MIAMI DADE COLLEGE - MEDICAL CENTER CAMPUS - SCHOOL OF NURSING NUR 1025L: Fundamentals Nursing Clinical Students Name:

Francisco J Ortiz Date: _06/08/13_ Clients Initials: ____IH____ Admission Date: _04/01/13_ Age: ___91___Yr_____Mo DOB: ______08/28/1921_____ Sex: Male X Female Race/Ethnicity: White/______________ Support System: ______son_________________________________________________________ Religion: _Catholic__________ MEDICAL HISTORY ALLERGIES: _____NKA__________________________________________________________________________________________ Admitting Medical Diagnosis (es): _____DMII; Fracture of humerus; dementia; hypertension; lipoid metabolic disorder, iron deficiency;
anemia___________________________________________ _________________________________________________________________________________________________________________________________________ Chief Complaint: ______Abnormal lab______________________________________________________________________________________________

History of Present Illness: Pt from nursing home history of GI bleeding. Pt was sent back to the hospital because of low HH__________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________ Past Medical History (include past surgical history): __Significant for hypertension, diabetes , dementia and hyperlipidemia_________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________

Clients (Parents)Understanding of Illness: ________Pt has dementia and cannot recollect information given____________________________________________________________________ __________________________________________________________________________________________________________________ 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: ________________________________________________________________________________ Height: _____54________ Weight: ____110lb___________ Placement in Growth Chart: _____________________________________________ Immunizations: ___________________________________________________________________________________________________ VITAL SIGNS Time Taken: _______________ Activity: ______________ Position: ____wheel chair__________ T_36.4____ P__96__ R 19__ BP _129/68___ Baseline (Normal Age for Age): T_ 36.137.8 P_60 -100 R_12-20_ BP 120/80 _ NUTRITION Diet: ______________________________ Food Preferences: ______________________________________________________________ 1

Nutritional Requirements: (Cal/Kg/Day): _____________________________ Total Calories per Day: _____________________________ Fluid Requirements (Ml/Kg/Day): __________________________________ _ Total Fluids per Day: _______________________________
Special Treatments: ___________________________________________________________________________________________________________

__________________________________________________________________________________________________________________ Medications at Home:_N/A___________________________________________________________________________________________ __________________________________________________________________________________________________________________

Medication(s) Worksheet
NAME CLASSIFICATION DOSE/ROUTE/FREQUENCY SAFE RANGE MECHANISM OF ACTION INDICATIONS SIDE EFFECTS NURSING CONSIDERATIONS AND PATIENT EDUCATION

Prilosec

20mg daily by mouth

Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen.

GERD/maintena nce of healing in erosive esopha- gitis. Duodenal ulcers (with or without anti-infec- tives for Helicobacter pylori). Shortterm treatment of active benign gastric ulcer. Pathologic hypersecretory conditions, including Zollinger-Ellison syndrome. Reduction of risk of GI bleeding in critically ill patients.

CNS: A Assess patient dizziness, routinely for drowsiness, epigastricor abdominal fatigue, pain and frank or occult headache, blood in the stool, weakness. emesis, or gastric CV: chest aspirate. pain. GI: abdominal Monitor CBC with pain, acid differential periodically regurgitatio during therapy. n, constipation , diarrhea, flatu- lence, nausea, vomiting. Derm: itching, rash. Misc: allergic reactions.

Norvasc

10mg 1 tab PO

Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in in- hibition of excitationcontraction coupling and subsequent contraction.

Indications:Alone or with other agents in the management of hypertension, angina pectoris, and vasospastic (Prinzmetals) angina.

CNS: headache, dizziness, fatigue. CV: peripheral edema, angina, bradycardia, hypotension , palpitations. GI: gingival hyperplasia, nausea. Derm: flushing. CNS:
NEUROLEPTIC MALIGNANT SYNDROME, SUICIDAL THOUGHTS,

Monitor blood pressure and pulse before therapy, during dose titration, and periodically during therapy. Monitor ECG periodically duing prolonged therapy.

Celexa

10mg 1 tab PO

Selectively inhibits the reuptake of serotonin in the CNS.

Depression.

apathy, confusion, drowsiness, insomnia, weakness, agitation, amnesia, anxiety.

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 may minimize dry mouth. If dry mouth persists for more than 2 wk, consult health care professional regarding use of saliva substitute

Namenda

10mg 1 tab PO

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

Moderate to severe Alzheimers dementia.

CNS: dizziness, fatigue, headache, sedation. CV: hypertensio n. 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.

Amaryl

4mg 1 tab PO (with breakfast)

Lower blood glucose by stimulating the release of insulin from the pancreas and increasing the sensitivity to insulin at receptor sites. May also decrease hepatic glucose production.

Control of blood glucose in type 2 diabetes mellitus when diet therapy fails. Require some pancreatic function.

CNS: dizziness, drowsiness, headache, weakness. GI: constipation , cramps, diarrhea, druginduced hepatitis, heartburn, q appetite, nausea, vomit- ing. Derm: photosensiti vity, rashes.

Observe for signs and symptoms of hypoglycemic reactions (sweating, hunger, weakness, dizziness, tremor, tachycardia, anxiety).

Medication(s) Worksheet
CLASSIFICATION NAME DOSE/ROUTE/FREQUENCY SAFE RANGE MECHANISM OF ACTION INDICATIONS SIDE EFFECTS NURSING CONSIDERATIONS AND PATIENT EDUCATION

Zestril

10mg 1 tab PO

ACE inhibitors block the conversion of angiotensin I to the vasoconstric tor angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandi ns. ACE inhibitors also q plasma renin levels and p aldosterone levels. Net result is systemic vasodilation.

Alone or with other agents in the management of hypertension.

CNS: dizziness, drowsiness, fatigue, headache, insomnia, vertigo, weakness. Resp: cough, dyspnea. CV: hypotension, chest pain, edema, tachycardia. Endo: hyperuricem ia

Hypertension: Monitor bloodpressure and pulse frequently during initial dose adjustment and periodically during therapy. Notify health care professional of significant changes.

Ferrous sulfate

65mg tab with breakfast

An essential mineral found in hemoglobin, myo- globin, and many enzymes. Enters the bloodstream and is transported to the organs of the reticuloendoth elial system (liver, spleen, bone marrow), where it is separated out and becomes part of iron stores.

Prevention/treat ment of irondeficiency anemia

CNS: IM, IV SEIZURES, dizziness, headache, syn- cope. CV: IM, IV hypotension , hypertensio n, tachycardia. GI: nausea; PO, constipation, dark stools, diarrhea, epigastric pain, GI bleeding;

Assess nutritional status and dietary history to determine possible cause of anemia and need for patient teaching. Assess bowel function for constipation or diarrhea. Notify health care professional and use appropriate nursing measures should these oc- cur.

Zocor

20mg 1 tab PO nightly

Inhibit an enzyme, 3hydroxy-3methylglutar yl-coenzyme A (HMG-CoA) reductase, which is respon- sible for catalyzing an early step in the synthesis of cholesterol.

Adjunctive management of primary hypercholesterolemia and mixed dyslipidemias.

CNS: dizziness, headache, insomnia, weakness. CV: chest pain, peripheral edema. EENT: rhinitis; lovastatin, blurred vision. Resp: bronchitis.

Obtain a dietary history, especially with regard to fat consumption.

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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, HEPATOTOXICITY

(overdose). GU: renal failure (high doses/chroni c use). Hemat: neutropenia, pancytopeni a, 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 hepatotoxicity 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- Incidence of anemia reflect the presence of bone marrow failure or excessive loss of red blood cells or both. Bone marrow failure can occur due to nutritional deficiencies, toxic exposures, tumor, or mostly due to unknown causes. Red blood cells can be lost through hemorrhage or hemolysis (destruction) in the latter case, the problem can be caused by the effects of red blood cells that do not correspond to the resistance of normal red blood cells or due to several factors outside the red blood cells that causes red blood cell destruction. Red blood cell lysis (dissolution) occurs mainly in the phagocytic system or in the reticuloendothelial system, especially in the liver and spleen. As a byproduct of this process the bilirubin that is formed in phagocytes will enter the bloodstream. Any increase in red blood cell destruction (hemolysis) immediately reflected by increasing plasma bilirubin (normal concentration of 1 mg / dl or less; levels of 1.5 mg / dl result in jaundice in the sclera. Anemia is a blood disease characterized less low levels of hemoglobin (Hb) and red blood cells (erythrocytes). The function of the blood is carrying food and oxygen to all organs of the body. If the supply is less, then the intake of oxygen will be less. As a result, can inhibit the work of the vital organs, the brain One. The brain consists of 2.5 billion bioneuron cells. If capacity is lacking, then the brain will be like computer memory is weak, slow catch. And if it is damaged, can not be repaired (Sjaifoellah, 1998). 12

Client

Classification- Anemias can be classified by cytometric schemes (i.e., those that depend on cell size and hemoglobincontent parameters, such as MCV and MCHC), erythrokinetic schemes (those that take into account the rates of rbc production and destruction), and biochemical/molecular schemes (those that consider the etiology of the anemia at the molecular level. Etiology- The most common cause of anemia is deficiency of nutrients required for the synthesis of red blood cells, such as iron, vitamin B12 and folic acid. The rest is the result of a variety of conditions such as hemorrhage, genetic abnormalities, chronic disease, drug toxicity, and so on. Statistics 7% of children aged 1-2 had anemia in the US 1999-2000 (MMWR, NCHS, CDC) 12% of women aged 12-49 had anemia in the US 19992000 (MMWR, NCHS, CDC) 174,600 nursing home residents had anemia in the US 1999 (National Nursing Home Survey, NCHS, CDC) 10.7% of nursing home residents had anemia in the US 1999 (National Nursing Home Survey, NCHS, CDC) 3.4 million cases in the US (Mayo Clinic) 1.3% of population self-reported having anemia in Australia 2001 (ABS 2001 National Health Survey, Australias Health 2004, AIHW) 0.3% of male population self-reported having anemia in Australia 2001 (ABS 2001 National Health Survey, Australias Health 2004, AIHW) 2.3% of female population self-reported having anemia in Australia 2001 (ABS 2001 National Health Survey, Australias Health 2004, AIHW) 217,000 women self-reported having anemia in Australia 2001 (ABS 2001 National Health Survey, Australias Health 2004, AIHW) 13

DIAGNOSTIC TESTS

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Test
(i.e. X-Ray, MRI, EEG, EKG)

RESULTS
Date, Result, Significance

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Laboratory values
CHEMISTRY PROFILE NORMAL VALUES DATE SODIUM CLIENTS VALUES DATE DATE WBC HEMOTOLOGY NORMAL VALUES DATE CLIENTS VALUES DATE DATE

135-145 Meq/L 3.5- 5.1 mEq/L 98-108 mEq/L

19-34

142 2/21/13 4.5 2/21/13 109 2/21/13 23.0 2/21/13 7.7 2/21/13 261 2/21/13 36.0* 2/21/13 1.35* 2/21/13

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

4.822/21/13 2.06* 2/21/13

POTASSIUM CHLORIDE CO2 CALCIUM GLUCOSE

RBC HGB HCT MCV MCH

8.2-10.3 mg/dL 70-105 mg/dL 7-25 mg/ Dl 0.6-1.2 mg/dL 6.4-8.9 g/dL 3.5-5.0 g/dL 13-39 U/L 7-52 U/L 0.3-1.0 mg/dL

79.4-94.8fL

90.7 2/21/13

BUN CREATININE PHOSPHORUS CHOLESTEROL TOTAL PROTEIN ALBUMIN ALBUMIN/GLOBULI N RATIO AST (SGOT) ALT (SGPT) TOTAL BILIRUBIN AMYLASE LIPASE

MCHC PLATELETS

25.6-32.2 pg 11.5-15.0%

27.8 2/21/13 16.6 2/21/13

6.4 2/21/13 3.48 2/21/13 2.92 2/21/13 23 2/21/13 15 2/21/13

DIFFERENTIAL NEUTROPHILS SEGMENTS BANDS LYMPHOCYTES EOSINOPHILS BASOPHILS MONOCYTES COAGULATION STUDIES PTT

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SODIUM

135-145 Meq/L 3.5- 5.5 mEq/L 98-108 mEq/L

19-34

142 2/21/13 4.5 2/21/13 109* 2/21/13 23.0 2/21/13 7.7* 2/21/13 261* 2/21/13 36.0* 2/21/13

WBC

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

4.82 2/21/13 2.05* 2/21/13

POTASSIUM CHLORIDE CO2 CALCIUM GLUCOSE

RBC HGB HCT MCV MCH

8.2-10.3 mg/dL 70-105 mg/dL 7-25 mg/ Dl CBC Hgb Hct

BUN

MCHC

BMP Na K
+ +

WBC

Plts

Cl

HCO3

Glucose Creatinine

BUN

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URINALYSIS COLOR APPEARANCE SP. GRAVITY 1.010-1.025 PH 4.5-8.0 GLUCOSE KETONE OCCULT BLOOD PROTEIN BILRUBIN UROBILINOGEN NITRITE LEUCOCYTE CAST WBC RBC CRYSTALS SQUAMOUSCELLS/ EPITHELIAL CELLS

TEST

MISCELLANEOUS TEST NORMAL CLIENTS VALUES VALUES DATE DATE DATE

Relate the clinical significance of abnormal lab values above: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ _______________________________________________________________

Head to Toe Assessment

General Appearance: The pt is resting comfortably in no acute distress 18

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: 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: Risk for infection related to abnormal labs Supporting Data: Subjective: Patient states I am tired Objective: Labs show abnormal labs Expected Outcome (Goals) Long Term: Short Term: Nursing Interventions Nursing Actions Scientific Principle and/or Rationale Evaluation Modification of Plan of Care

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CARE PLAN RUBRIC Student: ___________________________________ Date: ______________________ CATEGORIES SUBJECTIVE DATA (Relevant and timely and quoted from patient) POSSIBL E POINTS 10 YOUR POINTS COMMENTS

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OBJECTIVE DATA (Includes vital signs, physical assessment findings, diagnostic tests and procedures, relevant medications, etc.) NURSING DIAGNOSIS (NANDA, R/T, AEB) GOAL (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)

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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: ______________________________ 23 Date: ___________________

Signature

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