Data Collection

Student Name: Jennifer Carey Age Range Allergies: Assignment #: 8 Date(s) of Care: 12/7/11 Gender M F Neonate <1 1-4 5-9 10-14 15-19 20-29 30-39 40-49 50-59 60-69 70-79 >80 Actos, demetrol, enalapril, Fosamax, IVP dye, Lipitor, lisinopril, nicotine patch, raloxifene Admission Date: 4/18/2011 Code Status: DNR Diabetes Mellitus II

Primary Medical Diagnosis Comorbidities:

Hypercholesterolemia, macular degeneration, vascular dementia, Chronic Obstructive Pulmonary Disease (COPD),

hypertension, trigeminal neuralgia, Gastroesophageal Reflux Disease (GERD) Developmental Stage: Integrity vs Despair (Erickson) Pathophysiology of above conditions: Name: Diabetes Mellitus II Patho: In type 2 diabetes, the pancreas continues to produce some insulin, it is just not enough for the bodys needs or it is used poorly by the body tissues (Corwin, 2008). Etiology: Insulin resistance, decreased pancreatic production of insulin and inappropriate glucose production by the liver all play a role in developing type 2 diabetes (Corwin, 2008). S/S: Usually nonspecific and include fatigue, recurrent infections, prolonged wound healing and vision changes (Corwin, 2008). R/T Meds: Prandin with meals. Name: Hypercholesterolemia Patho: High levels of cholesterol on the blood. Abnormalities of lipoproteins which are the particles which carry the cholesterol. Cholesterol is an essential component to cell membranes and steroids. 3 types of cholesterol: LDL, VLDL and HDL. Can lead to heart disease. Total= <200. HDL= >60 carries lowest risk. LDL= <70. Triglycerides= <150 (High Cholesterol, 2011) Etiology: Environmental (dietary/obesity) and genetic factors (High Cholesterol, 2011). S/S: usually asymptomatic hence the importance of having it checked (High Cholesterol, 2011). Name: Macular Degeneration Patho: There are two different kinds of macular degeneration: wet and dry. In dry macular degeneration there are pigment changes in the retina, yellow spots and areas of chorioretinal atrophy. There is no edema, hemorrhage or exudation. Ninety percent of clients have wet macular degeneration which begins as dry. Abnormal vessels form under the retina. There is edema or hemorrhage which may cause retinal detachment. Eventually, neovascularization occurs causing and elevated scar (Garg, 2008).
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Etiology: Some risk factors for developing macular degeneration are genetic, smoking, heart disease, hypertension, age and a diet low in omega 3 fatty acids (Garg, 2008). S/S: Dry: loss of central vision, pigment changed. Usually bilateral. Wet: Rapid vision loss. Central blind spot. Usually unilateral. Retinal edema (Garg, 2008). R/T Meds: None Name: Vascular Dementia Patho: It is a subtle, progressive decline in memory and cognitive function. This occurs when blood supply to the brain is reduced (Block, Smith, & Segal, 2010). Etiology: A history of a stroke, small vessel disease or a mixture of the two can cause vascular dementia. Most commonly, there is a blockage of small blood vessels somewhere in the vascular system of the brain. Hypertension is thought to be a cause of vascular dementia (Block et al., 2010). S/S: Slowed thinking, forgetfulness, mood changes (depression), confusion, dizziness, balance problems, bowel and bladder incontinence, slurred speech, aphasia, reduced ability to function in daily life (Block et al., 2010). R/T Meds: Celexa Name: Chronic Obstructive Pulmonary Disease COPD is a disease in which an airflow obstruction caused by chronic bronchitis of emphysema is present. Usually a progressive, non-reversible (completely) condition. There is inflammation also. Chronic bronchitis is defined as a chronic productive cough for at least 3 months in 2 or more years. Emphysema is an abnormal permanent enlargement of the airspaces with structural changes (Lewis, Heitkemper, & Dirksen, 2000). Patho: Emphysema: 2 types: centrilobular and panlobular. In centrilobular, the primary area of involvement is the central part of the lobule. Respiratory bronchioles enlarge, the walls are destroyed, and the bronchioles become confluent. Chronic bronchitis is often associated with centrilobular emphysema which is more common. Panlobular involves distention and destruction of the whole lobule. Bronchioles, alveolar ducts and sacs, and alveoli are all affected. There is a progressive loss of lung tissue and a decreased alveolar-capillary surface area. Chronic bronchitis: an excessive production of mucus in the bronchi accompanied by a recurrent cough. Structural changes include hyperplasia of mucous-secreting glands in the trachea and bronchi, increase in goblet cells, disappearance of cilia, chronic inflammatory changes and narrowing of the small airways and altered functioning of alveolar macrophages leading to more infections (Lewis, Heitkemper, & Dirksen, 2000). Etiology: Cigarette smoking is the primary cause of COPD and is true for this client. Other etiologies include recurrent respiratory tract infections, high levels of air pollution, heredity and aging (Lewis, Heitkemper, & Dirksen, 2000). S/s: Emphysema: Dyspnea on exertion that becomes progressively worse, Coughing with no sputum to little sputum, flattened diaphragm leading to barrel chest, chest breathing, hypoxemia, hypercapnia late in disease, thin and underweight, finger clubbing (Lewis, Heitkemper, & Dirksen, 2000). R/T Meds: Name: Hypertension is a sustained elevation in BP. When systolic pressure is greater than 140 or diastolic pressure is greater than 90. Diagnosis of hypertension comes when elevated readings occur on 3 consecutive occasions during several weeks. High BP means the heart is working hard, putting the heart and the vessels under stress (Lewis, Heitkemper, & Dirksen, 2000).
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Patho: An increase in cardiac output or systemic vascular resistance (SVR) must occur for pressure to rise. The true diagnosis of hypertension comes when there is a persistence elevation is SVR (Lewis, Heitkemper, & Dirksen, 2000). Etiology: Heredity, Water and sodium retention, altered renin-angiotensin mechanism, stress, insulin resistance, smoking, race, sex and age are some causes of hypertension (Lewis, Heitkemper, & Dirksen, 2000). S/s: None at first. Usually a patient seeks medical attention because of secondary issues hypertention causes or the high BP effects on organs like CAD (Lewis, Heitkemper, & Dirksen, 2000). R/T Meds: Name: Trigeminal Neuralgia Patho: Trigeminal neuralgia is a nerve disorder. The trigeminal nerve is the fifth cranial nerve and has both sensory and motor branches. The mandibular and maxillary branches which are sensory are involved in trigeminal neuralgia (Corwin, 2008). Etiology: No specific cause has been identified. Some thoughts include: nerve compression by tortuous arteries, demyelinating plaques, herpes virus infection, infection of the teeth or jaw, and brainstem infarct. Attacks are usually brief lasting just 2 to 3 minutes and usually happen on one side of the face. Recurrences are unpredictable. Things that may bring an attack on are: chewing, teeth brushing, hot or cold air on the face, yawning, washing the face, or even talking. Touch and tickle seem to be great triggers (Corwin, 2008). S/S: Abrupt onset of pain in lips, upper or lower gums, cheek, forehead or side of the nose is a classic feature of trigeminal neuralgia. Other signs include: intense pain, twitching, grimacing, and frequent blinking and tearing of the eye (Corwin, 2008). R/T Meds: Tegretol. This drug therapy may work because it stabilizes the neuronal membrane (Corwin, 2008). Name: GERD Gastroesophageal reflux Patho: Poor esophageal motility decreases the clearance of the gastric juice. Delayed gastric emptying can increase volume and pressure (Patti, 2011). Etiology: Stomach contents backing back up into the esophagus (Patti, 2011). S/S: Typical symptoms include: heartburn, regurgitation, dysphagia (sensation of food being stuck) can be an advanced symptom (Patti, 2011). R/T Meds: Prilosec
Course-specific data attached

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Laboratory Tests
Date
11/29/11

Time
0001

Abnormal/Significant Lab Findings

Hgb A1C 6.6% Est. Ave. Glucose 146 mg/dL

Normal range per Facility/Lab 4-5.6%

How does the result relate to the pathophysiology of your patients condition(s)? In a patient with diabetes, it is considered controlled if they are under 7%, making the clients 6.6% normal. Hgb A1C is a measure of diabetes control over weeks or months (Malarkey & McMorrow, 2005). According to the safe range of Tegretol, the client is safe (Malarkey & McMorrow, 2005). If her current dose of 200 MG BID is controlling her symptoms, I would not anticipate a change in her dose to make her in the therapeutic range.

8/4/11

0001

Carbamazapine 6.5 mcg/mL

Suggested level: 8-12 mcg/mL

7/19/11

0615

TSH 1.45 uiU/mL

0.4-4.5 uiU/mL

Stimulates thyroid gland to produce thyroid hormones (Malarkey & McMorrow, 2005). Clients current medication dose is working.

DiagnosticTests
Date Time Impressions How does the result relate to the pathophysiology of your patients condition(s)?
Atelectasis is a partial lung collapse caused by blocked air passages or by pressure on the outside of the lung. Risks include mucus, pleural effusion, prolonged bedrest without position change, and shallow breathing. Signs and symptoms include cough, chest pain, and breathing difficulty. Treatment includes breathing exercises, turning and ambulating (Atelectasis", 2010). Pneumonia is an infection of the lung that is bacterial, viral or fungal. Causes include bacteria or viruses living in the nose, sinus or mouth that can spread to the
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4/16/11

1425

Chest Xray Pa and Lat: 1.) LLL opacity- atelectasis and or pneumonia. 2.) No failure.

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lungs, clients can breathe the bacteria directly into their lungs, or with aspiration pneumonia, fluids or food is inhaled into the lungs unintentionally. Risk factors for pneumonia are COPD, smoking, diabetes, recent cold, and impaired consciousness. Signs and symptoms include cough (can be productive), fever, chills and shortness of breath. Treatment usually consists of IV fluids and antibiotics, supplemental oxygen and breathing treatments (Pneumonia, 2011).

4/22/11

2201

Ct Head wo Contrast: Moderate diffuse cerebral atrophy and moderate microangiopathy, chronic. No acute abnormality.

Microangiopathy generally refers to age related changes in white matter usually due to hypertension that can cause a decline in cognitive function (Corwin, 2008).

Enter the labs/diagnostics under related Key Problems

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Medications
Generic & Brand Names Prescribed Dose & Recommended Range
2 mg PO with meals Rec: 0.5-4 mg taken before meals not to exceed 16 mg/day.

Why is my patient getting this medication?

Type 2 diabetes Action: Stimulates the release of insulin from pancreatic beta cells by closing K+ channels which opens Ca+ channels. This is followed by a release of insulin.

Potential Side Effects and/or Adverse Reactions

Angina Chest pain Hypoglycemia hyperglycemia

Drug to Drug Food to Drug Interactions/Cautions

With Lopressor: may result in hypoglycemia, hyperglycemia, or hypertension. With synthroid: may result in decreased effectiveness of the antidiabetic agent. With tegretol: may result in decreased repaglinide plasma concentrations. With celexa: may result in increased metoprolol plasma concentrations and possible loss of metoprolol cardioselectivity. With Prandin: may result in hypoglycemia, hyperglycemia, or hypertension. Taking Lopressor with food may increase the concentration.

What will I monitor about this medication r/t my patients problems?

Blood sugars. S/s of hypoglycemia: sweating, hunger, abdominal pain, hunger, weakness, tachycardia, tremor. Ensure client is taking in food after taking the med.

Prandin Repaglinide Antidiabetic/ Meglitinides

Lopressor Metoprolol Beta Blocker

50 mg PO QAM Rec: 25-100 mg/day up to 450 mg/day

Hypertension Action: Blocks beta 1 receptors. Decreases BP and HR and the workload of the heart.

Insomnia Nausea Fatigue Bradycardia Weakness Increased cholesterol and blood sugar. CHF/PULMONARY EDEMA

BP and HR before administration. Intake and Output ratios and weights. S/S CHF (dyspnea, rales, crackles, weight gain, edema, JVD).

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Cozaar Losartan Angiotensin 2 Receptor Antagonist (like an ARB)

100 mg PO QAM Rec: 25-100 mg/day

Hypertension Action: Blocks the binding of angiotension 2 to specific tissue receptors found in vascular smooth muscle and adrenal glands. Blocks the vasoconstriction and release of aldosterone. Decrease in BP by a decrease in peripheral resistance and blood volume. Hypothyroidism Action: Synthetic hormone replacement. Increases cellular metabolism, plays a role in growth, CNS and bone function, body temp, increases oxygen consumption, respiration, HR, metabolism of fats, carbs and proteins.

Dizziness Anxiety Confusion Cough Upper Resp. Infection Insomnia Hypotension Visual changes ANGIOEDEMA

None.

BP and HR before administration. S/S of angioedema (dyspnea, facial swelling) Electrolyte balance

Synthroid Levothyroxine Hormone Supplement

25 mcg PO QAM (0600) Rec: 50-200 MCG Daily (dose titrated based on TSH, T3, T4)

palpitations appetite increased tachycardia nervousness tremor weight loss diaphoresis diarrhea abdominal cramps insomnia fever headache alopecia heat intolerance nausea anxiety

Always give on an empty stomach preferably before breakfast. With tegretol: may result in decreased levothyroxine effectiveness. With Prandin: may result in decreased effectiveness of the antidiabetic agent.

Labs if available (TSH/T3/T4). S/S hyperthyroidism (irritability, insomnia, hyperthermia, wt loss, palpitations, tachycardia, increased BP, sweating).

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Prilosec Omeprazole Proton Pump Inhibitor

40 mg PO QAM (0600) Rec: up to 120 mg/day

GERD Action: Suppresses gastric acid secretion

Abdominal pain Diarrhea Flatulence N/V HA Steven Johnsons Syndrome

With Celexa: May increase exposure to Celexa resulting in risk of QT interval prolongation. With tegretol: may result in an increased risk of carbamazepine toxicity.

Assess for epigastric pain or abdominal pain. Blood on stools, emesis or gastric content.

Tegretol Carbamazepine anticonvulsants

200 mg PO BID (AM and PM) Rec: 6001200 mg/day in divided doses Q 68 hrs

Trigeminal Neuralgia Action: Decreases synaptic transmission in the CNS by affecting Na channels in neurons.

Suicidal thoughts (also a mood stabilizer), Steven Johnsons syndrome toxic epidermin necrolysis, agranulocytosis, aplastic anemia, thrombocytopenia.

With Tylenol: May increase risk of Tylenol hepatotoxicity With synthroid: may result in decreased levothyroxine effectiveness. With Prilosec: may result in an increased risk of carbamazepine toxicity. With Prandin: Concurrent may result in decreased repaglinide plasma concentrations. FOOD: No grapefruit juice. With tegretol: May increase risk of Tylenol hepatotoxicity

Assess for facial pain (location, intensity and duration). Monitor WBC r/t agranulocytosis side effect.

Tylenol Acetaminophen Nonopiod analgesic

650 mg PO Q4 hrs PRN pain Rec: 325650 mg PO Q 46 hrs not to exceed 4 grams (or 2.5 g in renal/hepatic patients) in 24 hrs

Pain r/t trigeminal neuralgia Action: thought to inhibit prostaglandin synthesis and elevate pain threshold.

Hepatic Failure Hepatotoxicity Renal failure Rash HA Nausea Low WBC counts

Ensure client is not receiving more than the max dose per day (4 grams). Pain assessment to include location, duration, intensity, pain scale number

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Celexa Citalopram SSRI

20 mg PO Daily (AM) Rec: up to 40 mg/day in gero patients Action: Inhibits the reuptake of serotonin causing a build up

Miralax polyethylene glycol Osmotic laxative

17 gm PO (in 8 oz water) PRN constipation Rec: 17 g in 8 oz water, may be used for up to 2 weeks.

Constipation Action: Draws water into the stoolincreases the salt concentration in the large intestine, which causes water to be drawn into the intestine; the increased amount of water in the intestine softens the stools. Rash Action: Suppresses immune response and inflammation

Neuroleptic malignant syndrome Suicidal thoughts Apathy Confusion Drowsiness Insomnia Weakness Abdominal pain Diarrhea Dry mouth Dyspepsia Flatulence Sweating Tremor Serotonin syndrome Abdominal bloating Cramping Flatulence Nausea

With Prilosec: May increase exposure to Celexa resulting in risk of QT interval prolongation. With Lopressor: may result in increased metoprolol plasma concentrations and possible loss of metoprolol cardioselectivity.

Clients mood and any changes. Assess for serotonin syndrome: mental changes like agitation, hallucinations and coma, autonomic instability: tachycardia, labile BP, hyperthermia, neuromuscular aberrations: hyperreflexia, incoordination and Gi symptoms: n/v and diarrhea. Assess for abdominal distention, bowel sounds usual bowel function, color, consistency and amount of stool produced.

None however I would not give it with other medications

Kenalog Triamcinolone 0.1% Corticosteroid

1 Application Topically BID to leg rash until resolved Rec: apply 3-4 times a day

Burning Dryness Folliculitis Hypersensitivity

None.

Skin assessment with attention to degree of inflammation and pruritus. Watch for s/s infection like increased pain, erythema, purulent exudate.

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Oxygen

2 LPM via NC (titrate to 90%) Recommended Range: 1-6 L per NC

Hypoxia r/t COPD Action: improved perfusion. Saturated blood with oxygen.

Dry mucus membranes. Bloody Nose.

None.

O2 saturation. Lung sounds.

RFS

BID Rec Range:

Diabetes type 2

Hyper: Increased thirst, ha, blurred vision, frequent urination, fatigue, BS >180 mg/dL Hypo: tremor, sweating, hunger, anxiety. Confusion, heart palpitations.

None

Monitor what the result is. Ensure client is taking Prandin. Ensure client is not eating differently than normal. Ensure client is not consuming an excessive amount of carbs.

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Demographic Data Assignment # 9 Age range: >80 Gender: Female Ht: 137.2 cm Wt: 85 kg BMI: 32.1 (Obese) Code Status: DNR Medical Diagnosis: Diabetes Mellitus II Diet/Texture: Calorie Restricted, small portions Allergies: Actos, demetrol, enalapril, Fosamax, IVP dye, Lipitor, lisinopril, nicotine patch, raloxifene VS: 11/11/11: T: 97 P: 76 RR: 18 BP: 120/72

Gordon's Functional Health Pattern

Gordon's Functional Health Pattern

Gordon's Functional Health Pattern

Subjective Client states she has a "diabetes problem" Client is open to small portion meals.

Subjective

Subjective
Client states, "I can't do it by myself" when asked about dressing herself.

Objective BMI 32.1 Client has gained 20# since admission in April.

Objective Client uses oxygen at 2 LPM nc Client has a history of pneumonia or atelectasis.

Objective Staff assists client in dressing and sets her up at the sink for oral care and hair combing inthe am.

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Priority #1 Nursing Diagnosis: Imbalanced Nutrition: More than Body Requirements RT increased intake and decreased activity

Priority #1 Nursing Diagnosis: Impaired gas exchange RT ventilation-perfusion inequality (Ackley & Ladwig, 2010) AEB need for supplemental oxygen

Priority #1 Nursing Diagnosis: Self Care Deficit RT fatigue AEB clients need for help to dress SMART Patient Goal: Client will participate in ADLs today by breakfast time.

AEB BMI of 32.1 SMART Patient Goal: Client will have no weight gain during the two weeks SN will be following her.

SMART Patient Goal: Client will maintain clear lung sounds during the shift 12/7/2011.

SMART Interventions followed by Evidenced-Based Rationale (minimum 3): 1. Client will walk to and from breakfast with gait belt, walker, oxygen, and staff member during todays shift. Rationale: Walking burns more calories than being pushed to the dining room in her wheel chair. 2. Client will have small portions for all meals today. Rationale: A decrease in calorie intake should helo the client not gain weight. 3. Client will be weighed and have it charted and assessed at least once per week on Wednesdays. Rationale: SN must have a weight at least once a week to be able to assess if the client is successful in not gaining weight. 4. Client will be compliant with taking her Prandin at meal times Rationale: Taking her medication will help control her diabetes.

SMART Interventions followed by Evidenced-Based Rationale (minimum 3): 1. SN will auscultate breath sounds Q4 hours. Rationale: Checking for the presence of crackles or wheezes will alert the nurse to a problem which may lead to an exacerbation of hypoxia (Ackley & Ladwig, 2010). 2. SN will monitor oxygen saturation Q4 hours. Rationale: This would be another indicator of a problem that could lead to adventitious lung sounds. 3. Client will reposition every 2 hours and PRN. Rationale: Keeping clients active will decrease atelectasis and risk for pneumonia which can cause adventitious lung sounds (Ackley & Ladwig, 2010). 4. SN will ensure oxygen administration is being delivered by appropriate device (Ie nasal cannula) at an appropriate liter flow by lunch time. Rationale: There is a fine line between proper oxygenation and over oxygenation (Ackley & Ladwig, 2010) Evaluation (at end of day, did client reach stated goal?)

SMART Interventions followed by Evidenced-Based Rationale (minimum 3): 1. SN/Staff will assist client with AM dressing and grooming by breakfast time. Rationale: Client will need help getting dressed for breakfast. 2. SN/Staff will keep the clients personal preferences in mind when dressing and grooming before breakfast. Rationale; Keeping the clients preferences in mind helps promote self esteem (Ackley & Ladwig, 2010). 3. Client will assist in dressing and grooming herself rather than letting SN/Staff do it for her by breakfast time. Rationale: Doing these tasks on her own will help promote independence.

Evaluation (at end of day, did client reach stated goal?)

Evaluation (at end of day, did client reach stated goal?)

SMART: Specific Measureable Appropriate Realistic Time element Revised September 2011

References on back or on attached page.

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Post Conference Report

What new Nursing knowledge did you learn today?

Was it effective or able to be utilized in the care of your patient or a patient?

Any changes in medications, labs or diagnostics you need to be aware of that will change how you will for your patient again? (you will need to complete a new medication sheet, lab or diagnostic sheet if there are changes)

Did you participate in any discharge planning? If not why not?

Would you change any nursing action done for your patient or with a patient today? What?

What did you observe about the nurses working on the unit you were assigned?

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REFERENCES Atelectasis - PubMed Health. (2010, September 15). National Center for Biotechnology Information. Retrieved December 5, 2011, from Block, J., Smith, M., & Segal, J. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001130/ Vascular Dementia: Signs, Symptoms, Prevention, and Treatment. (June 2010). Helpguide.org: Expert, ad-free articles help empower you with knowledge, support & hope.. Retrieved December 3, 2011, from http://www.helpguide.org/elder/vascular_dementia.htm Corwin, E. J. (2008). Handbook of pathophysiology (3rd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. DrugGuide.com | Davis's Drug Guide Online + Mobile. (n.d.). DrugGuide.com | Davis's Drug Guide Online + Mobile. Retrieved October 26, 2011, from http://drugguide.com/ddo/ub/home High cholesterol - MayoClinic.com. (2011, June 1). Mayo Clinic. Retrieved December 5, 2011, from http://www.mayoclinic.com/health/high-bloodcholesterol/DS00178 Garg, S. (2008, December 15). Age-Related Macular Degeneration (AMD or ARMD): Retinal Disorders: Merck Manual Professional . THE MERCK MANUALS - Trusted Medical and Scientific Information. Retrieved December 5, 2011, from Karch, A. (2008). Focus on nursing pharmacology . (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Malarkey, L. M., & McMorrow, M. E. (2005). Saunders nursing guide to laboratory and diagnostic tests. St. Louis: Elsevier Saunders. Patti, M. (2011, August 19). Gastroesophageal Reflux Disease . Medscape. Retrieved November 14, 2011, from emedicine.medscape.com/article/176595clinical#aw2aab6b3b2 Pneumonia - PubMed Health. (2011, May 1). National Center for Biotechnology Information. Retrieved December 5, 2011, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001200/

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