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MIAMI DADE COLLEGE - MEDICAL CENTER CAMPUS - SCHOOL OF NURSINGNUR 1025L: Fundamentals Nursing Clinical

Students Name: Francisco J Ortiz Date:_06/15/13_ Clients Initials: ____EP____ Admission Date:_06/24/2011

Age: 75yr DOB: ______02/19/1936_____ Sex: X Male Female Race/Ethnicity: White/______________Support System: _____No living family membes _________________________________________________________

Religion: _Catholic__________

MEDICAL HISTORYALLERGIES: _NKA_Admitting Medical Diagnosis (es): COPD, hypertension, A Flutter, seizure disorder, dementia

Chief Complaint: patient states shortness of breath

History of Present Illness: Pt is a 75 year old who is complaining of shortness of breath. The patientreports that he can ambulate but limited. The patient denies any pain.

Past Medical History (include past surgical history):Heavy smoker , 2 to 3 packs a day. 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 genitalstage lasts throughout adulthood. He believed the goal is to develop a balance between all areas of

life. Piaget _ Formal Operational

____Special Developmental Considerations: N/AHeight: 65 inches Weight: 117.1 kg Placement in Growth Chart: _N/AImmunizations: Patient refused flu vaccine

VITAL SIGNSTime Taken: ______0900_________ Activity: ______________ Position: ____wheel chair__________

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T_36.1 P72 R 16 BP _111/68Baseline (Normal Age for Age):T_ 36.137.8 P_60 -100 R_12-20_ BP120/80 _

NUTRITIONDiet: REGULAR Food Preferences:_EXTRA SYRUP IN BREAKFAST, COFFEE AFTER LUNCH, COOKIEAFTER DINNERNutritional Requirements: (Cal/Kg/Day): 2100 CAL/KG/DAY Total Calories per Day: _1900___________Fluid Requirements (Ml/Kg/Day): __________________________________ ________________Total Fluids per Day:_______________________________

Special Treatments: ____________N/AMedications atHome:_N/A_____________________________________________________________________________________________________________________________________________________________________________________________________________

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Medication(s) Worksheet

NAMECLASSIFICATI

ON

DOSE/ROUTE/FREQUENCY SAFE RANGE

MECHANISMOF ACTION

INDICATIONS SIDEEFFECTS

NURSINGCONSIDERATIOS AND PATIEN

EDUCATION

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PHENYTOIN 100mg daily by mouth Limits seizurepropagation byaltering iontrans- port.May alsodecreasesynaptictransmission.Antiarrhythmicproperties as aresult ofshortening theactionpotential anddecreasingautomaticity.

Treatment/prevention of tonic-clonic(grand mal)seizures andcomplex partialseizures.

CNS:SUICIDAL

THOUGHTS,ataxia,agitation,confusion,dizziness,drowsiness,dysarthria,dyskinesia,extrapyramidal syndrome,headache,insomnia,weakness.EENT:diplopia,nystagmus.CV:hypotension

Monitor closely fonotable changesbehavior that couindicate theemergence orworsening ofsuicidal thoughtsbehavior ordepression.

Assess patient fophenytoinhypersensitivitysyndrome (feverskin rash,lymphadenopathRash usuallyoccurs within thefirst 2 wk oftherapy.Hypersensitivitysyndrome usuallyoccurs at 38 wkbut may occur up

to 12 wk afterinitiation oftherapy. May leato renal failure,rhabdomyolysis, hepatic necrosis;may be fatal.

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MEMANTINE 10mg 1 tab daily bymouth

Binds to CNSN-methyl-D-aspartate(NMDA) re-ceptor sites,preventingbinding ofglutamate, anexcitatoryneurotransmitter.

Moderate tosevere Alzheimersdementia.

CNS:dizziness,fatigue,headache,sedation. CV:hypertension.Derm: rash.GI: weightgain. GU:urinaryfrequency.Hemat:anemia.

Assess cognitivefunction (memorattention,reasoning,language, abilityperform simpletasks) periodicallduring therapy.

Lab Test

Considerations:May cause anem

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CITALOPRAM 10mg 1 tab daily bymouth

Selectivelyinhibits thereuptake ofserotonin inthe CNS.

Depression. NS:NEUROLEPTICMALIGNANTSYNDROME,SUICIDAL

THOUGHTS,apathy,confusion,drowsiness,insom- nia,weakness,agitation,amnesia,anxiety, p li-bido,dizziness,fatigue,impairedconcentration, qdepression,migraineheadache.EENT: ab-

normalaccommodation. Resp:cough.

Monitor moodchanges duringtherapy.

Assess for suicidtendencies,especially duringearly therapy anddose changes.

Restrict amount drug available topatient. Risk maybe increased inchildren,adolescents, andadults 24 yr. Aftstarting therapy,children,adolescents, andyoung adultsshould be seen bhealth careprofessional at

least weekly for 4wk, every 3 wk fothe next 4 wk, anon advice of heacare professionathereafter.

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ENALAPRIL 5mg 1 tab daily bymouth

ACE inhibitorsblock theconversion ofangioten- sin Ito thevasoconstrictor angiotensinII. ACE in-hibitors alsoprevent thedegradation ofbradyki- ninand othervasodilatoryprostaglandins. ACE inhibitorsalso q plasmarenin levelsand p al-dosteronelevels. Netresult issystemicvasodila- tion.

Alone or withother agents in themanagement ofhypertension.

CNS:dizziness,drowsiness,fatigue,headache, in-somnia,vertigo,weakness.Resp: cough,dysp- nea.CV:hypotension,chest pain,edema,tachy- cardia.Endo:hyperuricemia. GI: tastedisturbances,abdominalpain,anorexia,consti-pation,

diarrhea,nausea,vomiting.

Hypertension:Moor blood pressureand pulsefrequently duringinitial doseadjustment andperiodically durintherapy. Notifyhealth careprofessional ofsignificant chang

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CLONAZEPAM 0.5MG daily by mouthAnticonvulsanteffects may bedue topresynapticinhibition.Producessedativeeffects in theCNS, probablyby stimulatinginhibitoryGABA recep-tors.

Prophylaxis of:Petit mal, Petit malvariant, Aki- netic,Myoclonic seizures.Panic disorder withor withoutagoraphobia.

CNS:SUICIDAL

THOUGHTS,behavioralchanges,drowsiness,fatigue,slurredspeech,ataxia, seda-tion,abnormal eyemovements,diplopia,nystag- mus.Resp:increasedsecretions.CV: palpita-tions. GI:constipation,diarrhea,hepatitis,weight gain.

GU: dysuria,nocturia,urinaryretention.

Observe andrecord intensity,duration, andlocation of seizuractivity.

Assess degree anmanifestations oanxiety and menstatus (orientatio

mood, behavior)prior to andperiodically durintherapy.

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Medication(s) Worksheet

CLASSIFICATION NAME

DOSE/ROUTE/FREQUENCY SAFE RANGE

MECHANISM

OF ACTION

INDICATIONS

SIDE EFFECTS NURSINGCONSIDERATIONS

AND PATIENTEDUCATION

LEVALBUTEROL

45MCG PRN R-enantiomerof racemicalbuterol.Binds tobeta- 2adrenergicreceptors inairwaysmoothmuscleleading toactivation ofadenylcyclase and in-creasedlevels ofcyclic-3, 5-adenosinemono-phosphate(cAMP).

Bronchospasm due toreversibleairwaydisease(short-termcontrolagent).

CNS: anxiety,dizziness,headache,nervousness.Resp:PARADOXICALBRONCHOSPASM (excessiveuse ofinhalers),increasedcough,turbinateedema. CV:tachycardia.GI: dyspepsia,vomiting.Endo:hyperglycemia.F and E:hypokalemia.Neuro: tremor.

Assess lung sounds,pulse,and bloodpressure beforeadministration andduring peak of med-ication. Note amount,color, and character ofsputum produced.Closely monitorpatients on higherdose for adverseeffects.

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PREDNISONE 60MG DAILY PRN Inpharmacologic doses,all agentssuppress in-flammationand thenormalimmuneresponse. Allagents havenumerousintensemetaboliceffects (seeAdverseReactions/Side Effects).S

Management ofadrenocorticalinsufficiency.

CNS:depression,euphoria,headache, qintra- cranialpressure(children only),personalitychanges,psychoses,restlessness.

These drugs areindicated for manyconditions. Assessinvolved systemsbefore and periodicallyduring therapy.

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Aspirin 81mg daily PO Inhibits thesynthesis ofprostaglandins that mayserve asmediators ofpain andfever,primarily inthe CNS.Has nosignificantanti-inflammatory propertiesor GItoxicity.

Mild pain.Fever.

GI: HEPATICFAILURE,HEPATOTOXICI

TY (overdose).GU: renalfailure (highdoses/chronicuse). He- mat:neutropenia,pancytopenia,leukopenia.Derm: rash,urticaria.

Assess overall healthstatus and alcoholusage beforeadministeringacetaminophen.Patients who aremalnourished orchronically abusealcohol are at higherrisk of developinghepato- toxicity withchronic use of usualdoses of this drug.

Assess amount,frequency, and type ofdrugs taken in patientsself-medicating,especially with OTCdrugs. Prolonged useof acetaminophenincreases the risk ofadverse renal effects.For short-term use,

combined doses ofacetaminophen andsalicylates should notexceed therecommended dose ofeither drug givenalone.

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PATHOPHYSIOLOGY-BRIEF TEXTBOOK PICTURE WITH CLIENT COMPARISONDefinition, Etiology, Incidence, Pathophysiology, Diagnostic tests, Signs & symptoms, Medical

treatments

Textbook Client

Pathology- Chronic obstructive pulmonarydisease (COPD) is characterised by poorlyreversible airflow obstruction and an abnormalinflammatory response in the lungs. The latterrepresents the innate and adaptive immuneresponses to long term exposure to noxiousparticles and gases, particularly cigarettesmoke. All cigarette smokers have some

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inflammation in their lungs, but those whodevelop COPD have an enhanced or abnormalresponse to inhaling toxic agents. This amplifiedresponse may result in mucous hypersecretion(chronic bronchitis), tissue destruction(emphysema), and disruption of normal repairand defence mechanisms causing small airwayinflammation and fibrosis (bronchiolitis).Classification- The twofold nature of thepathology has been studied in thepast.Furthermore, in recent studies, manyauthors found that each patient could beclassified as presenting a predominantlybronchial or emphysematous phenotype bysimply analyzing clinical, functional, andradiological findings or studying interestingbiomarkers.Etiology- The primary cause of COPD is exposureto tobacco smoke. Overall, tobacco smokingaccounts for as much as 90% of COPD risk.

Cigarette smoking induces macrophages torelease neutrophil chemotactic factors andelastases, which lead to tissue destruction.Clinically significant COPD develops in 15% ofcigarette smokers, although this number isbelieved to be an underestimate. Age ofinitiation of smoking, total pack-years, andcurrent smoking status predict COPD mortality.

People who smoke have an increased annualdecline in FEV1: the physiologic normal declinein FEV1 is estimated to be 20-30 ml/y, but therate of decline in COPD patients is generally 60

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463976/figure/fig1/

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ml/y or greater.

Statistics-

The National Health Interview Survey reports theprevalence of emphysema at 18 cases per 1000persons and chronic bronchitis at 34 cases per1000 persons.[24] While the rate of emphysemahas stayed largely unchanged since 2000, therate of chronic bronchitis has decreased.Another study estimates a prevalence of 10.1%in the United States.[25] However, the exactprevalence of COPD in the United States isbelieved to be underestimated. This is largelydue to the fact that it is an underdiagnosed (andundertreated) disease, because most patientsdo not present for medical care until the diseaseis in a late stage.

The exact prevalence of COPD worldwide islargely unknown, but estimates have variedfrom 7-19%. The Burden of Obstructive LungDisease (BOLD) study found a global prevalenceof 10.1%.[26] Men were found to have a pooledprevalence of 11.8% and women 8.5%. Thenumbers vary in different regions of the world.Cape Town, South Africa, has the highestprevalence, affecting 22.2% of men and 16.7%of women.

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DIAGNOSTIC TESTS

Test(i.e. X-Ray, MRI, EEG, EKG)

RESULTSDate, Result, Significance

NOT APPLICABLE

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Laboratory values

CHEMISTRYPROFILE

NORMALVALUES

CLIENTSVALUES

HEMOTOLOGY

NORMALVALUES

CLIENTS VALUES

DATE DATE

DATE DATE DATE

DATE

SODIUM 135-145

Meq/L

138

2/21/13

WBC 3.8-10.8

K/uL

4.6

2/21/13

POTASSIUM 3.5- 5.1mEq/L

4.62/21/13

RBC 3.80-5.20 3.56*2/21/13

CHLORIDE 98-108mEq/L

1082/21/13

HGB 11.8-15.4g/dl

11.8*

CO2 19-34 24.02/21/13

HCT 41-50 34.5*

CALCIUM 8.2-10.3mg/dL

8.32/21/13

MCV 79.4-94.8fL

96.9*2/21/13

GLUCOSE 70-105mg/dL

852/21/13

MCH

BUN 7-25 mg/

Dl

23

2/21/13

MCHC 25.6-32.2

pg

34.2

2/21/13CREATININE 0.6-1.2

mg/dL1.12/21/13

PLATELETS 11.5-15.0%

1092/21/13

PHOSPHORUSCHOLESTEROL

DIFFERENTIAL

TOTALPROTEIN

6.4-8.9g/dL

6.42/21/13

NEUTROPHILS

ALBUMIN 3.5-5.0g/dL

3.532/21/13

SEGMENTS

ALBUMIN/GLOBULIN RATIO

2.922/21/13

BANDS

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AST (SGOT) 13-39 U/L 272/21/13

LYMPHOCYTES

ALT (SGPT) 7-52 U/L 152/21/13

EOSINOPHILS

TOTALBILIRUBIN

0.3-1.0mg/dL

BASOPHILS

AMYLASE MONOCYTES

LIPASECOAGULATION

STUDIESPTT

SODIUM 135-145Meq/L

1382/21/13

WBC 3.8-10.8 K/uL 4.62/21/13

POTASSIUM 3.5- 5.5mEq/L

4.62/21/13

RBC 3.80-5.20 3.56*2/21/13

CHLORIDE 98-108mEq/L

1082/21/13

HGB 11.8-15.4g/dl 11.8*

CO2 19-34 24.02/21/13

HCT 34.5*

CALCIUM 8.2-10.3mg/dL

8.32/21/13

MCV 96.92/21/13

GLUCOSE 70-105mg/dL 852/21/13 MCH

BUN 7-25 mg/Dl

232/21/13

MCHC 34.22/21/13

CBC BMP

Hgb Na+

Cl-

BUNWBC Plts Glucose

Hct K+ HCO3 Creatinine

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URINALYSISCOLOR YELLOWAPPEARANCE CLEARSP. GRAVITY 1.015 MISCELLANEOUS

TESTPH 5 TEST NORMAL

VALUESCLIENTS VALUES

DATE DATE DATEGLUCOSE NORMA

L

URINE

CULTURE

PENDI

NG

06/10/1

3KETONE NEGATIVE

OCCULT BLOODPROTEIN NEGATI

VEBILRUBIN NEGATI

VEUROBILINOGEN NORMA

LNITRITE NEGATI

VELEUCOCYTE NEGATI

VE

CASTWBCRBCCRYSTALSSQUAMOUSCELLS/ EPITHELIALCELLS

Relate the clinical significance of abnormal lab values above:

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.

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HGB(LOW)- INDICATIONS:- Low Hct leads to anemia. Anemia can be caused by blood loss, decreasedblood cell production, increased blood cell destruction, and hemodilution. Causes of blood lossinclude menstrual excess or frequency, gastrointestinal bleeding, inflammatory bowel disease, andhematuria. Decreased blood cell production can be caused by folic acid deficiency, vitamin B12deficiency.

HCT (HIGH)- INDICATIONS:- High Hct leads to polycythemia. Polycythemia can be caused bydehydration, 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, ordecreased fluid intake decreases the plasma component of whole blood, thereby increasing the ratioof RBCs to plasma, and leads to a higher than nor- mal Hct. Causes of decreased oxygen includesmoking, exposure to carbon monoxide, high altitude, and chronic lung disease, which leads to amild hemoconcentration of blood

MCV(HIGH)- INDICATIONS- Lipemia will falsely increase the Hgb measurement, also affecting the meancorpuscular volume (MCV) and MCHC.

Head to Toe Assessment

General Appearance:The pt is resting comfortably in no acute distressHead & Hair: Norm cephalic and atraumatic

Face: Norm cephalic and atraumatic

Eyes: Norm cephalic and atraumaticEars: Norm cephalic and atraumaticNose: Turbinates bright red and swollen, mucous pink, no swellingLips/Mouth/Throat: No cracking/ lesions on lips, mouth is clean and free from debris, mild breath odor.Neck:

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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/ARectum (Internal Exam Deferred): N/AExtremities:No edema clubbing or cyanosisBack: 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:

Risk Nursing Diagnosis: Impaired Gas Exchange related to Altered oxygen supply as evidenceby:Supporting Data:

Subjective:Patient states I can hardly breathe when I walkObjective:patient spoke in short sentences

Expected Outcome (Goals)

Long Term: Patient will be able to provide self-care with less fatigue and dyspnea by discharge

Short Term: After 4 hrs. Of nursing interventions, the client will demonstrate behaviors to improve airway

clearance. e.g. cough effectively and expectorate secretions

Nursing InterventionsNursing Actions Scientific Principle

and/or RationaleEvaluation Modification of Plan of

Care

Pt will maintain clear lungfields and remain free ofsigns of respiratorydistress throughouthospital stay

Auscultate breathsounds Q1- 2 .Presence of crackles,wheezes maysignify airwayobstruction, leading toor exacerbatingexisting hypoxia.

Pt demonstratedeffective coughingtechniques for studentnurse

Monitor vital signs:Auscultate breath sounds,

Respiratory systemmay become

BP is 111/68 Lungsounds are clear to

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heart rate and rhythm,respirations q 4 hours.

decompensated.Tachycardia andchanges in bloodpressure may bepresent because ofpain, anxiety andreduced cardiacoutput.

auscultation, respiratoryrate is between 20 to 24breaths per minute andpulse is at 72

Assess peripheral pulses,

capillary refill, skin turgor,and mucous membranes q4 hours.

Indicators of level of

hydration andadequacy of circulatingvolume.

Mucous membrane are

moist, capillary refill isless than 2 seconds andskin turgor has increased

Pt will maintain a patentairway at all time

Monitor resp. rate,depth, and effort, useof accessory muscles,nasal flaring, andabnormal breathingpatterns. respiratory rate, useof accessory muscles,nasal flaring,

and abdominalbreathing may indicatehypoxia.

Pts airway remainedopen

Identify priority of learningneeds within the overallcare plan as soon aspossible.

Teaching standardizedcontent that thepatient already knowswastes valuable timeand hinders criticallearning. Adults learnmaterial that is

The patientverbalizes understandingof priority learning needs.

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important to them

Provide a quietatmosphere withoutinterruption within 2 hoursof admission.

A calm quietenvironment assiststhe patient withconcentrating morecompletely.

The patient is verycomfortable in herprivate room and readyto express her concernsregarding her healthcare.

Encourage questionsbefore and after eachteaching.

Questions facilitateopen communicationbetween patient andhealth careprofessionals, andallow verification ofunderstanding of giveninformation and theopportunity to correctmisconceptions

The patient askedquestions regarding herregimen, diet andconcerns when injectingherself.

Elevate head of bed,

assist patient to assumeposition to ease work of

breathing. Include periods

of time in prone position

as tolerated. Encourage

deep-slow or pursed-lip

breathing as individually

needed/ tolerated.

Oxygen delivery may

be improved by uprightposition and breathing

exercises to decrease

airway collapse,

dyspnea, and work of

breathing. Note: Recen

t research supports use

of prone position to

increase Pao2.

The patient tolerateddeep breathing exercisesafter showing correcttechniques

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Monitor vital signs and

cardiac rhythm.

Tachycardia, dysrhyth

mias, and changes in

BP can reflect effect of

systemic hypoxemia

on cardiac function.

Patient blood pressuredropped to a stable levelafter medications weregiven

Monitor level of

consciousness/mental

status. Investigate

changes.

Restlessness and

anxiety are common

manifestations of

hypoxia. WorseningABGs accompanied by

confusion/somnolence

are indicative of

cerebral dysfunction

due to hypoxemia.

Patient was alert aftermaking necessarychanges

Evaluate level of activity

tolerance. Provide calm,

quiet environment. Limit

patients activity or

encourage bed/chair rest

during acute phase. Have

patient resume activitygradually and increase as

individually tolerated.

During

severe/acute/refractory

respiratory distress,

patient may be totally

unable to perform

basic self-care

activities because ofhypoxemia and

dyspnea. Rest

interspersed with care

activities remains an

important part of

treatment regimen. An

exercise program is

aimed at increasing

endurance and

Patient toleratedambulating from chair tobed after a short rest

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strength without

causing severe

dyspnea and can

enhance sense of well-

being.

CARE PLAN RUBRICStudent: ___________________________________ Date: ______________________

CATEGORIES POSSIBLE POINTS

YOURPOINTS

COMMENTS

SUBJECTIVE DATA(Relevant and timely and quotedfrom patient)

10

OBJECTIVE DATA(Includes vital signs, physicalassessment findings, diagnostictests and procedures, relevantmedications, etc.)

10

NURSING DIAGNOSIS(NANDA, R/T, AEB)

20

GOAL 20

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(Condition, Time Frame,Parameters, and must be realistic)

INTERVENTIONS ANDRATIONALES(Assess, Assist, and Teach)

20

EVALUATION OF CARE PLAN(Evaluate each nursing action foreffectiveness)

10

MODIFICATION OF CARE PLAN(Modify patient care plan based onpatients response to interventions)

10

*TOTAL SCORE:

*Student must obtain score of > 77% in order to obtain a grade of S on the weekly care plan.

Reviewed with student: ______________________________ Date: ___________________Signature

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