Download concept map 3 GRADED

1. Ineffective Airway Clearance r/t excessive mucus, secretions in the
bronchi:
Chart/History:
Pneumonia
86 y.o.
217 lbs.
GERD, mild
seizures
Assessment:
loud respirations
hoarseness on inspiration and expiration
intermittent wheezes
periods of apnea.
Respiratory rate: @0730- 40, @1300- 28 lung sounds?
Coughing spells
Inability to speak
Inability to stay upright
Inability to swallow
Bil. Edema LE
-
@ 0730, bp 153/90. @ 1300, bp 134/70 pulse ox?
Labs:
WBC: 10.8 -chest x-ray: cardiomegaly & pacemaker
RBC: 4.67 -CT scan: motion artifact w/ area of
Hbg: 13.9
encephalomalacia over left PCA territory
Hct: 42.5 -EKG: sinus tachycardia, left axial deviation
Plt: 216
Blood gases
Psychosocial: Major cognitive impairment—few words spoken
Medications:
3L O2 NC, continuous
Hydrodiuril 12.5 mg PO daily
Topamax 25 mg PO daily
Forosemide 20 mg PO @ bedtime
Sodium Chloride 1000 mL q13h20m IV
Ativan 1 mg IV PRN
4. Acute Confusion r/t recent seizures:
Chart/History:
86 y.o.
Seizures
Urinary incontinence/UTI
Stage 3 chronic kidney disease
Depression/anxiety
Assessment:
Inability to speak Spontaneous purposeful
movement? Following simple requests?
Inability to stay upright
Inability to swallow
Constricted pupils
@ 0730, bp 153/90. @ 1300, bp 134/70
Respiratory rate: @0730- 40, @1300- 28
Limited ROM bil. Upper and lower extremities
Labs:
WBC: 10.8 -CT scan: motion artifact w/ area of
RBC: 4.67
encephalomalacia over left PCA
Hbg: 13.9
territory
Hct: 42.5
Plt: 216
Blood gases EEG
BUN: 17
Creatinine: 1.4
Psychosocial: Major cognitive impairment—few words spoken
Medications: Hydrodiuril 12.5 mg PO daily, Topamax 25 mg
PO daily, Forosemide 20 mg PO @ bedtime, Sodium Chloride
1000 mL q13h20m IV, Ativan 1 mg IV PRN, Trazadone 100
mg PO bedtime, Ditropan 5 mg PO daily, Zocor 40 mg PO
daily
2. Ineffective Breathing Pattern r/t body position, cognitive impairment, obesity:
Chart/History:
Pneumonia
86 y.o.
217 lbs.
GERD, mild
Seizures for significant HX it is best to reflect on presence or
absence during your care. So no seizure activity during shift of care
HTN
A. Fib, pacemaker
Hx ruptured blood vessel L upper arm
Urinary incontinence/UTI
Depression/anxiety
Assessment:
loud respirations
hoarseness on inspiration and expiration
intermittent wheezes
periods of apnea.
Respiratory rate: @0730- 40, @1300- 28
Coughing spells
Inability to speak
Inability to stay upright
Inability to swallow again pulse ox should be clustered here
Bil. Edema LE
Capillary refill 1-2 seconds
-
@ 0730, bp 153/90. @ 1300, bp 134/70
Labs:
WBC: 10.8 -chest x-ray: cardiomegaly & pacemaker
RBC: 4.67 -CT scan: motion artifact w/ area of
Hbg: 13.9
encephalomalacia over left PCA territory
Hct: 42.5
-EKG: sinus tachycardia, left axial deviation
Plt: 216
Blood gases
Psychosocial: Major cognitive impairment—few words spoken
Medications: 3L O2 NC, continuous; Hydrodiuril 12.5 mg PO daily, Topamax
25 mg PO daily, Forosemide 20 mg PO @ bedtime, Sodium Chloride 1000 mL
q13h20m IV, Ativan 1 mg IV PRN, Trazadone 100 mg PO bedtime, Aspirin 81
mg PO daily
Reason for seeking healthcare: seizures
Dx: seizures
Allergy: fish containing products, ibuprofen, povidone-iodine
5. Impaired physical mobility r/t cognitive impairment, activity intolerance, obesity:
Chart/History:
86 y.o.
216 lbs.
Urinary incontinence/UTI
Seizures
Stage 3 chronic kidney disease
Depression/anxiety
Chronic lower back pain
Knee implants
Pneumonia
GERD, mild
Hx ruptured blood vessel
R. renal artery stenosis
Assessment:
Inability to stay upright
Limited ROM bil upper and lower extremities did PT Evaluaate?
Inability to speak
Stage 2 pressure ulcer R. heel
Labs:
BUN: 17
-chest x-ray: cardiomegaly & pacemaker
Creatinine: 1.4 -CT scan: motion artifact w/ area of encephalomalacia over left
Calcium: 9.4
PCA territory
WBC: 10.8
-EKG: sinus tachycardia, left axial deviation
RBC: 4.67
Hbg: 13.9
Hct: 42.5
Plt: 216
Psychosocial: Major cognitive impairment—few words spoken
Medications: 3L O2 NC, continuous; Hydrodiuril 12.5 mg PO daily, Topamax 25 mg PO daily,
Forosemide 20 mg PO, Ativan 1 mg IV PRN, Trazadone 100 mg PO bedtime, Colace 100 mg PO
@ bedtime, Ditropan 5 mg PO daily
3. Decreased Cardiac Output
Chart/History:
86 y.o.
HTN
A. fib, pacemak
216 lbs.
GERD, mild
Hx ruptured blo
R. renal artery s
Assessment:
Bil. Edema LE a
Disoriented, dro
loud respiration
hoarseness on in
intermittent whe
periods of apnea
Respiratory rate
Coughing spells
HR: @0730- 75
Distant heart so
1+ radial, pedis
Capillary refill 1
Pale, warm, mo
Lose turgor
Stage 2 pressure
@ 0730, bp 153
Labs:
WBC: 10.8 - B
RBC: 4.67
Hbg: 13.9
Hct: 42.5
-c
Plt: 216
-E
Glucose: 154
Potassium 4.6
Psychosocial: Major cognitive
Medications: 3L O2 NC, cont
Topamax 25 mg PO daily, Fo
Chloride 1000 mL q13h20m I
bedtime, Aspirin 81 mg PO d
6. Imbalanced Nutritio
Chart/History:
86 y.o.
216 lbs.
Seizures
Depression
GERD, mi
Pneumonia
Appendect
Cholecyste
Stage 3 chr
R. renal art
Assessment:
Inability to
Inability to
Inability to
Inability to
Skin pale,
Stage 2 pre
Labs:
-
BUN: 17
Creatinine: 1
Tbil: 0.3
AST: 24
ALT: 21
Alk. Phos.
Psychosocial: Major c
Medications: Colace 1
daily, Forosemide 20 mg P
Ditropan 5 mg PO daily
Grading Criteria Concept maps with Discharge Planning
Third concept map
Mapping each week will include:
1. Clustering of all data(minimum 6 clusters) this includes information
20 points
a.
b.
c.
d
e.
f.
6 nursing dx
from the chart and history
your assessed data.
significant labs and xray information
medications (see Appendix G)
psychosocial/cultural assessment/subjective info
2 points
2 points
6 points
4 points
5 points
1 point
2
2
5
4
5
1
19/ 20
2. Prioritization of all problems with rationale
a. prioritizes all problems
b. develops supportive rationale
5 points
5 points
10 points
5
5
10 / 10
3. Map out your three top priority problems
a. nursing dx. and goals
b. two outcomes
c. all relevant interventions
(minimum of 4) with rationalization
d. evaluation of all interventions
e. impression: goal met/not met: suggestions
for further interventions
4. Pathophysiology to include:
20 points
2 points
3 points
2
2
8 points
4 points
3 points
7
4
3
18 / 20
a. detailed description of disease process
& etiology
1.5 points
b. signs and symptoms (include those signs and symptoms that your patient experienced
1 pointc.
how is this disease diagnosed
1 point
5/ 5 points
d. how is this disease treated
e. reference – APA format
5. Cultural assessment – see guidelines
6. Medication sheet – appendix G
5 /5 points
15/ 15 points
23/ 25 points
7. Discharge Planning
TOTAL POINTS =
1 point
0.5 points
95 /100 Very Nice Work!!!
Part II: Prioritization of Problems with RationaleIneffective Airway Clearance r/t excessive mucus, secretions in the bronchi: Pt has inability to clear secretions from the respiratory tract to
maintain a clear airway. Some other classic symptoms of pneumonia include but are not limited to: loud respirations, hoarseness on
inspiration/expiration, intermittent wheezes, and periods of apnea. Ineffective Airway Clearance is the first problem for the pt because when
thinking of the “ABCs”, Airway is the top priority. This pt has problems with airway clearance because of secretions blocking the ability of air to
pass in and out of the lungs.
Ineffective Breathing Pattern r/t body position, cognitive impairment, obesity: Pt has alterations in depth of breathing and varying breathing
rates. This causes the breathing pattern to be irregular. Irregular breathing patterns can cause anxiety which can lead to tachycardia and
palpitations; things this patient does not need. This is the second problem because after airway, breathing pattern must be adequate in order to
maintain homeostasis. The pt is diagnosed with Ineffective Breathing Pattern because inspiration and expiration do not provide adequate
ventilation.
Decreased Cardiac Output r/t altered heart rhythm, altered contractility: Pt heart sounds are distant and pedis pulses are 1+ bilaterally. Pt
shows signs of cough and orthopnea which are classic of altered contractility of the heart. If the heart is not pumping correctly, the body’s tissues
are not able to receive oxygenated blood. This is the third problem because circulation is the main focus after airway and breathing have been
assessed. This pt has this problem because there is an inadequate volume of blood pumped by the heart per minute to meet metabolic demands of
the body.
Acute Confusion r/t recent seizures: Pt is very disoriented. Because of this disorientation, there is a breech in communication which can cause
issues involving choosing the right care for the pt. Because of the fluctuation of cognition, depressed level of consciousness, and decreased
psychomotor activity; the pt is restless and agitated. This is a top problem because the pt’s primary diagnosis upon admission is seizures. The
seizures have caused an abrupt onset of disturbances in the brain which effect consciousness, cognition, and perception.
Impaired physical mobility r/t cognitive impairment, activity intolerance, obesity: Pt shows great difficulty in movement and is agitated with
assistance to movement. Ambulation is critical for circulation, joint integrity, etc. Pt has impaired physical mobility because of the inability to get
out of bed. This problem is seen as limiting the independent, purposeful physical movement of the body. Pt’s joints need ambulation to avoid the
stiffness caused by impaired mobility. If circulation is affected because of impaired mobility, the pt could be at risk for clotting.
Imbalanced Nutrition r/t inability to ingest food: Because of recent seizures that caused cognitive impairment, pt has trouble swallowing whole
foods. When there is an inability to swallow, other measures must be taken to provide the body with what it needs to function. Fluid and
electrolyte replacement are given but do not make up for the loss of the ability to consume foods with wholesome nutrients. This is a problem
because of the inability to take in these foods which is an insufficient intake of nutrients to meet metabolic needs.
Part III: Top priority problems
Problem # 1- Ineffective Airway Clearance r/t excessive mucus, secretions in the bronchi
General Goal: The patient will have a decreased cough.
Outcome: The patient will demonstrate effective coughing and clear breath sounds by 1300.
Nursing Interventions/Rationales
1. Auscultate breath sounds q4h. Breath sounds are normally clear
or scattered fine crackles at bases, which clear with deep
breathing. The presence of coarse crackles during late
inspiration indicates fluid in the airway; wheezing indicates an
airway obstruction.
2. Monitor respiratory patterns, including rate, depth, and effort. A
normal respiratory rate for an adult without dyspnea is 12-16.
With secretions in the airway, the respiratory rate will increase.
3. Monitor pulse oxygen saturation levels throughout the shift. An
oxygen saturation of less than 90% indicates significant
oxygenation problems.
4. Position the client to optimize respiration. An upright position
allows for maximal lung expansion. Because this pt could not sit
or stand up, the optimal position was semi-fowlers to avoid
difficulty breathing.
5. Administer oxygen as ordered: 3L NC. Oxygen administration
has been shown to correct hypoxemia which causes dyspnea.
Patient responses
1. Throughout the shift, pt had very loud respirations, hoarseness
on inspiration and expiration, intermittent wheezes, and periods
of apnea.
2. Pt had tendency to have periods of apnea that lasted 5-10
seconds every hour. A 0730, resp. rate was 40. At 1300, resp.
rate was 28. Pt had a cough with sounds of secretions about
once an hour. Pt showed signs of stress when coughing.
3. @ 0730, oxygen saturation level was 98%. @ 1300,
oxygenation saturation level was 95%.
4. Pt stayed in semi-fowlers until she was relaxed and fell asleep.
The relaxation caused her to slump to the left and curl up on
left side.
5. Pt dyspnea was controlled while on oxygen. While the NC was
out (during bath and prep for EEG), pt became anxious and
more dyspneic
Impression: Patient’s respiration patterns were typical of pneumonia (loud, hoarse, wheezes, secretions, apnea). Pt showed
an excellent O2 sat% and had improved breathing in semi-fowlers.
Outcome: By 1300, the patient demonstrated the same loud respirations, hoarseness, wheezes, and apnea as @ 0730 and
throughout the day. The cough did not improve and was still intermittent every hour. Pt showed little improved symptoms in
semi-fowlers position but could not maintain the position for more than 20 minutes at a time.
Problem # 2- Ineffective Breathing Pattern r/t body position, cognitive impairment, obesity
General Goal: The patient will have an improved breathing pattern.
Outcome: The patient show the ability to breathe comfortably by 1200.
Nursing Interventions/Rationales
1. Monitor respiratory patterns, including rate, depth, and effort. A
normal respiratory rate for an adult without dyspnea is 12-16.
With secretions in the airway, the respiratory rate will increase.
2. Note pattern of respiration. If client is dyspneic, note what
seems to cause the dyspnea, the way in which the client deals
with the condition, and how the dyspnea resolves or gets worse.
A normal respiratory pattern is regular in a healthy adult. To
assess dyspnea, it is important to consider all of its dimensions,
including antecedents, mediators, reactions, and outcomes.
3. Auscultate breath sounds, noting decreased or absent sounds,
crackles, or wheezes. These abnormal lung sounds can indicate
a respiratory pathology associated with an altered breathing
pattern.
4. Administer oxygen as ordered: 3L NC. Oxygen administration
has been shown to correct hypoxemia which causes dyspnea.
Patient responses
1. Pt had tendency to have periods of apnea that lasted 5-10
seconds every hour. A 0730, resp. rate was 40. At 1300,
resp. rate was 28. Pt had a cough with sounds of secretions
about once an hour. Pt showed signs of stress when
coughing.
2. @ 0730, respiratory rate was 40by 1300 it was 28. Pt is
dyspneic when coughing and shows signs of anxiety
during coughing episodes. Dyspnea and apnea get worse
when pt is at complete rest, curled on her side.
3. Throughout the shift, pt had very loud respirations,
hoarseness on inspiration and expiration, intermittent
wheezes, and periods of apnea.
4. Pt dyspnea was controlled while on oxygen. While the NC
was out (during bath and prep for EEG), pt became
anxious and more dyspneic
Impression: Patient was dyspneic throughout the shift and continued to have abnormal lung sounds (hoarseness, wheezes,
apnea).
Outcome: By the end of the shift, patient continued to show signs of dyspnea and apnea even with interventions. Patient’s
lung sounds did not show improvement by 1300.
Problem # 3- Decreased Cardiac Output r/t altered heart rhythm, altered contractility
General Goal: The patient will show signs of increased cardiac output.
Outcome: Patient will demonstrate adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters
for this patient.
Nursing Interventions/Rationales
1. Monitor for symptoms of heart failure and decreased cardiac
output; listen to heart sounds, lung sounds including dyspnea,
crackles. These are major criteria for diagnosis of HF—the
Framingham Criteria.
2. Administer oxygen as needed: 3L NC. Supplemental oxygen
increases oxygen availability to the myocardium.
3. Place client in semi-fowler’s. Elevating the head of the bed
may decrease the work of breathing and my also decrease
venous return and preload.
4. Check blood pressure and pulse before administering cardiac
medications (Cardizem, Prinivil, Aspirin, Rhytmol) . It is
important that the nurse evaluate how well the client is
tolerating current medications before administering cardiac
medications.
Patient responses
1. Heart sounds were distant but with no abnormal sounds upon
assessment throughout the shift. Pt had very loud respirations,
hoarseness on inspiration and expiration, intermittent wheezes,
and periods of apnea.
2. Pt was less anxious when the NC was on. During times when it
was off (bath, EEG), dyspnea increased.
3. Pt stayed in semi-fowlers until she was relaxed and fell asleep.
The relaxation caused her to slump to the left and curl up on
left side.
4. @ 0730, blood pressure was 153/90. @ 1300, blood pressure
was 134/70. Pulse @ 0730 was 75. Pulse @ 1300 was 81.
Impression: Patient may need further evaluation for CHF.
Outcome: By 1300, heart and lung sounds had stayed consistent (distant—heart, loud, hoarseness, wheezes, apnea)
throughout the shift. Blood pressure and pulse were within parameters (high) to administer cardiac medications.
Part IV: Pathophysiology-Seizures
My patient was admitted to the unit due to seizures. “A seizure represents an abrupt and temporary alteration in
cerebral activity resulting in changes in electrical discharge from neurons in the cerebral cortex,” (INTERNAL CITATION
BOOK pg 955). They are assumed to be from neuron excitability changes. The come from sensory, motor, autonomic or
psychic sources. Seizures are classified as a central nervous system dysfunction and can occur anytime (Porth, p 955, 2007).
My patient had a tonic-clonic seizure, also known as a grand mal seizure. It is the most common major motor seizure.
Signs and symptoms are sometimes hard to detect until a “sharp tonic contraction of the muscles with extension of the
extremities and immediate loss of consciousness,” (Porth, p 958, 2007). Other symptoms include incontinence and cyanosis.
After the initial phase of the tonic-clonic seizure, the extremities contract again and the person stays unconscious. These two
phases last from 60-90 seconds (Porth, p 958, 2007). The patient did not have a seizure during the shift but did show
symptoms such as difficulty swallowing/speaking and loss of muscular activity which indicate a seizure had previously
occurred.
Seizure disorders are diagnosed with a history and neurologic exam. Labs will rule out any other metabolic disease
that could cause seizures. MRIs are also looked at to see if anything in the brain could have caused the seizure such as lobe
sclerosis or congenital issues. The EEG is also an important test to see brainwave changes (Porth, p 958, 2007). Patient had
an EEG and the woman who performed the test explained that the brainwaves were not within normal limits for an adult
which indicates seizures. The test was to be sent to a neurosurgeon to interpret the results.
Seizure disorders are treated by trying to eliminate any underlying disorder that could have caused them. Treatment
is unique to each patient and usually involves antiepileptic or anticonvulsant drugs. The goal of pharmacologic treatment is
to treat the problem while maintaining the best lifestyle possible. Surgery can also be done to remove the amygdala, part of
the temporal pole, or part of the corpus callosum (Porth, p 958, 2007).
Porth, C. M. (2007). In C. M. Porth (Ed.), Essentials of pathophysiology: Concepts of altered health. Philadelphia: Lippincot,
Williams & Wilkins.
Part V: Cultural Assessment
Pt’s communication patterns were very limited because of previous seizures. She was unable to share culture
information due to the inability to speak. However when I spoke to the patient, she did show signs of
acknowledgement with facial expressions. She also showed some anxiety throughout the shift with her facial
expressions.
Pt is a retired widow who lived independently until 2011. Has no reported history of alcohol or drug use.
Next of Kin lives in Riner. Physical activity is very limited because of the impaired neuromuscular function, age,
as well as obesity. Pt is Catholic. On Medicare.
Pt has a history of depression and anxiety that is being treated. Expression of pain is facial grimacing and
moaning. Pt wears dentures. Has bilateral thumb and knee implants. Has had the following procedures:
hysterectomy, tonsillectomy, cholecystectomy. Pt currently lives at the Kroontje Health Care Center.
Part VI: Medication List
Name of Med
Class
Action
Dose
Dose Range
Freq.
Lab Values
Side Effects
Diltiazem/
Cardizem
Anti-htn
CCB that inhibits
calcium ion
influx across
cardiac and
smooth muscle
cells, dec.
myocardial
contractility and
O2 demand
240
mg
30 mg q.i.d
360 mg/day
max dose
PO
daily
Tbil: 0.3
AST: 24
ALT: 21
Alk phos:
102
HydroDiuretic
chlorothiazide/
Hydrodiuril
12.5
mg
12.5-50 mg PO
daily
PO
daily
Glucose:
154
Ca: 9.4
BUN: 17
Creat.: 1.4
Lexapro
10
mg
10-30 mg PO
daily
PO
daily
Tbil: 0.3
AST: 24
ALT: 21
Alk phos:
102
Headache,
dizziness,
edema,
arrhythmias,
bradycardia,
heart failure,
flushing, htn,
nausea,
constipation,
acute
hepatic
injury, rash
Dizziness,
vertigo,
headache,
ortho. Hypotension,
pancreatitis,
renal failure,
polyuria
Suicidal
behavior,
fever, HTN,
insomnia,
dizziness,
N/V, weight
gain/loss
Inc. sodium and
water excretion
by inhibiting
sodium and
chloride
reabsorption in
distal segment
of nephron
AntiInc. of
depress/ serotonergic
SSRI
activity in CNS
by inhibition
neuronal
reuptake of
serotonin
Nursing
Considerations
Monitor BP and HR
when starting
therapy, max. antihtn therapy effect
may not be seen
for 14 days, if
systolic BP is below
90 or HR is below
60, with-hold dose
and notify Dr.
Reason
Monitor I&O,
watch for hypokalemia
HTN
Closely monitor pts
at high risk of
suicide, evaluate hx
of drug abuse,
reassess pt to
determine need for
maintenance tx
Anxiety
depression
A-fib.
Name of
Med
Lisinopril/
Zestril
(Prinivil)
Class
Action
Dose
Dose
Range
5-10 mg
PO daily
Freq.
Lab Values
Side Effects
AntiHTN
Dec. production of
angiotensin II,
suppression of
renin-angiotensinaldosterone
system
20mg @
home,
5mg @
hospital
PO
daily
Tbil: 0.3
AST: 24
ALT: 21
Alk phos:
102
BUN: 17
Creat.: 1.4
K+: 4.6
Dizziness,
headache,
ortho. Htn,
nasal decongestion,
diarrhea,
nausea,
impaired
renal fx
Oxybutynin
(ditropan)
Urinary
antispasm
Relaxes smooth
muscle of bladder
by antagonizing
muscarinic
receptors,
relieving sx of
overactive bladder
10 mg @
home, 5
mg @
hospital
5-20 mg
PO daily
PO
daily
@
home,
5 mg
@ bed
@
hosp.
Glucose:
154
Ca: 9.4
BUN: 17
Creat.: 1.4
K+: 4.6
WBC: 10.8
25 mg
10-30 mg
PO daily
PO
bedtime
Tbil: 0.3
AST: 24
ALT: 21
Alk phos:
102
WBC: 10.8
Dizziness,
insomnia,
fever, blurry
vision,
constipation,
dry mouth,
N/V, rash,
fatigue,
diarrhea
Anxiety,
ataxia,
confusion,
suicide
attempts,
chest pain,
N/V,
leukopenia
Topamax
(Topirimate)
Anticonvuls.
May block sodium
channel,
potentiate activity
of GABA, and
inhibit kainate’s
ability to activate
an amino acid
receptor
Nursing
Considerations
Monitor BP
frequently may
add diuretics,
monitor WBC
Reason
Get confirmation
of neurogenic
bladder, If UTI
treat with ABX,
monitor pt for
residual rine after
voiding
Urinary
incontinence,
freq. UTI
Closely monitor
pts at high risk of
suicide, withdraw
gradually,
measure baseline
bicarbonate, stop
drug if pt
experiences
seizure
HTN
Name of
Med
Vitamin K
Class
Action
Dose
Vitamin
K
cofactor for the
gammacarboxylase
enzymes which
catalyze the
posttranslational
gammacarboxylation of
glutamic acid
residues
hypercholesterole
mia
20 meq
HOME MED
Dose
Freq.
Range
2 mcg-120 2X a
mcg
day
Lab Values
Side Effects
K+: 4.6
Ca: 9.4
BUN: 17
Creat.: 1.4
Tbil: 0.3
AST: 24
ALT: 21
Alk phos:
102
Dysrhythmia
s, kidney
disease, liver
disease,
bleeding,
bruising
40 mg
PO 580mg
daily
PO
daily
Tbil: 0.3
AST: 24
ALT: 21
Alk phos:
102
100 mg
150-600
mg daily
PO
bedtime
Tbil: 0.3
AST: 24
ALT: 21
Alk phos:
102
2-10 mg
Every
other
day
RBC: 4.67
WBC: 10.8
Hgb: 13.9
Hypersensiti
vity, active
liver disease,
hepatitis,
jaundice, HA,
vertigo, N/V
diarrhea,
abdominal
pain
Drowsiness,
dizziness,
blurry vision,
dry mouth,
N/V, anemia,
rash
N/V,
anorexia,
bleeding,
Simvastatin/
Zocor
HMGCOA
reductas
e
inhibitor
Trazadone
Antidepress.
Inhibits CNS
neuronal uptake
of serotonin, not a
tricyclic derivative
Coumadin
Anticoag.
depressing hepatic 3-4 mg
synthesis of vit. Kdependent coag.
acute myopia
Nursing
Considerations
Monitor K+ levels
closely, do not
take with
Coumadin
Reason
Rupture
blood
vessel
assess/report
unexplained
muscles pain,
monitor coags,
report bleeding,
DC grapefruit
Blood
vessel
prob.
(lowers
risk)
Monitor for
serotonin
syndrome, record
mood changes
Anxiety/
depress.
Determine
PT/INR
Rupture
blood
vessel
factors: II, VII, IX, X
Action
Name of
Med
Aspirin Chew
(baby)
Class
Dose
NSAID
Inhibits the
formation of
prostaglandins
involved in the
production of
inflammation,
pain, and fever.
81 mg
Docusate
Sodium
(Colace)
Stool
softener
100 mg
Forosemide
(Lasix)
Loop
diuretic,
anti-htn
Anionic surfaceactive agent with
emulsifying and
wetting
properties.
Inhibits sodium
and chloride
reabsorption at
proximal and
distal tubules and
ascending loop of
Henle
20 mg
Plt: 216
Dose
Range
Mild to
moderate
pain - 350
– 650 mg
q4h (max:
4 g/day)
Antiplatelet –
81 – 325
mg daily

Freq.
Hct: 42.5
Lab Values
PO
daily
Tbil: 0.3
AST: 24
ALT: 21
Alk phos:
102
BUN: 17
Creat.: 1.4
RBC: 4.67
WBC: 10.8
Hgb: 13.9
Hct: 42.5
Plt: 216
PO
bedtime
20-40 mg
daily
PO @
0800
daily
Glucose:
154
Ca: 9.4
BUN: 17
Creat.: 1.4
K+: 4.6
WBC: 2-5
skin necrosis
Side Effects
Nursing
Reason
Considerations
Hypersensiti Monitor for loss
Antivity,
of tolerance to
platelet
dizziness,
aspirin.
confusion,
Symptoms usually
drowsiness,
occur 15 min – 3
tinnitus,
hrs. after
hearing loss, ingestion: profuse
N/V,
rhinorrhea,
diarrhea,
erythema,
heartburn, GI nausea, diarrhea,
bleed,
etc.
thrombocyto
penia,
anemia, imp.
renal
function
diarrhea,
Withhold drug if
Stool
nausea,
diarrhea develops softener
bitter taste,
and notify
throat
physician.
irritation
Vertigo,
Monitor weight
HTN
headache,
and BP, watch for
dizziness,
hypokalemia,
ortho. hypo., monitor I&O,
jaundice,
monitor uric acid
muscle
spasm
Name of
Med
Propafenone
(Rythmol)
Class
Action
Dose
Antiarrhyth
mic
Reduces inward
sodium current in
cardiac cells,
prolongs
refractory period
in AV node, dec.
excitability.
150 mg
Sodium
Chloride
Electrolyte
replace
Replaces sodium
and chloride and
maintains levels
1000 mL
Ativan
sedate.
hypnotic
;Benzo,
antianxiety
Effects
1 mg
(antianxiety,
sedative, hypnotic,
and skeletal
muscle relaxant)
are mediated by
the inhibitory
neurotransmitter
GABA
Dose
Range
150-225
q8h
Freq.
Lab Values Side Effects
PO
t.i.d.
Tbil: 0.3
AST: 24
ALT: 21
Alk phos:
102
Individual
Q13h
20m
IV
Na: 141
2-6 mg
IV PRN Tbil: 0.3
AST: 24
ALT: 21
Alk phos:
102
RBC: 4.67
Dizziness,
heart failure,
bradycardia,
ventricular
fib., blurry
vision, N/V,
abd. Pain,
rash
Aggravation
of heart
failure,
hypernat.,
pulmonary
edema
Drowsiness,
sedation,
hypo/htn,
N/V
Nursing
Considerations
Monitor cardiac
status carefully
Reason
Correct
electrolyte levels
before giving,
may induce
colonic mucosal
ulceration,
monitor pt for
signs of
dehydration
Supervise
ambulation of
older pts for at
least 8h after
injection,
supervise pt w/
depression and
anxiety closely
Electrolyte
replace.
A. fib.
anxiety
Part VII: Discharge planning/teaching
1. Describe data supporting need for teaching and discharge planning for this patient/family during this hospitalization. Include
information from consults (e.g., case manager, social worker, pharmacy consults, and information from the staff nurses’
documentation).
-
-
-
-
-
Health beliefs and behaviors: Pt hasn’t had a Pneumonia or Influenza vaccine since 2006. These are critical to get to prevent disease
especially in immune-compromised patients. Pt needs to be taught risk factors of chronic heart failure such as poor diet, bad lifestyle
choices, and little exercise. Pt needs to know the warning signs of Pneumonia (cough with mucus, fever, shaking, fast breathing, chest
pain, high HR, fatigue, N/V, diarrhea); seizures (see patho); MI (chest/jaw/neck/arm pain, S.O.B., nausea, cold sweat, etc.). Pt (or pt’s
family/caretaker) should understand the components of a cardiac, soft, low sodium diet.
Psychosocial adaptations/maladaptations: Pt has depression and anxiety so there needs to be education regarding who she can get
counseling from, what medications she is taking and where she can refill them, and things she can do to make her more relaxed and
happy. This teaching would include discussing what she is able to do and what she enjoys doing in her spare time.
Ability and readiness to learn: Pt is disoriented and unable to speak following a grand-mal seizure so family education will play a big
part in making sure she is taken care of upon discharge. This teaching will include confirming that the family understands how to take
care of her, how to cope with her symptoms, and how to assess her progression through the process of health improvement.
Person’s expectations for self-care: Because pt is disoriented and unable to speak, her expectations for self-care are unable to be
assessed. Family expectations for patient’s probable self-care will be evaluated and feedback will be given upon learning those
expectations.
What specific teaching is needed for both the patient and family: Mentioned above: signs and symptoms of pneumonia/seizures,
diet, medication education, self-care
2. Referrals made (or needed) to other health care providers. (Specify nature of request).
- Needed referrals:
 Kroontje Health Care Center (nursing home)where pt was previously living before admission to the hospital. They will
need to know information from this hospital stay including: additional medications prescribed, procedures done, follow-up
appointments, plan of care, etc.
 Cardiac care: Pt needs to be further evaluated by a cardiologist for possible CHF.
 Rehab: Pt will need to go to rehabilitation to help improve the impaired neuromuscular function caused by the seizures. She
also needs to see a speech therapist.
3. Resources for Home Care
a. What plans have been made or need to be made regarding care of the patient on discharge from the hospital? (e.g., home? Self-care?
stay with relative/friend? nursing home transfer?). Has transportation been arranged?
 Pt will return to Kroontje Health Care Center upon discharge. Ambulance transportation will be provided.
b. Anticipated caregiver if not totally self-care (e.g., mother, sister, friend, spouse): next of kin (didn’t specify in chart and pt. could not
communicate who that would be. At what frequency intervals does the caregiver anticipate being with patient after discharge?
 Pt will be living in a nursing home and will have constant care from health care providers. Chart says next of kin lives in Riner
so it is anticipated that he/she may not be able to be in Blacksburg at the Kroontje Facility as often as hoped.
4. Physical EnvironmentConsidering the probable needs of the patient on discharge/transfer, what environmental factors will most likely be needed
Probable Patient Need at Discharge
Dressing changeStage 2 pressure ulcer, R. heel
Soft, low-sodium, cardiac diet
Supplemental O2
multiple new medications
Portable EEG
Lab work to evaluate antiseizure medications
Safety precautions as patient is high fall risk
Required equipment, facilities, etc., needed within
patient’s environment (e.g., running water, electricity,
stove, etc.)
Running water, bandages, saline
Stove, grocery store or another adequate food supply source,
running water, electricity
Electricity, oxygen tank + supplies (NC, mask, tubing, etc.),
running water
Pharmacy in close proximity
electricity, EEG monitor with attachments
5. Economic Resources:
a. What type of insurance coverage, if any, does the patient have? Are there any perceived concerns regarding economic resources?
What referrals are necessary?
 Medicare, no perceived concerns regarding economic resources
 No referrals are necessary
6. Community Resources:
a. What community resources are available to the patient in his/her community? (e.g., home health, other support services that may be
helpful)
 Kroontje Health Care Center, Associates in Brief Therapy, CVS pharmacy, St. Mary’s Catholic Church
b. Which ones are indicated for this patient?
Kroontje Health Care Center, Associates in Brief Therapy, CVS pharmacy, St. Mary’s Catholic Church