MIAMI-DADE COLLEGE

MIAMI DADE COLLEGE - MEDICAL CENTER CAMPUS - SCHOOL OF NURSING

NUR 1025L: Fundamentals Nursing Clinical

Students Name: Francisco J Ortiz Date: _06/15/13_ Clients Initials: ____EP____ Admission Date: _06/24/2011Age: 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 patient reports 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 abuseClients (Parents)Understanding of Illness: patient understands and full aware of conditionStage of Development: Erickson Ego Integrity vs. Despair _ Freud: According to Freud, the genital stage lasts throughout adulthood. He believed the goal is to develop a balance between all areas of life. Piaget _

____Special Developmental Considerations: N/AHeight: 65 inches Weight: 117.1 kg Placement in Growth Chart: _N/AImmunizations: Patient refused flu vaccineVITAL SIGNSTime Taken: ______0900_________ Activity: ______________ Position: ____wheel chair__________T_36.1 P72 R 16 BP _111/68 Baseline (Normal Age for Age): T_ 36.137.8 P_60 -100 R_12-20_ BP 120/80 _Nutrition

Diet: REGULAR Food Preferences:_EXTRA SYRUP IN BREAKFAST, COFFEE AFTER LUNCH, COOKIE AFTER 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 at Home:_N/A_____________________________________________________________________________________________________________________________________________________________________________________________________________Medication(s) WorksheetNAMECLASSIFICATIONDOSE/ROUTE/FREQUENCY SAFE RANGEMECHANISM OF ACTIONINDICATIONSSIDE EFFECTSNURSING CONSIDERATIONS AND PATIENT EDUCATION

PHENYTOIN100mg daily by mouth Limits seizure propagation by altering ion trans- port. May also decrease synaptic transmission. Antiarrhythmic properties as a result of shortening the action potential and decreasing automaticity.

Treatment/prevention of tonic-clonic (grand mal) seizures and complex partial seizures.

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

Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression. Assess patient for phenytoin hypersensitivity syndrome (fever, skin rash, lymphadenopathy). Rash usually occurs within the first 2 wk of therapy. Hypersensitivity syndrome usually occurs at 38 wk but may occur up to 12 wk after initiation of therapy. May lead to renal failure, rhabdomyolysis, or hepatic necrosis; may be fatal.

MEMANTINE10mg 1 tab daily by mouth Binds to CNS N-methyl-D-aspartate (NMDA) re- ceptor sites, preventing binding of glutamate, an excitatory neurotransmitter.

Moderate to severe Alzheimers dementia.

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

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

CITALOPRAM10mg 1 tab daily by mouth Selectively inhibits the reuptake of serotonin in the CNS.

Depression. NS: NEUROLEPTIC MALIGNANT SYNDROME, SUICIDAL THOUGHTS, apathy, confusion, drowsiness, insom- nia, weakness, agitation, amnesia, anxiety, p li- bido, dizziness, fatigue, impaired concentration, q depression, migraine headache. EENT: ab- normal accommodation. Resp: cough.

Monitor mood changes during therapy.

Assess for suicidal tendencies, especially during early therapy and dose changes. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults 24 yr. After starting therapy, children, adolescents, and young adults should be seen by health care professional at least weekly for 4 wk, every 3 wk for the next 4 wk, and on advice of health care professional thereafter.

ENALAPRIL5mg 1 tab daily by mouth ACE inhibitors block the conversion of angioten- sin I to the vasoconstrictor angiotensin II. ACE in- hibitors also prevent the degradation of bradyki- nin and other vasodilatory prostaglandins. ACE inhibitors also q plasma renin levels and p al- dosterone levels. Net result is systemic vasodila- tion.

Alone or with other agents in the management of hypertension.

CNS: dizziness, drowsiness, fatigue, headache, in- somnia, vertigo, weakness. Resp: cough, dysp- nea. CV: hypotension, chest pain, edema, tachy- cardia. Endo: hyperuricemia. GI: taste disturbances, abdominal pain, anorexia, consti- pation, diarrhea, nausea, vomiting.

Hypertension:Monitor blood pressure and pulse frequently during initial dose adjustment and periodically during therapy. Notify health care professional of significant changes

CLONAZEPAM 0.5MG daily by mouth Anticonvulsant effects may be due to presynaptic inhibition. Produces sedative effects in the CNS, probably by stimulating inhibitory GABA recep- tors.

Prophylaxis of: Petit mal, Petit mal variant, Aki- netic, Myoclonic seizures. Panic disorder with or without agoraphobia.

CNS: SUICIDAL THOUGHTS, behavioral changes, drowsiness, fatigue, slurred speech, ataxia, seda- tion, abnormal eye movements, diplopia, nystag- mus. Resp: increased secretions. CV: palpita- tions. GI: constipation, diarrhea, hepatitis, weight gain. GU: dysuria, nocturia, urinary retention.

Observe and record intensity, duration, and location of seizure activity.

Assess degree and manifestations of anxiety and mental status (orientation, mood, behavior) prior to and periodically during therapy.

Medication(s) WorksheetCLASSIFICATION NAMEDOSE/ROUTE/FREQUENCY SAFE RANGEMECHANISM OF ACTIONINDICATIONSSIDE EFFECTSNURSING CONSIDERATIONS AND PATIENT EDUCATION

LEVALBUTEROL 45MCG PRN R-enantiomer of racemic albuterol. Binds to beta- 2 adrenergic receptors in airway smooth muscle leading to activation of adenylcyclase and in- creased levels of cyclic-3, 5-adenosine mono- phosphate (cAMP).

Bronchospasm due to reversible airway disease (short-term control agent).

CNS: anxiety, dizziness, headache, nervousness. Resp: PARADOXICAL BRONCHOSPASM (excessive use of inhalers), increased cough, turbinate edema. CV: tachycardia. GI: dyspepsia, vomiting. Endo: hyperglycemia. F and E: hypokalemia. Neuro: tremor.

Assess lung sounds, pulse,and blood pressure before administration and during peak of med- ication. Note amount, color, and character of sputum produced. Closely monitor patients on higher dose for adverse effects.

PREDNISONE

60MG DAILY PRN In pharmacologic doses, all agents suppress in- flammation and the normal immune response. All agents have numerous intense metabolic effects (see Adverse Reactions/Side Effects). S

Management of adrenocortical insufficiency.

CNS: depression, euphoria, headache, q intra- cranial pressure (children only), personality changes, psychoses, restlessness.

These drugs are indicated for many conditions. Assess involved systems before and periodically during therapy.

Aspirin81mg daily POInhibits the 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.

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

Assess overall health status and alcohol usage before administering acetaminophen. Patients who are malnourished or chronically abuse alcohol are at higher risk of developing hepato- toxicity with chronic use of usual doses of this drug.

Assess amount, frequency, and type of drugs taken in patients self-medicating, especially with OTC drugs. Prolonged use of acetaminophen increases the risk of adverse renal effects. For short-term use, combined doses of acetaminophen and salicylates should not exceed the recommended dose of either drug given alone.

PATHOPHYSIOLOGY-BRIEF TEXTBOOK PICTURE WITH CLIENT COMPARISON

Definition, Etiology, Incidence, Pathophysiology, Diagnostic tests, Signs & symptoms, Medical treatments

TextbookClient

Pathology- Chronic obstructive pulmonary disease (COPD) is characterised by poorly reversible airflow obstruction and an abnormal inflammatory response in the lungs. The latter represents the innate and adaptive immune responses to long term exposure to noxious particles and gases, particularly cigarette smoke. All cigarette smokers have some inflammation in their lungs, but those who develop COPD have an enhanced or abnormal response to inhaling toxic agents. This amplified response may result in mucous hypersecretion (chronic bronchitis), tissue destruction (emphysema), and disruption of normal repair and defence mechanisms causing small airway inflammation and fibrosis (bronchiolitis).

Classification- The twofold nature of the pathology has been studied in the past.Furthermore, in recent studies, many authors found that each patient could be classified as presenting a predominantly bronchial or emphysematous phenotype by simply analyzing clinical, functional, and radiological findings or studying interesting biomarkers.

Etiology- The primary cause of COPD is exposure to tobacco smoke. Overall, tobacco smoking accounts for as much as 90% of COPD risk.

Cigarette smoking induces macrophages to release neutrophil chemotactic factors and elastases, which lead to tissue destruction. Clinically significant COPD develops in 15% of cigarette smokers, although this number is believed to be an underestimate. Age of initiation of smoking, total pack-years, and current smoking status predict COPD mortality.

People who smoke have an increased annual decline in FEV1: the physiologic normal decline in FEV1 is estimated to be 20-30 ml/y, but the rate of decline in COPD patients is generally 60 ml/y or greater.

Statistics-

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

The exact prevalence of COPD worldwide is largely unknown, but estimates have varied from 7-19%. The Burden of Obstructive Lung Disease (BOLD) study found a global prevalence of 10.1%.[26] Men were found to have a pooled prevalence of 11.8% and women 8.5%. The numbers vary in different regions of the world. Cape Town, South Africa, has the highest prevalence, affecting 22.2% of men and 16.7% of women.

DIAGNOSTIC TESTS

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

NOT APPLICABLE

Laboratory valuesCHEMISTRY

PROFILE

NORMAL VALUES CLIENTS VALUESHEMOTOLOGY NORMAL VALUES CLIENTS VALUES

DATEDATEDATEDATE

DATEDATE

SODIUM135-145 Meq/L

138

2/21/13WBC3.8-10.8 K/uL4.6

2/21/13

POTASSIUM3.5- 5.1 mEq/L4.6

2/21/13RBC3.80-5.203.56*2/21/13

CHLORIDE98-108 mEq/L108

2/21/13HGB11.8-15.4g/dl11.8*

CO219-3424.0

2/21/13HCT41-5034.5*

CALCIUM8.2-10.3 mg/dL8.3 2/21/13MCV79.4-94.8fL96.9*2/21/13

GLUCOSE70-105 mg/dL

85

2/21/13MCH

BUN7-25 mg/ Dl23

2/21/13MCHC25.6-32.2 pg34.22/21/13

CREATININE0.6-1.2 mg/dL1.1

2/21/13PLATELETS11.5-15.0%1092/21/13

PHOSPHORUS

CHOLESTEROLDIFFERENTIAL

TOTAL PROTEIN6.4-8.9 g/dL6.4 2/21/13NEUTROPHILS

ALBUMIN3.5-5.0 g/dL3.53 2/21/13SEGMENTS

ALBUMIN/GLOBULIN RATIO2.92 2/21/13BANDS

AST (SGOT)13-39 U/L27

2/21/13LYMPHOCYTES

ALT (SGPT)7-52 U/L

15

2/21/13EOSINOPHILS

TOTAL BILIRUBIN0.3-1.0 mg/dLBASOPHILS

AMYLASEMONOCYTES

LIPASE

COAGULATION STUDIES

PTT

SODIUM135-145 Meq/L

138

2/21/13WBC3.8-10.8 K/uL4.6

2/21/13

POTASSIUM3.5- 5.5 mEq/L4.6

2/21/13RBC3.80-5.203.56*

2/21/13

CHLORIDE98-108 mEq/L108

2/21/13HGB11.8-15.4g/dl11.8*

CO219-3424.0

2/21/13HCT34.5*

CALCIUM8.2-10.3 mg/dL8.3 2/21/13MCV96.9

2/21/13

GLUCOSE70-105 mg/dL

85

2/21/13MCH

BUN7-25 mg/ Dl23

2/21/13MCHC34.2

2/21/13

CBC BMP

Hgb Na+ Cl- BUN

WBC Plts Glucose Hct K+ HCO3 Creatinine

URINALYSIS

COLORYELLOW

APPEARANCECLEAR

SP. GRAVITY1.015 MISCELLANEOUS TEST

PH5TESTNORMAL

VALUESCLIENTS VALUES

DATEDATEDATE

GLUCOSENORMALURINE CULTUREPENDING06/10/13

KETONENEGATIVE

OCCULT BLOOD

PROTEINNEGATIVE

BILRUBINNEGATIVE

UROBILINOGENNORMAL

NITRITENEGATIVE

LEUCOCYTENEGATIVE

CAST

WBC

RBC

CRYSTALS

SQUAMOUSCELLS/ EPITHELIAL CELLS

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.

HGB(LOW)- INDICATIONS:- Low Hct leads to anemia. Anemia can be caused by blood loss, decreased blood cell production, increased blood cell destruction, and hemodilution. Causes of blood loss include menstrual excess or frequency, gastrointestinal bleeding, inflammatory bowel disease, and hematuria. Decreased blood cell production can be caused by folic acid deficiency, vitamin B12 deficiency.

HCT (HIGH)- INDICATIONS:- High Hct leads to polycythemia. Polycythemia can be caused by dehydration, decreased oxygen levels in the body, and an overproduction of RBCs by the bone marrow. Dehydration from diuretic use, vomiting, diarrhea, excessive sweating, severe burns, or decreased fluid intake decreases the plasma component of whole blood, thereby increasing the ratio of RBCs to plasma, and leads to a higher than nor- mal Hct. Causes of decreased oxygen include smoking, exposure to carbon monoxide, high altitude, and chronic lung disease, which leads to a mild hemoconcentration of blood

MCV(HIGH)- INDICATIONS- Lipemia will falsely increase the Hgb measurement, also affecting the mean corpuscular volume (MCV) and MCHC. Head to Toe Assessment

General Appearance:

The pt is resting comfortably in no acute distress

Head & Hair: Norm cephalic and atraumatic

Face: Norm cephalic and atraumatic

Eyes: Norm cephalic and atraumatic

Ears: Norm cephalic and atraumatic

Nose: Turbinates bright red and swollen, mucous pink, no swelling

Lips/Mouth/Throat:

No cracking/ lesions on lips, mouth is clean and free from debris, mild breath odor.

Neck:

Chest/Breast:

Clear to palpation and auscultation lateral chest is larger than anterior/posterior diameter.

Lungs:

Clear to auscultation; no abnormal sounds heard.

Heart:

Normal rhythm sounds heart at the fine precordial points.

Abdomen/Kidneys:

Normal bowel sounds, no masses, lumps, or tenderness found.

Genitalia (Internal Exam Deferred): N/A

Rectum (Internal Exam Deferred): N/A

Extremities:

No edema clubbing or cyanosis

Back: no deformities

R.O.M.: Limited range of motion. Patient is in the wheelchair bound.

Document findings on next page

Plan of CarePriority Nursing Diagnosis:

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

Subjective: Patient states I can hardly breathe when I walk

Objective: 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 ActionsScientific Principle and/or RationaleEvaluationModification of Plan of Care

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

Auscultate breath sounds Q1- 2 .

Presence of crackles, wheezes may signifyairway obstruction, leading to orexacerbating existing hypoxia.

Pt demonstrated effective coughing techniques for student nurse

Monitor vital signs: Auscultate breath sounds, heart rate and rhythm, respirations q 4 hours.Respiratory system may become decompensated. Tachycardia and changes in blood pressure may be present because of pain, anxiety and reduced cardiac output.BP is 111/68 Lung sounds are clear to auscultation, respiratory rate is between 20 to 24 breaths per minute and pulse is at 72

Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes q 4 hours.

Indicators of level of hydration and adequacy of circulating volume. Mucous membrane are moist, capillary refill is less than 2 seconds and skin turgor has increased

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

respiratory rate, use of accessorymuscles, nasal flaring, andabdominal breathing may indicate hypoxia.

Pts airway remained open

Identify priority of learning needs within the overall care plan as soon as possible. Teaching standardized content that the patient already knows wastes valuable time and hinders critical learning. Adults learn material that is important to them The patient

verbalizes understanding of priority learning needs.

Provide a quiet atmosphere without interruption within 2 hours of admission. A calm quiet environment assists the patient with concentrating more completely. The patient is very comfortable in her private room and ready to express her concerns regarding her health care.

Encourage questions before and after each teaching. Questions facilitate open communication between patient and health care professionals, and allow verification of understanding of given information and the opportunity to correct misconceptions The patient asked questions regarding her regimen, diet and concerns when injecting herself.

Elevate head of bed, assist patient to assume position 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 upright position and breathing exercises to decrease airway collapse, dyspnea, and work of breathing.Note:Recent research supports use of prone position to increase Pao2.The patient tolerated deep breathing exercises after showing correct techniques

Monitor vital signs and cardiac rhythm.Tachycardia,dysrhythmias, and changes in BP can reflect effect of systemic hypoxemia on cardiac function.Patient blood pressure dropped to a stable level after medications were given

Monitor level of consciousness/mental status. Investigate changes.Restlessness and anxiety are common manifestations of hypoxia. Worsening ABGs accompanied by confusion/somnolence are indicative of cerebral dysfunction due to hypoxemia.Patient was alert after making necessary changes

Evaluate level of activity tolerance. Provide calm, quiet environment. Limit patients activity or encourage bed/chair rest during acute phase. Have patient resume activity gradually and increase as individually tolerated.During severe/acute/refractory respiratory distress, patient may be totally unable to perform basic self-care activities because of hypoxemia and dyspnea. Rest interspersed with care activities remains an important part of treatment regimen. An exercise program is aimed at increasing endurance and strength without causing severe dyspnea and can enhance sense of well-being.Patient tolerated ambulating from chair to bed after a short rest

CARE PLAN RUBRIC

Student: ___________________________________ Date: ______________________

CATEGORIESPOSSIBLE POINTSYOUR POINTSCOMMENTS

SUBJECTIVE DATA

(Relevant and timely and quoted from patient)

10

OBJECTIVE DATA

(Includes vital signs, physical assessment findings, diagnostic tests and procedures, relevant medications, etc.)10

NURSING DIAGNOSIS

(NANDA, R/T, AEB)

20

GOAL

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

20

INTERVENTIONS AND RATIONALES

(Assess, Assist, and Teach)

20

EVALUATION OF CARE PLAN

(Evaluate each nursing action for effectiveness)

10

MODIFICATION OF CARE PLAN

(Modify patient care plan based on patients 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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