MIAMI DADE COLLEGE - MEDICAL CENTER CAMPUS - SCHOOL OF NURSING NUR 1025L: Fundamentals Nursing Clinical Students Name:

Francisco J Ortiz Date: _07/06/13_ Clients Initials: ____ER____ Admission Date: _05/20/2013 Age: 78yr DOB: ______06/15/1940_____ Sex: X Male Female Race/Ethnicity: WHITE/______________ Support System: _____No living family membes _________________________________________________________ Religion: _Protestant__________ MEDICAL HISTORY ALLERGIES: _NKA_ Admitting Medical Diagnosis (es): Cardiac dysrthmias, CHF, hypertension, Constipation, seizure disorder, dementia Chief Complaint: patient right-side epitaxis History of Present Illness: Pt is a 78 has history of pulmonary embolism and was anticoagulation because of this condition. Pt came back to hospital wih right-side epistaxis and currently at the bedside. Pt doesnot appear to have any acute bleeding. Past Medical History (include past surgical history): Senile,Dementia, pulmonary embolism hypertension, asthma, Esophageal Reflux; No alcohol abuse, no drug abuse Clients (Parents)Understanding of Illness: patient understands and full aware of condition

Stage of Development: Erickson Ego Integrity vs. Despair _ Freud: According to Freud, the genital stage lasts throughout adulthood. He believed the goal is to develop a balance between all areas of life. Piaget _ Formal Operational ____ Special Developmental Considerations: N/A Height: 170.18 cm Weight: 46.36 kg Placement in Growth Chart: _N/A Immunizations: Patient refused flu vaccine

VITAL SIGNS Time Taken: ______0930_________ Activity: ______________ Position: ____wheel chair__________ T_96.0 P65R 18 BP _145/60 Baseline (Normal Age for Age): T_ 36.137.8 P_60 -100 R_12-20_ BP 120/80 _

Diet: Regular/Puree

NUTRITION Food Preferences: coffee with 2 splenda, yogurt for LUNCH, N/A for DINNER

Nutritional Requirements: (Cal/Kg/Day): 1725CAL/KG/DAY Total Calories per Day: _1800___________ Fluid Requirements (Ml/Kg/Day): ____30-35 Ml/Kg/Day_____________ __Total Fluids per Day: _____14401680__________________________ Special Treatments: ____________N/A Medications at Home:_N/A___________________________________________________________________________________________ __________________________________________________________________________________________________________________

Medication(s) Worksheet NAME CLASSIFICATI ON DOSE/ROUTE/FREQUE NCY SAFE RANGE MECHANISM OF ACTION INDICATIONS SIDE EFFECTS NURSING CONSIDERATIONS AND PATIENT EDUCATION

BUDESONIDE

0.5mg 1 tab Q12 by mouth

Potent, locally acting antiinflammatory and immune modifier.

Maintenance treatment of asthma as prophylactic therapy. May decrease the need for or eliminate use of systemic corticosteroids in patients with asthma.

CNS: headache, agitation, depression, dizziness, fatigue, insomnia, restlessness . EENT: dysphonia, hoarseness, cataracts, nasal congestion, pharyngitis, sinusitis. Resp: bronchospas m, cough, wheezing. GI: diarrhea, dry mouth

Monitor respiratory status and lung sounds. Assess pulmonary function tests periodically during and for several months after a transfer from systemic to inhalation corticosteroids. Assess patients changing from systemic corticosteroids to inhalation corticosteroids for signs of adrenal insufficiency (anorexia, nausea, weakness, fatigue, hypotension, hypoglycemia) during initial therapy and periods of stress. If these signs appear, notify health care professional immediately; condition may be lifethreatening

MEMANTINE

10mg 1 tab daily by mouth

Binds to CNS N-methyl-Daspartate (NMDA) receptor sites, preventing binding of glutamate, an excitatory neurotransmitt er.

Moderate to severe Alzheimers dementia.

CNS: dizziness, fatigue, headache, sedation. CV: hypertensio n. Derm: rash. GI: weight gain. GU: urinary frequency. Hemat: anemia.

Assess cognitive function (memory, attention, reasoning, language, ability to perform simple tasks) periodically during therapy. Lab Test Considerations: May cause anemia

CEPHALEXIN

500MG TAB Q8 by mouth

Bind to bacterial cell wall membrane, causing cell death. T

Treatment of the following infections caused by susceptible organisms: Skin and skin structure infections (including burn wounds), Pneumonia

CNS:
SEIZURES

(high doses). GI:

PSEUDOMEMBRANOUS COLITIS,

diarrhea, nausea, vomiting, cramps. Derm:

STEVENSJOHNSON SYNDROME,

Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning and during therapy. Before initiating therapy, obtaina history to determine previous use of and reactions to pencillins or cephalosporins. Persons with a negative history of penicillin sensitivity may still have an allergic response.

CLONIDINE

0.2MG TAB Q12 BY MOUTH

Stimulates alphaadrenergic receptors in the CNS, which results in decreased sympathetic outflow inhibiting cardioaccelera tion and vasoconstriction centers. Prevents pain signal transmission to the CNS by stimulating alphaadrenergic receptors in the spinal cord.

PO, Transdermal: Management of mild to moderate hypertension.

CNS: drowsiness, depression, dizziness, nervousness, nightmares. CV: bradycardia, hypotension (q with epidural), palpitations. GI: dry mouth, constipation, nausea, vomiting.

Monitor intake and output ratios and daily weight, and assess for edema daily, especially at beginning of therapy. Monitor blood pressure and pulse frequently during initial dose adjustment and periodically throughout therapy. Report significant changes.

ARICEPT

5MG TAB ONCE DAILY BY MOUTH

Inhibits acetylcholinest erase thus improving cholinergic function by making more acetylcholine available

Mild to moderate dementia associated with Alzheimers disease.

CNS: headache, abnormal dreams, depression, dizziness, drowsiness, fatigue, insomnia, syncope, sedation (unusual). CV: atrial fibrillation, hypertension, hypotension, vasodilation.

Assess cognitive function(memory, attention, reasoning, language, ability to perform simple tasks) periodically during therapy. Administer Mini-Mental Status Exam(MMSE) initially and periodically as a screening tool to rate cognitive functioning. Administer Clock Drawing Test initially and periodically as a screening tool to measure severity of dementia.

Medication(s) Worksheet CLASSIFICATI ON NAME DOSE/ROUTE/FREQUE NCY SAFE RANGE MECHANISM OF ACTION FERROUS SULFATE 325MG DAILY BY MOUTH An essential mineral found in hemoglobin, myoglobin, and many enzymes. Enters the blood- stream and is transported to the organs of the reticuloendot helial system (liver, spleen, bone marrow), where it is separated out and becomes part of iron stores. PO: Prevention/treat ment of irondeficiency anemia. CNS: IM, IV SEIZURES, dizziness, headache, syncope. CV: IM, IV hypotension, hypertension, tachycardia. GI: nausea; PO, constipation, dark stools, diarrhea, epigastric pain, GI bleeding; IM, IV, taste disorder, vomiting. INDICATIONS SIDE EFFECTS NURSING CONSIDERATIO NS AND PATIENT EDUCATION Assess nutritional status and dietary history to determine possible cause of anemia and need for patient teaching. Assess bowel function for constipation or diarrhea. Notify health care professional and use appropriate nursing measures should these occur.

EVERY 4 TO 6 HOURS ATROVENT SAN

Inhaln: Inhibits cholinergic receptors in bronchial smooth muscle, resulting in decreased concentration s of cyclic guanosine monophospha te (cGMP). Decreased levels of cGMP produce local bronchodilati on

Inhaln: Maintenance therapy of reversible airway obstruction due to COPD, including chronic bronchitis and emphysema.

Assess for allergy to atropine CNS: dizziness, and belladonna headache, alkaloids; patients nervousness. with these EENT: blurred allergies may also vision, sore be sensitive to throat; nasal ipratropium. only, epistaxis, Atrovent HFA MDI nasal does not contain dryness/irritati CFC or soy and on. Resp: may be used bronchospasm, safely in soy or cough. CV: CFC-allergic hypotension, patients. palpitations. However, GI: GI irriCombivent MDI tation, nausea. should be avoided Derm: rash in soy or peanutallergic patients.

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Aspirin

81mg daily PO

Inhibits the synthesis of prostaglandin s that may serve as mediators of pain and fever, primarily in the CNS. Has no significant antiinflammatory properties or GI toxicity.

Mild pain. Fever.

GI: HEPATIC FAILURE, HEPATOTOXICI TY (overdose). GU: renal failure (high doses/chronic use). He- mat: neutropenia, pancytopenia, leukopenia. Derm: rash, urticaria.

Assess overall health status and alcohol usage before administering acetaminophen. Patients who are malnourished or chronically abuse alcohol are at higher risk of developing hepato- toxicity with chronic use of usual doses of this drug. Assess amount, frequency, and type of drugs taken in patients self-medicating, especially with OTC drugs. Prolonged use of acetaminophen increases the risk of adverse renal effects. For shortterm use, combined doses of acetaminophen and salicylates should not exceed the recommended dose of either drug given alone.

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PATHOPHYSIOLOGY-BRIEF TEXTBOOK PICTURE WITH CLIENT COMPARISON Definition, Etiology, Incidence, Pathophysiology, Diagnostic tests, Signs & symptoms, Medical treatments Textbook Pathology- Nosebleeds are due to the rupture of a blood vessel within the richly perfused nasal mucosa. Rupture may be spontaneous or initiated by trauma. Nosebleeds are reported in up to 60% of the population with peak incidences in those under the age of ten and over the age of 50 and Client Patient has rupture of a blood vessel within the richly perfused nasal mucosa

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appear to occur in males more than females.[3] An increase in blood pressure (e.g. due to general hypertension) tends to increase the duration of spontaneous epistaxis.[4] Anticoagulant medication and disorders of blood clotting can promote and prolong bleeding. Spontaneous epistaxis is more common in the elderly as the nasal mucosa (lining) becomes dry and thin and blood pressure tends to be higher. The elderly are also more prone to prolonged nose bleeds as their blood vessels are less able to constrict and control the bleeding. Classification- Commonly used classification according to site of bleeding source Anterior epistaxis:

Patient has anterior epitaxis that originates from the Kiesselbach plexus, a rich vascular anastomosis located at the anterior nasal septum;

Accounts for approximately 90% of nosebleeds Usually originates from the Kiesselbach plexus, a rich vascular anastomosis located at the anterior nasal septum; this region is called Little's area.

Posterior epistaxis:

Originates from the posterior nasal cavity or nasopharynx [3] [4] Posterior nasal and nasopharyngeal vessels often have a larger calibre and may produce more active bleeding. Patient epitaxis appears local

Etiology- etiology of epistaxis is multi factorial but can be divided into two broad groups Local and systemic. It must be noted that most cases of epistaxis do not have an easily identifiable

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cause. StatisticsEpistaxis that occurs in children younger than 10 years usually is mild and originates in the anterior nose, whereas epistaxis that occurs in individuals older than 50 years is more likely to be severe and to originate posteriorly [9]. Data from the National Hospital Ambulatory Medical Care Survey indicate that epistaxis accounted for <1 percent of all emergency department visits between 1992 and 2001 [10]. Overall, there were approximately two emergency department visits for epistaxis per 1000 population annually. The age-related frequency was bimodal with one peak in individuals younger than 10 years (4 per 1000 population) and a second peak in those 70 to 79 years Patient lies within the range of those between the ages of 70 to 79 years that may get onset epitaxis

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DIAGNOSTIC TESTS Test (i.e. X-Ray, MRI, EEG, EKG) CHEST XRAY RESULTS Date, Result, Significance REVEALS EMPHYSEMATOUS CHANGES

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Laboratory values CHEMISTRY PROFILE NORMAL VALUES CLIENTS VALUES DATE D A T E DATE HEMOTOL OGY NORMAL VALUES DATE CLIENTS VALUES DA TE DATE

SODIUM POTASSIUM CHLORIDE CO2 CALCIUM GLUCOSE BUN CREATININE

135-145 Meq/L 3.5- 5.1 mEq/L 98-108 mEq/L 19-34 8.2-10.3 mg/dL 70-105 mg/dL 7-25 mg/ Dl 0.6-1.2 mg/dL

137 4/20/13 4.4 4/20/13 101 4/20/13 27 4/20/13 8.3 4/20/13 154 *H 4/20/13 9.2 4/20/13 1.1 4/20/13

WBC RBC HGB HCT MCV MCH MCHC PLATELETS DIFFEREN TIAL NEUTROPHI LS SEGMENTS BANDS 17

3.8-10.8 K/uL 3.80-5.20 11.815.4g/dl 41-50 79.494.8fL

6.1 4/20/13 3.12*L 4/20/13 9.8*L 4/20/13 29.7*L 4/20/13 95.3 4/20/13 31.3 4/20/13 32.8 4/20/13 12 4/20/13

25.6-32.2 pg 11.515.0%

PHOSPHORUS CHOLESTERO L TOTAL 6.4-8.9 PROTEIN g/dL ALBUMIN 3.5-5.0 g/dL ALBUMIN/GLO BULIN RATIO

6.7 4/20/13 3.77 4/20/13 2.97 4/20/13

AST (SGOT) ALT (SGPT) TOTAL BILIRUBIN AMYLASE LIPASE

13-39 U/L 7-52 U/L 0.3-1.0 mg/dL

27 2/21/13 15 2/21/13

LYMPHOCYT ES EOSINOPHIL S BASOPHILS MONOCYTE S COAGULATION STUDIES

SODIUM POTASSIUM CHLORIDE CO2 CALCIUM GLUCOSE BUN

135-145 Meq/L 3.5- 5.5 mEq/L 98-108 mEq/L 19-34 8.2-10.3 mg/dL 70-105 mg/dL 7-25 mg/ Dl CBC Hgb

137 4/20/13 4.4 4/20/13 101 4/20/13 27 4/20/13 8.3 4/20/13 154 *H 4/20/13 9.2 4/20/13

PTT WBC RBC HGB HCT MCV MCH MCHC BMP

3.8-10.8 K/uL 3.80-5.20 11.8-15.4g/dl

6.1 4/20/13 3.12*L 4/20/13 9.8*L 4/20/13 29.7*L 4/20/13 95.3 4/20/13 31.3 4/20/13 32.8 4/20/13

Na Plts K+

Cl

BUN Glucose Creatinine 18

WBC Hct

HCO3

URINALYSIS COLOR YELLOW APPEARANCE CLEAR SP. GRAVITY 1.04 PH GLUCOSE KETONE OCCULT BLOOD PROTEIN BILRUBIN UROBILINOGEN NITRITE LEUCOCYTE CAST WBC RBC CRYSTALS SQUAMOUSCEL LS/ EPITHELIAL CELLS Relate the clinical significance of abnormal lab values above: 5 NORMA L NEGATI VE NEGATI VE NEGATI VE NORMA L NEGATI VE NEGATI VE TEST TEST URINE CULTURE

MISCELLANEOUS NORMAL CLIENTS VALUES VALUES DATE DATE DATE PENDI 06/17/1 NG 3

GLUCOSE(LOW)- INDICATIONS:-Symptoms of elevated glucose levels include abdominal pain, fatigue, muscle cramps, nausea, vomiting, polyuria, and thirst. Possible interventions include sub- cutaneous or IV injection of insulin with continuous glucose 19

monitoring.

RBC(LOW)- INDICATIONS:-Low RBC count leads to anemia. Anemia can be caused by blood loss, decreased blood cell production, increased blood cell destruction, or hemodilution. HGB(LOW)- INDICATIONS:- Low Hct leads to anemia. Anemia can be caused by blood loss, decreased blood cell production, increased blood cell destruction, and hemodilution. Causes of blood loss include menstrual excess or frequency, gastrointestinal bleeding, inflammatory bowel disease, and hematuria. Decreased blood cell production can be caused by folic acid deficiency, vitamin B12 deficiency. HCT (LOW)- INDICATIONS:- High Hct leads to polycythemia. Polycythemia can be caused by dehydration, decreased oxygen levels in the body, and an overproduction of RBCs by the bone marrow. Dehydration from diuretic use, vomiting, diarrhea, excessive sweating, severe burns, or decreased fluid intake decreases the plasma component of whole blood, thereby increasing the ratio of RBCs to plasma, and leads to a higher than nor- mal Hct. Causes of decreased oxygen include smoking, exposure to carbon monoxide, high altitude, and chronic lung disease, which leads to a mild hemoconcentration of blood

Head to Toe Assessment General Appearance: The pt is resting comfortably in no acute distress. No weight loss or gain. No fever Head & Hair: Norm cephalic and atraumatic Face: Norm cephalic and atraumatic Eyes: Norm cephalic and atraumatic Ears: Norm cephalic and atraumatic 20

Nose: Turbinates bright red and swollen, mucous pink, no swelling Lips/Mouth/Throat: No cracking/ lesions on lips, mouth is clean and free from debris, mild breath odor. Neck: Chest/Breast: Clear to palpation and auscultation lateral chest is larger than anterior/posterior diameter. Lungs: Clear to auscultation; no abnormal sounds heard. Heart: Normal rhythm sounds heart at the fine precordial points. Abdomen/Kidneys: Normal bowel sounds, no masses, lumps, or tenderness found. Genitalia (Internal Exam Deferred): N/A Rectum (Internal Exam Deferred): N/A Extremities: No edema clubbing or cyanosis Back: no deformities R.O.M.: Limited range of motion. Patient is in the wheelchair bound. Document findings on next page

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Plan of Care Priority Nursing Diagnosis: Ineffective airway clearance related to epitaxis Risk Nursing Diagnosis: Risk of bleeding as evidence by patient showing signs of right-side bleeding: Supporting Data: Patient came in with right-sided epitaxis Subjective: Patient states I am bleeding from my nose Objective: patient shows obvious signs of bleeding Expected Outcome (Goals) Long Term: Patients right-side epitaxis will be minimized by discharge Short Term: After 1 hrs. Of nursing interventions, the client epitaxis will be managed Nursing Interventions Nursing Actions Monitor vital signs: Auscultate breath sounds, heart rate and rhythm, respirations q 4 hours. Scientific Principle and/or Rationale Respiratory system may become decompensated. Tachycardia and changes in blood pressure may be present because of pain, anxiety and reduced cardiac output. Indicators of level of hydration and Evaluation BP is 145/60 Lung sounds are clear to auscultation, respiratory rate is between 20 to 24 breaths per minute and pulse is at 65 Modification of Plan of Care

Assess peripheral pulses, capillary refill, skin turgor,

Mucous membrane are moist, capillary refill is 23

and mucous membranes q 4 hours. Clean secretions from the mouth and trachea

adequacy of circulating volume. To prevent obstruction / aspiration. Positioning helps maximize lung expansion and reduce respiratory effort. Helping dilution of secretions. Teaching standardized content that the patient already knows wastes valuable time and hinders critical learning. Adults learn material that is important to them

less than 2 seconds and skin turgor has increased Clean patient and assess for any continuous bleeding Patient will remain in semi fowler to manage nose bleed Patient will intake atleast 250ml daily The patient verbalizes understanding of priority learning needs. Ask doctor if intake can be increase if improvements are shown Continue to monitor patient and assess for any bleeding

Give Fowler's or semiFowler position. Maintain a fluid inclusion at least as much as 250 ml / day unless contraindicated. Identify priority of learning needs within the overall care plan as soon as possible.

Evaluate level of activity tolerance. Provide calm, quiet environment. Limit patients activity or encourage bed/chair rest during acute phase. Have patient resume activity gradually and increase as individually tolerated.

During severe/acute/refractory Patient tolerated respiratory distress, ambulating from chair to patient may be totally bed after a short rest unable to perform basic self-care activities because of hypoxemia and dyspnea. Rest interspersed with care activities remains an 24

important part of treatment regimen. An exercise program is aimed at increasing endurance and strength without causing severe dyspnea and can enhance sense of wellbeing. Encourage questions before and after each teaching. Questions facilitate open communication between patient and health care professionals, and allow verification of understanding of given information and the opportunity to correct misconceptions Auscultate breath sounds Q1- 2 . Presence of crackles, wheezes may signify airway obstruction, leading to or exacerbating existing hypoxia. The patient asked questions regarding her regimen, diet and concerns when injecting herself.

Pt will maintain clear lung fields and remain free of signs of respiratory distress throughout hospital stay

Pt demonstrated effective coughing techniques for student nurse

Elevate head of bed, assist patient to assume position to ease work of breathing. Include periods

Oxygen delivery may be improved by upright position and breathing The patient tolerated deep breathing exercises exercises to decrease 25

of time in prone position as tolerated.

airway collapse, dyspnea, and work of breathing. Note: Recent research supports use of prone position to increase Pao2.

after showing correct techniques

Review individuals target blood Although this range varies glucose levels as soon as possible. per person, the ideal range for the adult diabetic is considered to be 80 to 120 mg/dL. (Doenges pg 418)

Patient understood that their normal blood sugar levels are between 70 to 100 milligrams per deciliter.

Pt will maintain a patent airway at Monitor resp. rate, all time depth, and effort, use of accessory muscles, nasal flaring, and abnormal breathing patterns. respiratory rate, use of accessory muscles, nasal flaring, and abdominal breathing may indicate hypoxia.

Pts airway remained open

Review clients dietary program; Identifies deficits and compare with recent intake before deviations from therapeutic end of shift. plan, which may precipitate unstable glucose and

The patient complies with the new way of teaching nutritional intake and insulin pattern.

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uncontrolled hyperglycemia. (Doenges pg 412)

Administer glucose solution 5% Glucose solutions may be dextrose and half-normal saline to added after insulin and fluids 1000ml in 24 hours. have brought the blood glucose to approximately 400 mg/dL. Encourage deep-slow or pursed-lip breathing as individually needed/ tolerated. Oxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea, and work of breathing. Note: Recent research supports use of prone position to increase Pao2.

Patients blood glucose level was at 450mg/dL after administration of IV.

The patient tolerated deep breathing exercises after showing correct techniques

CARE PLAN RUBRIC Student: ___________________________________ Date: ______________________ CATEGORIES POSSIBL E POINTS YOUR POINTS 27 COMMENTS

SUBJECTIVE DATA (Relevant and timely and quoted from patient) OBJECTIVE DATA (Includes vital signs, physical assessment findings, diagnostic tests and procedures, relevant medications, etc.) NURSING DIAGNOSIS (NANDA, R/T, AEB) GOAL (Condition, Time Frame, Parameters, and must be realistic) INTERVENTIONS AND RATIONALES (Assess, Assist, and Teach) EVALUATION OF CARE PLAN (Evaluate each nursing action for effectiveness) MODIFICATION OF CARE PLAN (Modify patient care plan based on patients response to interventions)

10

10

20

20

20

10

10

*TOTAL SCORE:

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*Student must obtain score of > 77% in order to obtain a grade of S on the weekly care plan. Reviewed with student: ______________________________ Signature Date: ___________________

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