment to assess for MI.
Regularly monitor HR and rhythm during
therapy. Pt teaching regarding the
avoidance 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.

Confusion, depression, excitability,


irritability, anorexia, nausea, rash,
pruritus, erythema, bronchospasm,
anaphylaxis

Assess for signs of megaloblastic anemia


which can include anemia, fatigue,
dyspnea or weakness. Evaluate pt to see
if therapeutic response is indicated
through increased orientation and
absence of fatigue. Perform pt teaching
about replacing folic acid supplements
with foods rich in folic acid such as organ
meats, vegetables and fruit.

Acute MI, angina, angioedema,


flushing, peripheral edema, nausea,
dizziness, fatigue

Pt should avoid activities requiring


coordination until drug effects are
realized as drug may cause dizziness.
Assess pt regularly for peripheral
edema. Assess heart sounds and ECG

also reduces
peripheral vascular
resistance and lowers
BP by causing direct
vasodilation in the
peripheral arteries of
the vascular
smoother muscle.

for palpitations. Instruct pt to notify you


if experiencing adverse effects such as
fatigue, headaches, abdominal pain,
nausea. Instruct pt to report s/s of MI
such as pain, fullness, and/or squeezing
sensation of the chest, jaw pain,
toothache, headache, SOB, nausea,
vomiting, and/or general epigastric
(upper middle abdomen) discomfort,
sweating, heartburn and/or indigestion,
arm pain (more commonly the left arm,
but may be either arm) or upper back
pain. When increasing dose, use
especial precaution in COPD because
there is an increased risk of worsening
angina

Given to this pt to
reduce her BP
(antihypertensive)

Influenza Virus (Fluvirin)


Vaccine

0.5mL/IM/once

Live attenuated
influenza vaccine
viruses replicate
primarily in the
ciliated epithelial cells
of the
nasopharyngeal
mucosa to induce
immune responses
(via mucosal
immunoglobulin [Ig]A,
serum IgG
antibodies, and
cellular immunity),
but LAIV viruses do
not replicate well at
the warmer
temperatures found
in the lower airways
and lung. During the
course of replication,
all LAIV viral proteins
would be presented
to the immune
system in their native
conformation and in
the context of

Stevens-Johnson syndrome,
anaphylaxis, fatigue, fever, headache,
erythema at injection site or tenderness.

10

Inject into the deltoid muscle. EMC


protocol: MAKE SURE DOCTOR HAS
ORDERED VACCINE AND THAT PT
HAS SIGNED AN INFORMED
CONSENT DOCUMENT! Explain
procedure to pt. Prepare medication and
select an appropriately sized needle.
Cleanse skin with antiseptic. Remove
needle from protector and expel any air
from the syringe. Inject needle into skin
at 90 degree angle. Do not aspirate with
deltoid muscle injections. Withdraw
needle and activate safety device.
Massage area gently and inform pt that
they may experience muscle soreness
for a few days following the injection.
Advice pt to report any unusual or severe
reactions following the vaccination.

histocompatibility
proteins.
Given to prevent this
pt from getting the
influenza virus.

Oxybutynin Chloride
(Ditropan)

5mg/PO/BID

Antimuscarinic; urinary
antispasmodic

Metoclopramide (Reglan)
Antiemetic; dopamine
antagonist

10mg/PO/daily

Causes relaxation of
the bladder smooth
muscle by reducing
the muscarinic effect
of acetylcholine on
smooth muscle. In
pts with involuntary
bladder contractions,
oxybutyin chloride
increases bladder
capacity, reduced the
frequency of
uninhibited
contractions of the
detrusor muscle, and
slows the initial
desire to void leading
to a decrease in
urgency and
frequency of both
incontinent episodes
and voluntary
urination.
Given to this pt to
improve her bladder
incontinence.
Promotes motility in
the upper
gastrointestinal tract
by sensitizing tissues
to the action of
acetylcholine. It
hastens gastric
emptying and

Confusion, seizure, psychotic disorder,


angioedema, mycosis, constipation,
gastroenteritis, nausea, dizziness,
headache, somnolence

Instruct pt to swallow ER tabs whole and


to take med with liquid; do not crush,
divide or chew. This medication may be
given with or without meals. Assess
regularly for symptomatic improvement.
Pt should avoid activities requiring
mental alertness until drug effects are
realized as drug may cause drowsiness
or blurred vision. Monitor I&O because
drug can cause urinary retention.
Instruct pt to immediately report s/s of
angioedema such as Large, thick, firm
welts, swelling of the skin, pain or
warmth in the affected areas, difficulty
breathing or swallowing, in severe cases.
Advise pt to report s/s of severe CNS
effects including hallucinations, agitation,
and confusion. Advise pt that
concomitant use of alcohol may enhance
drowsiness.

Neuroleptic malignant syndrome,


tardive dyskinesia, body fluid retention,
nausea, vomiting, asthenia, headache,
somnolence, fatigue

Advice pt to administer 30 minutes


before each mean and at bedtime or as a
single dose. Administer on an empty
stomach and do not repeat dose if taken
with food. Discard tablet if it breaks or
crumbles. Monitor hydration level and
BP. Assess for s/s of extrapyramidal side
effects and parkinsonian-like symptoms.

11

intestinal transit by
increasing tone and
amplitude of gastric
contractions.
Given for nausea and
dehydration for this
pt.

Gabapentin (Neurontin)

600mg/PO/TID

Anticonvulsant; gamma
aminobutyric acid

Tiotropium Bromide
(Spiriva)
Antimuscarinic;
bronchodilator.

18 mcg INH
cap/rt daily

Structurally related to
the neurotransmitter
GABA, however,
gabapentin and its
metabolites do not
bind to GABA or
GABA B receptors or
influence the
degradation or
uptake of GABA.
The mechanism in
which gabapentin
exerts its analgesic
and anticonvulsant
effects is unknown.
For pts arthritis and
fibromyalgia related
pain in this pt.
Long-acting
antimuscarinic agent,
which isoften referred
to as an
anticholinergic.It
exhibits
pharmacological
effects through
inhibition of M3receptors at the
smooth muscle
leading to
bronchodilation.

Stevens-Johnson syndrome, drug


hypersensitivity syndrome, druginduced coma, seizure, suicidal
thoughts, peripheral edema, nausea,
vival diease, ataxia, dizziness,
nystagmus, hostile behavior

Bowel obstruction, hypersensitivity


reaction, cerebrovascular accident,
constipation, upper respiratory infection,
pharyngitis, sinusitis, xerostomia

12

Teach pt to avoid activities requiring


mental alertness until drug effects are
realized. Instruct pt to report s/s of
tardive dyskinesia which include jerky
muscle movements, tongue thrusting,
facial grimacing/ticks, and random
movements of extremities. This disorder
is serious and often irreversible so know
that risk is increased with duration of
treatment and total cumulative dose.
Instruct pt to not drink alcohol while
taking this drug.
Advise pt to immediately report a rash or
other s/s of hypersensitivity such as fever
or lymphadenopathy. Instruct pt to report
new or worsening depression, suicidal
ideation or unusual changes in behavior.
Advise pt against sudden discontinuation
of drug, as this may increase seizure
frequency. Pt should avoid alcohol while
taking this drug.

Readvise pt on proper method of


medication administration; place capsule
into the center of chamber, close
mouthpiece; press and release the
piercing button only once; exhale
completely then inhale med powder and
hold breath for as long as is comfortable;
repeat exhalation and inhalation once
more before discarding. Advise pt that
drug is not indicated for acute
bronchospasm. Instruct pt to report s/s
of acute narrow-angle glaucoma such as
eye pain or discomfort, blurred vision, or

vision halos.
LORazepam (Lorazepam)

1mg/IV/Q2HR

Sedative, hypnotic; antianxiety; benzodiazepine,


short acting.

For pts COPD and


asthma.
Potentiates the
actions of GABA,
especially in the
limbic system and the
reticular formation.

Dizziness, drowsiness, confusion,


depression, orthostatic hypotension,
ECG changes, tachycardia, apnea,
cardiac arrest, blurred vision,
constipation.

Used in this pt to
combat symptoms of
alcohol withdrawal.

Ondansetron HCL (Zofran)


Antiemetic; serotonin type 3
antagonist;

4mg/IV/Q4H PRN

Blocks serotonin a 5HT receptor sites in


vagal nerve terminals
by disrupting CNS
chemoreceptor
trigger zone.

Headache, fatigue, chest pain,


hypotension, constipation,
bronchospasm

To reduce nausea
related to long term
abuse of alcohol and
alcohol withdrawal.

13

Observe pt for changes in mental status.


Monitor for drowsiness, dizziness, and
suicidal tendencies. Asses for physical
dependency and withdrawal symptoms
such as headache, nausea, vomiting,
muscle pain, weakness, tremors,
seizures. Assist pt with ambulation
during beginning of therapy since
dizziness can occur. Perform pt and
family teaching that med must be taken
with food. Instruct pt not to take med for
more than 4 mo unless directed. Instruct
pt to avoid alcohol while taking
medication. Finally, instruct pt not to
discontinue med abruptly after long-term
use and to rise slowly because fainting
can occur. Dilute med with an equal
volume of NS immediately prior to use
and mix thoroughly by gently. Give over
a period of 1 to 2 minutes.
Monitor GI status. Auscultate bowel
sounds and palpate for tenderness.
Watch for hypotension and
bronchospasm. Instruct pt to
immediately report symptoms of allergic
reaction such as rash or hives. Give
undiluted by direct IV and administer
slowly over 2 to 5 minutes. Flush SL
before and after administration with 5mL
of water.

14

Concept Mapping
Step 2. List clinical manifestations under each nursing diagnosis and other relevant data to support each diagnosis, including lab
data, medications, interventions, and assessment findings. All medical & nursing interventions should be found in one or more of the
boxes.

ND #1: Risk for Injury


Data to support:
Excessive drinking which impairs
cognition.
Pt has a latex allergy which puts her at
great risk every time she is in the
hospital.
Pt requires help when ambulating
Pt lives alone.

ND #2: Anxiety
Data to support:
Administration of LORazepam for anxiety.
Anxiety due to living alone.
Pt expresses need for medication when anxiety
become unbearable for her.
Admission of having an anxiety disorder.
High BP since admission.

ND #4: Risk-prone health


behavior
Data to support:
Smoking
Alcoholism
Living alone and becoming
intoxicated.
Pt recent fall while
intoxicated

Chief Medical Diagnosis: Acute Chronic


Alcohol Intox
Priority Assessments: Assess mental state.
Assess lab values related to nutrition and
hydration status and liver disease.

8. Pt Education
Education on dangers of
smoking.
Education on dangers of
drinking
Education on self
maintenance.

LA8/2011

ND # 3: Risk for loneliness


Data to support:
Pt lives alone.
Pt alcoholism makes her
behavior socially unacceptable.
Pt expresses need to be around
others.
Pt has repeatedly tried to get
into a care home but is
continually denied.

7. Discharge
Speak to discharge nurse
about at home care or care
home placement.

ND # 5: Knowledge Deficit
Data to support:
Unaware of the consequences
of having COPD.
Pt continually smoking and
drinking as health problems
become more severe.

15

Concept Mapping
Evaluate Effects of Nursing Actions- Patient Outcomes, Documentation (Done During Clinical)
1. ND/Nursing Care:
Nursing Actions(NIC)

Risk for Injury

Make sure nonslip socks are on before ambulating.


Make sure bed is in lowest position with side rails up x3
Encourage assisted ambulation to increase muscle strength and stability.
Make sure bed alarm is on and call light is within pt reach
Monitor pt carefully when anxiety medication levels are low and before next administration to prevent injury.
Perform pt teaching about alcohol abuse and the increased risk of injury associated with intoxication.
Assess pt readiness to acquire help at home or be placed in a care home to reduce risk of fall or any other kind of injury
Always double check that nonlatex gloves are worn when assessing or touching pt
Inform all staff of latex allergy
Replace latex gloves in room with nonlatex gloves
Inform pt about all medication and their side effects
Monitor pts mental status regularly.

Patient Response: Pt is A&O x4. Nonslip socks are on properly and continually. I encouraged pt to take a walk down the hall with
me at some point during the day but pt refused and was noticeable anxious when the topic was brought up. Bed alarm was up and pt
was instructed on how to use the call light. Pt had a tendency to try and get out of bed during anxiety attacks. Talked through areas
of concerns with pt during these times and checked MAR for time of next available dose. Pt expressed a readiness to quit drinking
and an awareness of the implications of her drinking. Pt also expressed a desire to be placed in a care home in Patterson where she
lives. The discharge nurse talked with the pt about in home nursing care until care home placement can be initiated. Pt agreed.
Nonlatex gloves placed in pts room.Pt was informed that nonlatex gloves are blue in color and to be aware than anyone making
contact with the pt should not be wearing any other colored gloves. Pt is aware of all drugs being taken and their side effects.

2. ND/Nursing Care:
Nursing Actions(NIC)
LA8/2011

Anxiety
16

Assess pts level of anxiety and her physical reactions to anxiety.


Assess the role that alcohol withdrawal plays in pts anxiety
Use empathy to encourage the pt to interpret the anxiety
Offer the pt accurate information regarding her anxious thoughts
Provide backrubs or massage for the client to decrease anxiety.
Use therapeutic touch and healing touch techniques
Monitor the client for depression
Observe for changes and improvements when anxiety meds are taken
Assess pts response to taking anxiety medication
Teach the clients family to recognize the s/s of anxiety

Patient Response: During the two anxiety attacks, pt described her anxiety as being severe. Pts HR rose to 92 during the attack
and pt repeatedly tried to get out of bed. Pt believes that her anxiety attacks have become worse wince she started drinking more
heavily and since she started to live alone. Pt was anxious that she was not going to be able to get to the bank in time and that she
wouldnt be able to have enough money to pay for the cab that she needed to get home. I informed pt about the times that the
banks closed and reassured her that we would get her home safely. I held the pts hand during the attack and this kept the pt from
getting out of bed until the medication could be administered. Pts symptoms were significantly decreased after the administration
of the medication. The pt acknowledges her need for anxiety medication and takes it very willingly. Family teaching was not
performed because none of the pts family came to visit her during the day.

3. ND/Nursing Care:
Nursing Actions(NIC)

LA8/2011

Ineffective Coping

Assess for contributing factors of ineffective coping such as lack of support or a recent change in life situation
Use verbal and nonverbal therapeutic communication approaches including empathy, active listening and confrontation to
encourage the pt to express her emotions
17

Encourage the pt to describe previous stressors and coping mechanisms used


Assist the pt in setting realistic goals
Offer instruction regarding alternate coping strategies
Encourage the use of social resources
Actively listen to complaints and concerns
Engage the client in reminiscence.

Patient Response: Pt lives alone and has no close friends or companions to keep her company or to offer her help at home.
Recently the pt moved here from Philadelphia. Pt moved here in hopes to spend more time with her family, but reports hardly
seeing her family at all. It is unclear to be whether the family does not see her more often because of her drinking or whether she
is drinking because the family will not see her. Pt was hesitant to talk about her family for a period of time, but then started to open
up as I began to listen more intently. I discussed in home care with the pt. I encouraged her to take the in home care that is being
offered to her until she can secure a spot in the care home she is interested in.

4. ND/Nursing Care:

Risk-prone health behavior

Nursing Actions(NIC)

LA8/2011

Allow the client adequate time to express feelings about health status
Use open-ended questions to allow the client free expression
Discuss the clients current goals
Provide assistance with activities as needed
Maintain consistency and continuity in daily schedule
Refer to community resources
Assess pts willingness to quit smoking
Asses pts willingness to quit drinking

18

Patient Response: Pt is unhappy with living alone, not seeing her family regularly, about her drinking habit and about other
aspects of her life. Pt wishes to stop drinking and to live in a care home. I discussed with pt the fact that living in a care home
will prevent her from consuming alcohol and possibly from smoking. Pt seemed to welcome the idea and expressed readiness
for this change in her lifestyle. I helped the pt ambulate to the bathroom and encouraged a walk down the hall which the pt
declined. I tried to be as dependable as I could for the pt. When she made a request, I fulfilled it as soon as I could. I did this
in an attempt to establish trust with the client so that she could maybe feel more comfortable in disclosing information with me.
Pt expressed an unwillingness to quit smoking. Pt expressed a willingness and desire to quit drinking and improve her lifestyle.
5. ND/Nursing Care:

Knowledge Deficit

Consider clients ability and readiness to learn


Pt teaching on COPD
Pt teaching on consequences of smoking
Pt teaching on consequences of drinking
Pt teaching on current medications
Family teaching to reinforce information

Patient Response: I advised pt about her current diagnosis of COPD. I also advised pt that her continuing to smoke would make
the inevitable progression of the disease accelerate. I used the pts goal of seeing her family as an incentive to stop smoking. I
also informed the pt that getting intoxicated increases her risk of injury and therefore time in the hospital which would further keep
her from spending time with her family. Pt expressed desire to quit drinking. I went over pts med list with her and her knowledge
of the medications was good. I was unable to perform family teaching because the family was not present during the day.

LA8/2011

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