homework

calemnji

CarePlan1SampleMedSurg.docx

Home >Nursing homework help >homework

Care Plan

name

instructor

school

Care Plan #2

Background and Etiology

The patient is a 65-75-year-old African American female who was admitted to the adult intensive care unit (AICU) due to elevated lactic acid level, metabolic acidosis, anasarca, and pleural effusion which was drained via chest tube by interventional radiology (IR). She also complained of worsening abdominal pain since her admission and has had increasing shortness of breath, dyspnea, increased work of breathing, and bilateral lower extremity edema. She was diagnosed with severe sepsis due to malnutrition, deconditioning, and recurrent bacteremia with worsening respiratory failure. Her past medical history is significant for adenocarcinoma of the pancreas treated with neoadjuvant chemotherapy and radiation (April 2019), a jejunal ulcer at the biliary anastomosis, vancomycin-resistant enterococci (VRE) bacteremia and Pseudomonas at the abdominal laparotomy site, multi-loculated liver abscesses growing Klebsiella and VRE, right ureteropelvic junction (UPJ) obstruction causing hydronephrosis, hypertension (HTN), hypothyroidism, osteoarthritis, diverticulosis, transient ischemic attack (TIA), Hepatitis C (2014), Vitamin D deficiency, and right foot fracture (2016). Her past surgical history is significant for a Whipple procedure (6/25/19), exploratory laparotomy (6/28/19), IR-guided drain placement for hepatic abscesses and right double-J ureteral stent (9/19), port placement (2018), and total abdominal hysterectomy-bilateral salpingo-oophorectomy (TAH/BSO) (1990s). The patient does not smoke, does not drink alcohol, or use illicit drugs. The patient has two adult sons from a previous marriage and has been with her significant other for 40 years.

The patient has difficulty moving in the bed but is able to move all of her extremities and follow commands. She has an 18-gauge IV in her left arm, double-lumen central line in the right subclavian vein, two hepatic drains attached to a collection bag for her liver abscesses, a nephrostomy tube draining into a urine collection bag, and a chest tube that had drained 450mL of serosanguinous fluid. She is unable to ambulate or use the restroom. She has no known drug allergies. She has full code status.

According to the Sepsis Alliance (2019), sepsis “is the body’s overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death”. It is a medical emergency which requires immediate treatment (Cedars Sinai, 2019). It occurs when the chemicals released by the immune system to fight infection overwhelm the body, causing “widespread inflammation” that impedes blood flow and causes a decrease in nutrients and oxygen to organs which leads to organ damage and failure (National Institute of General Medical Sciences (NIGMS), 2019). Sepsis can be caused by a bacterial or fungal infection in the bloodstream, infection of the kidney, bladder, or other part of the urinary system, and abnormal function of the liver (Mayo Clinic, 2019). Some complications of sepsis can include kidney failure, permanent lung damage from acute respiratory distress syndrome (ARDS), and damage to heart valves which can lead to heart failure (Cedars Sinai, 2019).

Morbidity and Mortality

Sepsis is described as a collection of symptoms in response to an infection, characterized by critical patient response with organ dysfunction related to that infection (Lewis, Bucher, Heitkemper, & Harding, 2017, p. 1592). According to the Centers for Disease Control (CDC) (2019) and Cedars Sinai (2019), these symptoms can include tachycardia, shortness of breath, increased respiratory rate (RR), leukocytosis, extreme pain or discomfort, and shivering or feeling very cold. This patient presented with all of these symptoms when she was admitted to the AICU. These symptoms can be caused by bacteremia due to vancomycin-resistant enterococcus (VRE) bacteria, cancer, kidney infections, abnormal liver function, and invasive devices (Sepsis Alliance, 2019), and this patient presented with all of these conditions.

According to NIGMS (2019), each year, around 1.7 million adults in the United States develop sepsis and almost 270,000 die as a result. Sepsis cases per year have increased, due to several factors: people who have chronic diseases are living longer – sepsis is more common and dangerous in older adults and those with chronic diseases; some infections can no longer be cured with antibiotics – antibiotic resistance can lead to sepsis; and people who undergo procedures with medications that can suppress or destroy the immune system have a higher risk of developing sepsis.

Pathophysiology

Bacteremia is the presence of bacteria in the bloodstream due to an infection when the immune system fails or becomes overwhelmed. The bacteria can evade the immune response, increase in number, and become a localized infection that eventually migrates to other parts of the body. If this occurs, the infection may progress to septicemia. Medical procedures that pass through the skin interfere with the skin’s natural defense barriers and increase the potential for bacteria to proliferate and cause sepsis (Smith & Nehring, 2019). This patient was diagnosed with VRE in her surgical abdominal wound. According to Johnstone et al. (2018), patient risk factors for VRE bacteremia include those with cancer, those who are admitted to the intensive care unit (ICU), and those receiving treatment at large hospitals and teaching centers. They also found that 40% of patients with VRE bacteremia died within 30 days of VRE bacteremia diagnosis and that being admitted to the ICU was the most important predictor of death.

According to the CDC (2019), having cancer and undergoing treatment such as chemotherapy can cause the body to be unable to fight off infections as it normally would. Chemotherapy kills both bad and good cells within the body. In addition to killing the fast-growing cancer cells, chemo also kills the infection-fighting white blood cells (WBC). This leaves the patient immunocompromised and more prone to acquiring an infection that can lead to sepsis. Patient risk factors for cancer include age, immunosuppression, chronic inflammation, alcohol use, and obesity (National Cancer Institute, 2015). According to the Sepsis Alliance (2019), people with cancer are more at risk for sepsis due to frequent hospital stays (which increases the risk for a hospital-acquired infection), surgeries or procedures that puncture the skin allowing for the increased possibility of infection, a depressed immune system due to treatment for cancer, and weakness due to malnutrition, illness, or age-related frailty.

Hepatic abscess is defined as “an encapsulated collection of suppurative material within the liver parenchyma which may be infected by bacterial, fungal, and/or parasitic micro-organisms” (Mavilia, Molina, & Wu, 2016). According to Jun (2018), hepatic abscesses are pockets of pus that form due to a bacterial infection primarily caused by strains of Klebsiella pneumoniae and that most of these infections are community-acquired. Patient risk factors that contribute to the development of hepatic abscess include diabetes mellitus, general immune-compromised state, age, gender (Mavilia, et al. 2016), and history of antibiotics use (Jun, 2018).

An invasive device is any medical device that is introduced into the body through a break in the skin or opening in the body. Whenever one of these devices is used, there is an increased potential for infection, including healthcare-acquired infections, that can lead to sepsis. Although the device itself does not cause infection, it can provide a route for bacteria and/or fungi to enter the body. Types of invasive devices include urinary catheters, IV lines (peripheral venous catheters), nephrostomy tubes, central lines, and chest tubes (Sepsis Alliance, 2019). According to the United States Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) (2015) and the CDC (2019), patient risk factors for requiring invasive devices include urinary tract infections requiring catheterization, receiving IV fluids, medications, or blood through peripheral venous catheters (the most commonly used catheter), respiratory failure requiring endotracheal tubes for mechanical ventilation, and cancer or cardiac treatments that require central venous catheters (central lines) that can remain in place for weeks or months.

Clinical Manifestations

During her hospitalization, the patient experienced abdominal pain with left-sided rigidity and distention, difficulty breathing, tachycardia, elevated RR, and edema in her abdomen, both lower extremities, and her right arm. She also complained of muscle weakness, and this was evidenced by her having difficulty moving in the bed and needing assistance. Any physical effort was extremely tiring due to her respiratory difficulty. She verbalized that she felt cold, so extra blankets were placed to provide warmth and try to make her more comfortable. She became irritable during several attempts to draw blood for cultures and stated, “I just want to be left alone” and appeared to be anxious and in distress demonstrated by moaning and restlessness in the bed. Because of her severe anemia, one unit of packed red blood cells was transfused. She had sequential compression devices (SCDs) on her legs and was given IV heparin for deep vein thrombosis (DVT) prophylaxis.

Over the next few days she became intermittently hypotensive and required IV fluids and supplemental oxygen. She was given Lasix to decrease her edema, and albumin to counteract the malnutrition and inflammatory process due to her abdominal wound infection and liver abscesses. Her respiratory symptoms continued to decline, bilateral crackles were heard with decreased air movement, and she complained of chest pain. She was noted to have 2+ pitting edema in both lower extremities that extended to mid-thigh. Because of the hydronephrosis, her urine output was decreased, and her white blood cell (WBC) count continued to be elevated. Due to her declining health and shortness of breath at rest, a palliative care consult was obtained and morphine 2mg IV q3h PRN was ordered to keep her RR less than 20. In spite of these efforts, the patient did not recover, and she expired six days after her admission.

Diagnosis

Diagnostic Data

Laboratory Data (Pagana & Pagana, 2018)

Test	Normal Range	10/25/19	10/26/19	10/27/19	Significance
PT	11.0-12.5 seconds	14.8			Elevated: may be due to liver abscesses (p. 394)
INR	0.8-1.1	1.4			Elevated: may be due to liver abscesses (p. 394)
APTT	23-31	36		66	Elevated: due to heparin administration (p. 346)
WBC	4.5-10 thou/mcL	27.9	20.6	21.3	Elevated: due to bacterial infection (p. 471)
RBC	4-5 mil/mcL	2.22	2.58	2.73	Low: due to renal disease (p. 398)
Hemoglobin	12-15 gm/dl	7.6	8.5	8.8	Low: due to renal disease (p. 254)
Hematocrit	36-44%	22.1	25.3	25.8	Low: due to renal disease (p. 251)
Platelet count	140-450 thou/mcL	173	190	199	WNL
Sodium	136-145 mEq/L	134	135	138	Low: due to chronic renal insufficiency (p. 420)
Potassium	3.5-5.1 mEq/L	3.6	3.6	3.9	WNL
Chloride	98-107 mEq/L	100	102	103	WNL
Carbon Dioxide	>60 yrs 23-31 mEq/L	27.9	24	21.6	Low: due to metabolic acidosis (p. 127)
BUN	>60 yrs 8-23 mg/dl	6	6	6	Low: possibly due to liver abscesses (p. 456)
Creatinine	>60 yrs 0.6-1.2 mg/dl	0.2	0.3	0.4	Low: possibly due to decreased muscle mass (p. 173)
Random Glucose	70-99	138	92	116	Elevated: may be due to diuretics (p. 229)
Calcium	8.6-10.2 mg/dl	7.9	7.5	7.8	Low: due to renal failure (p. 123)
Phosphorus	2.5-4.5 mg/dl	2.9	3.5	4.0	WNL
Magnesium	1.5-2.5 mEq/L	1.6	1.7	2.1	WNL
Bedside Glucose	70-99		133	86	Elevated: may be due to diuretics (p. 229)
Blood culture	Negative	Candida species		Enterococcus species	May be due to invasive devices (Sepsis Alliance, 2019)

Diagnostic Studies

Date	Procedure	Result	Significance
10/28/19	Abdominal computerized tomography (CT)	Large multiloculated abscess in the right hepatic lobe. Tiny, noncom-municating abscesses in the hepatic dome appear grossly unchanged. A larger tubular-appearing abscess in the right posterior hepatic lobe medially has slightly increased since previous exam on 10/15/19. Evolutionary changes of right posterior renal subcapsular hematoma decreased since 10/15/19. Right nephroureteral stent and nephrostomy tube appropriately positioned. Surgical changes of Whipple’s procedure similar to prior exam. Decrease in right pleural effusion with drainage catheter in place. Slight increase in moderate left pleural effusion. Diffuse anasarca again noted.	Results compatible with patient’s admitting diagnosis of hepatic abscesses, hydronephrosis, and pleural effusion
10/28/19	Pelvic CT	Bladder is mildly distended containing the distal right nephroureteral stent. Surgical changes of the rectosigmoid junction identified. Surgical changes of appendectomy noted; diffuse anasarca identified. No bulky lymphadenopathy identified or any significant fluid.	Results compatible with patient’s history of right ureteropelvic junction (UPJ) obstruction

Vital Signs

Date	Temp	Pulse	RR	B/P	Pulse Ox	O2 Delivery	O2 Flow Rate
10/30/19	98.0	113	25	62/44	84	Non-rebreather mask	100
10/29/19	98.4	115	23	89/55	92	Oxymask	15
10/28/19	97.3	117	18	101/69	100	Nasal Cannula	4
10/27/19	98.1	110	14		100	Nasal Cannula	4
10/26/19	98.6	109	18	107/71	100	Nasal Cannula	4
10/25/19	98.7	121	16	81/55	99	Room air	N/A

Due to this patient’s pancreatic cancer and hydronephrosis, two physiologic problems she

experienced were VRE bacteremia and decreased urinary output. Two psychosocial problems identified were irritability due to multiple treatment procedures and anxiety about her health.

Physiologic Nursing Diagnoses

1. Impaired skin integrity r/t surgical procedures AEB VRE bacteremia (Doenges, Moorhouse & Murr, 2016, p. 783).

2. Excess fluid volume r/t hydronephrosis AEB oliguria and anasarca (Doenges et. al., 2016, p. 338).

Psychosocial Nursing Diagnoses

1. Anxiety r/t health status AEB patient appearing distressed and restless (Doenges et al., 2016, p. 28).

2. Ineffective coping r/t frequent illness AEB patient stating, “I just want to be left alone” (Doenges, et al., 2016, p. 206).

Analysis/Synthesis

I was very concerned about well-being of my patient when she was admitted to the unit. She was very frail in appearance and had a defeated look about her. When she got to her room, she appeared very weak, kept her eyes closed most of the time, moaned a great deal, and kept repeating that she just wanted “to be left alone”. There were a lot of medical personnel in her room in the beginning which created an anxious environment for her. There was also some difficulty in obtaining the blood that was needed for cultures and that caused her a great deal of pain. Once everyone was gone, I tried to make her as comfortable and calm as possible. I kept the lights off and opened the curtains so that there was diffused light in the room. I adjusted the temperature in the room and covered her with a blanket when she told me that she felt cold. I was very gentle as I went through my assessment and I told her everything that I would be doing before I did it so that she would feel less anxious. She was very cooperative and appreciative of my methods. When we found out that she had adult sons, we let her know that a nurse would contact them so they could come and be with her so that she would not be there alone. I believe that also made her less anxious about her situation. When I left her room, I closed the curtain at the doorway to block out some of the light from the nursing station.

By implementing these interventions on that clinical day, I was able to provide comfort measures (calm, quiet environment and blanket), manage the environmental factors in the room (adjust the temperature and lighting so it was less stressful for her), and minimize the stimuli in her room as described in our nursing diagnosis book (Doenges et al., 2016, p. 31-32). When it was time to leave for the day, she appeared to be resting comfortably and no longer anxious.

Because of the positive response from my patient after these interventions, I feel more confident about my ability to implement anxiety-reducing interventions and provide comforting care to any patient who exhibits anxiety. Something I would like to try in the future, if the patient’s condition would allow, is deep breathing exercises. It is something the patient and I could do together, it would not take a lot of time, and it would help to relieve stress and anxiety.

References

Cancer. (2019). Retrieved November 21, 2019, from https://www.sepsis.org/sepsisand/cancer/.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurses pocket guide: diagnoses,

prioritized interventions, and rationales(14th ed.). Philadelphia: F.A. Davis Company

Epidemiology of invasive devices and complications. (2015, October). Retrieved November 22,

2019, from https://www.ahrq.gov/hai/cauti-tools/phys-championsgd/section2.html.

Frequently asked questions about catheters. (2019, May 9). Retrieved November 22, 2019, from

https://www.cdc.gov/hai/bsi/catheter_faqs.html.

Huether, S. & McCance, K. (2017). Understanding pathophysiology (6th ed.) (p. 909). St.

Louis, MO: Elsevier.

Invasive Devices. (2019.). Retrieved November 22, 2019, from

https://www.sepsis.org/sepsisand/invasive-devices/.

Johnstone, J., Chen, C., Rosella, L., Adomako, K., Policarpio, M. E., Lam, F., … Vearncombe,

M. (2018). Patient- and hospital-level predictors of vancomycin-resistant Enterococcus

(VRE) bacteremia in Ontario, Canada. American Journal of Infection Control, 46(11),

1266–1271. doi: 10.1016/j.ajic.2018.05.003

Jun, J. B. (2018) Klebsiella pneumoniae liver abscess. Infection and Chemotherapy, 50(3), 210–

218. doi:10.3947/ic.2018.50.3.210

Lewis, S. M., Bucher, L., Heitkemper, M. M. L., Harding, M. (2017). Medical surgical nursing:

assessment and management of clinical problems (10th ed.). St. Louis: Elsevier.

Mavilia, M. G., Molina, M., Wu, G. Y. (2016) The evolving nature of hepatic abscess: A

review. Journal of Clinical and Translational Hepatology, 4(2), 158–168.

doi:10.14218/JCTH.2016.00004

Pagana, K. D., & Pagana, T. J. (2018). Mosbys manual of diagnostic and laboratory tests (6th

ed.). St. Louis, MO: Elsevier.

Risk factors for cancer. (2105, December 23). Retrieved November 21, 2019, from

https://www.cancer.gov/about-cancer/causes-prevention/risk.

Sepsis. (2019). Retrieved November 20, 2019, from https://www.cedars-sinai.org/health-

library/diseases-and-conditions/s/sepsis.html.

Sepsis. (2019, September). Retrieved November 20, 2019, from

https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx.

Cancer, infection, and sepsis fact sheet. (2019). Retrieved November 21, 2019, from

https://www.cdc.gov/sepsis/pdfs/cancer-infection-and-sepsis-fact-sheet.pdf.

Smith, D. A., & Nehring, S. M. (2019, November 12). Bacteremia. Retrieved November 21,

2019, from https://www.ncbi.nlm.nih.gov/books/NBK441979/.

What is sepsis? (2019, August 27). Retrieved November 20, 2019, from

https://www.cdc.gov/sepsis/what-is-sepsis.html.

What is Sepsis. (2019). Retrieved November 18, 2019, from https://www.sepsis.org/sepsis-

basics/what-is-sepsis/.

Appendix A

Pathophysiology Flow Chart

Appendix B

Subjective (S) and Objective (O) Findings

Data

Findings

Problems Identified

Psychosocial

S: Patient states “I just want to be left alone” d/t multiple medical personnel in her room and multiple attempts to draw blood for culture

O: Patient is visibly agitated and restless

Ineffective coping, r/t frequent illness AEB patient stating, “I just want to be left alone” (Doenges, et al., 2016, p. 136)

Anxiety r/t health status AEB patient appearing distressed and restless (Doenges et al., 2016, p. 28)

Neurologic

S: No headache, dizziness, or tremors; History of TIA without deficit

O: Alert and oriented x 4; appearance, behavior, speech appropriate

Within normal limits

Cardiac

S: No chest pain; no orthopnea; history of HTN

O: Sinus tachycardia on EKG; heart sounds normal, no murmurs

Risk for impaired cardiovascular function r/t age >65 and HTN AEB sinus tachycardia on EKG (Doenges et al., 2016, p. 111)

Respiratory/Thorax

S: No cough; History of pleural effusion

O: SpO2 – 99% on room air; RR – 16; Dyspnea without accessory muscle use; Crackles heard bilaterally; Right chest tube – 450 mL of serosanguineous fluid in drainage system

Impaired gas exchange r/t anemia AEB dyspnea and pleural effusion (Doenges, et al., 2016, p. 358)

GI/Abdominal

S: History of pancreatic cancer with Whipple procedure; LLQ fistula repair; No nausea or vomiting

O: Abdomen soft; slight distention; bowel sounds present x 4; rigid on left; 2 hepatic drains on right attached to collection bag; fluid collected is brown & clear

Impaired skin integrity r/t multiple surgical procedures AEB VRE bacteremia (Doenges, Moorhouse & Murr, 2016, p. 783)

Renal/GU

S: History of hydronephrosis; history of TAH/BSO

O: Right nephrostomy tube connected to collection bag; oliguria; urine is yellow, cloudy

Excess fluid volume r/t hydronephrosis AEB oliguria and anasarca (Doenges et al., 2016, p. 338)

Impaired skin integrity r/t hydronephrosis AEB nephrostomy tube (Doenges et al., 2016, p. 783)

Muscular/Skeletal

S: Arthritis in knees

O: Patient has difficulty moving in bed; appears weak; SCD on legs bilaterally for DVT prophylaxis

Impaired bed mobility r/t physical deconditioning AEB inability to reposition self in bed (Doenges, et al., 2016, p. 542)

Integumentary

S: No history of skin disease; no change in pigmentation; no rash or lesions

O: Intact; warm; appropriate color; IV in left forearm; healed central abdominal wound; scar on left upper chest from previous chemotherapy port

Within normal limits

Peripheral (vascular and neurologic)

S: No tingling or numbness in extremities

O: Edema bilaterally in lower extremities; 2+ pitting edema in right arm

Excess fluid volume r/t decrease in hemoglobin and hematocrit (Doenges et al., 2016, p. 339)

HEENT

S: Patient says she wears glasses – not in room at present

O: PERRLA; EOMs intact; patient wears upper and lower dentures

Within normal limits

Appendix C

Medications

(Skidmore-Roth, 2020)

Generic and Trade Name

Dose/Route/

Frequency

Classification/

MOA

Indication

Side Effects

Teaching points

Daptomycin

(Cubicin RF)

(p. 363)

400mg/NaCl 108mL IV @ 216mL/hr q24hr

Anti-infective; Inhibits DNA, RNA, & protein synthesis

VRE bacteremia;

Pseudomonas

Headache (HA); insomnia; dizziness; heart failure; anemia; thrombocytopenia; rash; rhabdomyolysis; eosinophilic pneumonia; dyspnea

(p. 365)

PT: Allergies before treatment/reaction to medication; Report sore throat, fever, fatigue – could indicate superinfection; Avoid driving; Avoid breastfeeding

NC: Assess: Eosinophilic pneumonia, nephrotoxicity, rhabdomyolysis, bowel function; BP during administration; I/O ratio; check CBC, CPK

(p. 365)

Docusate Sodium

(Colace)

(p. 425)

100mg po BID

Laxative, emollient; stool softener; Increases water, fat penetration in intestine; allows for easier passage of stool

Prevention of dry, hard stools

Bitter taste; throat irritation; nausea; diarrhea; cramps; anorexia; rash

(p. 425)

PT: Normal BM do not always occur daily; Do not use if having abdominal pain, N/V; notify HCP if symptoms unrelieved; may take up to three days to soften stools; Take oral med with full glass of water & increase fluid intake

NC: Assess: cause of constipation; cramping, rectal bleeding, N/V (D/C product if these occur); Evaluate therapeutic response – decrease in constipation

(p. 425)

Fluconazole/NaCl

(Diflucan)

(p. 565)

400mg/200mL IV @ 200mL/hr qday

Antifungal; Inhibits ergosterol biosynthesis, causes direct damage to fungal membrane phospholipids

Fungemia, as indicated by HCP in AICU notes

Seizures; QT prolongation; N/V/D; hepatotoxicity; agranulocytosis; neutropenia; thrombocytopenia; angioedema; Stevens-Johnson syndrome

(p. 566-567)

PT: Notify HCP of N/V/D, jaundice, dark urine, rash, abdominal pain, bleeding; Long-term therapy may be needed to clear infection

NC: Assess: infection – obtain C&S baseline and throughout treatment; QT prolongation; Monitor for increasing AST/ALT, alk phos, bilirubin, BUN, creatinine

(p. 567)

Furosemide

(Lasix)

20mg IV BID

Loop diuretic; Inhibits reabsorption of Na+ & Cl- at proximal & distal tubule and in loop of Henle

Pulmonary edema; Hepatic disease

HA; fatigue; circulatory collapse; tinnitus; hyperglycemia; nausea; diarrhea; renal failure; thrombocytopenia; agranulocytosis; neutropenia; photosensitivity; rash; cramps

(p. 600)

PT: Contact HCP if rash, cramps, nausea, dizziness; Need for high-potassium diet or potassium replacement; recognize adverse reactions; use sunscreen to prevent photo-sensitivity; Take early in the day; Avoid OTC meds unless directed by HCP

NC: Assess: weight, I/O daily; BP; Hearing; Serious rash

(p. 601)

Gabapentin

(Neurontin)

(p. 602)

100mg po BID

Anticonvulsant; Mechanism unknown – gabapentin binding sites in neocortex, hippocampus

Adjunct treatment of partial seizures

Confusion; dizziness; drowsiness; peripheral edema; diplopia; N/V/D; leukopenia; thrombocytopenia; Stevens-Johnson syndrome; myalgia; cough

(p. 603)

PT: Do not D/C medication quickly after long-term use – taper over >1week because withdrawal seizures may occur;

Carry emergency

ID; Avoid driving d/t dizziness; Report changes in vision, diplopia to HCP

NC: Assess: Mental status; Seizures & seizure precautions; Pain; WBC; Therapeutic response – decreased seizure activity

(p. 603)

Heparin Sodium/Dextrose

(p. 634)

25,000 units/500mL IV @ 22mL/hr

Anticoagulant; Prevents conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing inhibitory effects of antithrombin III

DVT & PE prophylaxis;

Anticoagulant for transfusion procedures

HA; fever; chills; hematuria; anemia; heparin-induced thrombo-cytopenia (HIT); rash

(p. 636)

PT: Report any signs of bleeding to HCP; Use soft-bristle toothbrush to avoid bleeding gums; Avoid OTC medications; Notify all HCP of heparin use; Report any rash, chills, fever to HCP

NC: Assess: bleeding, hemorrhage; Blood studies; Thrombosis; HIT; Evaluate therapeutic response – prevention of DVT/PE

(p. 637)

Levothyroxine Sodium (Levoxyl)

(p. 768)

50mcg po qday

Thyroid hormone; Increases metabolic rate, cardiac output, renal blood flow, O2 consumption, body temperature, blood volume via action on thyroid hormone receptors

Hypothyroidism; Thyroid hormone replacement

Anxiety; insomnia; tremors; tachycardia; cardiac arrest; nausea; diarrhea; cramps; weight loss; decreased bone mineral density

(p. 769)

PT: Report excitability, anxiety; Avoid OTC meds with iodine; Take on empty stomach 30 min. before food; Treatment is life-long

NC: Assess BP; daily weight; thyroid studies; bleeding/bruising; increased nervousness; cardiac status; bone density

(p. 770)

Senna

(Senokot)

(Burcham & Rosenthal, 2019, p. 976)

1 tablet po qday

Stimulant laxative; Stimulates intestinal motility; Increases amount of water and electrolytes within intestinal lumen

Constipation

Abdominal pain; nausea, cramps; diarrhea

(p. 980)

PT: Can cause harmless pink or yellowish-brown color to urine; Educate about normal bowel function; Exercise after meals

NC: Assess therapeutic response – decrease in constipation

Oxycodone HCl

(p. 973)

5mg po q6hr PRN pain

Opiate analgesic; Inhibits ascending pain pathways in CNS, increases pain threshold, alters pain perception

Moderate to severe pain

Drowsiness; dizzi-ness; confusion; respiratory depression; bradycardia; tinnitus; blurred vision; N/V; constipation; dysuria; increased urinary output

(p. 975)

PT: Physical dependency may result from extended use; withdrawal symptoms may occur after long-term use: N/V, cramps; Avoid CNS depressants, alcohol; Report any CNS changes, allergic reactions

NC: Assess: pain, I/O ratio, CNS changes, Allergic reactions; Bowel status

Evaluate therapeutic response – decrease in pain without dependence

(p. 975)

Ibuprofen (Motrin)

(p. 661)

600mg po q6h PRN fever

NSAID; Inhibits COX-1, COX-2 by blocking arachidonate

Antipyretic

HA; dizziness; tachycardia; CV thrombotic events; MI; stroke: tinnitus; hepatitis; GI bleeding, ulceration, GI perforation; nephrotoxicity; blood dyscrasias; rash

(p. 662)

PT: Report blurred vision, roaring in ears; Avoid driving if dizzy or drowsy; Report change in urinary pattern, edema, hema-turia; Avoid alcohol; Take with full glass of water, take with food to decrease GI effects

NC: Assess: renal, hepatic, blood studies: BUN, Cr, AST, ALT, Hgb stool guaiac; Cardiac status – peripheral edema, tachycardia, monitor BP; Pain – note type, duration, location, intensity

(p. 663)

Appendix D

Physiologically-Based Diagnosis/Problem

Excess fluid volume r/t hydronephrosis AEB oliguria and anasarca (Doenges et al., 2016, p. 338)

Desired Outcome

Dependent Interventions

Independent Interventions

Evaluation of the Outcome

Short-term Goal

The patient will demonstrate decrease in shortness of breath by the end of the nursing shift

Long-term Goal

The patient will verbalize understanding of individual dietary and fluid restrictions by time of discharge from hospital.

Short-term Goal

The nurse will:

1. Work with the primary care physician to administer medications (e.g., diuretics, steroid replacement, plasma or albumin volume expanders), reducing congestion and edema. (Doenges et al., 2016, p. 341)

2. Work with the nephrologist to prepare for and assist with procedures as indicated (e.g., peritoneal or hemodialysis, ultrafiltration; mechanical ventilation). This may be done to correct volume overload, correct electrolyte and acid-base imbalances, or improve cardiac function and support individual during shock state. (Doenges et al., 2016, p. 342)

Long-term Goal

The nurse will:

1. Review laboratory data (e.g., Hb/Hct, BUN/Cr, serum albumin, proteins, and electrolytes, urine studies, and chest x-ray) with the primary care physician to evaluate the degree of fluid and electrolyte imbalance and response to therapies. (Doenges et al., 2016, p. 341)

2. Work with a dietician as needed to develop dietary plan and identify foods to limited or omitted (Doenges et al., 2016, p. 342)

Short-term Goal

The nurse will:

1. Place patient in semi-Fowler’s position when at bedrest, as appropriate. This may promote recumbency-induced diuresis and facilitate respiratory effort when movement of the diaphragm is limited or breathing is impaired because of lung congestion. (Doenges et al., 2016, p. 342)

2. Elevate edematous extremities and change position frequently to increase venous return to the heart and reduce edema, reduce tissue pressure and risk of skin breakdown. (Doenges et al., 2016, p. 341)

Long-term Goal

The nurse will:

1. Instruct the client in ways to keep track of intake (e.g., marked water bottle) and output (e.g., use of voiding record) to monitor possible development of fluid overload (Doenges et al., 2016, p. 342)

2. Instruct patient to weigh themselves on regular basis, and report gain of more than 2 pounds/day (or as indicated by individual situation). If weight is rising daily, fluid is likely being retained. (Doenges et al., 2016, p. 342)

Short-term Goal

Met

The patient appeared to be breathing more easily by the end of the shift.

Long-term Goal

Not Met

The patient expired prior to discharge.

Appendix E

Psychosocially-Based Diagnosis/Problem

Anxiety r/t health status AEB patient appearing distressed and restless (Doenges et al., 2016, p. 28)

Desired Outcome

Dependent Interventions

Independent Interventions

Evaluation of the Outcome

Short-term Goal

The patient will appear relaxed and report that anxiety is reduced to a manageable level by the end of the nursing shift

Long-term Goal

The patient will identify healthy ways to deal with and express anxiety by time of discharge from hospital.

Short-term Goal

The nurse will:

1. Work with the primary care physician to provide accurate information about the situation. This helps the client identify what is reality based. (Doenges et al., 2016, p. 31)

2. With the primary care physician, review results of diagnostic tests (e.g., drug screens, cardiac testing, CBC, and chemistry panel) which may point to physiologic sources of anxiety. (Doenges et al., 2016, p. 31)

Long-term Goal

1. Work with social workers to list helpful resources and people to provide ongoing/timely support. (Doenges et al., 2016, p. 33)

2. Work with primary care physician to determine if currently prescribed medications (e.g., steroids, thyroid preparations) are appropriate. These medications can heighten feelings and sense of anxiety (Doenges et al., 2016, p. 30)

Short-term Goal

The nurse will:

1. Manage environmental factors such as harsh lighting and high traffic flow, which may be confusing and stressful for older individuals. (Doenges et al., 2016, p. 32)

2. Provide comfort measures (e.g., calm/quiet environment, soft music, warm bath, or back rub) to help lessen feelings of anxiety. (Doenges et al., 2016, p. 31)

Long-term Goal

1. Monitor vital signs (e.g., rapid or irregular pulse, rapid breathing/hyperventilation, changes in blood pressure, diaphoresis, tremors, or restlessness) to identify physical responses associated with both medical and emotional conditions. (Doenges et al., 2016, p. 30)

2. Modify procedures as much as possible (e.g., substitute oral for intramuscular medications or combine blood draws/use fingerstick method) to limit the degree of stress and avoid overwhelming an anxious adult. (Doenges et al., 2016, p. 32)

Short-term Goal

Met

By the end of the shift, the patient was resting comfortably and appeared to be calm.

Long-term Goal

Not Met

Patient expired prior to discharge.

homework

image1.emf