Download medication

Case Study # 1
Mrs. Jackson is a 72 year-old female that had bowel resection surgery this morning
for colon cancer.
Her orders include the following:
Diet: NPO
Oxygen prn
Incentive Spirometry Q1 hour while awake
JP (bulb) Drain
Foley catheter to gravity
D5½ NS @ 125mL/hr
Potassium 500mg po BID
Synthroid 125mcg po daily
Vancomycin 1gm IVPB Q8hrs
Percocet 2 po q4hrs prn
About an hour after the patient was admitted to the unit from the recovery room,
you are assigned as the nursing student to care for her. You and your instructor are
entering the room to administer her scheduled medications. As you enter the room
you see the patient vomiting into a container and her family is at the bedside with
her.
What would you do?
1. Help the patient and clean up the vomit
2. Ask the patient how she is feeling after vomiting
3. Call the doctor to get an order for an antiemetic
After cleaning up the patient, what assessments would you make?
1. Check her incision (vomiting can rupture sutures)
2. Breath sounds
What made this patient at risk for vomiting?
1. Anesthetics
2. Handling the bowel during surgery
After cleaning up and assessing Mrs. Jackson, she tells you that she is having a lot of
pain.
What would you do?
1. Assess her pain (location, intensity, characteristics)
2. See what the patient has ordered for pain
The patient says that her pain sharp/stabbing in her abdomen and rates her pain at
an 8 on a 0-10 scale.
What is the location of her pain?
1. Abdomen
What are the characteristics of her pain?
1. Sharp/stabbing
What is the intensity of her pain?
1. 8 out of 10
You see that she has Percocet ordered q4hrs prn.
What are your concerns with this order?
1. Patient is vomiting
2. Patient is NPO
3. Patient’s age is not conducive to this type of order (why)
Percocet contains a combination of acetaminophen and
oxycodone. Oxycodone is an opioid pain medication
What would you do?
1. Call the physician for clarification
The physician orders for you to begin a PCA of Hydromorphone on Mrs. Jackson.
While waiting on the pharmacist to verify and load your medication into the Pixis,
you ask Mrs. Jackson to take some breaths with her incentive spirometer.
Explain the steps to educate Mrs. Jackson on the use of the incentive spirometer?
1. Elevate the HOB
2. Firm seal between lips and mouth piece
3. Inhale slowly and stea]
4.
The nurse for Mrs. Jackson returns to the room with the medication for the PCA
pump. The nurse and your instructor perform a 2-nurse verification and set up the
PCA pump.
Up to this point, what needs to be documented?
1.
2.
3.
4.
Patient’s pain assessment and vomit amount in I&O
Use of Incentive Spirometer
Call to the physician and new orders received
Set up of the PCA pain meds
When do you document the new PCA pain medicine?
1. After starting the medication
You and your instructor prepare for placement of the NG tube and prepare the
patient’s medications that still need to be administered. What position and
technique would you use for insertion of the NG tube?
1. Chin tuck
2. Patient sips on some water
As a highly skilled nursing student you know that the best way to check for proper
placement is to:
1. Get an X-Ray
What is another way to check to placement each shift before giving medications?
1. Aspirate gastric contents and check pH
After administering the patient’s medications via the NG tube, what do you know to
do before leaving the patient’s room?
1. Position the patient sitting up or high fowler’s to prevent aspiration
A couple hours later you go into assess the patient’s I&O and notice that there is
only about 30 mL of urine in her foley bag.
After checking the bag for kinks and patency, what is your next step?
1. (First) Palpate the bladder or use a bladder scanner
2. Notify the physician immediately
3. Ask for an order to irrigate the catheter
You receive an order to irrigate the catheter and afterwards urine starts flowing.
What is every catheter patient at risk for?
1. Infection
What can you do to prevent infection?
1. Remove as soon as possible
2. Provide catheter care every shift
After taking care of the patient’s foley catheter, you check the JP drain. The bulb is
round and has some fluid in it. What are your next steps?
1. Empty and recompress the drain
It is now the end of your shift and the patient is settling in with her pain now under
control, her NG placed and working, and catheter draining. Her family is getting
ready to leave and you go into say goodbye. You have instructed the patient not to
get up out of bed, but are a little worried she might forget in the middle of the night
being that she is in a strange place and on some heavy pain medication.
What is the number one thing you can ensure the patient understands about safety
prior to leaving the room?
1. How to use her call bell to call for help if needed.
The next week you return and once again are assigned to Mrs. Jackson. Her NG tube,
foley and PCA pump have been removed. Over the past week Mrs. Jackson has
gotten weaker, begun having diarrhea, and even fallen out of bed. She has
diminished breath sounds bilaterally.
What are your concerns for Mrs. Jackson and what might be going on with her?
1.
2.
3.
4.
Hypovolemia with electrolyte imbalance
Atelectasis
Safety
Skin breakdown
You go in to see Mrs. Jackson, complete her assessment, and get her vital signs.
While doing the assessment of her skin, you notice that she has 3 red, round oval
blisters on her sacrum where the skin is open. She has had diarrhea and think that
she may have some irritation from the stool.
When looking at ways to prevent skin breakdown in the elderly, what are some
interventions that you could do?
1. Turn the patient every 2 hours to prevent pressure ulcers
2. Keep the patient clean and dry
3. Ask for an air mattress or specialty mattress
How does turning the patient every two hours help?
1. Relieves pressure on the capillaries and promotes blood/oxygen
circulation
How would you document the blisters?
1. 3 round oval blisters that are red and open on sacrum. Minimal drainage.
What is an additional intervention to prevent skin breakdown with this patient?
1. Change pads frequently
2. Give antidiarrheal
3. Apply a moisture barrier to the perineal area
During your assessment, you assess Mrs. Jackson’s bladder. She winces when you
palpate.
What would you ask Mrs. Jackson?
1. When was the last time you voided
She states that she cannot remember, but that she can try to get up to void now. You
proceed to help Mrs. Jackson up to the bedside commode. This is the first time she
has been up this morning and she is week.
What device would you use to assist her to the commode?
1. Gait belt
When you first stand Mrs. Jackson up, she states that she feels dizzy.
What would you do?
1. Sit her on the side of the bed until the dizziness passes
Once Mrs. Jackson states that the dizziness has passed, you proceed with helping her
to the commode. She is able to void and you assist her with wiping/cleaning herself.
While assisting her you notice that her pulse ox drops from 98% to 84%.
What would you do?
1.
2.
3.
4.
(First)Assist her back to bed
Administer oxygen at 2L because you know it was ordered prn.
Monitor for improvement.
Document
Knowing that Mrs. Jackson is having frequent diarrhea and witnessing her
experience with your assistance in getting up to the commode,
What is Mrs. Jackson at risk for that could cause severe injury?
1. Fall
In continuing your assessment of Mrs. Jackson you know that you still need to assess
her incision and her pain level. Her incision is partially open this week and they are
performing wet-to-dry dressings qshift.
You know as a nursing student that the reason for this type of dressing is that?
1. It facilitates healing by debriding as the old dressing is removed
Currently Mrs. Jackson’s pain level is at 6. You know the dressing change can be
painful. It is not time for another dose of pain medication, but the nurse has
instructed you that the dressing needs to be changed now because Mrs. Jackson will
be leaving the unit soon for PT.
What can you do for Mrs. Jackson’s pain?
1. Call the physician and request an additional order for something for pain
You receive an order for additional pain medication and administer the medication
with your instructor. You then proceed with the wet-to-dry dressing change. You
note that the drainage is minimal, but that the wound appears to be black along one
side. You notify the physician and he states that he will be down this afternoon to
see the patient. Physical Therapy arrives and your nursing instructor tells you to go
with the patient to therapy. About 10 minutes into the session, while ambulating,
the patient states that she doesn’t feel well and begins to pass out.
What do you and the physical therapist do for the patient?
1. Gently lower the patient to the floor
2. Once the patient comes to, transfer the patient to a wheelchair (ensuring
the wheels are locked)
3. Return the patient to the room and cancel the rest of the session
The physician later arrives to assess the patient and determines that the patient
needs to return to the operating room and have a surgical debridement of the
wound. Upon further examination of the patient’s labs, he notes that the patient’s
Hgb is 7.4. He orders two units of Packed Red Blood Cells to be given STAT. He then
squeezes the patient in at the end of the day on the surgical schedule for the
debridement.
What is your priority when administering blood?
1. Accuracy of the Type and Cross match to the blood about to be
administered.
What is the procedure for assessment with administering blood?
1. Pre vital signs, then 15 minutes, then at the end.
2. Must remain with the patient for the first 15 minutes
While the blood is running and prior to the patient going to surgery, you have a little
bit of time to clean up the patient.
What is the purpose of bathing a patient especially before surgery?
1. Remove bacteria and clean the skin
After the blood is administered and the patient is clean and ready to go. The nurse
goes in to get the patient’s signature on the surgical consent. The patient and her
family appear confused and not able to articulate why she is going back to surgery.
What should the nurse do?
1. Notify the physician to come and explain
A week later you return and are assigned to Mrs. Jackson once again. She is much
more with it and feeling 100% better this week. She is almost ready to go home, but
is still having some diarrhea. One of the goals she has prior to discharge is to
establish a normal stooling routine.
What is a patient outcome that you would use to evaluate this goal?
1. The patient has normal stool
Case Study # 2
Mr. Sanchez was admitted from the emergency department to the unit you are
assigned to for your clinical rotation. He is an 88 year old with a history of CHF,
respiratory failure, renal disease, throat cancer, and diabetes type II. He was in a car
accident and is being admitted for respiratory distress. He has a tracheostomy that
has been in place for many years, a chest tube due to a pneumothorax caused in the
accident, an IV, and foley catheter. The patient is Spanish speaking and his family is
on their way to the hospital.
Upon arrival to your unit the nurse reviews his orders from the ED physician and
notices that they are handwritten instead of being entered in to the computer as per
protocol.
What should the nurse do?
1. Call the physician for clarification of the orders
2. Then enter as written/phone orders from the physician
When going into assess the patient, the nurse realizes that she is unable to
communicate with the patient.
What should she do?
1. Call for an interpreter
When the patient’s family arrives, they too speak very little English. The interpreter
stays to assist with communication between the patient, family, and caregivers.
While completing the patient’s history, the patient’s family states that the patient
has a living will and requests that no life sustaining measure be taken. The patient is
moderately confused from what the nurse can gather and the family has appropriate
paperwork giving the daughter power of attorney. When presented to the physician
caring for the patient on the unit, he writes a DNR order for the patient.
What does this mean?
1. Treatments will focus on comfort and symptom management
In his confused state, Mr. Sanchez is pulling at the chest tube and IV. He is unable to
understand that he is not supposed to pull at them.
What can the nurse do to stop Mr. Sanchez from pulling at these items?
1. Try a restraint alternative
During further assessment of Mr. Sanchez, the nurse notes that his bowel sounds are
Hypoactive.
What should the nurse ask his family?
1. When was the last time Mr. Sanchez had a bowel movement or ate
anything
While assessing his vital signs, the nurse notes that his respiratory rate is in the 30s,
his heart is 142, and his B/P is 88/67. His oxygen saturation is 88%. They did not
have oxygen on him when they brought him up from the ED despite his diagnosis of
respiratory distress and this is the first time the nurse has had time to check his
vitals. She also notes that he has “gurgling” coming from his trach.
What should the nurse do first?
1. Apply oxygen
2. Raise the HOB
What is another thing the nurse can do to facilitate exchange of oxygen?
1. Suction the tracheostomy
2. Remember to hyper oxygenate before suctioning
What is a nursing diagnosis for this patient?
1. Impaired gas exchange
What else does the patient have that the nurse should check?
1. Chest Tube
2. IV
3. Foley
What does the nurse need to check on the chest tube?
1. Drainage and patency
What does the nurse access on the IV?
1. Patency
2. S&S of complications
3. Correct IVF
What does the nurse access with the foley?
1. Flow of urine from the catheter
2. S&S of complications(redness, drainage from around the catheter)
3. Urine assessment (amount, color, odor, etc)
The next week the patient is doing better. The IV and Chest tube have been
removed, but the prognosis for a full recovery is not good. The physician speaks to
the family about the patient’s prognosis. Together they decide to set the patient up
with hospice since the life expectancy is only about 6-12 months.
What is an important factor to understand when dealing with a family regarding the
impending death of a loved one?
1. The family’s personal and cultural views on death
2. Stage of the grieving process (Anger, Denial, Bargaining, Depression,
Acceptance)
Finally, what are three things to consider for nursing care when dealing with a
terminally ill patient?
1. Treat with respect and dignity
2. Give optimal and effective pain management
3. Give holistic and compassionate care