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

Students Name: Francisco J Ortiz Date:_07/06/13_ Clients Initials: ____ER____ Admission Date:_05/20/2013

Age: 78yr DOB: ______06/15/1940_____ Sex: X Male Female Race/Ethnicity: WHITE/______________Support System: _____No living family membes _________________________________________________________

Religion: _Protestant__________

MEDICAL HISTORYALLERGIES: _NKA_Admitting Medical Diagnosis (es): Cardiac dysrthmias, CHF, hypertension, Constipation, seizure

disorder, dementia

Chief Complaint: patient right-side epitaxis

History of Present Illness: Pt is a 78 has history of pulmonary embolism and was anticoagulationbecause of this condition. Pt came back to hospital wih right-side epistaxis and currently at thebedside. Pt doesnot appear to have any acute bleeding.

Past Medical History (include past surgical history):Senile,Dementia, pulmonary embolism hypertension, asthma, Esophageal Reflux; No alcohol abuse,no drug abuse

Clients (Parents)Understanding of Illness: patient understands and full aware of condition

Stage of Development: Erickson Ego Integrity vs. Despair _ Freud: According to Freud, the genitalstage lasts throughout adulthood. He believed the goal is to develop a balance between all areas oflife. Piaget _ Formal Operational

____Special Developmental Considerations: N/AHeight: 170.18 cm Weight: 46.36 kg Placement in Growth Chart: _N/AImmunizations: Patient refused flu vaccine

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VITAL SIGNSTime Taken: ______0930_________ Activity: ______________ Position: ____wheel chair__________

T_96.0 P65R 18 BP _145/60Baseline (Normal Age for Age):T_ 36.137.8 P_60 -100 R_12-20_ BP 120/80_

NUTRITIONDiet: Regular/Puree Food Preferences: coffee with 2 splenda, yogurt for LUNCH, N/A for DINNER

Nutritional Requirements: (Cal/Kg/Day): 1725CAL/KG/DAY Total Calories per Day: _1800___________

Fluid Requirements (Ml/Kg/Day): ____30-35 Ml/Kg/Day_____________ __Total Fluids per Day: _____1440-1680__________________________

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

NURSINGCONSIDERATIONS

AND PATIENTEDUCATION

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BUDESONIDE 0.5mg 1 tab Q12 bymouth

Potent, locallyacting anti-inflammatoryand immunemodifier.

Maintenancetreatment ofasthma asprophylactictherapy. Maydecrease theneed for oreliminate use ofsystemiccorticosteroidsin patients withasthma.

CNS:headache,agitation,depression,dizziness,fatigue,insomnia,restlessness. EENT:dysphonia,hoarseness,cataracts,nasalcongestion,pharyngi-tis, sinusitis.Resp:bronchospasm, cough,wheezing.GI: diarrhea,dry mouth

Monitor respiratorystatus and lungsounds. Assesspulmonary functiontests periodicallyduring and for severamonths after a transffrom systemic toinhalationcorticosteroids.

Assess patientschanging fromsystemic cortico-steroids to inhalationcorticosteroids forsigns of adrenalinsufficiency (anorexnausea, weakness,fatigue, hypotensionhypoglycemia) durininitial therapy andperiods of stress. Ifthese signs appear,

notify health careprofessionalimmediately; conditiomay be life-threatening

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MEMANTINE 10mg 1 tab daily bymouth

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

Moderate tosevereAlzheimersdementia.

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

Assess cognitivefunction (memory,attention, reasoning,language, ability toperform simple tasksperiodically duringtherapy.

Lab TestConsiderations: May

cause anemia

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CEPHALEXIN 500MG TAB Q8 bymouth

Bind tobacterial cellwallmembrane,causing celldeath. T

Treatment ofthe followinginfectionscaused bysusceptibleorganisms: Skinand skinstructureinfections(including burnwounds),Pneumonia

CNS:SEIZURES

(highdoses). GI:PSEUDOMEM-BRANOUSCOLITIS,

diarrhea,nausea,vomiting,cramps.Derm:STEVENS-

JOHNSONSYNDROME,

Assess for infection(vital signs;appearance of woundsputum, urine, andstool; WBC) at be-ginning and duringtherapy.

Before initiatingtherapy, obtaina

history to determineprevious use of andreactions to pencillinor cephalosporins.Persons with anegative history ofpenicillin sensitivitymay still have anallergic response.

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CLONIDINE 0.2MG TAB Q12 BYMOUTH

Stimulatesalpha-adrenergicreceptors inthe CNS, whichresults indecreasedsympatheticoutflowinhibitingcardioacceleration andvasoconstric-tion centers.Prevents painsignaltransmissionto the CNS bystimulatingalpha-adrenergicreceptors inthe spinalcord.

PO,Transdermal:Management ofmild tomoderatehypertension.

CNS:drowsiness,depression,dizziness,nervous-ness,nightmares.CV:

bradycardia,hypotension(q withepidural),palpitations.GI: drymouth,constipation,nausea,vomiting.

Monitor intake andoutput ratios and daiweight, and assess foedema daily, especiaat beginning oftherapy.

Monitor blood pressuand pulse frequentlyduring initial dose

adjustment andperiodically throughotherapy. Reportsignificant changes.

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ARICEPT 5MG TAB ONCE DAILYBY MOUTH

Inhibitsacetylcholinesterase thusimprovingcholinergicfunction bymaking moreacetylcholineavailable

Mild tomoderatedementiaassociated withAlzheimersdisease.

CNS:headache,abnormaldreams,depression,dizziness,drowsiness,fatigue,insomnia,syncope,sedation(unusual).CV: atrialfibrillation,hyper-tension,hypotension,vasodilation.

Assess cognitivefunction(memory,attention, reasoning,language, ability toperform simple tasksperiodically duringtherapy.

Administer Mini-MenStatus Exam(MMSE)

initially andperiodically as ascreening tool to ratecognitive functioning

Administer ClockDrawing Test initiallyand periodically as ascreening tool tomeasure severity ofdementia.

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Medication(s) Worksheet

CLASSIFICATION NAME

DOSE/ROUTE/FREQUENCY SAFE RANGE

MECHANISM

OF ACTION

INDICATIONS SIDE EFFECTS NURSINGCONSIDERATIO

NS ANDPATIENT

EDUCATIONFERROUS

SULFATE325MG DAILY BY

MOUTHAn essentialmineral foundinhemoglobin,myoglobin,and manyenzymes.Enters theblood- streamand istransportedto the organsof thereticuloendothelial system(liver, spleen,bonemarrow),where it isseparated outand becomespart of ironstores.

PO:Prevention/treatment of iron-deficiencyanemia.

CNS: IM, IVSEIZURES,dizziness,headache,syncope. CV:IM, IVhypotension,hypertension,tachycardia.GI: nausea;PO,constipation,dark stools,diarrhea,epigastric pain,GI bleeding;IM, IV, tastedisorder,vomiting.

Assess nutritionalstatus and dietaryhistory todeterminepossible cause ofanemia and needfor patientteaching.

Assess bowelfunction forconstipation ordiarrhea. Notifyhealth careprofessional anduse appropriatenursing measures

should theseoccur.

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ATROVENTSAN

EVERY 4 TO 6 HOURS Inhaln:Inhibitscholinergicreceptors inbronchialsmoothmuscle,resulting indecreasedconcentrations of cyclicguanosinemonophosphate (cGMP).Decreasedlevels ofcGMPproduce localbronchodilation

Inhaln:Maintenancetherapy ofreversibleairwayobstruction dueto COPD,includingchronicbronchitis andemphysema.

CNS: dizziness,headache,nervousness.EENT: blurredvision, sorethroat; nasalonly, epistaxis,nasal

dryness/irritation. Resp:bronchospasm,cough. CV:hypotension,palpitations.GI: GI irri-tation, nausea.Derm: rash

Assess forallergy to atropineand belladonnaalkaloids; patientswith theseallergies may alsobe sensitive toipratropium.Atrovent HFA MDIdoes not containCFC or soy andmay be usedsafely in soy orCFC-allergicpatients.However,Combivent MDIshould be avoidedin soy or peanut-allergic patients.

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Aspirin 81mg daily PO Inhibits thesynthesis ofprostaglandins that mayserve asmediators ofpain andfever,primarily inthe CNS. Hasno significantanti-inflammatoryproperties orGI toxicity.

Mild pain. Fever. GI: HEPATICFAILURE,HEPATOTOXICI

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

Assess overallhealth status andalcohol usagebeforeadministeringacetaminophen.Patients who aremalnourished orchronically abusealcohol are athigher risk ofdevelopinghepato- toxicitywith chronic useof usual doses ofthis drug.

Assess amount,frequency, andtype of drugstaken in patientsself-medicating,especially withOTC drugs.

Prolonged use ofacetaminophenincreases the riskof adverse renaleffects. For short-term use,combined dosesof acetaminophenand salicylatesshould not exceedthe recommendeddose of eitherdrug given alone.

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

treatments

Textbook Client

Pathology-Nosebleeds are due to the rupture of a bloodvessel within the richly perfused nasal mucosa. Rupture may

be spontaneous or initiated by trauma. Nosebleeds arereported in up to 60% of the population with peak incidences

in those under the age of ten and over the age of 50 and

Patient has rupture of a blood vessel within the richly perfused nasalmucosa

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appear to occur in males more than females.[3] An increase in

blood pressure (e.g. due to general hypertension) tends toincrease the duration of spontaneous epistaxis.[4]

Anticoagulant medication and disorders of blood clotting can

promote and prolong bleeding. Spontaneous epistaxis is morecommon in the elderly as the nasal mucosa (lining) becomes

dry and thin and blood pressure tends to be higher. Theelderly are also more prone to prolonged nose bleeds as their

blood vessels are less able to constrict and control thebleeding.

Classification- Commonly used classification according to

site of bleeding source

Anterior epistaxis:

Accounts for approximately 90% of nosebleeds

Usually originates from the Kiesselbach plexus, a rich

vascular anastomosis located at the anterior nasal

septum; this region is called Little's area.

Posterior epistaxis:

Originates from the posterior nasal cavity ornasopharynx [3] [4]

Posterior nasal and nasopharyngeal vessels often have

a larger calibre and may produce more active

bleeding.

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

Etiology- etiology of epistaxis is multi factorialbut can be divided into two broad groups Localand systemic. It must be noted that most casesof epistaxis do not have an easily identifiable

Patient epitaxis appears local

13

http://en.wikipedia.org/wiki/Nosebleed#cite_note-AAFP-3http://en.wikipedia.org/wiki/Nosebleed#cite_note-4http://en.wikipedia.org/wiki/Anticoagulanthttp://bestpractice.bmj.com/best-practice/monograph/421/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/421/resources/references.html#ref-4http://en.wikipedia.org/wiki/Nosebleed#cite_note-AAFP-3http://en.wikipedia.org/wiki/Nosebleed#cite_note-4http://en.wikipedia.org/wiki/Anticoagulanthttp://bestpractice.bmj.com/best-practice/monograph/421/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/421/resources/references.html#ref-4

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cause.

Statistics-

Epistaxis that occurs in children younger than 10years usually is mild and originates in theanterior nose, whereas epistaxis that occurs inindividuals older than 50 years is more likely tobe severe and to originate posteriorly [9].

Data from the National Hospital AmbulatoryMedical Care Survey indicate that epistaxisaccounted for

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DIAGNOSTIC TESTS

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

RESULTSDate, Result, Significance

CHEST XRAY REVEALS EMPHYSEMATOUS CHANGES

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Laboratory values

CHEMISTRYPROFILE

NORMALVALUES

CLIENTSVALUES

HEMOTOLOGY

NORMALVALUES

CLIENTS VALUES

DATE DATE

DATE DATE DATE

DATE

SODIUM 135-145

Meq/L

137

4/20/13

WBC 3.8-10.8

K/uL

6.1

4/20/13

POTASSIUM 3.5- 5.1mEq/L

4.44/20/13

RBC 3.80-5.20 3.12*L4/20/13

CHLORIDE 98-108mEq/L

1014/20/13

HGB 11.8-15.4g/dl

9.8*L4/20/13

CO2 19-34 274/20/13

HCT 41-50 29.7*L4/20/13

CALCIUM 8.2-10.3mg/dL

8.34/20/13

MCV 79.4-94.8fL

95.34/20/13

GLUCOSE 70-105mg/dL

154 *H4/20/13

MCH 31.34/20/13

BUN 7-25 mg/

Dl

9.2

4/20/13

MCHC 25.6-32.2

pg

32.8

4/20/13CREATININE 0.6-1.2

mg/dL1.14/20/13

PLATELETS 11.5-15.0%

124/20/13

PHOSPHORUSCHOLESTEROL

DIFFERENTIAL

TOTALPROTEIN

6.4-8.9g/dL

6.74/20/13

NEUTROPHILS

ALBUMIN 3.5-5.0g/dL

3.774/20/13

SEGMENTS

ALBUMIN/GLOBULIN RATIO

2.974/20/13

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

1374/20/13

WBC 3.8-10.8 K/uL 6.14/20/13

POTASSIUM 3.5- 5.5mEq/L

4.44/20/13

RBC 3.80-5.20 3.12*L4/20/13

CHLORIDE 98-108mEq/L

1014/20/13

HGB 11.8-15.4g/dl 9.8*L4/20/13

CO2 19-34 274/20/13

HCT 29.7*L4/20/13

CALCIUM 8.2-10.3mg/dL

8.34/20/13

MCV 95.34/20/13

GLUCOSE 70-105mg/dL 154 *H4/20/13 MCH 31.34/20/13

BUN 7-25 mg/Dl

9.24/20/13

MCHC 32.84/20/13

CBC BMP

Hgb Na+

Cl-

BUNWBC Plts Glucose

Hct K+ HCO3 Creatinine

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URINALYSISCOLOR YELLOWAPPEARANCE CLEARSP. GRAVITY 1.04 MISCELLANEOUS

TESTPH 5 TEST NORMAL

VALUESCLIENTS VALUES

DATE DATE DATEGLUCOSE NORMA

L

URINE

CULTURE

PENDI

NG

06/17/1

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:

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

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monitoring.

RBC(LOW)- INDICATIONS:-Low RBC count leads to anemia. Anemia can be caused by blood loss,decreased blood cell production, increased blood cell destruction, or hemodilution.

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

hematuria. Decreased blood cell production can be caused by folic acid deficiency, vitamin B12deficiency.

HCT (LOW)- INDICATIONS:- High Hct leads to polycythemia. Polycythemia can be caused bydehydration, decreased oxygen levels in the body, and an overproduction of RBCs by the bonemarrow. 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

Head to Toe AssessmentGeneral Appearance:

The pt is resting comfortably in no acute distress. No weight loss or gain. No feverHead & Hair: Norm cephalic and atraumatic

Face: Norm cephalic and atraumatic

Eyes: Norm cephalic and atraumaticEars: Norm cephalic and atraumatic

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Nose: 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: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: Ineffective airway clearance related to epitaxis

Risk Nursing Diagnosis: Risk of bleeding as evidence by patient showing signs of right-sidebleeding:Supporting Data: Patient came in with right-sided epitaxis

Subjective:Patient states I am bleeding from my noseObjective:patient shows obvious signs of bleeding

Expected Outcome (Goals)

Long Term: Patients right-side epitaxis will be minimized by discharge

Short Term: After 1 hrs. Of nursing interventions, the client epitaxis will be managed

Nursing InterventionsNursing Actions Scientific Principle

and/or RationaleEvaluation Modification of Plan of

CareMonitor vital signs:

Auscultate breath sounds,heart rate and rhythm,respirations q 4 hours.

Respiratory system

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

BP is 145/60 Lung

sounds are clear toauscultation, respiratoryrate is between 20 to 24breaths per minute andpulse is at 65

Assess peripheral pulses,capillary refill, skin turgor,

Indicators of level ofhydration and

Mucous membrane aremoist, capillary refill is

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and mucous membranes q4 hours.

adequacy of circulatingvolume.

less than 2 seconds andskin turgor has increased

Clean secretions from themouth and trachea

To preventobstruction /aspiration.

Clean patient and assessfor any continuousbleeding

Continue to monitor patientand assess for any bleeding

Give Fowler's or semi-Fowler position.

Positioning helpsmaximize lung

expansion and reducerespiratory effort.

Patient will remain insemi fowler to manage

nose bleed

Maintain a fluid inclusion at least

as much as 250 ml / day unless

contraindicated.

Helping dilution of

secretions.

Patient will intake atleast

250ml daily

Ask doctor if intake can be

increase if improvements are shown

Identify priority of learning needswithin the overall care plan as

soon as possible.

Teaching standardizedcontent that the patient

already knows wastesvaluable time and hinders

critical learning. Adults learn

material that is important tothem

The patientverbalizes understandingof priority learning needs.

Evaluate level of activitytolerance. Provide calm,quiet environment. Limitpatients activity orencourage bed/chair restduring acute phase. Havepatient resume activitygradually and increase asindividually tolerated.

Duringsevere/acute/refractoryrespiratory distress,patient may be totallyunable to performbasic self-careactivities because ofhypoxemia anddyspnea. Restinterspersed with careactivities remains an

Patient toleratedambulating from chair tobed after a short rest

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important part oftreatment regimen. Anexercise program isaimed at increasingendurance andstrength withoutcausing severedyspnea and canenhance sense of well-being.

Encourage questions before andafter each teaching.

Questions facilitate opencommunication between

patient and health careprofessionals, and allow

verification of understandingof given information and the

opportunity to correct

misconceptions

The patient askedquestions regarding herregimen, diet andconcerns when injectingherself.

Pt will maintain clear lungfields and remain free ofsigns of respiratorydistress throughout

hospital stay

Auscultate breathsounds Q1- 2 .

Presence of crackles,

wheezes maysignify airwayobstruction, leading toor exacerbatingexisting hypoxia.

Pt demonstrated effectivecoughing techniques for student

nurse

Elevate head of bed,assist patient to assumeposition to ease work ofbreathing. Include periods

Oxygen delivery maybe improved by uprightposition and breathingexercises to decrease

The patient tolerateddeep breathing exercises

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of time in prone positionas tolerated.

airway collapse,dyspnea, and work ofbreathing. Note: Recentresearch supports useof prone position toincrease Pao2.

after showing correcttechniques

Review individuals target blood

glucose levels as soon as possible.

Although this range varies

per person, the ideal range

for the adult diabetic is

considered to be 80 to 120

mg/dL. (Doenges pg 418)

Patient understood that their

normal blood sugar levels are

between 70 to 100 milligrams

per deciliter.

Pt will maintain a patent airway atall 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 remained open

Review clients dietary program;

compare with recent intake before

end of shift.

Identifies deficits and

deviations from therapeutic

plan, which may precipitate

unstable glucose and

The patient complies with the

new way of teaching nutritional

intake and insulin pattern.

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uncontrolled hyperglycemia.

(Doenges pg 412)

Administer glucose solution 5%

dextrose and half-normal saline to

1000ml in 24 hours.

Glucose solutions may be

added after insulin and fluids

have brought the blood

glucose to approximately

400 mg/dL.

Patients blood glucose level

was at 450mg/dL after

administration of IV.

Encourage deep-slow orpursed-lip breathing asindividually needed/tolerated.

Oxygen delivery maybe improved by uprightposition and breathingexercises to decreaseairway collapse,dyspnea, and work ofbreathing. Note: Recentresearch supports useof prone position toincrease Pao2.

The patient tolerateddeep breathing exercisesafter showing correcttechniques

CARE PLAN RUBRICStudent: ___________________________________ Date: ______________________

CATEGORIES POSSIBLE POINTS

YOURPOINTS

COMMENTS

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

20

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:

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

Reviewed with student: ______________________________ Date: ___________________Signature

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