Patient Profile 1
Christopher Lando
School of Nursing, Liberty University
NURS 031-001: Strategies for Adult Health Care 1 Clinical
Mrs. Davis
09/11/2020
1
PATIENT PROFILE WORKSHEET
Clinical Date: _ 09_ / _ 11_ / __ 2020
A. Personal Information
Room # _ 542_ Gender _ F_ Ethnicity _ White_ Age if <90 _ 69_
Place of Residence: __ home MD _ Vanichkachorn, Jed, MD_
Emergency Contact: _ Sister_ Marital Status _ Divorced_
Admitting Diagnosis: _ Spinal stenosis, lumbar_
Co-Morbidities: _ Asthma, Hypertension, GERD, Liver disease, Diabetes Mellites type 2 _
Date of Admission: _ 09/09/20_ Date of Surgery: _09/09/20_ Allergies: _ Macrobid,
Prochlorperazine, Biaxin, Contrast agent (Iodine), and Percocet_
Code Status: _ Full_ Mental Status: _ A&Ox4_
B. Activity and Nutrition
Diet order: _ Diabetic_ Route/Rate: _ PO_ Last Wt: _ 87.1 Kg_
Level of Activity (bedrest, up ad lib, BRP, turning): _ Ambulation with aid_
Level of self-care: _ high_
C. Nursing Care
Drainage devices (foley, NGT, JPs, T-tube, etc.): _ Hemovac on back_ NGT Flushes:
_ NL_
Wound care/Dressing (be specific): _ gauze on incision wounds; Back, left leg, right leg. _
IV access (peripheral, central, location, care): _ Right central in CVC_
IVF: __ @ __ mL/hr Saline Lock? Locked__ TPN? _ NL_
Frequency of vital signs (including pulse oximetry): _ Q 6 hr_
Frequency of Glucometer: _ ACHC & bedtime_ Supplemental oxygen: _ 2 lpm via nasal
canula PRN_ OSA __ yes
2
Falls Risk _ high_
Precautions: _ none other than listed above_
3
Most Recent Labs
Lab Normal range Patient value Date/time Out of range?
CBC
WBC 4500-11000 nL
RBC 4000000-5200000
nL
Hb 12.5-16.0 g/dl 9.8 9/11/20 0355 Low
Hct 36-46%
MCV 80-100 nm^3
MCH 26-34 pg/cell
MCHC 31-37 g/dl
RDW 11.5-14.5%
Plts 165000-
415000 /ml
CHEM 12
Na+ 133-143 mEq/dl 136 9/10/20 0312
K+ 3.5-5.1 mEq/dl 4.6 9/10/20 0312
Cl- 98-107 mEq/dl 101 9/10/20 0312
TCO2 22-28 mEq/dl 24 9/10/20 0312
Anion Gap 7-16 mEq/dl 11 9/10/20 0312
Glucose 70-100 mEq/dl 156 9/11/20 1151 high
BUN 7-20 mg/dl 21 9/10/20 0312 high
Cr 0.6-1.2 mg/dl 0.97 9/10/20 0312
Calcium 9.0-10.5 mg/dl 8.7 9/10/20 0312
Total protein 6.3-8.2 g/dl
Albumin 3.5-5.5 g/dl
AST 0-35 IU/L
ALK 38-126 IU/L
Total bilirubin 0.3-1.0 mg/dl
ALT 0-35 IU/L
GFR 106-132 mOm/Kg 57 9/10/20 0312 Low
Osmolality 275-295 mOm/Kg
OTHER LABS
[ CITATION RHm10 \l 1033 ]
Other Diagnostic Tests
4
Diagnostic Study Date & Time Results
EKG
RADIOLOGY EXAMS 9/9/20
1940-1945 xR Chest Port (shows
central line in right spot)
1520-1636 xR Spine Thorac 2 V
imagery throughout surgery
Vital Signs
Date/Tim
e
Temp HR RR BP SpO2
9/11/20
1525
98.8 92 18 132/65 98%
9/11/20
1816
98.4 94 17 145/67 90%
PATIENT HISTORY WORKSHEET
Chief complaint:
Scheduled surgery to help alleviate pain in back
History of Present Illness:
Pt. has been suffering pain for many months. Has had this surgery a few months ago to take pain
away. Surgery did really help but there are feelings that more can be done. So, the Pt. is now
back to do a repeat of the surgery, but this time increase the depth fused.
Past Medical History:
No perennate past medical history on file.
Past Surgical History:
A few months ago this surgery was performed, other than that no perennate history shown.
Family History:
Not listed
5
Tobacco _ NL_ Alcohol _ NL_ Illegal Drugs _ NL_
Occupational Status __ retired
Religious Preference __ NL
Cultural Support Needs __ NL
PHYSICAL ASSESSMENT
GENERAL: (overall assessment)
Pt. is in a lot of pain; drain is still pulling fluid from the surgical site on her back. Once drain
stops producing fluid the Pt. has met all other objectives to be discharged. Pain is the only
notable concern the Pt. has about her healing process.
HEENT: (ED only)
Click or tap here to enter text.
CARDIAC: (heart sounds, rate, rhythm, pulses, circulation, etc)
S1 and S2 heard on auscultation, rate was 92 beats per minute. Rhythm was regularly regular
with equally strong pules bilaterally in both upper and lower extremities.
RESPIRATORY: (lung sounds, work of breathing, O2 sat)
Lungs were clear and loud bilaterally; pulse oximetry percentage was at 93%. Lobes were clear
upon auscultation.
ABDOMEN/GI: (bowel sounds, overall assessment)
Overactive bowel sounds (due to not eating dinner the night prior).
GU: (urinary output, catheters, etc.)
Pt. has been able to void and defecate since surgery in a manner that was similar to prior habits.
MUSCULOSKELETAL: (strength, gait, mobility status)
ROM, mobility, and strength are equal and strong.
6
INTEGUMENT: (list any wounds, dressings, other issues)
Incision on back from surgery, CVC triple lumen central line.
NEURO: (A&O x 4, pupils, etc.)
A&Ox4, PERRLA pupils, fully focused and aware. Attentive.
7
PATHOPHYSIOLOGY
The patient was admitted to the hospital following her scheduled surgery. The patient was
dealing with chronic back pain due to her kyphosis. Surgery was performed a few months ago to
fuse a few lumbar sections together, this procedure was successful but not enough vertebrae were
infused to produce the desire pain relief. Due to such results the surgeon scheduled a secondary
date to perform a spinal stenosis and thoracolumbar fusion from thoracic vertebrae number four
(T4) to the pelvis. The patient upon clinical date was in the recovery phase three days post
operation, chief complaint at this time was pain rated 8 on the scale 0-10. Which directly relates
to the highest nursing care plan of dealing with the pain. Airway was patent and under no threat
of obstruction. Breathing was regular, nonlabored, and clear bilaterally. The only potential
concern is the pulse oximetry reading was in the low 90’s, which indicates mild hypoxia. Seeing
that the patient was in serve pain and on an opioid the pulse oximetry is not a major concern so
long as her respiration rate and quality don’t bottom out. This puts respirations at an at risk for
category and due to such not the highest priority. Circulation was a concern during the surgery
and immediately after the operation. Now it is an at risk for category because the patient is at risk
for developing an embolus. Leaving pain as the highest actual concern, so the focus for this
patient is pain relief while also monitoring for the development of thrombi and the prevention
needed.[ CITATION Tan19 \l 1033 ]
The patient has an extensive history of Hyperlipidemia, Hypertension, Diabetes Mellites
type two, and is obese. Hypertension due to the inappropriate response of the chemoreceptors
located on the elastic tissues on the artery walls leading to vasoconstriction creating a higher-
pressure flow of the blood. And pairing with the stress response the blood pressure rises even
8
more. When the body identifies an internal or external form of distress it enters the general
adaptation system response, where many different hormones affect the body. First off will be the
release of adrenocorticotropic hormone (ACTH) from the pituitary gland which will travel in the
blood and stimulate the adrenal glands in releasing epinephrine, norepinephrine, and cortisol.
Epinephrine and norepinephrine are detected by beta1 receptors on the cell wall, which sends a
reflexive signal for the arteries to vasoconstrict. The beta1 receptor also signals to cortisol which
is a natural steroid to reduce inflammation by flooding a wound and acting as a means to reduce
the number of white blood cells at a certain location. This response is natural and good for a
short period of time, reducing edema, erythema, and overall reducing the immune system as a
whole. This is necessary to prevent that edema from potentially swelling so fast as to cause a
block in the blood vessels, nerves, and muscle fibers and thus starting compartment syndrome.
But too much of a good thing is never actually a good thing, when cortisol stays high for a long
period of time a patient is more likely to develop a sickness due to lack or white blood cell
response. So, in a post-surgical patient the healthcare team needs to be very cautious of the
potential for an infection both local and systemic. Cortisol also has a role in glucose levels,
because the body needs to quickly get energy during the alarm and beginning of resistance phase
cortisol and epinephrine work together to snap the body into ketoacidosis by breaking and
mobilizing some of the fat storage and turning it into glucose. This allows the blood glucose
levels to raise and allow for an immediate energy source as the body is in flight or fight stage.
During this time the vasoconstriction is also happening, as is the heartrate being increased from
the beta1 cells sending signals telling the SA node to fire faster. An increased blood pressure and
higher heart rate means a higher cardiac output, this is potentially lethal in patients with cardiac
comorbidities or chronically in patients with hyperlipidemia. The same chemo response that
9
triggered the systemic vasoconstriction also communicates with the capillaries and shunts blood
away from the gastral intestines and into the larger muscles of the legs promoting flight or fight.
Chemoreceptors also do the inverse at the pulmonary passages, meaning they bronchi dilate and
allow for a higher rate of gas exchange while also stimulating a higher respiratory rate and depth
(similar to that during heavy exercise). Just like the lungs the eyes also experience a dilation, but
in the pupils. Which allow for more light to be taken in and sent to the brain, this means a higher
level of awareness is achieved and will help the patient in determining if this stress is best
responded to with flight or fight. [ CITATION May191 \l 1033 ]
Hyperlipidemia, obesity, diabetes mellites type two, and hypertension are all related to
the stress response. Hyperlipidemia will cause a negative outlook because when the cardiac
output is increased as a result of epinephrine that cardiac output is raised. This results in the
lipids free floating to start slamming against the walls like a balloon and overtime/ after a long
period of time cause an aneurysm. If the patient has hyperlipidemia then they most likely have
fatty deposits blocking a percentage of the artery. Lipids floating around during this time can also
knock one of these thrombi off the wall and cause an embolism. This potential for an embolism
is one of the major risks following any surgery and is why the hospital is very purposeful with
movements. Add in the patient’s additional risk factors being obese and the history of
hypertension, and the risk for stasis blood dramatically increase. Static blood is one of the three
major causes of an embolus, known as Virchow’s triad. The other two points are hypercoagulable
state and vessel wall injury. The patient has a vessel wall injury as noted by her history of
surgery, meaning that as her incision is healing her cellular level is working overtime producing
histamine and responding to cortisol reducing histamine. With the purpose to keep a balance of
hemostasis in the patient’s body to help maintain homeostasis. Hypercoagulability describes the
10
hematology values and the bodies capabilities to form a clot. So, the hypercoagulability can be
evidenced by an increased Partial Thromboplastin Time (PTT), Prothrombin Time (PT),
Hemoglobin (Hgb), Hematocrit (Hct), and Platelets (Plt). The only notable value would be the
patients Hgb, which was low. However, hyperlipidemia still increases the risk for being in a
hypercoagulable state. Meaning that this patient has marked the check box for high risk of a
thrombus being formed, then turning into an embolus. Another note coming fresh from surgery is
that the patient has a low value for the globular filtration rate (GFR) and a high value for her
blood urine nitrogen (B.U.N). Partly due to the stress response shunting blood away from the
kidneys, decreasing the filtration rate, increasing the B.U.N. Partly due to the blood loss during
surgery also causing shunting from kidneys. And lastly due to blood loss causing a lower volume
and in turn reducing filtration rate. [ CITATION Pie14 \l 1033 ]
The patient also has diagnosed type two diabetes mellitus, this is where the insulin
produced by the beta cells in the islets of Langerhans in the pancreas are decreased or diminished
and the therapeutic intended purpose in the body can no longer be met. Resulting in an increased
blood glucose level, which is shown in the lab values for her. She has a blood glucose level of
156 which is high, partially due to the stress response which increases the blood glucose levels
naturally as the body breaks down some fat for energy during the response phase. This is the
reason the patient has been prescribed Insulin glargine and Insulin Lispro. The glargine is a long-
acting insulin, the patient was prescribed “as needed”. Lispro was also prescribed as a sliding
scale. Meaning doses will be given before every meal and before dinner. The insulin assists the
ineffective amount released by the pancreas in controlling the blood glucose levels. Insulin
attaches to the free sugar floating in the blood stream and delivers it muscles to break into
Adenosine triphosphate (ATP). Which is required for the immediate energy source during the
11
flight or fight response, also known as during the stress response. The excess amount is then
deposited into the yellow adipose tissues as a method of stage for when it is needed later. So,
when the insulin is not produced at the rate required to adequately serve the bodies need the body
starts craving more sugar. Because it doesn’t know why it doesn’t have enough glucose in the
muscles and fat. The three common signs indicating that there is an issue with insulin is known
as the three P’s. The three P’s include Polyphagia, Polyuria, and Polydipsia. Polyphagia is the
desire to eat more, because the body has chemoreceptors in the blood that detect the amount of
blood glucose but only for the function of relaying to the pancreas how much insulin to produce.
So, when the pathway is broken somewhere along the line the chemoreceptors no longer function
the way the need to and the body isn’t able to differentiate how much glucose is free floating in
the blood. So of course, the first response is to eat more food, which would raise the blood
glucose levels in a normal human. The next compensatory function would be polydipsia,
drinking water. Because the body senses the changes in the blood and doesn’t know why, so the
response is to drink water and try and retain an isotonic blood serum. Which leads right into the
next sign of polyuria, where the patient voids often. When a patient drinks a lot of water, a
patient then needs to void.[ CITATION Tan19 \l 1033 ]
The patient has many active medications currently ongoing, Amlodipine, Atorvastatin,
Losartan, Metoprolol Succinate, Hydromorphone, Senna-docusate, and Polyethylene glycol. The
Amlodipine inhibits excitation-contraction by inhibiting the transport of calcium into the
myocardium and helps to reduce the effects of hypertension. Atorvastatin suppresses an enzyme
which is responsible for helping synthesis cholesterol and helps to reduce the low-density lipids
(LDLs) and in turn help reduce the hyperlipidemia. Losartan blocks the vasoconstrictor and
aldosterone-secreting effects of angiotensin II, which helps lower the blood pressure. Metoprolol
12
succinate blocks the beta1 adrenergic receptors from stimulation, which reduces both the heart
rate and blood pressure in this patient. Senna-docusate acts as an irritant on the colon and
stimulates peristalsis; also, it works on incorporating some water into the stool to create a softer
stool. Resulting in the use for this patient as a stool softener, which is helpful since defecation is
required prior to discharge. Polyethylene glycol draws water into the lumen of the intestines, acts
as an osmotic agent, and therefore acts as a stool softener. Hydromorphone is an opiate that binds
to receptors in the central nervous system (CNS) to decrease the painful stimulation and
therefore act as an analgesic. [ CITATION Val19 \l 1033 ]
In conclusion the patient is on a good route to recovery from her surgery, and the healing
process is well underway. The patient has only pain as her chief complaint, mobility is on the rise
and she is active in moving because she has been educated the risk of developing a thrombus.
The nurse needs to evaluate a further increase in mobility before discharge is able to happen. The
risk of a clot is high, but the patient is on the right track not to get one. The diabetes will be a
focal point that the patient needs to understand proper regulation to ensure quick healing times.
13
MEDICATION LIST
Medication
Generic & Trade Route Dosage &
Frequency
Category/
Mechanism of Action
Contraindications /
Cautions
Side Effects Use for this
patient
Trade
(Generic)
Acetaminophen PO 1,000mg Q6 hr Inhibits synthesis of
prostaglandins that
may serve as
mediators of pain and
fever, primarily in the
CNS. Has no
significant anti-
inflammatory
properties or GI
toxicity. Therapeutic
Effects: Analgesia.
Antipyresis.
Contraindicated
in: Previous hypersensitivity;
Products containing alcohol,
aspartame, saccharin, sugar,
or tartrazine (FDC yellow dye
#5) should be avoided in
patients who have
hypersensitivity or
intolerance to these
compounds; Severe hepatic
impairment/active liver
disease.
CNS: agitation (↑ in
children) (IV),
anxiety (IV),
headache (IV),
fatigue (IV),
insomnia
(IV). CV: hypertensio
n (IV), hypotension
(IV). Derm: acute
generalized
exanthematous
pustulosis, stevens-
johnson
syndrome, toxic
epidermal necrolysis,
rash, urticaria. F
and E: hypokalemia
(IV). GI: hepatotoxici
ty (↑ doses),
constipation (↑ in
children) (IV), ↑ liver
enzymes, nausea
(IV), vomiting
(IV). GU: renal
failure (high
doses/chronic
use). Hemat: neutr
openia,
pancytopenia. MS:
muscle spasms (IV),
trismus
(IV). Resp: atelecta
sis (↑ in children)
Help kill pain,
beat swelling,
and act as an
antipyresis if
need be
14
(IV), dyspnea (IV).
amlodipine PO 10 mg
daily
Inhibits the transport
of calcium into
myocardial and
vascular smooth
muscle cells, resulting
in inhibition of
excitation-contraction
coupling and
subsequent
contraction. Therape
utic Effects: Systemic
vasodilation resulting
in decreased BP.
Coronary vasodilation
resulting in decreased
frequency and severity
of attacks of angina.
Ontraindicated
in: Hypersensitivity; Systolic
BP <90 mm Hg. Use
Cautiously in: Severe
hepatic impairment (dose
reduction recommended);
Aortic stenosis; History of
HF; Obstetric: Lactation: P
ediatric: Children <6 yr
(safety not
established); Geriatric: Dos
e reduction recommended; ↑
risk of hypotension.
CNS: dizziness,
fatigue. CV: periph
eral edema,
angina, bradycardia,
hypotension,
palpitations. Derm:
flushing. GI: gingiva
l hyperplasia,
nausea.
Pt. has high
blood pressure
and this
medication
lowers the BP
Atorvastatin PO 10 mg
daily
nhibits 3-hydroxy-3-
methylglutaryl-
coenzyme A (HMG-
CoA) reductase, an
enzyme which is
responsible for
catalyzing an early
step in the synthesis
of
cholesterol. Therape
utic Effects: Lowering
of total and LDL
cholesterol and
triglycerides. Slightly
increases HDL
cholesterol. Reduction
of lipids/cholesterol
reduces the risk of
myocardial infarction
and stroke sequelae.
Slows the progression
Contraindicated
in: Hypersensitivity; Active
liver disease or unexplained
persistent elevations in AST
and
ALT; Obstetric: Potential for
fetal
anomalies; Lactation: May
appear in breast milk. Use
Cautiously in: History of
liver disease; Alcoholism;
Renal impairment;
Concurrent use of
gemfibrozil, azole
antifungals, erythromycin,
clarithromycin, protease
inhibitors, niacin, or
cyclosporine (higher risk of
myopathy/rhabdomyolysis);
Obstetric: Women of
childbearing
CNS: amnesia,
confusion, dizziness,
headache, insomnia,
memory loss,
weakness. EENT: rh
initis. Resp: bronchi
tis. CV: chest pain,
peripheral
edema. GI: abdomi
nal
cramps, constipati
on, diarrhea, flatus
, heartburn, altered
taste, drug-induced
hepatitis, dyspepsia,
↑ liver enzymes,
nausea,
pancreatitis. Endo:
hyperglycemia. GU:
erectile
dysfunction. Derm:
This med
lowers the
amount of
lipids floating
around by
getting rid of
some LDLs
15
of coronary
atherosclerosis with
resultant decrease in
coronary heart
disease–related
events.
age; Pediatric: Children
<10 yr (safety not
established).
rashes,
pruritus. MS: rhabd
omyolysis,
arthralgia, arthritis,
immune-mediated
necrotizing
myopathy, myalgia,
myositis. Misc: hyper
sensitivity reactions
includingangioneurotic
edema.
Cholecalciferol PO 1000units/25m
cg (3 tablets)
Daily
Requires activation in
the liver and kidneys
to create the active
form of vitamin
D3(calcitriol). Promotes
the intestinal
absorption of dietary
calcium. Therapeutic
Effects: Treatment
and prevention of
deficiency states,
particularly bone
manifestations.
Contraindicated
in: Hypersensitivity;
Hypercalcemia; Vitamin D
toxicity; Concurrent use of
magnesium-containing
antacids or other vitamin D
supplements; Malabsorption
problems. Use Cautiously
in: Obstetric: Safety not
established.
Seen primarily as
manifestations of
toxicity
(hypercalcemia)
CNS: headache,
irritability,
somnolence,
weakness. EENT: co
njunctivitis,
photophobia. CV: ar
rhythmias,
hypertension. GI: a
norexia,
constipation, dry
mouth, ↑ liver
enzymes, metallic
taste,
nausea, pancreatitis,
polydipsia, vomiting,
weight
loss. GU: albuminuri
a, azotemia,
polyuria. Derm: pru
ritus. F and
E: hypercalcemia.
MS: bone pain,
muscle pain.
This med is to
help with the
liver since this
patient has a
semi broken
liver. And
allows for the
absorption of
extra calcium
through the GI
tract
Famotidine PO 20mg Inhibits the action of Contraindicated CNS: confusion, Inhibits gastric
16
BID histamine at the H2-
receptor site located
primarily in gastric
parietal cells, resulting
in inhibition of gastric
acid
secretion. Therapeut
ic Effects: Healing
and prevention of
ulcers. Decreased
symptoms of
gastroesophageal
reflux. Decreased
secretion of gastric
acid.
in: Hypersensitivity;
Phenylketonuria (chewable
tablets
only); Obstetric: Crosses
placenta; no adequate
human
studies; Lactation: Disconti
nue breastfeeding to avoid
exposure of infant to serious
side effects. Use
Cautiously in: Renal
impairment (more
susceptible to adverse CNS
reactions; ↑ dosage interval
recommended if CCr <10
mL/min); Pediatric: Injection
contains benzyl alcohol
which has been associated
with gasping syndrome in
neonates; Geriatric: More
susceptible to adverse CNS
reactions; dose ↓
recommended.
dizziness,
drowsiness,
hallucinations,
headache. CV: arrh
ythmias. GI: constip
ation, diarrhea,
nausea. GU: ↓
sperm count, erectile
dysfunction. Endo:
gynecomastia. Hem
at: agranulocytosis,
aplastic anemia,
anemia,
neutropenia,
thrombocytopenia.
Local: pain at IM
site. Misc: hyperse
nsivity reactions.
acid, inhibiting
GERD
Insulin glargine
(Lantus)
SubQ 60 units
daily
Lowers blood glucose
by : stimulating
glucose uptake in
skeletal muscle and
fat, , inhibiting hepatic
glucose production..
Other actions of
insulin: inhibition of
lipolysis and
proteolysis, ,
enhanced protein
synthesis.. Therapeu
tic Effects: Control of
hyperglycemia in
diabetic patients.
Contraindicated
in: Hypoglycemia; Allergy or
hypersensitivity to insulin
glargine. Use Cautiously
in: Stress and infection,
which may temporarily
increase insulin
requirement); Renal/hepatic
impairment (may ↓ insulin
requirements); Concomitant
use with pioglitazone or
rosiglitazone (↑ risk of fluid
retention and worsening HF).
Patients with visual
impairment who may rely on
audible clicks to dial their
dose
(Toujeo); Pediatric: Safety
and effectiveness not
established in children <18
Endo: hypoglycemia
. F and
E: hypokalemia. Lo
cal: lipodystrophy,
pruritus, erythema,
swelling. Misc: aller
gic reactions
including anaphylaxi
s.
Used to drop
BG levels if
and when need
be
17
yr (Toujeo) or <6 yr (Basaglar
and
Lantus); Obstetric: May
temporarily ↑ insulin
requirements.
Insulin lispro
(Humalog)
SubQ 4 times daily
AC
140-199= 2
units
200-249=3
units
250-299=4
untis
300-349=7
untis
350+ call MD
Bedtime
200-249=2
untis
250-299=3
units
300-349=4
units
350+ call MD
Lowers blood glucose
by: stimulating glucose
uptake in skeletal
muscle and fat, ,
inhibiting hepatic
glucose production..
Other actions of
insulin: inhibition of
lipolysis and
proteolysis, ,
enhanced protein
synthesis.. A rapid-
acting insulin with
more rapid onset and
shorter duration than
human regular insulin;
should be used with an
intermediate- or long-
acting
insulin. Therapeutic
Effects: Control of
hyperglycemia in
diabetic patients.
Contraindicated
in: Hypoglycemia; Allergy or
hypersensitivity to insulin
lispro; Hypoglycemia. Use
Cautiously in: Stress or
infection—may temporarily ↑
insulin
requirements); Renal/hepati
c impairment—may ↓ insulin
requirements; Must be used
with a longer-acting insulin in
patients with type 1
diabetes; Concomitant use
with pioglitazone or
rosiglitazone (↑ risk of fluid
retention and worsening
HF). Obstetric: Pregnancy
may temporarily ↑ insulin
requirements; Pediatric: Ch
ildren <3 yr (safety of lispro
insulin not established) or
<18 yr (safety of 75/25 mix
not established).
Endo: hypoglycemia
. F and
E: hypokalemia. Lo
cal: lipodystrophy,
pruritus, erythema,
swelling. Misc: aller
gic reactions
including anaphylaxi
s.
Used regularly
before eating
to keep BG
levels
managable
Losartan PO 100/25 mg
daily
Blocks the
vasoconstrictor and
aldosterone-secreting
effects of angiotensin
II at various receptor
sites, including
Contraindicated
in: Hypersensitivity; Bilateral
renal artery
stenosis; Obstetric: Can
cause injury or death of fetus
– if pregnancy occurs,
CNS: dizziness,
fatigue, headache,
insomnia,
weakness. CV: ches
t pain, edema,
hypotension. EENT:
Anto0ehr drug
that will lower
the BP in this
Pt.
18
vascular smooth
muscle and the
adrenal
glands. Therapeutic
Effects: Lowering of
BP in hypertensive
patients. Decreased
progression of diabetic
nephropathy.
Decreased incidence
of stroke in patients
with hypertension and
left ventricular
hypertrophy (effect
may be less in black
patients).
discontinue
immediately. Lactation: Dis
continue drug or use
formula. Use Cautiously
in: Volume- or salt-depleted
patients or patients receiving
high doses of diuretics
(correct deficits before
initiating therapy or initiate
at lower doses); Black
patients (reduction in stroke
risk may not apply to this
patient population); Impaired
renal function due to primary
renal disease or heart failure
(may worsen renal function);
Hepatic impairment (lower
initial doses recommended);
Women of childbearing
potential; Pediatric: Childre
n <6 yr (safety not
established).
nasal
congestion. Endo: h
ypoglycemia, weight
gain. GI: diarrhea,
abdominal pain,
dyspepsia,
nausea. GU: impair
ed renal function. F
and
E: hyperkalemia. M
S: back pain,
myalgia. Misc: angi
oedema, fever.
Metoprolol
succinate
PO 50 mg
daily
Blocks stimulation of
beta1(myocardial)-
adrenergic receptors.
Does not usually affect
beta2(pulmonary,
vascular, uterine)-
adrenergic receptor
sites. Therapeutic
Effects: Decreased BP
and heart rate.
Decreased frequency
of attacks of angina
pectoris. Decreased
rate of cardiovascular
mortality and
hospitalization in
patients with heart
failure.
Contraindicated
in: Uncompensated HF;
Pulmonary edema;
Cardiogenic shock;
Bradycardia, heart block, or
sick sinus syndrome (in
absence of a
pacemaker). Use
Cautiously in: Renal
impairment; Hepatic
impairment; Geriatric: ↑
sensitivity to beta blockers;
initial dose reduction
recommended; Pulmonary
disease (including asthma;
beta1selectivity may be lost
at higher doses); Diabetes
mellitus (may mask signs of
hypoglycemia);
Thyrotoxicosis (may mask
symptoms); Patients with a
CNS: fatigue, weak
ness, anxiety,
depression,
dizziness,
drowsiness,
insomnia, memory
loss, mental status
changes,
nervousness,
nightmares. CV: bra
dycardia, hf, pulmon
ary edema,
hypotension,
peripheral
vasoconstriction. De
rm: rash. EENT: blu
rred vision, stuffy
nose. Endo: hypergl
ycemia,
hypoglycemia. GI: c
onstipation,
This drug
lowers both
the heart rate
and the blood
pressure in the
paitent.
19
history of severe allergic
reactions (intensity of
reactions may be increased);
Untreated
pheochromocytoma (initiate
only after alpha blocker
therapy
started); Obstetric: Safety
not established; crosses the
placenta and may cause
fetal/neonatal bradycardia,
hypotension, hypoglycemia,
or respiratory
depression. Lactation: Safe
ty not
established. Pediatric: Safe
ty and effectiveness not
established in children <18
yr (tablets, extended-release
tablets, and injection) or
children <6 yr (extended-
release capsules).
diarrhea, drug-
induced hepatitis,
dry mouth,
flatulence, gastric
pain, heartburn, ↑
liver enzymes,
nausea,
vomiting. GU: erect
ile dysfunction, ↓
libido, urinary
frequency. MS: arth
ralgia, back pain,
joint
pain. Resp: bronch
ospasm,
wheezing. Misc: dru
g-induced lupus
syndrome.
Polyethylene
glycol
PO 17 g
daily
Polyethylene glycol
(PEG) in solution acts
as an osmotic agent,
drawing water into the
lumen of the GI
tract. Therapeutic
Effects: Evacuation of
the GI tract without
water or electrolyte
imbalance.
Contraindicated in: GI
obstruction; Gastric
retention; Toxic colitis;
Megacolon; Bowel
perforation. Use Cautiously
in: Abdominal pain of
uncertain cause, particularly
if accompanied by
fever; Obstetric: Pediatric
: Safety not established.
Derm: urticaria. GI:
abdominal bloating,
cramping, flatulence,
nausea.
Helps regulate
water into the
GI tract to help
prevent
constipation
and
dehydration
Senna-docusate PO 8.6-50 mg
BID
Senna's metabolite
acts as a local irritant
on the colon
stimulating peristalsis.
Docusate promotes
incorporation of water
into stool, resulting in
softer fecal
mass. Therapeutic
Contraindicated
in: Hypersensitivity;
Abdominal pain, nausea, or
vomiting, especially when
associated with fever or
other signs of an acute
abdomen; Concomitant use
of mineral oil. Use
Cautiously in: Excessive or
F and E: electrolyte
imbalances,
dehydration. GI: ab
dominal cramps,
nausea, vomiting,
diarrhea. Derm: ras
hes. GU: urine
discoloration.
Thids
medication is
used for the Pt.
to poop since
she is
constipated
after the
20
Effects: Softening and
passage of stool.
prolonged use may lead to
dependence, fluid and
electrolyte imbalance, and
vitamin and mineral
deficiencies.
surgery
spironolactone PO 25 mg
BID
Causes loss of sodium
bicarbonate and
calcium while saving
potassium and
hydrogen ions by
antagonizing
aldosterone. Therape
utic
Effects: Increased
survival in patients
with severe heart
failure (New York Heart
Association class II-IV).
Weak diuretic and
antihypertensive
response when
compared with other
diuretics. Conservation
of potassium.
Contraindicated
in: Hypersensitivity; Anuria;
Acute renal insufficiency;
Significant renal impairment
(CCr <30 mL/min); SCr >2.5
mg/dL (for patients with
heart failure); Hyperkalemia;
Addison's disease;
Concurrent use of
eplerenone. Use
Cautiously in: Hepatic
dysfunction; Geriatric or
debilitated patients or
patients with diabetes
mellitus (↑ risk of
hyperkalemia); Obstetric: L
actation: May cause
endocrine dysfunction in
infants. Is tumorigenic and
should not be given to
nursing mothers. Alternative
method of feeding should be
used if spironolactone is
essential.
CNS: dizziness,
clumsiness,
headache,
sedation. CV: arrhyt
hmias. GI: GI
irritation. GU: erecti
le dysfunction,
dysuria. Endo: ame
norrhea,
gynecomastia (in
males), breast
tenderness, ,
deepening of voice, ↑
hair growth (in
females), sexual
dysfunction. F and
E: hyperkalemia,
hyponatremia,
hyperchloremic
metabolic
acidosis. Hemat: ag
ranulocytosis,
thrombocytopenia.
Derm: drug rash
with eosinophilia and
systemic symptoms
(DRESS), stevens-
johnson
syndrome, toxic
epidermal necrolysis,
alopecia,
pruritis. MS: muscle
cramps. Misc: aller
gic reactions.
Allows high
concentration
of sodium to
leave while
retaining
potassium
cyclobenzaprine PO 10 mg Reduces tonic somatic
muscle activity at the
Contraindicated
in: Hypersensitivity; Should
CNS: dizziness, dr
owsiness,
Acts as a
neuro
21
BID
PRN
level of the brainstem.
Structurally similar to
tricyclic
antidepressants. Ther
apeutic
Effects: Reduction in
muscle spasm and
hyperactivity without
loss of function
not be used within 14 days of
MAO inhibitor therapy;
Immediate period after MI;
Severe or symptomatic
cardiovascular disease;
Cardiac conduction
disturbances;
Hyperthyroidism. Use
Cautiously
in: Cardiovascular
disease; Obstetric: Use only
if potential maternal benefit
justifies potential fetal
risk; Lactation: Use while
breast feeding only if
potential maternal benefit
justifies potential risk to
infant; Pediatric: Children
<15 yr (safety and
effectiveness not
established); Geriatric: App
ears on Beers list. Poorly
tolerated due to
anticholinergic effects.
confusion, fatigue,
headache,
nervousness.. CV: a
rrhythmias. EENT: d
ry mouth, blurred
vision. GI: constipat
ion, dyspepsia,
nausea, unpleasant
taste. GU: urinary
retention.
suppressor, pt.
can take to
help get into a
calm and
peaceful state
of mind
Hydromorphone PO 4mg
Q 3 hrs
PRN
Binds to opiate
receptors in the CNS.
Alters the perception
of and response to
painful stimuli while
producing generalized
CNS depression.
Suppresses the cough
reflex via a direct
central
action. Therapeutic
Effects: Decrease in
moderate to severe
pain. Suppression of
cough.
Contraindicated
in: Hypersensitivity; Some
products contain bisulfites
and should be avoided in
patients with known
hypersensitivity; Severe
respiratory depression (in
absence of resuscitative
equipment) (extended-
release only); Acute or
severe bronchial asthma
(extended-release only);
Paralytic ileus (extended-
release only); Acute, mild,
intermittent, or postoperative
pain (extended-release only);
CNS: confusion, se
dation, dizziness,
dysphoria, euphoria,
floating feeling,
hallucinations,
headache, unusual
dreams. CV: hypot
ension,
bradycardia. Derm:
flushing,
sweating. EENT: blur
red vision, diplopia,
miosis. Endo: adren
al
insufficiency. GI: co
nstipation, dry
Strong pain
medication to
help the pt.
become
relieved with a
massive
reduction in
sensation of
pain.
22
Prior GI surgery or narrowing
of GI tract (extended-release
only); Opioid non-tolerant
patients (extended-release
only); Severe hepatic
impairment (extended-
release only). Use
Cautiously in: Head
trauma; ↑ intracranial
pressure; Severe pulmonary
disease; Moderate or severe
renal disease (extended-
release only) (dose ↓
recommended). Moderate
hepatic impairment
(extended-release only)
(dose ↓ recommended).
Hypothyroidism; Seizure
disorder; Adrenal
insufficiency; Alcoholism;
Undiagnosed abdominal
pain; Prostatic hypertrophy;
Biliary tract disease
(including
pancreatitis); Obstetric: La
bor and
delivery; Obstetric: Lactati
on: Avoid chronic use;
prolonged use of opioids
during pregnancy can result
in neonatal opioid withdrawal
syndrome; Geriatric: Geriat
ric or debilitated patients (↑
risk of respiratory
depression; dose ↓
suggested).
mouth, nausea,
vomiting. GU: urina
ry
retention. Resp: res
piratory
depression (includin
g central sleep
apnea and sleep-
related
hypoxemia). Misc:
physical
dependence,
psychological
dependence,
tolerance.
[ CITATION Val19 \l 1033 ]
23
CARE PLAN
Top Three Prioritized Medical and Nursing Diagnosis
1. Actual, pain r/t the surgery AEB pain recorded as an 8 in a 0-10 scale.
2. Risk for thrombosis r/t stasis in blood AEB surgical healing.
3. Risk for infection r/t the delayed wound healing AEB diabetes.
Medical & Nursing Dx Nursing Outcomes (NOC) Nursing Interventions (NIC) Evaluation
1. Actual, pain r/t the surgery
AEB pain recorded as an 8 in a
0-10 scale.
1. reduce the pain
2. increase the pt.’s mobility
3. Teach importance of diet
and exercise
1a. The nurse will provide
proper wound care IOT reduce
pain from sites.
1b. The nurse will provide the
pain medication IOT keep the
pt. on the correct schedule
1c. The nurse will teach the pt.
distraction techniques IOT
help reduce the pain.
2a. The nurse will ambulate
the pt. IOT reduce the risk of
thrombosis.
2b. The nurse will ambulate
1. Surgery has helped reduce
the pain.
2. The pt. is able to ambulate
on their own.
3. Teaching was effective, and
the pt. is living a much
healthier lifestyle.
24
the pt. IOT promote healthy
movement.
2c. The nurse will teach the pt.
how to live an active lifestyle
IOT have a healthier and
longer life.
3a. The nurse will schedule
nutrition to come IOT teach
and help the pt. plan meals.
3b. The nurse will schedule
OT/PT to come IOT teach the
pt. home exercises to promote
a healthy lifestyle.
3c. The nurse will obtain a
back brief (talk-back) IOT
ensue the patient understands
the instructions.
25
[ CITATION Ack20 \l
1033 ]
26
References
Ackley, B., & Ladwig, G. (2020). Nursing Diagnosis Handbook. St. Louis: Elsevier.
AH, V., & CA, S. (2019, November 19). Davis's Drug Guide for Nurses. Retrieved from Nursing
Reference Center powered by EBSCOhost:
https://web.a.ebscohost.com/nrc/popsourcesbrowsefiltered?sid=313114ac-4dec-403f-b380-
2106f67d4061%40sdc-v-sessmgr01&vid=65&bk=1
Mayo Clinic staff. (2019, March 19). Healthy Lifestyle Stress Management. Retrieved from Mayo
Clinic: https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress/art-
20046037
Pierpont, Y., Dinh, T., Salas, E., Johnson, E. W., Robson, M., & Payne, W. (2014, Feb 20). Obesity and
Surgical Wound Healing: A Current Review. Retrieved from US National Library of Medicine
National Institutes of Health: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3950544/
RH med labs. (2010). RH medical labs. Retrieved from ResidentHelper:
http://residenthelper.com/Products/RHLabs/
Tanner, J. (2019). Structure nd the function of the cardiovascular system. In T. Norris, Porth's
Pathophysiology Concepts of Altered Health States (pp. 739-746). Philadelphia: Wolters Kluwer.
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