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CRITICAL THINKING SUMMARY
Student ___Kelli Howland_ Client Dx__Subdural Hematoma___ Age _87_ Allergies __Wool, Brilinta___
The MEDICAL DIAGNOSIS that brought the client to the hospital is:
Subdural Hematoma after a fall.
PATHOPHYSIOLOGY of diagnosed disease: (From text)
A collection of blood that develops between the surface of the brain and the dura mater, the brain’s tough outer covering, usually due
to stretching and tearing of veins on the brain’s surface. These veins rupture when a head injury suddenly jolts or shakes the brain.
SYMPTOMS typically seen with this diagnosis include (as identified in your text):
Confusion, difficulty walking/balancing, headache, lethargy, confusion, loss of consciousness, nausea, vomiting, numbness, seizures,
slurred speech, visual disturbances, and weakness.
CLIENTS’ SYMPTOMS of the diagnosed disease include:
Weakness, balance issues, and headache.
NUTRITIONAL ASSESSMENT:
Height (actual or estimated) __162.5cm__ Weight (actual or estimated) __70kg____
Estimate Ideal Body Weight ( Male: 105lb + 6 lb/inch > 5’. Female: 100lb + 5lb/inch > 5’) __59kg____
Does this client have characteristics of a well-nourished person? Yes __x__ No ______
Explain your answer.
Patient has bright and clear eyes, teeth are intact and white, clear strong nails, no broken bones, good skin color, and even though he
has diabetes, he has no negative side effects of the disease because it is well managed.
PSYCHOSOCIAL STAGE OF DEVELOPMENT
What is the client’s developmental stage?
Lake Adult: Integrity vs. despair
Has he/she met the necessary accomplishments? Yes __x__ No _____
Explain
The patient has met accomplishments by being married, having multiple kids, overcoming illnesses like diabetes and living with an
ileostomy, and retiring from work.
How is this illness affecting the client’s ability to meet these necessary accomplishments?
This illness is affecting the patient’s ability to fully meet these accomplishments because the illness happened so quick and severe
causing him to be ventilated and unconscious so he is not able to reflect back on his life. He isn’t able to feel if his life has been
fulfilled or feel regret.
STRESS MANAGEMENT: Identify coping mechanisms used by this client during stress.
Family support at bedside while patient is sedated and intubated.
NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS
Indicate below the 2 priority nursing diagnosis that are most relevant for your client.
#1 NURSING DIAGNOSIS (problem r/t)
Risk for infection related r/t craniotomy
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Long incision on top of patients head with no dressing covering. Increasing temperature. Abnormal lab values.
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Patient will stay free of infection.
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Monitor temperature closely and report if client has a low-grade temperature. Use a urinary bladder temperature.
2. Use of appropriate hand hygiene and protective equipment like gloves when coming in contact with patient.
3. Observe and report signs of infection of head incision such as drainage and swelling.
#2 NURSING DIAGNOSIS (problem r/t)
Risk for aspiration r/t presence of endotracheal tube.
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Dyspnea, cough, cyanosis, wheezing, adventitious breath sounds, fever.
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Maintain patent airway and clear lung sounds.
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Auscultate lung sounds frequently noting any changes.
2. Keep HOB elevated a minimum of 30 degrees.
3. Keep airway clear of secretions by suctioning as needed.
COMPLICATIONS:
If this client’s condition were to worsen, what would be the most likely reason and why?
If the patient’s condition were to worsen, the most likely reason would be from infection because his WBC levels are low and he had
craniotomy. This could go undetected because his WBC’s are so low and he is not on any antibiotics.
How would you know this is happening?
Because the patient’s WBC levels are so low, it would be hard to notice changes with lab values. However, the infection would be of
the brain or of his incision which could then travel to the brain which would cause many symptoms like increased intracranial
pressure, a swollen or drainage at the incision site, vital sign changes like increasing temperature, or seizures.
What will you do if this happens?
If this were to happen, the first thing I would be to take vital signs to ensure the readings were right and assess his incision site for
drainage and change in appearance. Next I would look at labs to see if his WBC’s had increased from what they had been at, if
everything was still indicating infection, I would notify the physician immediately so that antibiotic could be ordered stat and started. I
would make sure that seizure precautions were fully implemented.
EVALUATION:
Was the patient able to achieve the objectives identified on the first clinical day? yes
If no, list new objectives.
no
The patient was able to meet some of the objectives but because he is intubated and under sedation, objectives are more long term
then just for the day. He is not consciously able to meet each objective.
Did you choose the appropriate nursing diagnosis on the first clinical day? yes
If no, list nursing diagnosis that would have been more appropriate.
Were the interventions appropriate? yes no n/o
If no, list more appropriate interventions.
no
PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS
MEDS/IV’S/TX/DIET
(Include dose, route,
frequency)
REASON PRESCRIBED
(Drug Classification
What is it treating?)
NURSING IMPLICATIONS
FROM TEXT
(Checking for adverse reactions,
preparation & administration
concerns)
Anti-thrombotics
Heparin5000 Units, Subq, q8h
Prevention of thrombus
formation.
Adverse Reactions are druginduced hepatitis, alopecia,
rashes, urticaria, bleeding,
heparin-induced
thrombocytopenia, anemia, pain
in injection sight, osteoporosis,
fever, and hypersensitivity.
Apply pressure to prevent
bleeding or hematoma
formation.
Calcium acetate1334mg, 2 Cap,
PO/Feeding tube, qid
Mineral and electrolyte
replacement/supplement
To control
hyperphophosphatemia in endstage renal failure.
Anticonvulants
Lacosamide100MG, IVPB, q12h
Decrease incidence of seizures
Adverse Reactions:
Arrhythmias, hypercalcemia,
constipation, calculi,
hypercalciuria.
Laxatives
Adverse Reactions: diplopia,
atrial fibrillation/flutter,
bradycardia, PR interval
prolongation, agranulocytosis,
toxic epidermal necrolysis,
steven-johnson syndrome, drug
reaction with eosinophilia and
systemic symptoms.
Adverse Reactions: mild cramps,
diarrhea, rashes.
Stool softener
Do not administer within two
hours within 2 hours of other
laxatives.
Anticonvulsants
Phenytoin200mg, IVPB, Q12hr
Prevention of seizures.
(What data is important to know
before & after giving)
Assess for signs of bleeding and
hemorrhage; Notify health care
professional immediately if
occurs. Assess patient for
additional or increased
thrombosis. Monitor patient for
hypersensitivity reactions.
Monitor platelet count every 2-3
days throughout therapy. If
toxicity occurs, protamine
sulfate is the antidote.
Monitor serum calcium and
phosphate levels.
Administer on empty stomach
before meals.
Can be undiluted or diluted with
normal saline, D5W, or LR.
Solution should be clear and
colorless. Solution is stable at
room temperature for 24 hours.
Docusate100mg, PO/Feeding tube,
bid
PATIENT DATA FROM
YOUR ASSESSMENT
Adverse Reactions: dyskinesia,
EPS, diplopia, nystagmus,
hypotension, tachycardia,
gingival hyperplasia, druginduced hepatitis, stevensjohnson syndrome,
hypertrichosis, rash,
agranulocytosis, aplastic anemia,
osteomalacia, lymphadenopathy.
Administer undiluted. Precipitate
may form if refrigerated, but
dissolves after warming to room
Asses location, duration, and
characteristics of seizure
activity. Institute seizure
precautions.
Assess ECG prior to therapy in
patients with pre-existing cardiac
disease.
Assess patients skin for rash
frequently.
Monitor CBC and platelets
periodically during therapy.
Assess for abdominal distention,
presence of bowel sounds, and
usual pattern of bowel function
Assess color, consistency, and
amount of stool produced.
Assess oral hygiene. Vigorous
cleaning beginning within 10
days of initiation of therapy.
Assess for phenytoin
hypersensitivity reaction
(usually begins within first 2
weeks of therapy).
Observe for development of
rash.
Assess location, duration, and
characteristics of seizure
activity. Institute seizure
precautions.
Laxatives
Senna8.8mg, PO/Feeding tube,
bid
Stool softener
temperature. Discard solution
that is not clear.
Assess BP, ECG, and respiratory
function throughout therapy in
patients with pre-existing cardiac
disease.
Monitor CBC, serum calcium,
albumin, and hepatic function
tests prior to and monthly during
therapy.
Adverse Reactions: electrolyte
imbalances, diarrhea, rashes,
urine discoloration.
Assess for abdominal distention,
presence of bowel sounds, and
usual pattern of bowel function.
Assess color, consistency, and
amount of stool produced.
Do not administer within two
hours within 2 hours of other
laxatives. Administer preferably
in evening.
Lipid Lowering Agent
Simvastatin20mg, PO/Feeding Tube,
bid
Manage high cholesterol
Adverse Reactions: Peripheral
edema, abdominal cramps, heart
burn, increased liver enzymes,
Pancreatitis, rash, Drug induced
hepatitis, rhabdomyolosis,
hyperglycemia, dyspepsia,
hypersensitivity,
arthralgiamyopathy.
Evaluate serum cholesterol and
triglyceride levels before
therapy, after 4-6 weeks of
therapy, and periodically
thereafter.
Monitor liver function tests.
(May also increase alkaline
phosphate and bilirubin levels)
Monitor CPK levels.
Administer once a day in the
evening.
Anticonvulsant
Topiramate25mg, PO/Feeding tube,
qhs
Prevention of seizures
Adverse Reactions: increased
seizures, diplopia, nystagmus,
constipation, dry mouth,
encephalopathy,
hyperammonemia, kidney
stones, oligohydrosis,
hyperchloremia metabolic
acidosis, leukopenia, tremor,
fever.
Assess location, duration, and
characteristics of seizure
activity. Institute seizure
precautions.
Monitor CBC with differential,
liver function tests, and platelet
count before and throughout
therapy.
Capsules (not XR) can be
opened.
Antiulcer agents
Famotidine20mg, Feeding tube, Daily
Prevention of GI ulcers
Ad verse Reactions:
arrhythmias, constipation,
gynecomastia, agranulocytosis,
aplastic anemia, anemia,
neutropenia, thrombocytopenia,
hypersensitivity reactions.
Assess for frank or occult blood
in the stool, emesis, or gastric
aspirate.
Monitor CBC with differential
periodically throughout
treatment.
Administer with meals or after
and at bedtime to prolong effect.
If liquid, shake before
administration.
Antiulcer agent
Sodium Bicarbonate650mg, Feeding tube, daily
Prevention of GI ulcer
Adverse Reactions: edema,
gastric distention, metabolic
acidosis, hypernatremia,
hypocalcemia, hypokalemia,
sodium and water retention,
irritation at IV site, tetany,
cerebral hemorrhage.
Assess fluid balance throughout
therapy, Report symptoms of
overload.
Assess patient for signs of
acidosis. alkalosis,
hypernatremia, or hypokalemia
throughout therapy.
May be administered 1 to 3
hours after meals and at bedtime.
Anti-diabetic Hormones
Insulin regular100 units, IV, Continuous
drip
Glucose Control
Adverse Reactions:
hypoglycemia, Allergic reactions
(anaphylaxis), lipodystrophy,
swelling, pruritus, erythema,
Swelling.
Observe IV site closely.
Assess patient for frank or occult
blood in the stool, emesis, or
gastric aspirate.
Monitor serum sodium,
potassium, calcium, bicarbonate,
osmolarity, acid-base balance,
and renal function throughout
therapy,
Obtain arterial blood gases
frequently during parenteral
therapy.
Assess for signs and symptoms
of hypoglycemia (anxiety,
restlessness, tingling in hands
and feet, chills, cold sweats,
confusion, cool pale skin,
weakness, and tremors)
Do not use it cloudy, discolored,
or unusually viscous. May be
diluted with normal saline in
polyvinyl chloride infusion bag.
Sedative/Hypnotics
Midazolam- 100MG, IV,
Continuous drip
Short-term sedation and
control seizures.
Adverse Reactions: Apnea,
laryngospasm, respiratory
depression, cardiac arrest,
arrhythmias, rash, phlebitis at iv
site.
Assess level of sedation
throughout therapy and for 2-6
hours following administration.
Monitor BP, pulse, and
respiration continuously during
IV administration.
Do not administer medication
with any other liquids.
General anesthetics
Propofol1000mg, IV, Continuous
drip
Sedation while intubated.
Adverse Reactions: bradycardia,
hypotension, involuntary muscle
movements, flushing,
perioperative myoclonia,
discoloration of urine (green),
fever.
Dose is titrated to patient
response. Administered
undiluted but if diluted use
D5W. Shake well before using.
When used for sedation, discard
unused medication after 12 hrs.
Do not administer with filter less
than 5 micron pore size.
Potassium Chloride20mEq, Feeding tube, PRN
Mineral electrolyte
replacement supplement
Control Potassium level
Adverse Reactions:
Arrhythmias, ECG changes,
abdominal pain, diarrhea,
flatulence, and vomiting.
Administer with or after meals.
Dissolve effervescent tablets and
powder in 3-8oz of cold water.
Paricalcitol4mcg, PRN (with dialysis)
Vitamin
Adverse Reactions:
conjunctivitis, rhinorrhea,
Assess respiratory status, pulse,
and BP continuously throughout
therapy.
Assess level of sedation and
level of consciousness
throughout and following
therapy.
For ICU; wake-up and
assessment of CNS function
during maintenance to determine
minimum dose required for
sedation.
Monitor for propofol infusion
syndrome (severe metabolic
acidosis, hyperkalemia, lipemia,
rhabdomyolysis, hepatomegaly,
cardiac and renal failure).
Monitor Potassium levels.
Symptoms of toxicity are those
of hyperkalemia (slow heartbeat,
fatigue, muscle weakness,
parathesia, confusion, dyspnea,
peaked T waves, depressed ST
segments)
Assess for symptoms of vitamin
deficiency prior to and
Prevent hyperparathyroidism
and improve calcium and
phosphate homeostasis.
arrhythmias, edema,
hypertension, palpitations,
constipation, increased liver
function test, polydipsia,
albuminuria, rash, gout, and
hyperthermia.
Administer by rapid injection
through the catheter at the end of
a hemodialysis period.
periodically during therapy.
Assess patient for bone pain and
weakness prior to and during
therapy.
Observe patient carefully of
hypocalcemia.
Monitor serum calcium and
phosphate levels.
Analysis of Diagnostic Tests
DIRECTIONS:
1.
List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical treatments (i.e. medications)
and provide the patient values for each test. Explain why they are pertinent for this patient.
2.
List any screening diagnostic and laboratory tests that are not within normal limits. Explain why these tests are increased
or decreased in relation to your patient's medical condition.
Diagnostic/Lab Test
Patient Values
Analysis of Values
WBC
3.71- Low
Low level because patient had blood loss
during surgery and is on many medications
that can lower WBC.
Hgb
6.8- Critically low
Low level because of blood loss during
surgery.
Hct
21.5- Low
Low level because of blood loss during
surgery.
RBC
2.0- Low
Low level because of blood loss during
surgery.
MCV
107.5- High
High level because of lack of iron and b12
because of lack of nutrition and liver
function may be altered.
MCH
34.0- High
High level because of lack of iron and b12
because of lack of nutrition and liver
function may be altered.
MCHC
31.6- Low
Low level because of blood loss during
surgery.
RDW
16.1- High
High level because of lack of iron and liver
function may be altered.
Platelet
97- Low
Low level because patient had blood loss
during surgery and is on many medications
that can lower platelet count.
Lymphs Man
6- Low
Low level because patient had blood loss
during surgery and is on many medications
that can lower these values.
EOS Man
10- Low
Low level because patient had blood loss
during surgery and is on many medications
that can lower these level.
Meta Man
1- High
High level because of medications and other
blood cells deficiency.
Pco2
34- Low
Low level due to patient being on ventilator
and on medications (like antiulcer) that can
affect levels.
HCO3
20- Low
Low level due to patient being on ventilator
and on medications (like antiulcer) that can
affect levels.
Base Excess
-5.2- Low
Low level due to patient being on ventilator
and on medications (like antiulcer) that can
affect levels.
Chloride
114- High
High level because patient has renal failure
and an ileostomy in the right upper quadrant
so it is not being absorbed.
Urea Nitrogen
51- High
High level due to patient’s renal failure.
Creat
5.77- High
High level due to patient’s renal failure and
antiulcer medication.
MDRD eGFR
9- Low
Low level because patient’s renal failure.
Glucose
132- High
High level because patient is diabetic and on
medications that can increase glucose.
Calcium lvl total
8.0- Low
High level because patient has renal failure
and an ileostomy in the right upper quadrant
so it is not being absorbed.
Iron Binding Capacity
174- Low
High level because patient has renal failure,
isn’t able to consume iron since under
sedation.
Narrative Charting Sample