1 CSU, STANISLAUS B.S.N. CLINICAL PLAN OF CARE Student : Maggie Fabry Date of Care: 10/11/13 Room Number: 340 Patient Data Admitting Diagnosis : R humeral head fracture Age: 64 Spiritual Focus: Hindu Culture: Hindu Patient Initials: DJ Gender: F Height : 5 ft 1 in Weight: 159 lbs Admitting Date: 10/09 POD: 1 Vital Signs: T: 36.6 P: 89 R: 18 B/P: 141/78 O 2 Sat: 99 Pain Scale: 9 Past Medical History: DM type 2, HTN, hyperlipidemia, nonalcoholic fatty liver disease Surgical History: R shoulder, rotator cuff surgery Diet: NPO pre-surgery, vegetarian diet post-surgery Activity: bedrest. Up with one person assist Foley: Y NG/Feeding Tube: N Advance Directives: No Drains/ Tubes: 2 L NC Code Status: Full VS Freq: Q6hr Glucose Monitoring: Y TEDs/SCDs: N Vascular Access: PCA/Epidural: N Telemetry: Y IV Site: 22 gauze IV in L forearm IV Solution: NS 1000mL Safety Considerations: Fall risk Dressing Change: N Labs to be drawn: none scheduled Scheduled Procedures: R humeral head surgery 10/10/13 Notes on pathophysiology: Type 2 diabetes: Diabetes is a problem with your body that causes blood glucose (sugar) levels to rise higher than normal. This is also called hyperglycemia. Type 2 diabetes is the most common form of diabetes. If you have type 2 diabetes your body does not use insulin properly. This is called insulin resistance. At first, your pancreas makes extra insulin to make up for it. But, over time it isn't able to keep up and can't make enough insulin to keep your blood glucose at normal levels. HTN: High blood pressure. The force of blood against artery walls is too high and can cause health problems. The more blood your heart pumps and the narrower the arteries, the higher the blood pressure Hyperlipidemia: involves abnormally elevated levels of any or all lipids and/or lipoproteins in the blood.[1] It is the most common form of dyslipidemia (which includes any abnormal lipid levels). Lipids (fat-soluble molecules) are transported in a protein capsule. The size of that capsule, or lipoprotein, determines its density. The lipoprotein density and type of apolipoproteins it contains determines the fate of the particle and its influence on metabolism. Hyperlipidemias are divided in primary and secondary subtypes. Primary hyperlipidemia is usually due to genetic causes (such as a mutation in a receptor protein), while secondary hyperlipidemia arises due to other underlying causes such as diabetes. Lipid and lipoprotein abnormalities are common in the general population, and are regarded as a modifiable risk factor for cardiovascular disease due to their influence on atherosclerosis. In addition, some forms may predispose to acute pancreatitis.
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CSU, STANISLAUS B.S.N. CLINICAL PLAN OF CARE
Student : Maggie Fabry Date of Care: 10/11/13 Room Number: 340
Patient Data Admitting Diagnosis : R humeral head fracture Age: 64 Spiritual Focus: Hindu Culture: Hindu Patient Initials: DJ Gender: F Height : 5 ft 1 in Weight: 159 lbs Admitting Date: 10/09 POD: 1 Vital Signs: T: 36.6 P: 89 R: 18 B/P: 141/78 O2 Sat: 99 Pain Scale: 9 Past Medical History: DM type 2, HTN, hyperlipidemia, nonalcoholic fatty liver disease Surgical History: R shoulder, rotator cuff surgery Diet: NPO pre-surgery, vegetarian diet post-surgery Activity: bedrest. Up with one person assist Foley: Y NG/Feeding Tube: N Advance Directives: No Drains/ Tubes: 2 L NC Code Status: Full VS Freq: Q6hr Glucose Monitoring: Y TEDs/SCDs: N Vascular Access: PCA/Epidural: N Telemetry: Y IV Site: 22 gauze IV in L forearm IV Solution: NS 1000mL Safety Considerations: Fall risk Dressing Change: N Labs to be drawn: none scheduled Scheduled Procedures: R humeral head surgery 10/10/13 Notes on pathophysiology: Type 2 diabetes: Diabetes is a problem with your body that causes blood glucose (sugar) levels to rise higher than normal. This is also called hyperglycemia. Type 2 diabetes is the most common form of diabetes. If you have type 2 diabetes your body does not use insulin properly. This is called insulin resistance. At first, your pancreas makes extra insulin to make up for it. But, over time it isn't able to keep up and can't make enough insulin to keep your blood glucose at normal levels. HTN: High blood pressure. The force of blood against artery walls is too high and can cause health problems. The more blood your heart pumps and the narrower the arteries, the higher the blood pressure
Hyperlipidemia: involves abnormally elevated levels of any or all lipids and/or lipoproteins in the blood.[1] It is the most common form of dyslipidemia (which includes any abnormal lipid levels). Lipids (fat-soluble molecules) are transported in a protein capsule. The size of that capsule, or lipoprotein, determines its density. The lipoprotein density and type of apolipoproteins it contains determines the fate of the particle and its influence on metabolism. Hyperlipidemias are divided in primary and secondary subtypes. Primary hyperlipidemia is usually due to genetic causes (such as a mutation in a receptor protein), while secondary hyperlipidemia arises due to other underlying causes such as diabetes. Lipid and lipoprotein abnormalities are common in the general population, and are regarded as a modifiable risk factor for cardiovascular disease due to their influence on atherosclerosis. In addition, some forms may predispose to acute pancreatitis.
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Nonalcoholic fatty liver diease: Non-alcoholic fatty liver disease (NAFLD) is the build up of extra fat in liver cells that is not caused by alcohol. It is normal for the liver to contain some fat. However, if more than 5% - 10% percent of the liver’s weight is fat, then it is called a fatty liver (steatosis). NAFLD tends to develop in people who are overweight or obese or have diabetes, high cholesterol or high triglycerides. Rapid weight loss and poor eating habits also may lead to NAFLD.
Lab and Diagnostic Test Data Test
type(date) Normal Range Patient Results Trend
↓↑ Rationale
(specific to pt.) Nursing Implications related to patient care &
teaching Glucose 74-118 10/09 0119: 158
10/09 0422: 135 10/10 0400: 152
↑ Monitoring blood glucose levels
because pt is a type ll diabetic. Also
monitoring because many drugs the pt is taking can alter blood
glucose levels. Levels are controlled
by insulin and glucagon.
Pt blood glucose levels are slightly above normal limits. Monitor glucose levels closely for further increases.
Administer prescribed Insulin as needed and as dictated by the sliding scale. Signs of hyperglycemia include
frequent urination, increased thirst, blurred vision and headache. Signs of hypoglycemia include confusion, abnormal behavior, vision disturbances, shakiness,
test also monitors liver function. Pt has an elevated BP and
chronic htn. This can
Pt is within normal limits. A decrease could indicate malnutrition. Could also be due to her high BP. Monitor s/s of kidney malfunction such as nausea, vomiting, or
abdominal pain. Monitor other electrolyte levels to ensure nutrition. An increase could indicate dehydration
or GI bleeding.
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Test type(date)
Normal Range Patient Results Trend ↓↑
Rationale (specific to pt.)
Nursing Implications related to patient care & teaching
cause kidney disease, so function must be monitored.
↑ Used to monitor kidney function and evaluate stages of
kidney failure.
Pt is now WNL. If levels fall consistently, kidney failure could be indicated. However, antibiotic treatment can
sometimes alter labs. Use creatinine levels to confirm. Watch for s/s of kidney disease such as low output, low appetite, nausea and vomiting, and persistent fatigue.
Note that age, gender, height, race and weight can influence the glumerular filtration rate.
Pt levels slightly low, but slowly increasing. Watch for a decrease (hypoatremia) and s/s such as weakness,
fatigue, headache, nausea and vomiting, muscle cramps, irritability, and confusion. Low sodium levels can indicate dehydration or low sodium intake. This pt was NPO pre
surgery, so this may have caused the low levels. Pt teaching about how hydrating can prevent low sodium
levels. Potassium 3.6-5.1 10/09 0119: 4.6
10/09 0422: 5.1 10/10 0400: 4.6
↓ Used to ensure electrolyte balance. Hold meds if levels
are abnormal or nearly abnormal. This
is electrolyte is important to cardiac
function and is especially important
in patients taking diuretics or digoxin.
Pt WNL. An increase in these levels could indicate kidney disease. Monitor s/s such as low output, low
appetite, nausea and vomiting, and persistent fatigue. A decrease in levels could indicate excessive potassium
loss in the urine. This could be due to a large variety of issues such as GI disorders, renal tubular acidosis, or
hyperaldosteronism. Monitor s/s such as muscle aches, abnormal weakness, arrhythmias, diarrhea, and nausea and vomiting. Know which meds to hold if levels are not
↑ Used to monitor acid base balance in the body as well as to assist in evaluating
the pH.
Pt is WNL. Watch levels to ensure they do not increase. s/s include rapid respiration, rapid pulse rate, and SOB.
As CO2 levels increase, there could be a reduction in pt’s over all LOC. Monitor levels for any dramatic increases because it could lead to respiratory arrest. S/s of low
CO2 levels (respiratory alkalosis) include confusion, hand tremor, light headedness or nausea and vomiting.
Pt is WNL. An increase could indicate lactic acidosis or kidney failure. S/s would include headache, palpitations,
chest pain as well as kidney disease s/s. A decrease could indicate a low sodium blood level or bone marrow
cancer. Calcium 8.9-10.3 10/09 0119: 9.4
10/09 0422: 9.5 10/10 0400: 8.3
↓ Used to monitor parathyroid function
and calcium metabolism. Also used to monitor kidney function.
Pt is WNL. Low levels may be a result of malabsorption syndrome, hypoalbumenia, end stage kidney disease,
post thyroidectomy, hypoparathyroidism, vitamin D deficiency, inadequate intake, pancreatitis, low
phosphate, meds that block parathyroid function prevent absorption of Ca. S/s of progressing hypocalcemia would include tingling in hands, feet or lips, muscle spasms or slow uneven heart beat. An increase in levels may be caused by hyperparathyroidism, metastatic tumor to
bone, prolonged immobilization, vitamin D intoxication, lymphoma, acromegaly. Symptoms of hypercalcemia are
usually not significant, unless severe hypercalcemia results, which may cause generalized symptoms such as
GI disturbances, fatigue, and like with hypocalcemia, muscle twitching.
Total Protein 6.1-7.9 10/09 0119: 7.1 Used to diagnose, Pt WNL. A decrease in levels could indicate malnutrition.
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Test type(date)
Normal Range Patient Results Trend ↓↑
Rationale (specific to pt.)
Nursing Implications related to patient care & teaching
evaluate and monitor disorders such as liver dysfunction, impaired nutrition,
and protein-wasting states.
S/s to watch for would include weight loss, weakness or muscle fatigue, increased susceptibility to infections, or delayed healing of even small wounds. An increase in
levels could indicate dehydration or inflammatory disease. Inflammatory diseases are characterized by
episodes of inflammation that result in fever, rash or joint swelling. Will monitor lab values and use albumin and
globulin levels to confirm any abnormalities. Albumin 3.5-4.8 10/09 0119: 4.0 Just like the total
protein test, this test is used to diagnose, evaluate and monitor
disorders such as liver dysfunction, impaired nutrition,
and protein-wasting states.
Pt WNL. A decrease in levels could indicate malnutrition. S/s to watch for would include weight loss, weakness or muscle fatigue, increased susceptibility to infections, or delayed healing of even small wounds. An increase in
levels could indicate dehydration or inflammatory disease. Inflammatory diseases are characterized by
episodes of inflammation that result in fever, rash or joint swelling. Will monitor lab values and use total protein
and globulin levels to confirm any abnormalities. Globulin 2.3-3.5 10/09 0119: 3.1 Just like the total
protein test and albumin, this test is used to diagnose,
evaluate and monitor disorders such as liver dysfunction, impaired nutrition,
and protein-wasting states.
Pt WNL. A decrease in levels could indicate malnutrition. S/s to watch for would include weight loss, weakness or muscle fatigue, increased susceptibility to infections, or delayed healing of even small wounds. An increase in
levels could indicate dehydration or inflammatory disease. Inflammatory diseases are characterized by
episodes of inflammation that result in fever, rash or joint swelling. Will monitor lab values and use albumin and
total protein levels to confirm any abnormalities.
ALB/GLOB ratio 0-35 10/09 0119: 1.3 Used in the evaluation of pts that are expected to have
hepatocellular diseases
Pt WNL. An increase could indicate liver disease. Signs to watch for include loss of appetite, loss of energy,
weight loss, jaundice, or fluid retention. A decrease could indicate renal disease. S/s to watch for will include low
output, low appetite, nausea and vomiting, and persistent fatigue
Alkaline Phosphatase
38-126 10/09 0119: 66 Used to detect and monitor diseases of
the liver or bone.
Pt WNL. An increase in these levels could indicate primary cirrhosis or bone disease. S/s of cirrhosis
include loss of appetite, loss of energy, weight loss, jaundice, or fluid retention. S/s of bone disease would
include pain, weakness or tingling in the affected area. A decrease in levels could indicate malnutrition. These s/s
include weight loss, weakness or muscle fatigue, increased susceptibility to infections, or delayed healing
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Test type(date)
Normal Range Patient Results Trend ↓↑
Rationale (specific to pt.)
Nursing Implications related to patient care & teaching
of even small wounds. AST/SGOT 15-41 10/09 0119: 53 Test primarily used in
the evaluation of pts with suspected hepatocellular diseases. The amount of AST
elevation is directly related to the number of cells affected by a
disease or injury. Because this enzyme
is found in skeletal muscle and because
this pt just had a bone fracture, the test was indicated.
Pt levels above normal. This is mostly like due to her recent skeletal muscle trauma. Levels should decrease as the fracture heals. Monitor pt for healing progress and check lab value regularly to assess progression. If levels
were low, acute renal disease or diabetic ketoacidosis could be indicated.
ALT/SGPT 14-54 10/09 0119: 59 Used to identify hepatocellular
diseases of the liver or to monitor the improvement or
worsening states of these diseases
Pt levels are above normal. This could indicate cirrhosis, hepatic tumor or obstructive jaundice. A further increase could indicate hepatitis. Signs to watch for include loss of
appetite, loss of energy, weight loss, jaundice, or fluid retention. Another set of labs was not completed for this
pt. Plan to watch for these signs and symptoms and inquire about the test during my next trip to the hospital.
Bili Total 0.4-2.0 10/09 0119: 0.8 This is yet another test to evaluate liver
function.
Pt WNL. An increase in this level could indicate liver disease. S/s would include loss of appetite, loss of
energy, weight loss, jaundice, or fluid retention. Will watch for s/s and monitor pt closely.
Pt levels were WNL pre-surgery and slightly low post-op. This decrease could simply indicate blood loss due to
surgery. In general, a decrease could indicate anemia, renal disease, or bone marrow failure. S/s would depend
on the disease process being indicated. An increase
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Test type(date)
Normal Range Patient Results Trend ↓↑
Rationale (specific to pt.)
Nursing Implications related to patient care & teaching
hematocrit levels. Conducted as a routine part of a complete blood
count. Also used to check for anemia.
could indicate severe COPD of severe dehydration. S/s of increased severity of COPD include an ongoing cough that produces a lot of sputum, SOB, wheezing or chest
swelling and sudden numbness. A decrease could indicate anemia, renal disease, or bone marrow failure. Low levels are seen as pale skin, nail beds and gums,
shortness of breath, cardiac symptoms like palpitations, chest pain and aggravation of heart problems. I will
monitor labs for changes. Hematocrit 35-47 10/09 0119: 38.4
10/09 0422: 37.3 10/10 0400: 31.0
↓ This test closely reflects the
hemoglobin values. Used as a rapid,
indirect measurement of RBC number and volume, integral part
of evaluation of anemic patients.
Pt shows drop in levels post-op. This drop indicates a loss of blood during the surgery. Normally, a drop in levels could indicate anemia, renal disease, or bone
marrow failure. S/s would include constant fatigue and tiredness, pale skin, shortness of breath, hair loss,
worsening heart problems, and faster heart palpitations. An increase could indicate severe COPD or severe
Pt is within normal limits. When values are normal the anemia is said to be normochromic (hemolytic anemia).
An increase level in RDW could indicate a large variety of different kinds of anemia. S/s would include easy fatigue
and a loss of energy, SOB, dizziness and pale skin. Platelet Count
Auto 130-400 10/09 0119: 209
10/09 0422: 220 10/10 0400: 152
↓ Used to monitor platelet number in the blood. Used in this pt
to monitor risk for bleeding because they are receiving
heparin and because she is post-op.
Pt WNL. An increase could indicate anything from malignant disorder like leukemia or lymphoma to
rheumatoid arthritis. A decrease could indicate immune thrombocytopenia in which antibodies would be
destroying the body’s platelets, bleeding or infection. Monitor for s/s such as easy or excessive bruising,
superficial bleeding into the skin, or blood in urine or stools. Will monitor levels for changes and look for s/s
associated with abnormal levels Neutrophils % 42-75 10/09 0119: 83.3
10/09 0422: 78.5 ↑ Neutrophils primarily
fight acute bacterial Pt levels are high. High levels can suggest acute
bacterial infection as well as fungal infections. Levels
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Test type(date)
Normal Range Patient Results Trend ↓↑
Rationale (specific to pt.)
Nursing Implications related to patient care & teaching
10/10 0400: 84.2 infections and fungal infections. This pt
had a bone fracture and is therefore at risk for infection.
may be high due to the pt’s recent fracture and then a corrective surgery that followed. Will continue to monitor
labs to ensure that levels return to normal in a timely fashion. Pt being prescribed Ancef. Low levels could indicate sepsis or radiation therapy, aplastic anemia,
chemotherapy and influenza. Lymphocytes % 16-50 10/09 0119: 10.2
10/09 0422: 15.2 10/10 0400: 10.0
↓ Lymphocytes primarily fight chronic infection and acute viral infections. This
↓ Neutrophils primarily fight acute bacterial infections and fungal
infections. This pt had a bone fracture and is therefore at risk for infection.
Pt levels are high but decreasing. High levels can suggest acute bacterial infection as well as fungal
infections. Levels may be high due to the pt’s recent fracture and then a corrective surgery that followed. Will
continue to monitor labs to ensure that levels return to normal in a timely fashion. Pt being prescribed Ancef. Low levels could indicate sepsis or radiation therapy,
especially if or when dose is adjusted. Monitor renal function and electrolyte panel. Be aware that drug can cause hypoglycemia, so concurrent use with
insulin requires careful consideration. Pt should avoid activities requiring
coordination until drug effects are realized. Instruct pt to report s/s of
hypotension such as dizziness,blurry vision, confusion, weakness, fatigue or
nausea. Advise pt against sudden discontinuation of the drug. Provide pt teaching on lifestyle changes such as a diet low in salt and high in vegetables as
well as implementation of an exercise regimen. Pt should consult dr before
using potassium supplements or potassium-containing salt substitutes.
Escitalopram Oxalate (Lexapro)
Selective serotonin reuptake inhibitor;
antidepressant
10mg/PO/QAM Enhances serotonergic activity
in the CNS as a result of its inhibition of serotonin reuptake
Monitor pt closely for clinical worsening, suicidality, or unusual changes in
behavior. Family and caregivers should be advised of the need for close
observation and communication with prescriber. Advise pt not to drink alcohol while taking medication. Use precaution when withdrawing medication. Gradual
withdraw should be used whenever possible. Monitor for s/s of resolution
which would indicate drug efficacy. Counsel pt to report s/s of serotonin
syndrome such as high fever, agitation, confusion, hallucinations, hyperreflexia, nausea, vomiting or diarrhea. Advise pt that concomitant use of aspirin, NSAIDS
or heparin can increase the risk of bleeding. May take med without regard to
• Perform pt teaching regarding proper subQ injection techniques if pt wishes to give their own injections. This includes teaching on proper sites for injection and rotating injection sites to prevent lipodystrophy. Monitor glucose levels frequently to assess drug efficacy and appropriateness of dosage. Monitor for s/s of hypoglycemia. These include trembling, clammy skin, palpitations (pounding or fast heart beats), anxiety, sweating, hunger, and irritability. S/s of severe hypoglycemia can include difficulty thinking, confusion, headache, seizure and coma. Monitor for s/s of hyperglycemia such as polydipsia,
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polyphagia, polyuria, and diabetic ketoacidosis (as shown by blood and urinary ketones, metabolic acidosis, extremely elevated blood glucose level). Teach pt about life style changes that can help to control glucose levels and may help to reduce insulin intake. Perform pt teaching on tight glucose control. Maintaining tight glucose control may help pt to manage their htn and reduce other problems that can result from DM. Have another nurse verify dosage!
Diphenhydramine HCl
(Benadryl)
Ethanolamine derivative, nonselective histamine-
receptor antagonist; antihistamine, antitussive,
antiemetic, antivertigo agent, antidyskinetic
50mg/IV/Q6H PRN Acts as an antihistamine by competing with
Johnson syndrome, hearing loss, depression, acute renal failure, Reye’s
syndrome.
Know that NSAIDs increase the risk of serious cardiovascular thrombotic
events, MI and stroke. They can also increase the risk of GI adverse events. Medication may be given with food or
milk to reduce GI upset. Monitor for relief of pain or reduction in fever. Monitor renal and liver function tests with long term use. Advise pt to avoid use of additional NSAIDs or aspirin during therapy. Instruct pt to report s/s of
serious GI events such as bleeding, ulceration or perforation
Ondansatron HCl (Zofran)
Antiemetic; serotonin type 3 antagonist;
4mg/IV/Q6H PRN Blocks serotonin a 5-HT receptor sites in
Draw baseline blood sample for clotting studies before starting drug. Inject deep subQ (slowly into fat layer between iliac crests in lower abdomen). Leave needle
in place for ten seconds before withdrawing. Instruct patient to report s/s
of thrombocytopenia such as easy bruising (can be in the form of petechiae
which are red, flat spots on the skin), prolonged bleeding, excessive bleeding
of the mouth while brushing teeth or flossing, black stools, dark or red urine. Instruct pt to avoid taking aspirin during
therapy unless approved by a health care professional. Check hematocrit, PTT, and platelet count frequency. Monitor potassium level in pts with diabetes or
renal disease. Urge pts to avoid activities that can cause injury. Pt should
be urged to use soft bristle toothbrush and an electric razor. Use with extreme caution in this pt because of her history
Know that this drug has been associated with cases of acute liver failure, at times resulting in liver failure and death. Most
injuries are the result of excess acetaminophen. Monitor liver function
tests accordingly. Assess vitals. Respiration less than 10/min; hold medication and assesses sedation,
assess pain, have second practitioner verify dosage. Advise pt that drug that
may cause drowsiness. Give with food to reduce nausea. Pts should avoid
activities requiring mental alertness or coordination until drug effects are
realized. Advise pt that med contains acetaminophen and to not take additional drugs containing acetaminophen. Advise pt to report s/s of respiratory depression
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such as SOB, apnea and increased effort with breathing. Monitor pt for s/s of drug
overdose including nausea, vomiting, blurred vision, cool and clammy skin,
dizziness, confusion, dyspnea, respiratory depression, bradycardia, hearing loss, headache or mood or
behavior changes. Promethazine HCl (Prorex)
Laxative; Stimulant
12.5mg/IV/Q6H PRN
Completely blocks histamine H(1)
receptors without blocking the secretion
of histamine. The drug has sedative,
anti-motion sickness, antiemetic, and
anticholinergic effects but it has no
dopaminergic action due to a structural
difference with other phenothiazines.
For pt’s constipation
related to surgery and administration of
opioids.
Abdominal colic, abdominal discomfort, diarrhea, proctitis, atony of colon,
xerostomia, apnea, respiratory depression
Monitor pt for decreased abdominal pain. Monitor for BM which should take place 15-60 minutes after administration. Also monitor hydration level and mental status
during therapy. Reassess pt if rectal bleeding occurs or if no BM occurs after
laxative is given. Advise pt that drug may cause diarrhea or abdominal pain, discomfort and cramping. Instruct pt to
report rectal bleeding or failure to have a BM within 12 hrs. Drug should not be
taken for longer than 7 days. This drug must be administered IV with caution
because risk of perivascular extravasion and severe tissue damage is high. Dilute in 10 to 20 mL of NS and administer over 10 to 15 minutes. Insure patency of site
before administration. Instruct pt to immediately report any burning or pain
during or after the injection and stop administration immediately. Advise pt to avoid excessive sun exposure because drug can cause photosensitivity. Advise pt not to consume alcohol while taking
this drug.
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LA8/2011 19
Concept Mapping
Step 2. List clinical manifestations under each nursing diagnosis and other relevant data to support each diagnosis, including lab data, medications, interventions, and assessment findings. All medical & nursing interventions should be found in one or more of the boxes.
ND # 1: Acute Pain Data to support: R humeral head fracture Recent surgery for fracture (POD 1) Guarded behavior Pt reports pain Pain upon movement of R arm Prescribed pain medication
ND # 2: Risk for bleeding Data to support: Pt being administered Heparin Pt POD 1 R humeral fracture Fall risk/impaired physical mobility
ND # 3: Risk for constipation Data to support: Immobility Pt being administered opioids for pain Pt was NPO pre-surgery
ND # 4: Impaired physical mobility Data to support: Physician order of bed rest. R humeral fracture and surgery (POD 1) Pt report of pain with movement Administration of opioids (decreased awareness and coordination)
CMD: R Humeral fracture Priority Assessments: Pain! BM inquiry Vital signs and labs Pt understanding Assess injured area closely
7. Discharge Pt teaching prior Provide information about medications PT inquiry
8. Pt Education Meds Wound Care Recovery Process Pain management Immobility
ND # 5: Risk for Impaired Skin Integrity Data to support: Immobility/ Bedrest Recent fracture Recent surgery Altered nutritional state (overweight) Pt taking Heparin
ND # 6: Knowledge Deficit Data to support: Knowledge of surgery Knowledge of post-op lifestyle changes Knowledge of medications.
LA8/2011 20
Concept Mapping
Evaluate Effects of Nursing Actions- Patient Outcomes, Documentation (Done During Clinical)
1. ND/Nursing Care: Acute Pain
Nursing Actions(NIC)
• Determine if client is experiencing pain at the time of initial interview. • Assess pain level using 1-10 scale • Assess the client for pain presence routinely and frequently (when vital signs are taken, during activity, and during rest) • Ask pt to describe previous experiences with pain medications or therapy. What worked? What didn’t? • Identify pt’s comfort-function goal for pain • Prevent pain during any procedures or mobility • Administer opioids as ordered • Assess pain level, sedation level, and respiratory status at regular intervals during pain management with opioid
administration. • Assess for effectiveness of medication • Assess for constipation related to use of opioids. • Assess for adverse reactions closely and frequently and especially during the first dose. • Assess for influence of cultural beliefs on pain management and perception of pain.
Patient response: Initially, pt reported no pain and complained of numbness at the site of injury. As the nerve block worse off, pt did complain of pain and rated it at a 3/10 but noted that it was quickly increasing. Pt expressed fear of pain coming back. Pt vital signs were taken and were normal. Pt administered Norco. Assessed effectiveness of medication and reassessed pain level routinely following administration. Pt reported that Norco and Dilaudid both worked well at relieving her pain since admittance. Pt expressed her comfort-function goal as being a 1 or a 0. Pt was immobile throughout entire day, so no pre-ambulatory pain medication was needed. Vital signs were normal following administration of medications. Pt reports last BM two days prior. Pt reports no worry and claims it is only because she wasn’t allowed to eat before the surgery. Pt status was monitored closely following administration. Pt is Hindu, but expressed no hesitance about taking pain medication and communicated her pain levels often and clearly.
LA8/2011 21
2. ND/Nursing Care: Risk for Bleeding
Nursing Actions(NIC)
• Monitor for signs of bleeding in the urine, stool, sputum, vomitus. • Watch for nose bleeds, petechiae, purpura, or bruising. • Monitor laboratory values (hemoglobin, hematocrit, RBC, INR) • Implement safety precautions (Fall risk protocol, soft bristle tooth brush) • Acquire additional help when moving pt to prevent falls • Check bandaging regularly for saturation and bleeding • Check vital signs frequently and regularly (watch for low BP, elevated HR, and respiratory rate) • Before administering heparin, check APTT • Have protamine sulfate close by as a precaution for Heparin OD. • L&L bed at lowest position and put side rails up x3 before leaving room • Explain bleeding risk to pt and assess for understanding • Perform teaching on reducing risk of bleeding including elimination of risky behaviors
Patient response: no signs of bleeding visible. No bruising, petechiae or purpura visible or noted by patient. RBC high and being monitored continually and closely. All other lab values WNL. Pt successfully labeled as a fall risk pt. Pt had already brushed her teeth before my arrival, but stated that soft bristle brush was used. Pt was not ambulated throughout the entire day, so no additional help was required. Bandage monitored and checked for bleeding a saturation regularly. Vital all WNL with the exception of BP which was initially low. It was determined that the BP was low due to administrating Losartan. BP began to rise towards normal limits so no intervention was needed. No APTT was ordered. Planned to inquire as to the reasoning, but never followed through. Bed L&L each time I exited the room. Side rails up x3. Pt demonstrates good working knowledge regarding her increased risk for bleeding as well as the actions of Heparin.
3. ND/Nursing Care: Risk for constipation
Nursing Actions(NIC)
• Assess usual pattern of defecation (time of day, amount and frequency of stool, consistency of stool) • Assess for diet patterns including fiber and fluid intake
LA8/2011 22
• Review clients current medications • If client is constipated and taking medications that can cause constipation, consult a health care provider about switching
the medications • Palpate for abdominal distention • Inquire about discomfort or abdominal pain • Assess for effectiveness of laxatives • Assess for any adverse reactions of laxatives • Assess for pt’s desire to take additional laxatives to promote GI motility
Patient response: Pt reports normally producing two BMs per day. However, pt reports last BM two days prior. Pt is a vegetarian and reports eating a variety of vegetables with each meal. Pt admits to having a poor fluid intake at home. Pt is taking opioids for pain which contribute greatly to constipation. When weighing risks and benefits, keeping the pt’s pain at a low level is a priority to both the patient and the staff, so no adjustment was made to opioid prescription. However, additional laxatives were prescribed. No distention palpable. Pt reports no abdominal pain or discomfort. Pt has not yet had a BM since the beginning of her laxative therapy. Will continue to inquire about pt’s BMs. Pt reports no diarrhea or vomiting or other side effects of laxatives. Pt reports a lack of concern about constipation and claims it is because she was required not to eat proceeding the surgery.
• Screen for measures of physical function to assess strength of muscle groups • Assess for cause of impaired mobility • Monitor and record client’s ability to tolerate activity. • Before activity, treat with pain as necessary • Evaluate impact that pain has on immobility • Acquire additional help before ambulating • Consult with PT for further evaluation • Obtain any assistive devices needed for activity. • Perform ROM exercises at least twice a day • Help pt to achieve motility and start walking as soon as possible unless contraindicated.
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Patient response: Significantly decreased R hand and arm strength noted. Pt is immobile because she is recovering from her recent humeral surgery. Pt reports pain during even the slightest movement of her right arm. Planned to treat her pain before ambulating but pt did not ambulate throughout my time with her. Pain is the largest reason why this patient is immobile. She expresses fear of pain and is guarded. Planned to consult PT about starting therapy, but upon arriving, I was informed that the pt is no have a second surgery on her shoulder on 10/11. Pt is unable to perform ROM exercises with her R arm while it is still healing. Plan to start ambulating pt after her next surgery is complete.
5. ND/Nursing Care: Risk for Impaired Skin Integrity Nursing Actions(NIC)
• Monitor skin condition at least once a day for color and texture • Instruct pt to avoid harsh cleaning agents, hot water, and too frequent cleansing • Minimize exposure of the site of skin impairment to moisture, perspiration or wound drainage • Monitor condition of skin covering bony prominences • Implement prevention plan • Assess client’s nutritional status • Perform teaching to the client regarding skin assessment and ways to monitor for impending skin breakdown • Determine pt’s risk by using the Braden Scale.
Patient response: Skin integrity, color and texture appear and feel normal. Pt used warm rather than hot water while performing self cleansing as well as mild soap. Wound bandaging is tight and free of moisture or damage. Skin surrounding and covering pt’s bony prominences is without breakdown. Inquired about the need to rotate the pt’s positions regularly and was told that the brief nature of her visit was not cause for rotation. Also, pt is able to sit herself up which decreased her risk of developing any ulcers or areas of breakdown. Client electrolytes are normal which indicated good nutritional status. Pt is now eating her entire meals and is being hydrated via IV NS. Calculated pt’s Braden Scale risk at a 17 which puts her at mild risk for skin breakdown.
• Consider pt’s ability and readiness to learn • Assess personal context and meaning of injury • Assess family involvement and ability to assist with learning • Perform family and pt teaching • Pt teaching about medications • Pt teaching about recovery process • Pt teaching regarding safe mobility • Pt teaching regarding proper care and maintenance of injury and bandaging • Assess for understanding.
Patient response: Pt A&O x4 and has a good ability and readiness when it comes to learning. Pt reports anxiety regarding injury because it has stopped her from caring for and seeing her four grandchildren. For her, this injury means not spending time with her family, which she reports as being a very high priority. Pt’s husband and son are both physicians. The husband was at the bed side off and on throughout the entire day and was very helpful about providing information to the client. Pt demonstrated a good knowledge of the medications she was receiving as shown by her questioning nature during administration and by her concerns about receiving Losartan when her BP was low. Pt demonstrated good knowledge about surgery dates and the process of recovery. Pt and husband were very careful while pt is adjusting positions or when moving the HOB. Planned to perform teaching about proper care and maintenance of injury, but since pt was due to have another surgery the next day, it was no longer a priority.