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MIAMI DADE COLLEGE - MEDICAL CENTER CAMPUS - SCHOOL OF NURSING

NUR 1025L: Fundamentals Nursing Clinical

Students Name: Francisco J Ortiz Date:_06/08/13_ Clients Initials: ____IH____ Admission Date: _04/01/13_

Age:___91___Yr_____Mo DOB: ______08/28/1921_____ Sex: Male X Female Race/Ethnicity: White/______________Support System: ______son_________________________________________________________ Religion: _Catholic__________

MEDICAL HISTORY

ALLERGIES: _____NKA__________________________________________________________________________________________

Admitting Medical Diagnosis (es): _____DMII; Fracture of humerus; dementia; hypertension; lipoid metabolic disorder, iron deficiency;

anemia____________________________________________________________________________________________________________________________________________________________________________________

Chief Complaint: ______Abnormal lab______________________________________________________________________________________________

History of Present Illness: Pt from nursing home history of GI bleeding. Pt was sent back to the hospital because of low

HH__________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Past Medical History (include past surgical history): __Significant for hypertension, diabetes , dementia andhyperlipidemia_________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

Clients (Parents)Understanding of Illness: ________Pt has dementia and cannot recollect information

given____________________________________________________________________

__________________________________________________________________________________________________________________

Stage 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 _Formal Operational____

Special Developmental Considerations: ________________________________________________________________________________

Height: _____54________ Weight: ____110lb___________ Placement in Growth Chart:

_____________________________________________

Immunizations: ___________________________________________________________________________________________________

VITAL SIGNS

Time Taken: _______________ Activity: ______________ Position: ____wheel chair__________

T_36.4____ P__96__ R 19__ BP _129/68___ Baseline (Normal Age for Age): T_ 36.137.8 P_60 -100 R_12-20_ BP 120/80 _

NUTRITION

Diet: ______________________________ Food Preferences: ______________________________________________________________

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Nutritional Requirements: (Cal/Kg/Day): _____________________________Total Calories per Day: _____________________________

Fluid Requirements (Ml/Kg/Day): __________________________________ _Total Fluids per Day: _______________________________

Special Treatments: ___________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Medications at Home:_N/A___________________________________________________________________________________________

__________________________________________________________________________________________________________________

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Medication(s) Worksheet

NAME

CLASSIFICATION

DOSE/ROUTE/FREQUENCY

SAFE RANGE

MECHANISM

OF ACTION

INDICATIONS SIDE EFFECTS NURSING CONSIDERATIONS

AND PATIENT EDUCATION

Prilosec 20mg daily by mouth Binds to anenzyme ongastricparietal cellsin thepresence of

acidic gastricpH,preventingthe finaltransport ofhydrogenions into thegastriclumen.

GERD/maintenance of healingin erosiveesopha- gitis.Duodenal ulcers(with or without

anti-infec- tivesfor Helicobacter

pylori). Short-term treat-ment of activebenign gastriculcer.Pathologichypersecretoryconditions,includingZollinger-El-lison syndrome.Reduction of

risk of GIbleeding incritically illpatients.

CNS:dizziness,drowsiness,fatigue,headache,weakness.

CV: chestpain. GI:abdominalpain, acidregurgitation,constipation, diarrhea,flatu- lence,nausea,vomiting.Derm:itching,rash. Misc:

allergicreactions.

A Assess patientroutinely forepigastricor abdominalpain and frank or occultblood in the stool,emesis, or gastric

aspirate.

Monitor CBC withdifferential periodicallyduring therapy.

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Norvasc 10mg 1 tab PO Inhibits thetransport ofcalcium intomyocardialand vascularsmoothmuscle cells,resulting inin- hibition ofexcitation-contractioncoupling andsubsequentcontraction.

Indications:Aloneor with otheragents in themanagement ofhypertension,angina pectoris,and vasospastic(Prinzmetals)angina.

CNS:headache,dizziness,fatigue. CV:peripheraledema,angina,bradycardia,hypotension, palpita-tions. GI:gingivalhyperplasia,nausea.Derm:flushing.

Monitor blood pressureand pulse before therapy,during dose titration, andperiodically duringtherapy. Monitor ECGperiodically duingprolonged therapy.

Celexa 10mg 1 tab PO Selectivelyinhibits thereuptake ofserotonin inthe CNS.

Depression. CNS:NEUROLEPTICMALIGNANTSYNDROME,SUICIDALTHOUGHTS,

apathy,

confusion,drowsiness,insomnia,weakness,agitation,amnesia,anxiety.

Assess for suicidaltendencies, especiallyduring early therapy anddose changes. Restrictamount of drug availableto patient. Risk may be

increased in children,adolescents, and mayminimize dry mouth. If drymouth persists for morethan 2 wk, consult healthcare professionalregarding use of salivasubstitute

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Namenda 10mg 1 tab PO Binds to CNSN-methyl-D-aspartate(NMDA) re-ceptor sites,preventingbinding ofglutamate,an excitatoryneurotransmitter.

Moderate tosevereAlzheimersdementia.

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

Assess cognitive function(memory, attention,reasoning, language,ability to perform simpletasks) periodically duringtherapy.

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Amaryl 4mg 1 tab PO (with

breakfast)Lower bloodglucose bystimulatingthe releaseof insulinfrom thepancreasandincreasingthesensitivity toinsulin atreceptorsites. Mayalso de-creasehepaticglucoseproduction.

Control of bloodglucose in type2 diabetesmellitus whendiet therapyfails. Requiresomepancreaticfunction.

CNS:dizziness,drowsiness,headache,weakness.GI:constipation, cramps,diarrhea,drug-inducedhepatitis,heartburn, qappetite,nausea,vomit- ing.Derm:photosensitivity, rashes.

Observe for signs andsymptoms ofhypoglycemic reactions(sweating, hunger,weakness, dizziness,tremor, tachycardia,anxiety).

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Medication(s) Worksheet

CLASSIFICATION

NAME

DOSE/ROUTE/FREQUENCY

SAFE RANGE

MECHANISM

OF ACTION

INDICATIONS SIDE EFFECTS NURSING C ONSIDERATIONS

AND PATIENT EDUCATION

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Zestril 10mg 1 tab PO ACEinhibitorsblock theconversionofangiotensin Ito thevasoconstrictorangiotensinII. ACEinhibitorsalso preventthedegradationofbradykininand othervasodilatoryprostaglandins. ACEinhibitorsalso qplasma renin

levels and pal-dosteronelevels. Netresult issystemicvasodilation.

Alone or withother agents inthemanagement ofhypertension.

CNS:dizziness,drowsiness,fatigue,headache,insomnia,vertigo,weakness.Resp:cough,dyspnea.CV:hypotension,chest pain,edema,tachycardia.Endo:hyperuricemia

Hypertension: Monitorbloodpressure and pulsefrequently during initialdose adjustment andperiodically duringtherapy. Notify healthcare professional ofsignificant changes.

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Ferrous sulfate 65mg tab with breakfast An essentialmineralfound inhemoglobin,myo- globin,and manyenzymes.Enters theblood-stream andistransportedto theorgans ofthe re-ticuloendothelial system(liver,spleen, bonemarrow),where it isseparatedout andbecomes

part of ironstores.

Prevention/treatment of iron-deficiencyanemia

CNS: IM, IVSEIZURES,dizziness,headache,syn- cope.CV: IM, IVhypotension,hypertension,tachycardia.GI: nausea;PO,constipation,dark stools,diarrhea,epigastricpain, GIbleeding;

Assess nutritional statusand dietary history todetermine possible causeof anemia and need forpatient teaching.

Assess bowel function forconstipation or diarrhea.Notify health careprofessional and use

appropriate nursingmeasures should theseoc- cur.

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Zocor 20mg 1 tab PO nightly Inhibit anenzyme, 3-hydroxy-3-methylglutaryl-co-enzyme A(HMG-CoA)reductase,which isrespon- sibleforcatalyzingan earlystep in thesynthesis ofcholesterol.

Adjunctivemanagement ofprimaryhypercholes-terolemia andmixeddyslipidemias.

CNS:dizziness,headache,insomnia,weakness.CV: chestpain,peripheraledema.EENT:rhinitis;lovastatin,blurredvision.Resp:bronchitis.

Obtain a dietary history,especially with regard tofat consumption.

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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,HEPATOTOXICITY

(overdose).GU: renalfailure (highdoses/chronic use). He-mat:neutropenia,

pancytopenia,leukopenia.Derm: rash,urticaria.

Assess overall healthstatus and alcohol usagebefore administeringacetaminophen. Patientswho are malnourished orchronically abuse alcoholare at higher risk ofdeveloping hepato-toxicity with chronic useof usual doses of thisdrug.

Assess amount,frequency, and type ofdrugs taken in patientsself-medicating,especially with OTCdrugs. Prolonged use ofacetaminophen increasesthe risk of adverse renaleffects. For short-termuse, combined doses ofacetaminophen andsalicylates should not

exceed therecommended dose ofeither drug 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- Incidence of anemia reflect the presence of bone

marrow failure or excessive loss of red blood cells or both.Bone marrow failure can occur due to nutritional

deficiencies, toxic exposures, tumor, or mostly due tounknown causes. Red blood cells can be lost through

hemorrhage or hemolysis (destruction) in the latter case, the

problem can be caused by the effects of red blood cells thatdo not correspond to the resistance of normal red blood cells

or due to several factors outside the red blood cells thatcauses red blood cell destruction.

Red blood cell lysis (dissolution) occurs mainly in the

phagocytic system or in the reticuloendothelial system,especially in the liver and spleen. As a byproduct of this

process the bilirubin that is formed in phagocytes will enterthe bloodstream. Any increase in red blood cell destruction

(hemolysis) immediately reflected by increasing plasmabilirubin (normal concentration of 1 mg / dl or less; levels of

1.5 mg / dl result in jaundice in the sclera.

Anemia is a blood disease characterized less low levels ofhemoglobin (Hb) and red blood cells (erythrocytes). The

function of the blood is carrying food and oxygen to allorgans of the body. If the supply is less, then the intake of

oxygen will be less. As a result, can inhibit the work of the

vital organs, the brain One. The brain consists of 2.5 billionbioneuron cells. If capacity is lacking, then the brain will be

like computer memory is weak, slow catch. And if it isdamaged, can not be repaired (Sjaifoellah, 1998).

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Classification- Anemias can be classified by cytometric

schemes (i.e., those that depend on cell size and hemoglobin-content parameters, such as MCV and MCHC),

erythrokinetic schemes (those that take into account the ratesof rbc production and destruction), and

biochemical/molecular schemes (those that consider the

etiology of the anemia at the molecular level.

Etiology- The most common cause of anemia is deficiency of

nutrients required for the synthesis of red blood cells, such asiron, vitamin B12 and folic acid. The rest is the result of a

variety of conditions such as hemorrhage, geneticabnormalities, chronic disease, drug toxicity, and so on.

Statistics-

7% of children aged 1-2 had anemia in the US 1999-2000

(MMWR, NCHS, CDC)

12% of women aged 12-49 had anemia in the US 1999-

2000 (MMWR, NCHS, CDC)

174,600 nursing home residents had anemia in the US

1999 (National Nursing Home Survey, NCHS, CDC)

10.7% of nursing home residents had anemia in the US1999 (National Nursing Home Survey, NCHS, CDC)

3.4 million cases in the US (Mayo Clinic)

1.3% of population self-reported having anemia in

Australia 2001 (ABS 2001 National Health Survey,Australias Health 2004, AIHW)

0.3% of male population self-reported having anemia in

Australia 2001 (ABS 2001 National Health Survey,Australias Health 2004, AIHW)

2.3% of female population self-reported having anemia inAustralia 2001 (ABS 2001 National Health Survey,

Australias Health 2004, AIHW)

217,000 women self-reported having anemia in Australia2001 (ABS 2001 National Health Survey, Australias Health

2004, AIHW)

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DIAGNOSTIC TESTS

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

RESULTSDate, Result, Significance

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Laboratory values

CHEMISTRY

PROFILE

NORMAL

VALUES

CLIENTS VALUES HEMOTOLOGY NORMAL

VALUES

CLIENTS VALUES

DATE DATE DATE DATE DATE DATE

SODIUM 135-145Meq/L

142

2/21/13

WBC 3.8-10.8K/uL

4.82-

2/21/13

POTASSIUM 3.5- 5.1

mEq/L

4.5

2/21/13

RBC 3.80-5.20 2.06*

2/21/13

CHLORIDE 98-108mEq/L

1092/21/13

HGB 11.8-15.4g/dl

CO2 19-34 23.0

2/21/13

HCT

CALCIUM 8.2-10.3mg/dL

7.7

2/21/13

MCV 79.4-94.8fL 90.7

2/21/13

GLUCOSE 70-105mg/dL

261

2/21/13

MCH

BUN 7-25 mg/ Dl 36.0*2/21/13

MCHC 25.6-32.2 pg 27.8

2/21/13

CREATININE 0.6-1.2mg/dL

1.35*2/21/13

PLATELETS 11.5-15.0% 16.62/21/13

PHOSPHORUS

CHOLESTEROL DIFFERENTIAL

TOTAL PROTEIN 6.4-8.9 g/dL 6.42/21/13

NEUTROPHILS

ALBUMIN 3.5-5.0 g/dL 3.482/21/13

SEGMENTS

ALBUMIN/GLOBULIN RATIO

2.922/21/13

BANDS

AST (SGOT) 13-39 U/L 23 2/21/13 LYMPHOCYTES

ALT (SGPT) 7-52 U/L 15 2/21/13 EOSINOPHILS

TOTAL BILIRUBIN 0.3-1.0

mg/dL

BASOPHILS

AMYLASE MONOCYTES

LIPASE

COAGULATION STUDIES

PTT

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SODIUM 135-145

Meq/L

142

2/21/13

WBC 3.8-10.8 K/uL 4.822/21/13

POTASSIUM 3.5- 5.5mEq/L

4.5

2/21/13

RBC 3.80-5.20 2.05*

2/21/13

CHLORIDE 98-108mEq/L

109*

2/21/13

HGB 11.8-15.4g/dl

CO2 19-34 23.0

2/21/13

HCT

CALCIUM 8.2-10.3

mg/dL

7.7*

2/21/13

MCV

GLUCOSE 70-105

mg/dL

261*

2/21/13

MCH

BUN 7-25 mg/ Dl 36.0*2/21/13

MCHC

CBC BMP

Hgb Na+

Cl-

BUNWBC Plts Glucose

Hct K+ HCO3 Creatinine

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URINALYSIS

COLOR

APPEARANCE

SP. GRAVITY 1.010-1.025 MISCELLANEOUS TEST

PH 4.5-8.0 TEST NORMAL

VALUES

CLIENTS VALUES

DATE DATE DATE

GLUCOSE

KETONE

OCCULT BLOOD

PROTEIN

BILRUBIN

UROBILINOGENNITRITE

LEUCOCYTE

CAST

WBC

RBC

CRYSTALS

SQUAMOUSCELLS/

EPITHELIAL

CELLS

Relate the clinical significance of abnormal lab values above:___________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________

_______________________________________________________________

Head to Toe AssessmentGeneral Appearance:

The pt is resting comfortably in no acute distress

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Head & 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: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: Risk for infection related to abnormal labs

Supporting Data:

Subjective: Patient states I am tiredObjective: Labs show abnormal labs

Expected Outcome (Goals)

Long Term:Short Term:

Nursing Interventions

Nursing Actions Scientific Principleand/or Rationale

Evaluation Modification of Plan of Care

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CARE PLAN RUBRICStudent: ___________________________________ Date: ______________________

CATEGORIES POSSIBLE POINTS

YOURPOINTS

COMMENTS

SUBJECTIVE DATA(Relevant and timely and quotedfrom patient)

10

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

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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:

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

Reviewed with student: ______________________________ Date: ___________________

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Signature

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