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: _06/24/2011 Age: 75yr DOB: ______02/19/1936_____ Sex: X Male Female Race/Ethnicity: White/______________ Support System: _____No living family membes _________________________________________________________ Religion: _Catholic__________ MEDICAL HISTORY ALLERGIES: _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 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 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: N/A Height: 65 inches Weight: 117.1 kg Placement in Growth Chart: _N/A Immunizations: Patient refused flu vaccine

VITAL SIGNS Time Taken: ______0900_________ Activity: ______________ Position: ____wheel chair__________ 1

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 _

Diet: REGULAR AFTER DINNER Nutritional 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/A Medications at Home:_N/A___________________________________________________________________________________________ __________________________________________________________________________________________________________________

NUTRITION Food Preferences:_EXTRA SYRUP IN BREAKFAST, COFFEE AFTER LUNCH, COOKIE

Medication(s) Worksheet NAME CLASSIFICATI ON DOSE/ROUTE/FREQUE NCY SAFE RANGE MECHANISM OF ACTION INDICATIONS SIDE EFFECTS NURSING CONSIDERATION S AND PATIENT EDUCATION

PHENYTOIN

100mg 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/prevent ion of tonic-clonic (grand mal) seizures and complex partial seizures.

CNS: SUICIDAL THOUGHTS, ataxia, agitation, confusion, dizziness, drowsiness, dysarthria, dyskinesia, extrapyramid al 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.

MEMANTINE

10mg 1 tab daily by mouth

Binds to CNS N-methyl-Daspartate (NMDA) receptor sites, preventing binding of glutamate, an excitatory neurotransmitt er.

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

CITALOPRAM

10mg 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 libido, dizziness, fatigue, impaired concentration ,q depression, migraine headache. EENT: abnormal accommodati on. 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.

ENALAPRIL

5mg 1 tab daily by mouth

ACE inhibitors Alone or with block the other agents in the conversion of management of angioten- sin I hypertension. to the vasoconstricto r angiotensin II. ACE inhibitors also prevent the degradation of bradyki- nin and other vasodilatory prostaglandins . ACE inhibitors also q plasma renin levels and p aldosterone levels. Net result is systemic vasodila- tion.

CNS: dizziness, drowsiness, fatigue, headache, insomnia, vertigo, weakness. Resp: cough, dysp- nea. CV: hypotension, chest pain, edema, tachy- cardia. Endo: hyperuricemi a. GI: taste disturbances, abdominal pain, anorexia, constipation, diarrhea, nausea, vomiting.

Hypertension:Monit or 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 receptors.

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, sedation, abnormal eye movements, diplopia, nystag- mus. Resp: increased secretions. CV: palpitations. 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) Worksheet CLASSIFICATI ON NAME LEVALBUTERO L DOSE/ROUTE/FREQUE NCY SAFE RANGE 45MCG PRN MECHANIS M OF ACTION Renantiomer of racemic albuterol. Binds to beta- 2 adrenergic receptors in airway smooth muscle leading to activation of adenylcyclas e and increased levels of cyclic-3, 5adenosine monophosphate (cAMP). INDICATIO NS SIDE EFFECTS NURSING CONSIDERATIONS AND PATIENT EDUCATION Assess lung sounds, pulse,and blood pressure before administration and during peak of medication. Note amount, color, and character of sputum produced. Closely monitor patients on higher dose for adverse effects.

CNS: anxiety, Bronchospas dizziness, m due to headache, reversible nervousness. airway Resp: disease PARADOXICAL (short-term BRONCHOSPAS control M (excessive agent). use of inhalers), increased cough, turbinate edema. CV: tachycardia. GI: dyspepsia, vomiting. Endo: hyperglycemia. F and E: hypokalemia. Neuro: tremor.

PREDNISONE

60MG DAILY PRN

In pharmacolo gic doses, all agents suppress inflammation and the normal immune response. All agents have numerous intense metabolic effects (see Adverse Reactions/Si de Effects). S

Managemen t of adrenocortic al 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.

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Aspirin

81mg daily PO

Inhibits the synthesis of prostaglandi ns that may serve as mediators of pain and fever, primarily in the CNS. Has no significant antiinflammator y properties or GI toxicity.

Mild pain. Fever.

GI: HEPATIC FAILURE, HEPATOTOXICI TY (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.

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PATHOPHYSIOLOGY-BRIEF TEXTBOOK PICTURE WITH CLIENT COMPARISON Definition, Etiology, Incidence, Pathophysiology, Diagnostic tests, Signs & symptoms, Medical treatments Textbook 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 12 Client

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

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ml/y or greater. StatisticsThe 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.

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DIAGNOSTIC TESTS Test (i.e. X-Ray, MRI, EEG, EKG) NOT APPLICABLE RESULTS Date, Result, Significance

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Laboratory values CHEMISTRY PROFILE NORMAL VALUES CLIENTS VALUES DATE D A T E DATE HEMOTOL OGY NORMAL VALUES DATE CLIENTS VALUES DA TE DATE

SODIUM POTASSIUM CHLORIDE CO2 CALCIUM GLUCOSE BUN CREATININE

135-145 Meq/L 3.5- 5.1 mEq/L 98-108 mEq/L 19-34 8.2-10.3 mg/dL 70-105 mg/dL 7-25 mg/ Dl 0.6-1.2 mg/dL

138 2/21/13 4.6 2/21/13 108 2/21/13 24.0 2/21/13 8.3 2/21/13 85 2/21/13 23 2/21/13 1.1 2/21/13

WBC RBC HGB HCT MCV MCH MCHC PLATELETS DIFFEREN TIAL NEUTROPHI LS SEGMENTS BANDS 18

3.8-10.8 K/uL 3.80-5.20 11.815.4g/dl 41-50 79.494.8fL

4.6 2/21/13 3.56* 2/21/13 11.8* 34.5* 96.9* 2/21/13

25.6-32.2 pg 11.515.0%

34.2 2/21/13 109 2/21/13

PHOSPHORUS CHOLESTERO L TOTAL 6.4-8.9 PROTEIN g/dL ALBUMIN 3.5-5.0 g/dL ALBUMIN/GLO BULIN RATIO

6.4 2/21/13 3.53 2/21/13 2.92 2/21/13

AST (SGOT) ALT (SGPT) TOTAL BILIRUBIN AMYLASE LIPASE

13-39 U/L 7-52 U/L 0.3-1.0 mg/dL

27 2/21/13 15 2/21/13

LYMPHOCYT ES EOSINOPHIL S BASOPHILS MONOCYTE S COAGULATION STUDIES

SODIUM POTASSIUM CHLORIDE CO2 CALCIUM GLUCOSE BUN

135-145 Meq/L 3.5- 5.5 mEq/L 98-108 mEq/L 19-34 8.2-10.3 mg/dL 70-105 mg/dL 7-25 mg/ Dl CBC Hgb

138 2/21/13 4.6 2/21/13 108 2/21/13 24.0 2/21/13 8.3 2/21/13 85 2/21/13 23 2/21/13

PTT WBC RBC HGB HCT MCV MCH MCHC BMP

3.8-10.8 K/uL 3.80-5.20 11.8-15.4g/dl

4.6 2/21/13 3.56* 2/21/13 11.8* 34.5* 96.9 2/21/13

34.2 2/21/13

Na Plts K+

Cl

BUN Glucose Creatinine 19

WBC Hct

HCO3

URINALYSIS COLOR YELLOW APPEARANCE CLEAR SP. GRAVITY 1.015 PH GLUCOSE KETONE OCCULT BLOOD PROTEIN BILRUBIN UROBILINOGEN NITRITE LEUCOCYTE CAST WBC RBC CRYSTALS SQUAMOUSCEL LS/ EPITHELIAL CELLS Relate the clinical significance of abnormal lab values above: 5 NORMA L NEGATI VE NEGATI VE NEGATI VE NORMA L NEGATI VE NEGATI VE TEST TEST URINE CULTURE

MISCELLANEOUS NORMAL CLIENTS VALUES VALUES DATE DATE DATE PENDI 06/10/1 NG 3

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. 20

 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: 21

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

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Plan of Care Priority 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 Interventions Nursing Actions Pt will maintain clear lung fields and remain free of signs of respiratory distress throughout hospital stay Scientific Principle and/or Rationale Auscultate breath sounds Q1- 2 . Presence of crackles, wheezes may signify airway obstruction, leading to or exacerbating existing hypoxia. Respiratory system may become Evaluation Pt demonstrated effective coughing techniques for student nurse Modification of Plan of Care

Monitor vital signs: Auscultate breath sounds,

BP is 111/68 Lung sounds are clear to 24

heart rate and rhythm, respirations q 4 hours.

decompensated. Tachycardia and changes in blood pressure may be present because of pain, anxiety and reduced cardiac output. Indicators of level of hydration and adequacy of circulating volume. Monitor resp. rate, depth, and effort, use of accessory muscles, nasal flaring, and abnormal breathing patterns. respiratory rate, use of accessory muscles, nasal flaring, and abdominal breathing may indicate hypoxia. Teaching standardized content that the patient already knows wastes valuable time and hinders critical learning. Adults learn material that is

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. Pt will maintain a patent airway at all time

Mucous membrane are moist, capillary refill is less than 2 seconds and skin turgor has increased Pts airway remained open

Identify priority of learning needs within the overall care plan as soon as possible.

The patient verbalizes understanding of priority learning needs.

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important to them

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. The patient asked questions regarding her regimen, diet and concerns when injecting herself.

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 Oxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea, and work of breathing. Note: Recen t research supports use of prone position to increase Pao2.

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.

The patient tolerated deep breathing exercises after showing correct techniques

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Monitor vital signs and cardiac rhythm.

Monitor level of consciousness/mental status. Investigate 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.

Tachycardia, dysrhyth mias, and changes in BP can reflect effect of systemic hypoxemia on cardiac function. Restlessness and anxiety are common manifestations of hypoxia. Worsening ABGs accompanied by confusion/somnolence are indicative of cerebral dysfunction due to hypoxemia. 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

Patient blood pressure dropped to a stable level after medications were given Patient was alert after making necessary changes

Patient tolerated ambulating from chair to bed after a short rest

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strength without causing severe dyspnea and can enhance sense of wellbeing.

CARE PLAN RUBRIC Student: ___________________________________ Date: ______________________ CATEGORIES SUBJECTIVE DATA (Relevant and timely and quoted from patient) OBJECTIVE DATA (Includes vital signs, physical assessment findings, diagnostic tests and procedures, relevant medications, etc.) NURSING DIAGNOSIS (NANDA, R/T, AEB) GOAL POSSIBL E POINTS 10 YOUR POINTS COMMENTS

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20

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(Condition, Time Frame, Parameters, and must be realistic) INTERVENTIONS AND RATIONALES (Assess, Assist, and Teach) EVALUATION OF CARE PLAN (Evaluate each nursing action for effectiveness) MODIFICATION OF CARE PLAN (Modify patient care plan based on patients response to interventions) 20

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*TOTAL SCORE: *Student must obtain score of > 77% in order to obtain a grade of S on the weekly care plan. Reviewed with student: ______________________________ Signature Date: ___________________

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