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NUR 171
SUPPORTIVE EDUCATIVE NURSING
Rev 06.25.2012
AEB:
an
obstruction. (A+L 130)
Monitor ABGs weekly and pulse O2 levels q4 hours
& prn
O2 sats<90% and partial pressures<80 indicate
significant
oxygenation problems.(A+L 130)
TREAT: Administer O2 as ordered. O2
administration
has been shown to correct hypoxemia (A+L 130).
Turn patient q2 hours. Body movement helps
mobilize
secretions and decreases risk of atelectasis,
pooling of
secretions and resulting pneumonia (A+L
130,131).
Suction tracheostomy tube prn. (*hyperoxygenate,
explain procedure and asses for pain, DO NOT suction
>15sec., document)
Potential Complications
If this patients condition were to
worsen, what would be the most likely
reason?
Progression of patients pneumonia
leading an increase in ineffective lung
tissue.
SCHEDULE
How will you organize your time?
PROCEDURES
What procedures do you have to do?
CARE PATHWAYS
Is the patient on a Care Pathway?
0645: Report
By 0730: VS.
See Kardex
PATHOPHYSIOLOGIES
Primary Diagnosis Pathophysiology Pneumonia
An invading organism triggers an inflammatory response, causing vasodilatation and increased vascular permeability
as well as the activation of neutrophils in hopes of thwarting the ensuing invasion. Fluid that has leeched out of now
hyperpermeable vessels, as well as the neutrophils and the offending organism fill the alveoli, therefore, decreasing
gas exchange. Mucus production is also increased, further obstructing airflow.
Reference Med/Surg or Patho text (less than 5 years old):Lewis Med Surg text 2011
o Textbook S&S
Cough, fever, chills, dyspnea, tachypnea, chest pain. Sputum may be green, yellow, or rust colored (blood-tinged).
Positive blood
cultures, elevated WBCs.
o Patients S&S
Blood tinged sputum. Sputum cultures positive for MRSA. WBCs elevated at 13.4
Secondary Diagnosis Pathophysiology HTN
Hypertension consists of an increase in either cardiac output or increased systemic vascular resistance. This can arise
from a variety of reasons, such as: atherosclerosis, elevated blood lipid/cholesterol levels, stress, vasoconstriction from
caffeine or tobacco use, obesity..etc.. Normal BP should be <120/80, with prehypertension being 121/81-139/89,
hypertension I being at 140/90-159/99 and hypertension II being >160/100.
Reference Med/Surg or Patho text (less than 5 years old):Lewis Med Surg text 2011
o Textbook S&S Asymptomatic, silent killer until hypertension becomes severe and target organ disease occurs.
o Patients S&S: Asymptomatic. BP elevated at 147/83
Reference Med/Surg or Patho text (less than 5 years old) Lewis Med Surg text 2011
o Textbook S&S: Decreased motor/sensory function, hemiparesis, aphasia, dysphagia, cognitive deficits
o Patients S&S: Decreased swallow, aeb PEG tube, significant cognitive and speech deficits, decreased motor
function.
MEDICATION SUMMARY
ALLERGIES and usual reaction
NKDA
Generic/Brand
Name and
Class
Heparin Sodium
Heparin
Anticoagulant
Normal Dose
Patients Dose
Times to Give
Drug Action
Why ordered
for this patient?
5000U/1ml
5000U/1ml
Subcutaneous
q12hrs.
0900 2100
Deactivation of
thrombin,
prevention of
conversion of
fibrinogen to fibrin.
hx of CVA, DVT
prophylaxis
Levetiracetam
Keppra
Anticonvulsant
100mg/ml oral
solution
750mg dose.
750mg/7.5ml
PEG
q12hrs.
0900 2100
May inhibit
simultaneous
neuronal firing that
leads to seizure
activity.
hx of seizure
disorder
Make sure
patient is on
another
antiepileptic; not
to be given
crushed
-headache
-anxiety
Decreased
seizure activity.
Mycostatin
powder
Nystatin
Antifungal
1 application
BID prn
1 application
topically
3 times daily
1400 2100
0600
Alters cell
permeability in
fungal cells
Report of groin
excoriation
sores on
scrotum and
penis
S/S of rash or
fungal
infection.
Do not apply to
large open
areas
-rash
-sensitivity
Prevention
of/decrease in
s/s of fungal
infection
Pantoprazole
Protonix
PPI
40mg
suspension
40mg
PEG
Before
breakfast
Proton pump
inhibitor
Decrease risk
of aspiration.
-hyperglycemia
-nausea
Decrease in
acid reflux
Quetiapine
Seroquel
Antipsychotic
25mg
25mg
PEG
before bed
2100
Blocks
dopamine and
serotonin 5-HT2
receptors.
hx of
schizophrenia;
bipolar disorder
Give suspension
in apple juice 30
minutes prior to
food. DO NOT
give in other
liquids
Monitor VS-may
cause
hypotension.
-hypotension
-seizure activity
-hyperglycemia
Valoproic acid
Depakine
Anticonvulsant
200mg/5ml
250mg/5ml
PEG
q12hrs
0900 2100
Faciltates GABA
hx of seizure
disorder
Improved
management of
schizophrenic
and bipolar
symptoms
Decrease in
seizure activity.
Insulin Type
Items to check
before giving;
when to hold
Assess
patients VS,
monitor PTT
hold if patient
is
actively
bleeding
Liver function
test results,
and coagulation
studies.
Watch LOC and
behavior
closely.
Two common
side effects
-hemorrhage
-overly
prolonged
clotting time
-hepatotoxitiy
-depression
Onset
Peak
Duration
Generic/Brand
Name and
Class
Biscodyl
Dulcolax
Laxative
Normal Dose
Patients Dose
Times to Give
Drug Action
Why ordered
for this patient?
10mg rectal
suppository
10mg
rectal
suppository
every 3 days.
Stimulates
increased
peristalsis
Constipation r/t
feedings or
bedrest
Diphenhydrami
ne
Benadryl
Antihistamine
Normal IVP
dose not found.
But normal
dose 12.5mg.
12.5mg/0.25ml
IVP
prn q6hrs
Competes with
histamine for
H1 receptors
Allergic
reactions
Allergies?
Reaction
severity?
*Push VERY
slowly. May
consider diluting
with 10cc NS
-increased
sedation
-thickening of
bronchial
secretions
*may decrease
Hgb, Hct and
platelet count
Haloperidol
Haldol
Antipsychotic
2mg
2mg/0.4ml
IVP
prn q4hrs
hx
schizophrenia;
bipolar disorder
Monitor VS-may
cause
hypotension
Hydralazine
Apresoline
Antihypertensiv
e
10mg
10mg/0.5ml
IVP
q4hrs prn
Blocks
postsynaptic
dopamine
recptors
Peripheral
vasodilation
hx
hypertension
-dry mouth
-sedation
-increased
seizure activity
-severe
hypotension
-edema
Lorazepam
Ativan
Benzodiazepine
1-4mg
1mg/0.5ml
IVP
prn q6hrs
Potentiates
GABA
Anxiety
Monitor VS
LOC
Morphine
Sulfate
Morphine
Opioid
analgesic
2mg
1mg/0.5ml2mg/1ml
IVP
q2hrs prn
Binds with
opioid
receptors in
CNS.
Severe pain
400-500mg/5ml
PEG
q 3 days prn
Draws water
into intestinal
lumen. Osmotic
laxative.
Constipation
Magnesium
Hydroxide
Milk of
Magnesia
Laxative
Insulin Type
Onset
Items to check
before giving;
when to hold
Last BM?
Abdominal
assessment
Hold if patient is
experiencing
diarrhea
Two common
side effects
-abdominal
cramps
-irritation of
rectum
Decrease in
psychosis
symptoms
Decrease in BP
-drowsiness
-dizzyness
-sedation
Decrease in
anxiety
Assess VS,
including pain
(COLDSPA).
Hold if
RR<10bpm
-CNS
depression
(Respiratory
depression)
-constipation
Decrease in
pain scale
Last BM?
Abdominal
assessment
Hold if patient is
experiencing
diarrhea
-NVD
-abdominal
cramping
Relief from
constipation aeb
BM and/or
verbalized
comfort.
Peak
Duration
Medical
Diagnosis
List laboratory and
diagnostic tests
found in your text
for admitting and
secondary medical
diagnoses.
Pneumonia
CKD
BUN,creatinine
HTN
Gram
stain/sputum
CVA
CBC, coag.
studies
culture
electrolytes, BG,
CBC
Renal and
hepatic
studies, lipid
profile.
CT scan
GFR,
electrolytes,
lipid profile,UA
Renal US
Sphygmomanome
ter
Blood cultures
Chest X-ray
Pulse ox/ABGs
Test
RBC
Hemoglobin
Normal
Value
4.2-5.4
106microL
12.016.0g/dl
Implications
for care
4.01 106
microL 3/19
Cause of
abnormal
finding
CKD.
Decreased
erythropoieti
n
production
10.3g/dl 3/19
CKD
Continue to
monitor.
Administer O2 to
help with
perfusion.
Continue to
monitor.
Administer O2 to
help with
perfusion.
39-50%
35.1% 3/19
CKD
Platelets
150-400,000
390,000
WNL
WBC
411x103/microL
13.4x103/micr
oL
3/19
Infection.
Sodium
134145meq/L
3.5-5mmol/L
138
WNL
4.5
WNL
98108mmol/L
101
WNL
Chloride
BMP
CT scan
Hematocrit
Potassium
Diagnosis #4
Continue to
monitor.
Administer O2 to
help with
perfusion.
Continue to
monitor.
Administer
antibiotics as
ordered.
CO2
Creatinine
2231mmol/L
0.31.5mg/dL
26
WNL
WNL
Test
Normal Value
Admitting
date / value
Follow up
date / value
Cause of
Abnormal
finding
Implications
for care
Coagulatio
*None in
Patient should
chart
Studies
Albumin
heparin therapy!
3.5.5.5g/dL
2.5g/dL 3/27
CKD, possible
protein
deficiency?
Continue to monitor,
make sure patient is
getting adequate
protein in feedings.
BUN
7-22mg/dL
29mg/dL
3/27
CKD
Monitor BUN.
Provide
adequate fluids.
Protein
6.4-8.3g/dL
5.6g/dL 3/23
CKD, possible
protein
Glucose
70-110mg/dL
Continue to monitor,
make sure patient is
getting adequate
deficiency?
protein in feedings.
130mg/dL
No hx of
Continue to
3/27
diabetes noted in
monitor. May
chart. Possible
need HA1C to
determine cause
Seroquel
Date: 4/2/2015
MENTAL STATUS
LOC and orientation X3
Appearance
Cognition
PAIN
Location, severity, quality, radiation,
duration, precipitating/alleviating
factors, associated symptoms
HEAD AND NECK
Hair and skin
Eyes: sclerae, conjunctivae, pupil
reactivity
Eyes: vision/aids
Ears: lesions, hearing/aids
Nose: symmetry, mucosa, drainage
Mouth: mucosa, tongue, dentation,
lesions
Swallowing/ Appetite
Trachea position
JVD at 45 degrees
UPPER EXTREMITIES
Skin
Pulses
Capillary refill
Strength/ROM
Turgor/edema
CHEST/BACK
Shape
Respiratory effort/SpO2
Cough/sputum
LOWER EXTREMITIES
Skin color/integrity
Edema
Pulses
Capillary refill
Strength/ROM
EQUIPMENT
Pumps
Tubes
DURING SHIFT
Vital signs/time
No edema noted.
Dorsalis Pedis +1 and equal bilaterally
Capillary refill brisk <3 seconds
Leg muscles atrophied. Unable to assess.
N/A
PEG, Tracheostomy, PICC placed in left upper arm.
BP: 147/83, HR: 85, RR: 17, T: 98.4, SpO2: 96% (0730)
N/A.
Food intake/Appetite/Nausea
IV solution and rate/hourly checks
Significant lab results
Support system/SO involvement
Patient education completed
NURSING DIAGNOSIS
Ineffective Airway Clearance r/t increased secretions, presence of tracheostomy a.e.b frequent
blood tinged sputum from tracheostomy
Meds administered
Reported off to RN
and instructor
I&O documented
______________________________
MAR signed
Student signature
Yes
No
Yes
No
determined
before appropriate interventions can be
implemented
(A+L, 735 2011)
Date: 04/3/15
MENTAL STATUS
LOC and orientation X3
Appearance
Cognition
PAIN
Location, severity, quality, radiation,
duration, precipitating/alleviating
factors, associated symptoms
HEAD AND NECK
Hair and skin
Eyes: sclerae, conjunctivae, pupil
reactivity
Eyes: vision/aids
Ears: lesions, hearing/aids
Nose: symmetry, mucosa, drainage
Mouth: mucosa, tongue, dentation,
lesions
Swallowing/ Appetite
Trachea position
JVD at 45 degrees
UPPER EXTREMITIES
Skin
Pulses (brachial, radial)
Capillary refill
Strength/ROM
Turgor/edema
CHEST/BACK
Shape
Respiratory effort/SpO2
Cough/sputum
Tenderness
Urinary pattern/color
Bowel pattern/character/last BM
Perineum (if appropriate)
LOWER EXTREMITIES
Skin color/integrity
Edema
Pulses (femoral, popliteal, PT, DP)
Capillary refill
Strength/ROM
EQUIPMENT
Pumps
Tubes
DURING SHIFT
Vital signs/time
Skin pink, warm and dry. Wound on right ankle open to air.
Refer to pictures in chart.
No edema noted.
Dorsalis Pedis +1 and equal bilaterally
Capillary refill brisk <3 seconds
Leg muscles atrophied. Unable to assess.
N/A
PEG tube in LUQ, foley catheter, tracheostomy, PICC
line in left upper arm.
Apical HR 91, BP 108/78, RR 20, T 98.4, SpO2: 97% (6L
30% O2 per
tracheal mask) (0725)
N/A
Food intake/Appetite/Nausea
IV solution and rate/hourly checks
Significant lab results
Support system/SO involvement
Patient education completed
NURSING DIAGNOSIS
Ineffective Airway Clearance r/t increased secretions, presence of tracheostomy a.e.b frequent
blood tinged sputum from tracheostomy
SOAP NOTE (on above nursing diagnosis only)
S-Patient non-verbal secondary to mental illness and CVA.
O-Vital signs stable: apical HR 91, BP 108/78, RR 20, T: 98.4, SpO2: 97% (6L 30% O2 per tracheal
mask). Cardiovascular assessment negative. Heart sounds strong and regular, S1S2. Telemetry:
NSR. Lung sounds remain diminished in bases, cough remains productive with light green
sputum. Suctioned patient X2, copious amounts of light green and blood tinged sputum. Bowel
sounds active X3, hypoactive in RLQ, abdomen slightly distended. LBM 3/27. Pressure ulcer on
right lateral malleolus and calf continues to be open to air, bilateral ankles supported with air
boots.
A-Patient progressing toward discharge.
P-Patient to be discharged at 1400 today.
Meds administered
Reported off to RN
and instructor
I&O documented
______________________________
MAR signed
Student signature