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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