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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
Normal Range
Patient Results
Glucose
74-118
120
Trend
Rationale
(specific to pt.)
Monitoring blood
glucose levels that
could be altered due
Test
type(date)
Normal Range
Patient Results
Trend
Rationale
(specific to pt.)
to meds the pt is
taking.
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
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
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
Test
type(date)
Normal Range
Patient Results
Trend
Rationale
(specific to pt.)
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.
RBC Count
3.80-5.40
3.86
Hemoglobin
11.5-15.5
13.0
Hematocrit
35-47
38.6
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.
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
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
Test
type(date)
Normal Range
Patient Results
Trend
Rationale
(specific to pt.)
dose/Route
Frequency
Action of drug
and Rationale
(specific to Pt)
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.
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
1 mg/PO/daily
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
also reduces
peripheral vascular
resistance and lowers
BP by causing direct
vasodilation in the
peripheral arteries of
the vascular
smoother muscle.
Given to this pt to
reduce her BP
(antihypertensive)
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
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
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.
12
vision halos.
LORazepam (Lorazepam)
1mg/IV/Q2HR
Used in this pt to
combat symptoms of
alcohol withdrawal.
4mg/IV/Q4H PRN
To reduce nausea
related to long term
abuse of alcohol and
alcohol withdrawal.
13
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 #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.
8. Pt Education
Education on dangers of
smoking.
Education on dangers of
drinking
Education on self
maintenance.
LA8/2011
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)
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
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
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:
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
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
19