Data Collection

Student Assignment Date(s) of Gend Name: Jennifer Carey #: Care: 12/14/11 er MF Age Neonate <1 1-4 5-9 10-14 15-19 20-29 30-39 40-49 50-59 60-69 70-79 Range >80 Allergies Admission Code : NKA Date: 2/4/2011 Status: DNR Primary Medical Diagnosis Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) Comorbiditie s: Depression, Atrial Firbrilation (A fib), Diabetes Mellitus type 2, Hypertension, Chronic, senile dementia iron deficiency anemia, Constipation, lumbar degenerative joint disease, Coronary Artery Disease (CAD) Developmental Stage: 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: None 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
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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). 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: A fib Patho: Total disorganization of atrial electrical activity wo effective contraction (Lewis, Heitkemper, & Dirksen, 2000). Etiology: Can be chronic or intermittent. Usually pt has underlying cardiac disease (Lewis, Heitkemper, & Dirksen, 2000). S/S: R/T Meds: Coumadin Name: CAD is a blood vessel disease that is included in the general category of atherosclerosis (Lewis, Heitkemper, & Dirksen, 2000). Patho: Characterized by a deposit of cholesterol and lipids in the arterial wall (Lewis, Heitkemper, & Dirksen, 2000). Etiology: The exact cause is unclear. No single theory fully explains the process. Two theories: lipid hypothesis and chronic endothelial injury hypothesis. Lipid hypothesis states a high lipid level promotes lipid penetration of the arterial walls. When LDLs undergo oxidation, they become harder to mobilize and locally cytotoxic. Damage to the endothelial layer makes the damaged site more permeable to plasma components (Lewis, Heitkemper, & Dirksen, 2000).
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S/S: most common: angina (Lewis, Heitkemper, & Dirksen, 2000). R/T meds: Name: Congestive Heart Failure (CHF) is a cardiovascular condition in which the heart is unable to pump adequate amounts of blood to the bodys tissues (Lewis, Heitkemper, & Dirksen, 2000). Patho: Interference with cardiac output (Lewis, Heitkemper, & Dirksen, 2000). Etiology: CAD and advanced age are the biggest risk factors. Hypertension, diabetes, cigarette smoking, obesity, high cholesterol and proteinuria are other factors. CHF increases with the severity of the HTN. Systolic and Diastolic htn equally predict risk. CHF may be caused by any interference with the normal mechanisms regulating cardiac output (Lewis, Heitkemper, & Dirksen, 2000). S/S: R/T Meds: Name: Constipation is a decreased frequency of bowel movements for what is normal for the client (Lewis, Heitkemper, & Dirksen, 2000). Patho: May be hard stools. Stools may be hard to pass. There may be a decrease in the amount of stool (Lewis, Heitkemper, & Dirksen, 2000). Etiology: Can be due to insufficient fiber in the diet, decreased fluid intake, medication use (like pain meds), and lack of activity (Lewis, Heitkemper, & Dirksen, 2000). S/S: no BM, hard stools (Lewis, Heitkemper, & Dirksen, 2000). R/T meds: MOM Name: Senile Dementia causes cognitive impairment Patho: Loss of neurons. Atrophy of the brain. Progressive. Leads to death. Loss of cholinergic nerves especially in the memory area. Etiology: Still unclear, but age plays a roll. There may be a genetic factor. S/S: Loss of memory that is progressive, unable to learn new things, some patients get psychotic symptoms. Eventually even long term memories are gone. (Lewis, Heitkemper, & Dirksen, 2000) R/T meds: None Name: Osteoarthritis (OA) AKA Degenerative Joint disease (DJD) is a slowly progressing disorder of articulating joints, especially weight bearing ones, characterized by degeneration of articular cartilage. Patho: Degenerative changes over time cause the normally smooth, white, translucent joint cartilage to become yellow and opaque, with rough surfaces and areas of softening. As the cartilage becomes thinner, the bony surfaces of a joint come closer together. There may be inflammation in the synovial membrane. Etiology: Primary cause is unknown. Primary and secondary are influenced by many factors including metabolic, mechanical, genetic and chemical. Secondary OA could be caused by previous trauma, fractures, infections, or
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congenital deformities. S/s: Joint pain, stiffness, and limited range of motion. (Lewis, Heitkemper, & Dirksen, 2000) R/T Meds: Norco for pain Name: Anemia (Iron Defeciency) Patho: Iron makes up a large part of a red blood cell (RBC). Etiology: Low dietary intake of iron or slow blood loss S/S: Low hemoglobin, pale palms, pale conjunctivae, pale earlobes (Corwin, 2008). R/T Meds: Ferrous Sulfate Name: Depression Patho: Etiology: S/S: R/T Meds: Celexa
Course-specific data attached

Laboratory Tests
Date
12/6/11 10/18/11

Time
0600 1048

Abnormal/Significant Lab Findings

INR 2.2 CO2 34 mmol/L

Normal range per Facility/Lab

2-3. Critical is 4-5 or higher 22-31 mmol/L

How does the result relate to the pathophysiology of your patients condition(s)?
Client is therapeutic with current dose. This result is consistent with clients COPD/CHF diagnoses. Client has poor CO2 excretion by the lungs or an inadequate respiratory drive (Malarkey & McMorrow, 2005). Client has a type 2 diabetes diagnosis with this confirms. According to Malarkey and McMorrow, though, an elderly person is allowed to have a glucose of 80-150 mg/dL (2005). B-type Natriuretic Peptide: Differentiation between cardiac and

4/14/11

Unk

Glucose 125 mg/dL 70-99 mg/dL

BNP 191 pg/ml <100 pg/mL

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pulmonary causes of dyspnea. May be helpful in prognosis of heart failure. It is a hormone produced by myocardial myocytes in the ventricles of the heart primarily. BNP is secreted in response to stretching and increasing ventricular pressures. BNP causes a decrease in sodium retention and increase in diuresis by improving glomerular filtration, and a decrease in renin and aldosterone secretion (Malarkey & McMorrow, 2005).

DiagnosticTests
Date Time Impressions How does the result relate to the pathophysiology of your patients condition(s)?

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4/14/11

Unk

Portable 2 View chest xray: Bilateral small effusions. No infiltrates. Moderate vascular congestion. Moderate cardiomegaly also. Impression: CHF.

2/1/11

Unk

Echocardiogram: 1. Moderate to severe pulmonary hypertension 2. Moderately dialated R chamber sizes 3. Mildly dialated L atrium 4. Aortic sclerosis w/o stenosis 5. Moderate tricuspid and pulmonic insufficiency 6. Mild mitral and aortic insufficiency. 7. Low normal ejection fracture: 58%

Small effusions: excessive collection of pleural fluid. S/s: CP, cough, fever, hiccups, rapid breathing, SOB. Treatment: remove the fluid, which would not be indicated in this case since they are small, treating the cause (CHF) with diuretics (Pleural Effusion, 2011). Vascular congestion: usually associated with L sided heart failure. Increased L atrial pressure leads to increased pulmonary venous pressure and then to increased pulmonary capillary pressure with congestion and ultimately edema in the alveolar space (Pulmonary Vascular Congestion, n.d.). Cardiomegaly means the heart is enlarged, again due to heart failure.

Enter the labs/diagnostics under related Key Problems

Medications
Generic & Brand Names Prescribed Dose & Recommende d Range Why is my patient getting this medication? Potential Side Effects and/or Adverse Reactions Drug to Drug Food to Drug Interactions/Cauti ons What will I monitor about this medication r/t my patients problems?
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Coumadin Warfarin Anticoagulant

2 MG PO Mon and Fri 1 MG PO Sun, Tues, Wed, Thurs, Sat. (2-10 MG PO Daily)

Anticoagulation Action: Interferes with liver synthesis of vitamin K dependent clotting factors.

bleeding bruising easily abdominal cramps/pain nausea/vomiting diarrhea flatulence/bloating fatigue/malaise lethargy asthenia headache dizziness taste changes pruritus edema dermatitis rash/urticaria fever cold intolerance paresthesias alopecia

Foods high in Vit K (green leafy vegetables), pomegranate, cranberry juice. Concurrent use of CITALOPRAM and ANTICOAGULANTS may result in an increased risk of bleeding. Concurrent use of LACTULOSE and WARFARIN may result in elevated International Normalized Ratio serum values with potentiation of anticoagulation effects. Concurrent use of ACETAMINOPHEN and WARFARIN may result in an increased risk of bleeding. Concurrent use of ACETAMINOPHEN and WARFARIN may result in an increased risk of bleeding.

S/s DVT or PE. Bleeding. PT/INR. Green leafy vegetables. Coumadin interferes with the formation of Vitamin Kdependent clotting factors in the liver. It increases bleeding times. (Karch, 2008)

Norco Hydrocodone/ Acetaminophen

5/325 MG, 1 tab PO Q4-6 hours PRN Pain Recommended Range: 1-2 PO Q4-6 hours PRN not to exceed 4,000 MG Tylenol in 24 hrs.

Action: Inhibits prostaglandin synthesis with the exact mechanism unknown. Hydrocodone is thought to be related to the presence of opioid receptors in the CNS.

N/V, Dizziness, Sedation, thrombocytopenia, liver failure, respiratory depression.

Amount of Tyleno patient is getting. Pain assessment. S/s of respiratory depression, dizziness after administration. Constipation.

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Cardizem Diltiazem CCB

240 MG PO Daily (AM) Rec Range: 30120 MG PO 3-4 times a day, up to 360 MG/day

Hypertension Action: Prevents calcium from getting to the heart muscle and vascular smooth muscle cells resulting in inhibition of excitationcontraction coupling and subsequent contraction. Causes systemic vasodilation= lower BP Reduction in ventricular rate in a fib. Supplement/ Anemia as evidence by RBC

Cough, arrhythmias, CHF, peripheral edema, Steven Johnsons syndrome, polyuria, anxiety, confusion, syncope, anemia, joint stiffness, muscle cramps

Concurrent use of DILTIAZEM and BETAADRENERGIC BLOCKERS may result in an increased risk of hypotension, bradycardia, AV conduction disturbances.

BP and HR. I&O.

Ferrous Sulfate Feosol Hematinics

325 MG PO Daily (AM) Rec Range: Iron Def. Anemia: 750-1500 mg/ day in divided doses

dyspepsia nausea vomiting constipation diarrhea dark stools

2 hrs apart from antacids. Calcium and Iron: may decrease the level of Iron by increasing gastric pH.

Constipation. Labs (CBCRBC ferritin) if available. GI effects. Most of the drug that is taken is lost in feces, but slowly some of it is absorbed into the intestine and transported to the bone marrow. (Karch, 2008) Give with Vit C to max absorption (Mosby, 2007)

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Pepcid Famotidine Histamine h2 antagonist

20 MG PO Daily (0630) Rec Range: up to 40 MG per day for up to 12 weeks Action: Inhibits action of histamine at the h2 receptor site located in gastric parietal cells, resulting in inhibition of gastric acid secretion. Action: replace vitamins and minerals client is not getting from diet.

Confusion, dizziness, arrhythmias, constipation, agranulocytosis, aplastic anemia,

None.

Epigastric or abdominal pain, frank or occult blood in stool, increased confusion

Theragran Multiple Vitamins Supplement

1 tab PO Daily (AM) Rec Range: 1 dose unit per day or as rec. by manufacturer

Discoloration of urine

None.

Nutritional deficiency, toxicity of fat soluble vitamins

Zaroxolyn Metolazone Thiazide like diuretic

2.5 MG PO Daily (AM) Rec range: htn: 2.5-5 MG/day. Edema 5-20 MG/Day

Hypertension (based on the dose) Action: Inhibits reabsorption of Na+ and H2O in distal tubule therefore the client will excrete more. Promotes excretion of Cl-, K+, Mg++, and bicarb

Hypotension, hypokalemia, CP, lethargy, hyperuricemia, muscle cramps

Concurrent use of METOLAZONE and LOOP DIURETICS may result in increased risk of electrolyte and fluid imbalance. Concurrent use of METOLAZONE and CALCIUM CARBONATE may result in the milkalkali syndrome (hypercalcemia, metabolic alkalosis, renal failure).

BP, I&O, Weight, edema

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Lactulose Laxative (osmotic)

30 mL PO Daily (AM) Rec Range: up to 40 MG/day. Usually use 1530 ml/day

Constipation Action: brings water into the stool and softens it.

Belching, cramps, distention, flatulence, hyperglycemia

Concurrent use of LACTULOSE and WARFARIN may result in elevated International Normalized Ratio serum values with potentiation of anticoagulation effects. None.

Abdominal assessment, BMs: consistency, frequency, color, amount

KCl Potassium Chloride K-Dur

20 meq PO TID (AM/Noon/PM) For diuretic therapy: 20-40 mEq in 1-2 doses. Single dose should not exceed 20 mEq.

Os-Cal with Vit D Calcium Carbonate/ Cholecalciferol Nutritive agent. Fat Soluable Vitamin (Can get toxic because of this)

500 MG PO BID With 250 IU Vit. Dwith food (AM/PM) Calcium: PO (Adults): Treatment osteoporosis 12 g/day in 3 4 divided doses. Vit D Safe Range: 4001000 IU per day. 10,000 units daily is safe x5

nausea or vomiting; decreased Action: Act as an appetite; activator in the constipation; transmission of dry mouth or nerve impulses increased thirst; and contraction of or cardiac, skeletal, urinating more and smooth than usual. HA, muscle tingling, Calcium is a arrhythmias. regulator to storage and release of neurotransmitters

Replace K+ from diuretic Action: Replaces K+ lost from diuretic. Helps to maintain acidbase balance. Essential for nerve impulses, contraction of heart/skeletal/sm ooth muscle, gastric secretion, renal function, carb metabolism. Degenerative Joint Disease

Arrhythmias, EKG changes, abdominal pain, diarrhea, flatulence, nausea, vomiting

s/s hypokalemia (weakness, fatigue, polyuria, polydipsia) and hyperkalemia (slow, irregular HR, fatigue, muscle weakness, confusion, dyspnea). K+ level if available. I&O. DW.

Dont give with magnesium containing meds Concurrent use of METOLAZONE and CALCIUM CARBONATE may result in the milkalkali syndrome (hypercalcemia, metabolic alkalosis, renal failure).

Calcium level If available, BP because calcium plays a role with the heart.

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months.

and hormones. Need Vitamin D for Calcium to absorb properly in intestine. Requires activation in the liver and kidneys to create the active form of vitamin D3 (calcitriol) Hypertension Action: Blocks stimulation of B1 and B2 receptors Decreased HR and BP. Improved Cardiac output Constipation Action: brings water into the stool. Concurrent use of DILTIAZEM and BETA-ADRENERGIC BLOCKERS may result in an increased risk of hypotension, bradycardia, AV conduction disturbances. Abdominal cramping, bloating, diarrhea None.

Coreg Carvedilol Beta blocker

6.25 MG PO BID (AM) Hold if HR <60 or SBP <94 Rec Range: 6.25 BID for hypertension up to 25 mg/day 100 MG PO BID (AM/PM) Rec Range: 240 MG PO daily

Colace DOCUSATE Laxative/stool softner

None.

BMs, abdominal assessment, bowel sounds.

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Lasix furosemide (Black Box Warning! Electrolyte depletion) Loop diuretic

40 MG PO Daily (AM) Rec Range: 40-120 MG PO Daily. Max dose 600 MG/day.)

Hypertension. Action: Loop diuretic meaning they work in the loop of Henle. Block chloride pump which decreases reabsorption of sodium and chloride. Sodium rich urine (Karch, 2008). Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium (mosby, 2007).

Celexa Citalopram SSRI

20 mg PO Daily (AM) Rec: up to 40 mg/day in gero patients

Depression Action: Inhibits the reuptake of serotonin causing a build up

urinary frequency dizziness nausea/vomiting weakness muscle cramps hypokalemia hypomagnesemia hypotension, orthostatic elevated liver transaminases blurred vision anorexia abdominal cramps diarrhea pruritus rash hyperuricemia hyperglycemia hypocalcemia tinnitus paresthesias photosensitivity cholesterol incr. triglycerides incr. Neuroleptic malignant syndrome Suicidal thoughts Apathy Confusion Drowsiness,Insom nia Weakness Abdominal pain Diarrhea Dry mouth Dyspepsia Flatulence Sweating Tremor Serotonin

Concurrent use of METOLAZONE and LOOP DIURETICS may result in increased risk of electrolyte and fluid imbalance.

Electrolytes (especially K+). Urine output. Intake. Weight. Edema if present. Monitor BUN/Creatnine if available. Blocks Na and Cl reabsorption, increasing urine output. BP.

Concurrent use of CITALOPRAM and ANTICOAGULANTS may result in an increased risk of bleeding.

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.

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syndrome

MOM Magnesium Hydroxide Osmotic laxative/Bulk Stimulant

30 mL PO PRN Constipation Rec Range: 30-60 mL PO Daily. Max: 60 mL/ 24 hrs.

Constipation Action: Draws water into the stool and causes peristalsis.

diarrhea

None.

BMs. Abdominal assessment. I&O.

Dulcolax Bisacodyl Laxative/Chemi cal Stimulant

10 MG PR BID PRN no BM x3 days Rec Range: 515 MG each dose up to 30 MG per day Knee high to bilateral extremities 3 LPM via NC (titrate to 90%) Recommende d Range: 1-6 L per NC

Constipation Action: Stimulates peristalsis.

Abdominal cramps, nausea

None with current meds.

I and O. BMs. Bowel Sounds.

Ted Hose

Edema. Trying to get blood to flow back to the heart. Hypoxia r/t COPD Action: improved perfusion. Saturated blood with oxygen.

Must make sure there are no wrinkles in the hose. Dry mucus membranes. Bloody Nose.

None.

Monitor edema location and amount. O2 saturation. Lung sounds.

Oxygen

None.

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RFS

2x/week Rec Range: for elderly, 80150 mg/dL

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 not eating differently than normal. Ensure client is not consuming an excessive amount of carbs.

Priority #1 Nursing Diagnosis: Fluid volume excess RT impaired excretion of Na+ and H2O (Ackley & Ladwig, 2010) AEB lower extremity swelling SMART Patient Goal: Client will have no increase in edema 12/14/11. Client will maintain clear lung sounds with no evidence of dyspnea 12/14/11.

Priority #1 Nursing Diagnosis: Activity intolerance RT weakness and fatigue

Priority #1 Nursing Diagnosis: Functional Urinary Incontinence RT impaired mobility and cognitive deficits

AEB use of wheel chair SMART Patient Goal: Client will participate in restorative care during the shift 12/14/11. AEB SMART Patient Goal: Client will decrease amount of urinary incontinent episodes during the shift 12/14/11.

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SMART Interventions followed by Evidenced-Based Rationale (minimum 3): 1. SN will assess and monitor lung sounds, rate and effort Qshift 12/14/11. Rationale: Must have a baseline and recheck to know if the lungs are still clear or were clear in the first place. 2. SN will assess and monitor clients weight. Rationale: Weight can reflect a change in body fluid volume (Ackley & Ladwig, 2010). 3. SN will administer diuretics as prescribed with a blood pressure check prior to the administration by lunch time. Rationale: Diuretics are important in keeping excess fluid out of clients tissues. 4. SN will monitor clients intake and output. Rationale: It is important especially with diuretic therapy in place that the client has more output than intake.

SMART Interventions followed by Evidenced-Based Rationale (minimum 3): 1. Client will participate in walk to dine for at least one meal 12/14. Rationale: This will help build stamina and help the client be less intolerant to activity. 2. Client will wear supplemental oxygen while walking each time during the shift 12/14. Rationale: This will endure the client is getting enough oxygen and is not feeling more fatigued than necessary when involving self in activity.

3. Client will participate in sittercise today

12/14. Rationale: This will also help the client build stamina.

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

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

SMART Interventions followed by Evidenced-Based Rationale (minimum 3): 1. SN or other staff will take client to bathroom every two hours and as needed during the shift 12/14. Rationale: This should help train the bladder to go every two hours and reduce the amount of incontinence. 2. Client will be dressed in clothes that are easy to get down when toileting by breakfast time. Rationale: This will help reduce incontinence that happens in the bathroom. 3. Assess the clients ability to tell someone she needs to go to the bathroom by lunch time. Rationale: It would be more appropriate if the client was able to tell someone she needed to go to the bathroom, rather than assuming she does. Evaluation (at end of day, did client reach stated goal?)

SMART: Specific Measureable Appropriate Realistic Time element

Post Conference Report

What new Nursing knowledge did you learn today?

References on back or on attached page.

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

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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?

REFERENCES 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 December 13, 2011, from http://drugguide.com/ddo/ub/home
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Drug Interaction Results. (n.d.). Micromedex 2.0. Retrieved December 13, 2011, from http://www.thomsonhc.com.ctu.idm.oclc.org/micromedex2/librarian/PFDefaultActionId/evidencexpert.ShowD rugInteractionsResults Karch, A. (2008). Focus on nursing pharmacology . (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. (2000). Medical-surgical nursing: assessment and management of clinical problems (5th ed.). St Louis, Missouri: Mosby. Malarkey, L. M., & McMorrow, M. E. (2005). Saunders nursing guide to laboratory and diagnostic tests. St. Louis: Elsevier Saunders. Pleural effusion: MedlinePlus Medical Encyclopedia. (2011, September 15). National Library of Medicine - National Institutes of Health. Retrieved December 14, 2011, from http://www.nlm.nih.gov/medlineplus/ency/article/000086.htm Pulmonary Vascular Congestion. (n.d.). eAtlas of Pathology, UConn's Virtual Pathology Museum. Retrieved December 14, 2011, from http://radiology.uchc.edu/eAtlas/RESP/310.htm

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