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CSU, STANISLAUS B.S.N.

CLINICAL PLAN OF CARE


Student

Nikki Thao

Date of Care

February 28, 2013 Room Number 387

Patient Data
Admitting Diagnoses: Syncope CVA, Mandibular Fx Fall Past Medical History: Patient also had an ulcerative colitis,
Patient Initials: L.C.
Age: 58
ruptured colon/ and had colectomy, j-pouch. Since she had the
Gender: Female Height: 170 cm Weight: 77.11Kg
colectomy, she has been having loose stools. She had a trachea
Spiritual Focus: Catholic
before. HTN, stroke 1/13, mitral value prolapse, mass above left
Culture: Caucasian
kidney removed, salivary glands removed.
Admitting Date: 2/24/14
Surgical History: Colectomy, hysterectomy, tracheostomy, B12
deficiency.
Vital Signs: T 36. P 83 R 18 BP 129/71 O2 Sat 98% room air Pain Scale 7/10 (morphine IV administer, reduce pain to 5/10, MS con tin
and other medications on hold because of angiogram procedure).

Diet NPO Activity Normal


Advance Directives:
Yes ________ No X
Code Status Full Code VS Freq q4h
Vascular Access:

Foley N/a NG/Feeding Tube N/a


Drains/ Tubes N/a
Glucose Monitoring N/a TEDs/SCDs SCDs
PCA/Epidural N/a Telemetry Baseline sinus tachycardia, Cardiac Test
Ejection fraction= 41%.

IV Site: IV right hand, 22 gauge


IV Solution: NS 125mL/hr
Dressing Changes N/a

Safety Considerations Fall Risk


Labs to be drawn Normal CBC labs
Scheduled Procedures Cardiac Stress Test (2/26/13)
Angiogram (2/28/13)

Notes on pathophysiology:
Patient is a 58- year old female who was previously living in the hills. Then her house got burned down and she had to live in a group home. The day
before admission, she felt dizzy, light headed, and lost consciousness and fell on her jaw. She went to Merced ER, got a CAT scan of the face and neck,
which showed mandibular neck fractures and right mandibular body fracture. Head CT scan showed ischemic infarct (inadequate blood flow) in the
right frontal lobe. It is unclear whether it was old or new. Patient is diagnosed with Syncope CVA, which is condition is which there is a sudden and
temporary loss of consciousness. When this happens there is a disruption in sustaining adequate amount of oxygen supply to the brain. A diagnosis of
Syncope can be related to the heart. Patient is placed on telemetry, with Echocardiogram, carotid Doppler, and MRI- brain. A Cardiac Stress Test was
1

done to assess her hearts ability to take on external stress. Ejection fraction was 41%. Patient has an impression of a baseline sinus tachycardia.
Scheduled for angiogram procedure.

Lab and Diagnostic Test Data


Test type(date)
WBC x 103
(White blood count)
2/25/13
2/26/13

RBC x 10 6
(Red blood count)
2/25/13
2/26/13

Normal Range

4.8-10.8 /cmm

Patient
Results
5.2
4.8

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &


teaching

This test is to see if


Patient has an
infection or
inflammatory
response

Increased WBC count usually indicated an infection,


inflammation, or tissue necrosis. WBC test is done based
on a routine CBC routine examination. Patient has a dry,
crusty tongue with stitches, risk for infection because she
bit her tongue. Monitor patients temperature and diet,
also for signs of fever, chills, pain and body aches, which
can indicate a high WBC. A change in diet, physical
activity, and stress may also lead to increase WBC count.
Decreased levels of WBC may be associated with iron
and Vitamin B12 deficiency or overwhelming infections.
RBC count is closely related to hemoglobin.
Continue to monitor, patient is suspected to be anemic
because of low levels of hemoglobin. Make sure patient
takes her Ferrous Sulfate medication to prevent irondeficiency. Assess patient for any signs of bleeding in the
mouth because of her fractured mandible.
Closely monitor levels as Patient is suspected to be
anemic. Tell Patient that fasting is not required for test.
List on the laboratory slip any drugs that may affect test
results. Low levels of HGB can indicate iron deficiency
in patient. Make sure patient takes her Ferrous Sulfate
medication. Patient is taking aspirin which may decrease
HGB levels, monitor for any signs of active bleeding as
patient had a mandibular fracture. Monitor vital signs,
especially HR and BP.
Continue to monitor levels as patient is suspect to be
anemic.
Also monitor WBC levels which may be the reason for
the decrease in HCT.
Low levels of HCT can indicate blood loss or anemia.
Assess for signs of bleeding as patient had a mandibular
fracture. Monitor I and O, as patient is usually on
mechanical, soft diet but because of procedure, she is
NPO.

This test is to
evaluate for anemia.
4.70-6.10 /cmm

3.10L
2.99L

HGB (Hemoglobin)
2/25/13
2/26/13

14.0-17.5 /cmm

9.4L
8.9L

HCT (Hematocrit)
2/25/13
2/26/13

41.5-50.4 %

28.1L
27.1L

This test is to monitor


blood count.
Hemoglobin
determines the
oxygen- capacity of
the Patients blood.

This test is an
indirect measurement
of red blood cell
number and volume.
It is use to evaluate
anemic patients.

Test type(date)
MCV (Mean Corpuscular
Volume)

2/25/13
2/26/13
MCH (Mean Corpuscular
Hemoglobin)
2/25/13
2/26/13
MCHC (Mean Corpuscular
Hemoglobin Concentration)

2/25/13
2/26/13
RDW (Red blood cell
distribution width)

2/25/13
2/26/13
Platelet
2/25/13
2/26/13

MPV
2/25/13
2/26/13
Neutrophils
2/25/13
2/26/13

Lymphocytes
2/15/13
2/16/13

Normal Range

Patient
Results

Trend

80.0-94.0 fL
90.8
90.4

30.2
29.6

27.0-31.0 pg

32.0-36.0 g/dL
33.3
32.8

11.5-14.5 %
17.0H
16.5H

130-400 /cmm

194
180

7.4-10.4 Fl

7.9
7.8

42.2-75.2

60.8
64.3

20.5-51.1

17.9L
17.5L

Rationale
(specific to pt.)

Nursing Implications related to patient care &


teaching

This test is to provide


information about
size of RBCs. For
classifying anemia.
This test is to provide
information about
weight of RBCs.

Continue to monitor levels.


Patient is suspected to be anemic, so check to see if
patient has iron supplements (Ferrous Sulfate).
Patient has signed consent form, in case of need for blood
transfusion 2/27/13.

This test is to provide


information about
hemoglobin
concentration of
RBCS.
This test is to provide
information about
size of RBCs.
This test is done to
measure the number
of platelets available
to maintain platelet
clotting functions. To
check for blood clot.
This test is to
evaluation of platelet
disorder.
This test measures
the amount of
neutrophils in blood.
Neutrophils are a
type of white blood
cell
This test measures
the amount of T and
B cells in blood.

Monocytes

This test is to

High levels of RDW indicate iron- deficiency in Pt.


Monitor patients diet.
Medical records indicate patient is at risk for deep vein
thrombosis prophylaxis, and is on SCDs because of
bleeding in the mouth secondary to mandibular Fx.
Continue to monitor patient for any spontaneous
bleeding, such as hemorrhages. Check dosage for aspirin,
which causes decrease in platelet aggregation.
Tell patient that no fasting is required. Collect sample in
lavender- top tube. Assess venipuncture site for bleeding.
Test is done as part of a routine CBC count. Neutrophils
exist to kill and digest bacterial microorganisms. An acute
infection can increase neutrophil levels. Monitor patients
WBC level. Patient is suspected to be anemic, which may
increase neutrophil levels, as well as physical and
emotional stress.
Test is done as part of a routine CBC count. Lymphocytes
are important in fighting against chronic bacterial
infection and acute viral infections. Decrease levels of
lymphocytes can indicate signs of sepsis. Continue to
monitor WBC levels.
Test is done as part of a routine CBC count. Test is used

Test type(date)

Normal Range

Patient
Results

Trend

2/15/13
2/16/13

1.7-9.3

13.9H
10.8H

Eosinophils
2/15/13
2/16/13

0.0-10.0

4.8
7.0

Basophils
2/15/13
2/16/13

0.0-0.8

0.6
0.4

Seg+Band Absol
2/15/13
2/16/13

1.4-6.5

3.2
3.1

Lym Absol x 1000


2/15/13
2/16/13

1.2-3.4

1.0L
0.8L

0.1-0.6

0.7H
0.5

0.0-0.7

0.2
0.3

0.0-0.2

0.0
0.0
1877Hf

No Trend

Mono Absol x 1000


2/15/13
2/16/13
Eos Absol x 1000
2/15/13
2/16/13
Baso Absol x 1000
2/15/13
2/16/13
D- dimer, OT FEU
2/24/13

Rationale
(specific to pt.)

Nursing Implications related to patient care &


teaching
measure the amount to evaluate and manage blood disorders, certain
of monocytes in
problems with the immune system. Patient had a
blood.
history of ulcerative colitis which can be the reason
for high levels of monocytes. Continue to monitor
WBC levels.
This test is to
Eosinophils become active when a patient has
measure the amount certain allergic diseases, infections, and other
of eosinophils in
medical conditions. Increased levels can be indicated
blood.
because patient has a history of gastrointestinal
disease (ulcerative colitis). Continue to monitor
WBC levels.
This test is to
This test is used to help evaluate and manage
measure the amount treatments including certain allergic disorders, blood
of basophils in blood. disorders, neoplastic disorders, and infections caused
by parasites. Continue to monitor WBC levels.
This test is to

0-500

No Trend

calculate the total


number of white
blood cells.

This test is used to


identify intravascular
clotting. Patient is at

Test is done as part of a routine CBC count. Neutrophils


exist to kill and digest bacterial microorganisms. An acute
infection can increase neutrophil levels. Monitor patients
WBC level. Patient is suspected to be anemic, which may
increase neutrophil levels, as well as physical and
emotional stress.
Lymphocytes are important in fighting against chronic
bacterial infection and acute viral infections. Decrease
levels of lymphocytes can indicate signs of sepsis.
Continue to monitor WBC levels.
Patient had a history of ulcerative colitis which can be the
reason for high levels of monocytes. Continue to monitor
WBC levels.
Increased levels can be indicated because patient has a
history of gastrointestinal disease (ulcerative colitis).
Continue to monitor WBC levels.

High levels of D-Dimer can indicate a DVT or PE, which


means there is a clot. It is used to determine the duration
of anticoagulation therapy in patients with DVT. Due to a

Test type(date)

Normal Range

Patient
Results

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &


teaching

risk for medical


problem related to
DVT prophylaxis.
This test is to monitor
fluid and electrolyte
balance. The kidney
compensates by
conserving sodium
and water.

elevated D-dimer, a CTA should be done. Patient had one


done with no evidence of embolic defects identified. Do a
PT and INR lab test to check for clotting.
Continue to monitor electrolyte levels.
If Na+ level continue to rise, Patient decrease sodium
intake in diet.
High levels of Na+ typically mean patients intake of
sodium far exceeds bodys daily requirements. Assess for
dehydration, skin turgor, weakness, and weight gain.
Low levels of Na+ are due to GI losses, such as vomiting,
fasting diets, and excess water in the body. Patient has
present chronic diarrhea which indicates low level.
Assess frequency of bowel movement. Withhold any
laxatives/ diuretics in the order. Assess for increased BP,
headache, confusion, and muscle spasm which may
indicate low levels of Na+.
Potassium is an important electrolyte in the body.
Monitor levels is important because K+ can cause cardiac
arrest.
High levels of potassium can result due to any potassiumcontaining salt substitute, monitor patients diet.
Assess for anxiety, abdominal cramping, irregular pulse,
or cardiac arrest due to excess potassium.
Low levels of potassium can result due to any fluid loss.
Assess for muscle weakness, diarrhea, vomiting,
polyuria, and weak, irregular pulse, which may indicate
low potassium levels.
If patients K+ level is low, administer potassium Cl
replacement. Patient is taking aspirin which can decrease
K+ levels.
Chloride works as a neutrality between the electrolytes.
Monitor levels because Patient is taking NSAIDS which
can increase levels. Increase levels can raise blood levels.
Usually included with other electrolyte assessment.
Increased level can cause severe vomiting. Assess
patients breathing as CO2 plays an important role in
transportation in blood/ acid- base balance. Increased
levels of CO2 retention may result in severe pneumonia
and respiratory muscle weakness Decrease CO2 levels

Sodium
2/15/13
2/16/13

136-145 mEq/L

132L
134L

Potassium
2/15/13
2/16/13

3.5-5.1 mEq/L

3.8
4.1

Chloride
2/15/13
2/16/13
CO2
2/15/13
2/16/13

98-107 mEq/L

102
105

22-29 mEq/L

21L
21L

No Trend

This to monitor
electrolyte balance
and is important to
patients cardiac
function.

This is to monitor
acid- base balance
and hydration status.
This is to measure pH
status of patient and
assist in evaluation of
electrolytes.

Test type(date)

Normal Range

Patient
Results

Trend

Rationale
(specific to pt.)

Glucose Random
2/15/13
2/16/13

70-110 mg/dL

111H
93

This test is to
measure blood
glucose level.

Creatinine
2/15/13
2/16/13

0.7-1.2 mg/dL

1.2H
1.1H

This test is to check


for impaired renal
function.

BUN
2/15/13
2/16/13

8-23 mg/dL

23.0H
26.0H

This test is to check


for liver and renal
function.

Total Protein
2/25/13

6.4-8.3

6.5

No Trend

Albumin
2/25/13

3.5-5.2

3.5

No Trend

8.8-10.2 mg/dL

8.3L
8.2L

Calcium
2/15/13
2/16/13

A total serum protein


test measures the
total amount of
protein in the blood.
This is part of total
protein test. Test is
done to see if liver
and kidneys are
working.
This test is to monitor
Patient with renal
failure. Patients
mandibular fracture

Nursing Implications related to patient care &


teaching
may result in hyperventilation, due to fear, anxiety, pain.
Monitor for symptoms of vomiting and administer
Prochlorperazine Tab prn.
Patient is taking Metoprolol, a beta- blocker, which may
increase blood glucose levels.
Do Finger stick blood glucose before meals and at
bedtime. Patient does not have diabetes. Test was done as
part of routine.
Creatinine is important in determining if a Patient has
impaired renal function. It is a waste product of protein
breakdown. Because almost all creatinine in the blood is
normally excreted by the kidneys, creatinine clearance is
the most accurate indicator of renal function. It is also
important in approximating the GFR. Creatinine usually
remain constant for each person because they are not
significantly affected by protein indigestion, muscular
exercise, water intake, or rate of urine production.
Monitor Patients HTN because it can affect the kidneys
ability to filter waste.
This test is performed along with the Creatinine test.
Assess medications that can cause GI bleeding, for it can
cause Bun levels to increase. No Patient fasting is
required, avoid hemolysis when collecting sample.
It also measures the amounts of two major groups of
proteins in the blood: albumin and globulin. Monitor
Patients diet as patient had a colectomy. Must ensure that
you drink adequate amounts of water and drink plenty of
fluids to regulate the protein levels in the blood.
Albumin helps determine is the patient is eating proper
diet that contains enough proteins. A high level of
albumin indicates severe dehydration. Monitor patients
diet, I/O. Low levels indicate poor diet, risk for heart
failure, liver/ kidney disease.
Calcium is an important metabolism vital for muscle
contractility, cardiac function, neural transmission, and
blood clotting.
Monitor levels, as Patient is taking aspirin which can

Test type(date)

Normal Range

Patient
Results

Trend

Bilirubin Total
2/25/13

0.0-0.1

0.2

No Trend

Alk Phos
2/25/13

35-104

60

No Trend

SGOT/ AST
2/25/13

0-35

20

No Trend

SGPT/ ALT
2/25/13

0-35

No Trend

Globulin
2/25/13

2.1-3.5

3.0

No Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &


teaching

is a result of low
Ca2+ levels.

further decrease levels.


Assess for decreased memory, polyuria, dehydration,
fractures, and confusion which indicates high levels of
Ca2+ levels.
Assess for depression, numbness, tingling sensation, and
easy fatigability which indicates low levels of Ca2+
levels.

A bilirubin test
measures the amount
of bilirubin in a blood
sample. Check for
liver function.
An alkaline
phosphatase test is
often done at the
same time as a
routine blood test.
Check liver function.

Test is done for patients who are diagnose conditions that


cause increased destruction of red blood cells, such as
anemia. Patient has low RBC, which may indicate
anemia. Monitor RBC levels, as well as aspirin intake,
which can thin the blood.
Test is done to check for liver function. Symptoms of
liver disease can include jaundice, belly pain, nausea, and
vomiting. A decrease in Alk Phos can indicate a decrease
in Vitamin D, Monitor Patients electrolytes. Palpate liver
for pain, swelling. Scratch test.
AST is normally found in red blood cells, liver, heart,
muscle tissue, pancreas, and kidneys. Monitor
acetaminophen intake, which may increase AST levels.

Check liver function.

This test is
performed to look
7

Obtain a history of the patient's complaints,


including a list of known allergens, especially
allergies or sensitivities to latex.
Palpate liver for enlargement, pain.
Elevated levels of AST can indicate cardiac injury,
Cardiac stress test was done.
Inform the patient this test can assist with evaluation
of liver function and help identify disease.
Obtain a history of the patient's complaints,
including a list of known allergens, especially
allergies or sensitivities to latex.
Monitor liver damage resulting from hepatotoxic
drugs.
Palpate liver for enlargement, pain.
Test to determine patients chances of developing an
infection. Must ensure that you drink adequate

Test type(date)

Normal Range

Patient
Results

Trend

A/G Ratio
2/125/13

0.9-2.0

1.2

No Trend

ml/min

56f
62f

46
51

eGFR AF- AM fem


2/15/13
2/16/13
eGFR other-fem
2/15/13
2/16/13
Magnesium
2/15/13
2/16/13

ml/min

1.6-2.6

1.7
1.6

CPK
2/15/13
2/16/13

39-190

34L
68

CKMB
2/15/13
2/16/13

0.0-4.7

1.7
2.4

Rationale
(specific to pt.)
at globulin proteins
in the blood.

Nursing Implications related to patient care &


teaching
amounts of water and drink plenty of fluids to
regulate the protein levels in the blood.
Test is included
A high A/G ratio is used to indicate under production
because it can
of immunoglobulin. Low production of A/G ratio
provide a clue as to
indicates under production of albumin in conditions
why there is a change like liver cirrhosis. Continue to monitor protein
in protein levels.
levels.
.
This test is a measure
of the function of the
kidneys. GFR
determines the flow
rate of fluid in the
kidneys.
This test is used to
identify magnesium
deficiency or
overload.

This test is done to


support the diagnosis
of myocardial muscle
injury. Patient is
getting an angiogram.
Follow-up test incase
Patient had an
elevated CPK, which
can result because of
heart damage or
skeletal muscle
damage.

Monitor Creatinine levels to get a reasonable estimate of


the actual GFR. Patient has a history of high blood
pressure, so test is done. Monitor Patients high blood
pressure. Also, monitor/ assess urine. Patients diet should
be according to dietary guidelines, suggested by hospital.
It is important to monitor magnesium levels in cardiac
patients. Must monitor magnesium level because patient
has multiple medications for magnesium prn. Assess
bowel movements of patient. Patient is taking laxatives
which can increase Mg2+ levels. Monitor patients diet
and ability to urinate.
Assess for diarrhea, vomiting, impaired GI absorption
(due to removal of large intestine), and large urine output,
which can indicate low Mg levels.
Assess for renal failure which may indicate high Mg
levels.
Patient was diagnosed with Syncope CVA can cause
diminish cardiac output secondary to mechanical
obstruction or lack of blood flow.
Monitor patients heart rate. Monitor ECG as patient is
placed on telemetry and has a baseline sinus tachycardia.
A Cardiac Stress test was done to measure hearts ability
to respond to external stress in a controlled environment.

Test type(date)

Normal Range

Patient
Results

Trend

Troponin T
2/15/13
2/16/13

0.000-0.030

0.036H
<0.010

TSH
2/15/13
2/16/13

0.460-4.890

1.410
4.470

211-946

558

No Trend

Vitamin B12
2/24/13

Routine Urinalysis 2/24/13


Color
Appearance
SP Gravity
pH
Glucose
Bilirubin
Ketones
Blood
Protein
Urobilirubin
Nitrate
Leukocytes

Light/Yellow
Clear
1.030
5-8
Neg
Neg
Neg
Neg
Neg
1
Neg
Neg

Yellow
Clear
1.020
5.0
Neg
Neg
Neg
Small*
75*
Norm
Neg
Neg

Rationale
(specific to pt.)

Nursing Implications related to patient care &


teaching

The troponin test


measures the levels
of certain proteins
called troponin T and
troponin I in the
blood

These proteins are released when the heart muscle has


been damaged, such as a heart attack. The more damage
there is to the heart, the greater the amount of troponin T
and I there will be in the blood.
Patient is diagnosed with Syncope CVA
Monitor patients heart rate. Monitor ECG as patient is
placed on telemetry and has a baseline sinus tachycardia.
A Cardiac Stress test was done to measure hearts ability
to respond to external stress in a controlled environment.
Signs and symptoms of hyperthyroidism may include:
Increased heart rate, anxiety, weight loss, difficulty
sleeping, tremors in the hands, weakness.
Symptoms of hypothyroidism may include:
Weight gain, dry skin, constipation, cold intolerance

The TSH test is often


the test of choice for
evaluating thyroid
function and/or
symptoms of
hyperthyroidism or
hypothyroidism.
Patient has a history
of Vitamin B12
deficiency. The test is
done to monitor B12
levels and evaluate
for malnourishment.
The test is done as
part of a routine
medical exam to
screen for early signs
of disease.

No Trend

Medication Allergies: Linsinopril


9

Test is done as part of routine check. Vitamin B12 is


necessary to convert the inactive form of folate to the
active form, which is important in the formation and
function of RBCs.
Assess patient for malnourishment, and suggest foods
that are high in Vitamin B12, such as meat, eggs and
dairy products.
Small amount of blood in the urine indicates hematuria.
Sometimes it can be normal, but should be further
assessed.
Assess for signs of inflammation, infection, or injury to
urinary system which may result in blood in the urine.
Patient has HTN which may be the reason why proteins
are found in her urine.
HTN can cause damage to the kidney and should be
further assessed.
Palpate the kidneys, and check for CVA tenderness.

Medications
Generic & Trade Name
Drug classification

dose/Route
Frequency

Action of drug and


Rationale
(specific to Pt)

Significant Side Effects

Nursing Implications related to


patient care and teaching

Aspirin Tab
Therapeutic: antipyretics,
nonopioid analgesics
Pharmacologic: salicylates
Home medication

325 mg once a
day P.O.

GI bleeding, epigastria
distress, nausea, abdominal
pain, aspirin overdose; tinnitus
(ears ringing), dehydration
with electrolyte imbalance.

Give with milk or full glass of water to


decrease gastric irritation.
Patient should avoid for concurrent use with
alcohol to decrease GI irritation.
Caution patient to avoid taking concurrently
with acetaminophen or NSAIDs for more
than a few day.

Docusate Cap (Colace)


Therapeutic: Laxatives
Pharmacologic: stool softener

100 mg twice
a day P.O.

Patient has medical problem


related to DVT prophylaxis,
because of bleeding in the mouth
secondary to mandibular Fx and
for signs of coronary artery
ischemia. Drug decreases platelet
aggregation, meaning it stops
blood from clotting and MI.
For renal bowel care. Drug
promotes incorporation of water
into stool, resulting in softer fecal
mass; may also promote
electrolyte and water secretion into
the colon.

Throat irritation, rashes, mild


cramps

325 mg twice
a day P.O.

To treat patients low levels of


RBCs (2.99L) and Hemoglobin
(8.9L) Drug prevents iron
deficiency anemia. Iron is an
essential mineral found in
hemoglobin; it enters the
bloodstream and is transported to
the organs of the
reticuloendothelial system, where
it separates out to become part of
iron stores.

Hypotension, nausea,
constipation, dark stools,
diarrhea, epigastric pain.

10 mg once a
day P.O.

For patients depression. Drug


Selectively inhibits the reuptake of
serotonin in the CNS and causes

anxiety,
drowsiness, headache,

Assess for abdominal distention, presence of


bowel sound & usual pattern of bowel
function. Check for color, consistency, &
amount of stool produced. Advise Pt that
laxatives should be used only for short- term
therapy. Long-term may cause electrolyte
imbalance/ dependence. Encourage patient
to use other forms of bowel regulation, such
as bulk in diet, fluid intake (6- 8 full
glasses/day), mobility. Normal bowel
habits vary from 3x/day to 3x/wk. Instruct
PT w/ cardiac disease to avoid straining
bowel movements/ not to use laxatives
when have abdominal pain. Advise PT not
to take docusate w/in 2 hr of other laxatives.
Assess patient for signs of anaphylaxis
(rash, pruritus)
Assess bowel function for constipation or
diarrhea.
Monitor hemoglobin, hematocrit levels
during therapy.
Assess nutritional status and dietary history
to determine possible cause of anemia and
need for patient teaching.
Patient should comply with medication
regimen.
Observe for usual changes in behavior/
suicidal thinking (long- term therapy).

(Therapeutic &
Pharmacologic)

New medication

Ferrous Sulfate (Iron


Supplement)
Therapeutic: antianemics
Pharmacologic: iron
supplements
Home medication

FLUoxetine HCL Cap


(Prozac)

10

an antidepressant action.

insomnia, nervousness,
suicidal thoughts, seizures,
diarrhea, sexual dysfunction,
tremor, sweating, pruritus.

Monitor appetite and nutritional intake.


Weigh weekly.
Assess patient for sensitivity
reaction (urticaria, fever, arthralgia, edema,
carpal tunnel syndrome, rash, hives,
lymphadenopathy, respiratory distress) and
notify health care professional if present;
symptoms usually resolve by stopping
fluoxetine but may require administration of
antihistamines or corticosteroids.

600 mg t.i.d.
P.O.

An adjunct treatment to prevent


patient from having a seizure,
which can result from her
antidepressant medication.
Mechanism of action for this drug
is unknown. It may affect transport
of amino acids across and stabilize
neuronal membranes; decreases
incidence of seizures.

Suicidal thoughts, confusion,


depression, drowsiness, ataxia.

Monitor closely for notable changes in behavior


that could indicate the emergence or worsening
of suicidal thoughts or behavior or depression.
Seizures: Assess location, duration, and
characteristics of seizure activity.
Instruct patient to take medication exactly as
directed. Patients on tid dosing should not
exceed 12 hr between doses.
Advise patient and family to notify health care
professional if thoughts about suicide or dying,
attempts to commit suicide; new or worse
depression; new or worse anxiety; feeling very
agitated or restless; panic attacks; trouble
sleeping; new or worse irritability; acting
aggressive; being angry or violent; acting on
dangerous impulses; an extreme increase in
activity and talking, other unusual changes in
behavior or mood occur.

50 mg once a
day P.O.

Metoprolol is used to control


Patients HTN. Drug blocks
stimulation of beta1 (myocardial)adrenergic receptors, decreasing
high blood pressure and heart rate.

Fatigue, weakness, erectile


dysfunction, bradycardia,
edema, symptoms of CHF,
constipation, diarrhea.

Monitor BP and HR (<55bpm for HR or


<110 for SBP, withhold and notify health
care professional).
Warning: Do not withdraw abruptly;
gradually taper to avoid reduced symptomsacute tachycardia, HTN, and/or ischemia.
Monitor Patients tachycardia because if
often masked by the beta blockade.
Monitor I&Qs.
Tell Patient to report any weakness,
dizziness, bradycardia, or fainting.
Report edema or difficulty breathing.

30 mg at
bedtime P.O.

For patients depression. Drug


increases the effects/ levels of

Drowsiness, constipation, dry


mouth, increased appetite,

Observe for usual changes in behavior/ suicidal


thinking (long term therapy).

Therapeutic: antidepressants
Pharmacologic: selective
serotonin reuptake inhibitors
(SSRIs)
New medication

Gabapentin Tab (Neurontin)


Therapeutic: analgesic
adjuncts, therapeutic,
anticonvulsants, mood
stabilizers
Home medication

Metoprolol Tartrate Tab


(Lopressor)
Therapeutic: antianginals,
antihypertensives
Pharmacologic: beta blockers

Home medication

Mirtazapine Tab (Remereon)


Therapeutic: antidepressants

11

norepinephrine and serotonin,


which play an important in a
persons mood. Causes an
antidepressant action.

Pharmacologic: tetracyclic
antidepressants
Home Medication

Morphine Cont. Rel. Tabs


(Ms Contin Cont Rel)
Therapeutic: opioid analgesics
Pharmacologic: opioid
agonists

15 mg twice a
day P.O.

For severe pain. Patient has a


mandibular Fx. Drug binds to
opiod receptors in the CNS and
alters the stimuli perception of and
response to painful stimuli while
producing generalized CNS
depression.

1 Patch TD

Patient smokes to 1 pack of


cigarettes a day. The patch is a
replacement for cigarettes. Patch
aids as a smoking cessation by
acting as an agonist at nicotinic
cholinergic receptors where it
dramatically stimulates neurons
and ultimately blocks synaptic
transmission. (manages withdrawl)

New medication

Nicotine 21mg/24hr Patch


(Habitrol 21mg/24hr Patch)
Therapeutic: smoking
deterrents
New medication

weight gain.

Respiratory depression,
constipation, hypotension,
confusion, sedation, seizures.

12

fast or pounding heartbeats,


fluttering in your chest,
extreme weakness or
dizziness, severe nausea and
vomiting, bronchospasm
(wheezing, tightness in your
chest, trouble breathing),
severe stinging, burning, or
other irritation in your nose,
mouth, or throat, or blistering,
ulcerations, or bleeding in
your nose

May be given as a single dose at bedtime to


minimize excessive drowsiness or dizziness.
May be taken without regard to food.
For orally disintegrating tablets, do not attempt
to push through foil backing; with dry hands,
peel back backing and remove tablet.
Immediately place tablet on tongue; tablet will
dissolve in seconds, then swallow with saliva.
Administration with liquid is not necessary.
Advise patient to avoid alcohol or other CNS
depressant drugs during and for at least 37 days
after therapy has been discontinued.
Therapy for depression may be prolonged.
Emphasize the importance of follow-up exam to
monitor effectiveness and side effects.

Long- acting. To be swallowed whole. Do


not break, crush, or chew.
Monitor level of sedation, RR (hold, <10),
BP.
Warning: For use in opioid- tolerant patients
only, due to risk of severe cardiorespiratory
depressant effect.
Have naloxone and resuscitation equipment
readily available.
Assess pain, location, type, intensity.
Patient taking sustained- released morphine
may require additional short- acting opioid
doses for breakthrough pain.
Assess for smoking history (number of
cigarettes per day)
Assess patient for symptoms of smoking
withdrawal.
Evaluate progress in smoking cessation
periodically.
Patch can be worn for 16-24hr; the patch
can be removed before the patient goes to
bed or can remain on while the patient
sleeps.
Explain to patient the necessity of smoking
cessation.
Encourage patient to participate in smoking
cessation program.

Pantoprazole Tabec
(Protonix)
Therapeutic: antiulcer agents
Pharmacologic: proton-pump
inhibitors

40 mg twice a
day P.O.

Patient is on a PPI for GI


prophylaxis. Has a history of
ulcerative colitis. Drug Binds to an
enzyme in the presence of acidic
gastric pH, preventing the final
transport of hydrogen ions into the
gastric lumen. Decreases acid
reflux.

Headache, abdominal pain,


diarrhea, eructation, flatulence,
hyperglycemia.

May be administered with or without


food. Do not break, crush, or chew tablets.
Antacids may be used concurrently.
Advise patient to avoid alcohol, products
containing aspirin or NSAIDs, and foods
that may cause an increase in GI irritation.
Advise patient to report onset of black, tarry
stools; diarrhea; or abdominal pain to health
care professional promptly.

650mg q6h
prn P.O./ Rect

For temp over 38C prn for fever.


Drug Stops the synthesis of
prostaglandins that serve as
mediators of pain and fever.

Hepatic failure, renal failure,


rash.

10 mg= 1
supp prn Rect

For constipation. For bowel care.


Alters fluid & electrolyte transport,
producing fluid accumulation in
the colon to evacuate waste.

Abdominal cramps, nausea,


diarrhea, rectal burning, muscle
weakness.

5 mg/mL q4h
IV prn

For patients HTN. Drug Blocks


stimulation of beta1 (myocardial)and beta2 (pulmonary, vascular,
and uterine)-adrenergic receptor
sites, decreases blood pressure.

Fatigue, weakness, orthostatic


hypotension, anxiety,
depression.

Assess BP, HR, and RR. If RR < 10/min assess


sedation level.
Assess bowel function, take temperature.
Assess pain level. (OLDCART).
Patient should change position slowly to
minimize orthostatic hypotension.
Patient should turn, cough, and breathe deeply
every 2hr to prevent atelectasis. Avoid use with
alcohol.
May give rect if unable to give P.O.
Max= 4g/ day adult.
Assess for for Abdominal distention, presence of
bowel sounds, & usual pattern of bowel
function. For color, consistency, & amount of
stool produced.
Laxatives should be used only for short- term
therapy. Pt should fluig intake to at least 1,5002,000 mL/ day to prevent dehydration.
Medication should not be used w/ abdominal
pain, fever, nausea, or vomiting.
Supp or enema can be given at the time a bowel
movement is desired. Lubricate suppositories
with water or water- soluble lubricant before
insertion. Encourage patient to retain the
suppository or enema for 15-30 min before
expelling.
PRN for SBP > 160. Hold for HR < 55. DO
not exceed 300 mg total therapy.
Patients receiving labetalol IV must be supine
during and for 3 hr after administration. Vital
signs should be monitored every 515 min
during and for several hours after administration.
High Alert: IV vasoactive medications are
inherently dangerous. Before administering
intravenously, have second practitioner

Home medication
Acetaminophen (Tylenol)
OR
Acetaminophen Supp
(Tylenol)
Therapeutic: antipyretics,
nonopioid , Analgesics
New Medication
Bisacodyl Supp (Dulcolax)
Therapeutic: laxatives
Pharmacologic: stimulant
laxatives
New medication

Labetalol HCL Inj


(Labetalol HCL)
Therapeutic: antianginals,
antihypertensives
Pharmacologic: beta blockers

13

independently check original order, dosage


calculations, and infusion pump settings.
Direct IV: Diluent: Administer undiluted.
Concentration: 5 mg/mL Rate: Administer
slowly over 2 min.

Lorezepam Tab (Ativan)


OR
Lorezepam Inj (Lorazepam)
Therapeutic: anesthethic
adjuncts, antianxiety agents,
sedatives/ hypnotics.
Pharmacologic:
benzodiazepines

For agitation/ anxiety use. IV


Route if patient is NPO. Drug
produces muscle relaxation and
decreases anxiety.

CNS depression, physical


dependence, dizziness,
drowsiness.

400 mg- 800


mg= 2 Tab
q12h P.O. prn

For depletion in magnesium


electrolytes and evacuation of the
colon. Drug Play an important role
in neurotransmission and muscular
excitability. Is osmotically active
in GI tract, drawing water into the
lumen and causing peristalsis.

Diarrhea, flushing, sweating.

1 Tab q4h
P.O. prn

For moderate pain of 4-6 on pain


scale of 10. Drug binds to CNS
receptors and alters the perception
or painful stimuli.

Confusion, dizziness, sedation,


hypotension, constipation,
dyspepsia, nausea.

0.5 mg q6h
prn P.O.
0.5 mg/
0.25mL q6h
IV prn

New Medication
Magnesium Oxide Tabb
(Mag-OX-400)
Therapeutic: mineral and
electrolyte
replacements/supplements,
laxatives
Pharmacologic: salines
Magnesium Replacement
1.4-1.8= 400 mg q 12 h x2
doses
Recheck 4 hr after 2nd dose.
New medication
Hydrocodone 5/ 325 (Norco
5/325)
Therapeutic: allergy, cold/
cough remedy, opioid
analgesics.
Pharmacologic: opioid
agonists/ nonopioid analgesic
combinations.
New Medication

14

Teach patient other methods to reduce anxiety,


such as exercise, support groups, relaxation
techniques.
Avoid taking with alcohol or other CNS
depressant drugs.
Direct IV: Diluent immediately before use w/ an
equal amount of sterile water for injection, D5W,
or 0.9% NaCl for injection.
Rate: Administer at rate not to exceed 2 mg/ min
or 0.05mg/kg over 2- 5 min.
Rapid IV administration may result in apnea,
bradycardia, hypotension, or cardiac arrest.
PO: To prevent tablets entering small intestine
in undissolved form, they must be chewed
thoroughly before swallowing. Follow with
glass of water.
Advise patient not to take this medication within
2 hr of taking other medications, especially
fluoroquinolones, nitrofurantoin, and
tetracyclines.
ssess for heartburn and indigestion as well as
location, duration, character, and precipitating
factors of gastric pain.

Monitor BP, HR, RR. (Hold if BP< 100, HR<60,


RR<10)
Assess bowel function.
Assess pain (OLDCART)
Instruct patient how and when to ask for pain.
Avoid using with alcohol or other CNS
depressants.

Magnesium Sulfate in D5W


Soln (Magnesium Sulfate in
D5W)
Therapeutic: mineral and
electrolyte replacements/
supplements.
Pharmacologic: mineral/
electrolyte

1 GM/100mL
IV prn

To treat/ prevent
hypomagnesium, HTN.
Drug plays an important role in
neurotransmission and
muscular excitability; essential
for the activity of many
enzymes.

Diarrhea, drowsiness,
hypotension, muscle
weakness.

High alert: Accidental overdose of IV


magnesium can result in serious patient
harm and death. Double check dose order.
Monitor HR, BP, RR, and ECG frequently.
Respirations should be at least 16/min
before each dose.
Monitor neurologic status before and
throughout therapy.
Monitor I/O ratios.
Urine output should be maintained at a level
of at least 100mL/4hr.

1mg/ 0.5mL2mg/1mL q4h


IV prn

For moderate to severe pain.

Respiratory depression,
constipation, hypotension,
confusion, sedation, seizures.

Assess level of consciousness, BP, HR, and


RR (hold, RR<10).
Assess pain, location, type, intensity prior to
and after administration.
Direct IV: Dilute with at least 5mL of sterile
water/ 0.9% NaCl for injection.
Concentration: 0.5-5mg/mL Rate:
Administer 2.5-15mg over 5 min.
Rapid administration may lead to increased
respiratory depression, hypotension, and
circulatory collapse.

Magnesium Replacement
1.4-1.8= 1G over 1 hr
Recheck after infusion
complete.
1.3 or less= 1g over 1 hr x2
doses.
Recheck after infusion is
complete.
Morphine Syring (Morphine)
Therapeutic:
Pharmacologic:
1mg= moderate pain
2mg= severe pain
May be habit forming- use
with caution.

Drug binds to opiod receptors in


the CNS and alters the stimuli
perception of and response to
painful stimuli while producing
generalized CNS depression.

15

Potassium CL 10% Liqd


(Potassium CL 10%)
Therapeutic:
Pharmacologic:
Potassium Supplement
3.8-3.9= 20 mEq
3.5-3.7= 40 mEq
3.0-3.4= 40 mEq plus 20 mEq
in 4hr
Recheck 4hr after 2nd dose.
Call MD and continue to
cover. Take with food.
OR
Potassium CL IV PGBK
Potassium Supplement
3.8-3.9= 10 mEq over 1hr x2
doses
3.5-3.7= 10 mEq over 1hr x3
doses
3.0-3.4= 10 mEq over 1hr x4
doses
Recheck after infusion is
complete.
2.9 or less= 10 mEq over 1hr
x5 doses- Recheck after
infusion complete.
Continue to cover per order.
OR
Potassium CL tab TBTQ
(Potassium Chloride)
Potassium Replacement
3.8-3.9= 20 mEq
3.5-3.7= 40 mEq
3.0-3.4= 40 mEq plus 20 mEq
in 4hr
Recheck 4hr after 2nd dose
2.9 or less= 30 mEq plus 40
mEq in 4hr

20mEq/15mL
40mEq/30mL
P.O. prn

Treatment/prevention of potassium
depletion. Drug maintains acidbase balance, isotonicity, and
electrophysiologic balance of the
cell. Essential for transmission of
nerve impulses.

Confusion, restlessness,
weakness, arrthymias,
irritation at IV site.

Assess for signs and symptoms of hypokalemia


(weakness, fatigue, U wave on ECG,
arrhythmias, polyuria, polydipsia) and
hyperkalemia.
Monitor pulse, blood pressure, and ECG
periodically during IV therapy.
Monitor K+ serum labs.
High Alert: Medication errors involving too
rapid infusion or bolus IV administration of
potassium chloride have resulted in fatalities.
Continuous Infusion: High Alert: Do not
administer concentrations of 1.5 mEq/mL
undiluted; fatalities have occurred. Concentrated
products have black caps on vials or black
stripes above constriction on ampules and are
labeled with a warning about dilution
requirement. Each single dose must be diluted
and thoroughly mixed in 1001000 mL of IV
solution. Usually limited to 80 mEq/L via
peripheral line (200 mEq/L via central line).

10
mEq/100mL=
1PGBK IV
prn

Rate: High Alert: Infuse slowly, at a rate up to


10 mEq/hr in adults or 0.5 mEq/kg/hr in children
in general care areas. Check hospital policy for
maximum infusion rates (maximum rate in
monitored setting 40 mEq/hr in adults or 1
mEq/kg/hr in children). Use an infusion pump.

20mEq40mEq= 2
TBTQ P.O.
prn

16

Below 3.5 recheck 4hr after


2nd dose. Call MD and
continue to cover. Take with
food.
New Medication
Prochlorperazine Tab
(Compazine)
Therapeutic: antimetics,
antipsychotics
Pharmacologic:
phenothiazines

10 mg twice a
day P.O. prn

For nausea and/ or vomiting.


Drug alters the effects of
dopamine in the CNS.
Depresses chemoreceptor
trigger zone in the CNS.

Extrapyramidal reactions,
blurred vision, dry eyes,
constipation, and dry mouth.

Fall Risk.
Monitor BP, ECG, HR, and RR before and
frequently during therapy.
Assess patients level of sedation.
Monitor for development of neuroleptic
malignant syndrome (fever, respiratory
distress, tachycardia, seizures)
Liver function test should be evaluated
periodically during therapy.
Hepatoxicity is more likely to occur
between week 2 and 4 of therapy.
Liver function abnormalities may require
discontinuation of therapy.

5 mg at
bedtime P.O.
prn

For sleeplessness. Drug


produces CNS depression by
binding to GABA receptors.

Daytime drowsiness,
dizziness, diarrhea, nausea,
vomiting.

Fall Risk.
Assess mental status, sleep patterns, and
potential for abuse prior to administration.
Prolonged use of >710 days may lead to
physical and psychological dependence.
Limit amount of drug available to the
patient.
PO: Tablets should be swallowed whole
with full glass of water. For faster onset of
sleep, do not administer with or
immediately after a meal.
Swallow extended-release tablets whole; do
not crush, break, or chew.

Home medication

Zolpidem Tab (Ambien)


Therapeutic:
sedative/hypnotics
New medication

Concept Mapping
17

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.
Chief Medical Diagnosis: Syncope

CVA, Mandibular Fx Fall

Priority Assessments:

Vital Signs- BP, HR, RR, O2 sat, Pain level. Neuro Checks for depression.
Labs- HGB, RBC, WBC.
ABC (airway, breathing, circulation)
Nursing Diagnosis

#1: Risk for ineffective cardiac/


cerebral tissue Perfusion

#2: Decreased Cardiac Output

Data to Support

Hypertension
Drug abuse (Smokes to 1 pack per day,
takes marijuana)
CT scan showing an ischemic infarct of
right frontal lobe.
Hx of mitral valve prolapse.
Cardiac stress test- ejection fraction= 41%
Echocardiography- mild aortic, tricuspid
regurgitation.
Mildly elevated pulmonary artery
pressure.
Angiogram
Baseline sinus tachycardia.
Cardiac Stress Test= 41% ejection fraction
Patient placed on telemetry, with
echocardiogram, carotid Doppler, and
MRI.
Angiogram
RBC level- 2.99L
Hgb level- 8.9L
18

Expected Outcome/ Goal

Cardiac pump effectiveness.


Patient is able to modify lifestyle- quit
smoking and marijuana.
Patient is able demonstrate appropriate
orientation to person, place, time, and
situation.

Patient demonstrates adequate cardiac


output as evidenced by BP, HR, and
rhythm within normal parameters for
patient.
Patient is able to tolerate activity without
symptoms of chest pain and syncope.

#3: Pain

#4: Risk for infection

#5: Risk for Fall

#6: Diarrhea

Hct level- 27.1L


Pain level @ 1030- 10/10
@ 1305- 10/10
Pain Medications- MS Contin, Morphine
IV, Norco 5/325
Stitches in the tongue.
Lymphocytes- 17.5L
Inflammation around mouth/ jaw.
Diagnosis: Syncope, loss of consciousness
No family, patient lives in a group home.
Patient is on antidepressants.
Mandibular Fx Fall
Patient had a colectomy and hysterectomy.
Order for Colace, Biscadyl, and
Magnesium Oxide,
Generalized fatigue.
r/t depression, abdominal muscle
weakness.

Pain level is tolerable for patient: 2-3/10.

Patient remains free of infection.

Patient remains free of falls.


Change in environment to minimize the
incidence of falls.
Patient is able to defecate, soft stools.
Rectal area remain free of irritation.

Patient Teaching:

Smoking/ marijuana cessation education, introduces alternatives, such as patch and support groups.
Ask patient about changing diet to control HTN.
Angiogram education
Since Patient lives in a group home, make sure there is someone to take care of her needs.
Discharge:

Hypertension is controlled by P.O. medication.


Electrolytes are within acceptable limits.
Depression is controlled by P.O. medications, no signs of suicidal thoughts.
Pain level is within acceptable range, 2-3/10, controlled by P.O. medication.
Diarrhea is controlled, not loose stools.
19

20

Concept Mapping
Evaluate Effects of Nursing Actions- Patient Outcomes, Documentation (Done During Clinical)
1. ND/Nursing Care: Risk for ineffective cardiac/ cerebral tissue Perfusion
Nursing Actions(NIC)

Assess lab values


Monitor Vital Signs
Monitor Electrocardiography
Monitor I/Os
Pt teaching for Angiogram

Patient Response/ Outcome

RBC Levels trending down (2/25/13) 3.10L (2/26/13) 2.99L, HGB (8.9L)
VS 0730- T 36.1, RR 18, HR 83, BP 129/71, O2 98% RA
Normal Sinus Rhythm
Patient was NPO for procedure, Output~ 50-70 mL.
Patient was nice and happy to go over teaching again for the procedure.

2. ND/Nursing Care: Decreased Cardiac Output


Nursing Actions (NIC)

Monitor Pulse Oximetry


Place client in 30-45 degrees
Monitor K+, Mg2+, electrolytes levels.
Monitor bowel function
Teach importance of smoking cessation

O2 0730- 98% RA, O2 1130- 99%RA


Bed is elevated at 30 degrees
K+ serum level- 4.1, Na+ level- 134L, Mg2+ level- 1.6, Ca2+ level- 8.2L
Patient had a bowel movement, which was loose stools.
I slightly touched on the subject of quitting smoking/ marijuana with patient
and how it affects her heart, when she was given the nicotine patch. Patient
seemed willingly to comply because of her health, but was zoning in and out of
sleep during conversation.

3. ND/Nursing Care: Pain


Nursing Actions (NIC)

Assess pain with scale and mediate


Assess Respiratory rate
Administer Morphine prn

LA8/2011

Patient states pain of 10/10 on pain scale at 0830: 1030 is 7/10


RR at 0730- 18, at 1130-12
Morphine was given earlier that day at 0600 and was not due till 1000. Had to
call the physician to put in an order for Morphine STAT because was in a lot
of pain. MS Contin P.O.0900 was put on hold, due to procedure.
Reassessment: Patient stated that her pain was at 7/10, but seemed to zone in
and out of sleep. I told her that we had to put her medications on hold because
21

she was NPO and couldnt take anything before her procedure. We couldnt
give her Norco because it was too early.
Decreased light, Patient went back to sleep.
Patient felt relieved with ice pack to decrease pain in her jaw.

Check lighting in room


Provide ice pack for pain
4. ND/Nursing Care: Risk for infection
Nursing Actions (NIC)

Assess for sign of infection, redness, warmth


tongue, due

No signs of discharge present, there is swelling and redness of her


to her fall. Her skin is not warm to touch
Temp 0730- 36.1C, 1130- 95.4F
WBC (2/26)-4.8, Lymphocytes (2/26)- 17.5L, Monocytes (2/26)- 10.8H
Patient was given some water and oral care supply to rinse her mouth. She
seemed relieved to rinse her mouth, which was dry upon assessment. She was
instructed to not swallow any water because of her NPO status.
No sputum present, patient started to have a cough

Assess temperature
Assess labs
Oral care
Assess for sputum, cough
5. ND/Nursing Care: Risk for Fall
Nursing Actions (NIC)

Put up side rails


Assess physical function
Assess patients strength
Assess environment
Pt Teaching about fall risk

Two of the side rails were put up for patient safety, No fall.
Patient is able to get up on her, no restrictions on movement
Both arms- 5/5 good strength, Both legs- 5/5, good strength.
Bed in low position, call light within reach, pathway to bathroom is clear.
I asked patient about any family in the area who could assist her when she
leaves the hospital. She stated that she lives in a group home. I told her about
the importance of having assistance ambulating because of her first episode of
fainting, which put her in the hospital.

6. ND/Nursing Care: Diarrhea


Nursing Actions (NIC)

Assess bowel function


Inspect, auscultate, palpate abdomen
Assess for dehydration/ skin turgor
Check K+ and Na+ levels
Monitor I/Os
LA8/2011

Patient had bowel movement that day, loose stools


Patient state to no pain, tenderness of abdomen, BS x4
Patient on NS 125mL/hr. Skin turgor is good.
K+ level- 4.1, Na+ Level- 134L
No input, Patient was NPO. Output~50-7
22

Soap Note
S- Patient is a 58- year old Caucasian female who was previously living in the hills. Then her
house got burned down and she had to live in a group home. The day before her admission, she
had a complaint of being dizzy, lightheaded, and lost consciousness and fell on her jaw. She
sustained a fracture of the mandible. Patient has been doing well in the hospital. She has
evidence of coronary artery ischemia, is undergoing a workup for this with cardiology. Patient
has a history of a colectomy due to an ulcerative colitis. She also had a hysterectomy,
tracheostomy, mitral prolapse, ad hypertension. A cardiac stress test was done on 2/26 and
showed that she had an ejection fraction of 41%, which is low. An angiogram was schedule for
today, 2/28.
O- Head: Head is normalcephalic.
HEENT: Pupils are equal, round, and reactive to light. Tongue is swollen with present of stitches.
Visible dryness and crusting of tongue. Bruising on the right side of mandible towards the neck
region.
Lungs: Bilateral, equal sounds.
Cardiac: Patient is on telemetry- normal sinus rhythm.
Abdomen: Soft, non-tender. BSx4, hypoactive. No hepatosplenomegaly.
Extremities: No clubbing, edema, or cyanosis. Both leg strength- 5/5 good. Both arm strength5/5 good.
Perineal: Clean, no bruising.
Skin: Dry and intact, bruising on face.
VS 0730: T 36.1, RR 18, HR 83, BP 129/71, O2 98% RA, Pain @ 0830 was 10/10, medicated
morphine IV 2mg at 1030, pain 7/10.
VS 1130: T 95.4, RR 12, HR 80, BP 135/83, O2 99% RA , Pain @ 1305 was 10/10
A- Risk for ineffective cardiac/ cerebral tissue perfusion, Pain, Diarrhea
P- Patient states that her pain level is still high even after given pain medication. Call the doctor
to suggest increased in pain dosage. A smoker- give education on smoking cessation. Monitor
bowel function as patient has loose stools. She is on telemetry, so monitor her EKG. She is on
antidepressants, so monitor for any usual behavioral changes.

LA8/2011

23