CSU, STANISLAUS B.S.N.

CLINICAL PLAN OF CARE

Student :

Maggie Fabry

Date of Care: 10/11/13

Room Number: 340

Patient Data
Admitting Diagnosis : R humeral head fracture
Age: 64
Spiritual Focus: Hindu
Culture: Hindu
Patient Initials: DJ
Gender: F
Height : 5 ft 1 in
Weight: 159 lbs
Admitting Date: 10/09
POD: 1
Vital Signs: T: 36.6
P: 89
R: 18
B/P: 141/78
O2 Sat: 99
Pain Scale: 9
Past Medical History: DM type 2, HTN, hyperlipidemia, nonalcoholic fatty liver disease
Surgical History: R shoulder, rotator cuff surgery

Diet: NPO pre-surgery, vegetarian diet post-surgery

Activity: bedrest. Up with one person assist
Foley: Y
NG/Feeding Tube: N
Advance Directives: No
Drains/ Tubes: 2 L NC
Code Status: Full
VS Freq: Q6hr
Glucose Monitoring: Y
TEDs/SCDs: N
Vascular Access:
PCA/Epidural: N
Telemetry: Y
IV Site: 22 gauze IV in L forearm
IV Solution: NS 1000mL
Safety Considerations: Fall risk
Dressing Change: N
Labs to be drawn: none scheduled
Scheduled Procedures: R humeral head surgery 10/10/13
Notes on pathophysiology:
Type 2 diabetes: Diabetes is a problem with your body that causes blood glucose (sugar) levels to rise higher than normal. This is also called hyperglycemia. Type 2
diabetes is the most common form of diabetes. If you have type 2 diabetes your body does not use insulin properly. This is called insulin resistance. At first, your
pancreas makes extra insulin to make up for it. But, over time it isn't able to keep up and can't make enough insulin to keep your blood glucose at normal levels.
HTN: High blood pressure. The force of blood against artery walls is too high and can cause health problems. The more blood your heart pumps and the narrower
the arteries, the higher the blood pressure

Hyperlipidemia: involves abnormally elevated levels of any or all lipids and/or lipoproteins in the blood.[1] It is the most common form of dyslipidemia (which includes
any abnormal lipid levels). Lipids (fat-soluble molecules) are transported in a protein capsule. The size of that capsule, or lipoprotein, determines its density. The
lipoprotein density and type of apolipoproteins it contains determines the fate of the particle and its influence on metabolism. Hyperlipidemias are divided in primary
and secondary subtypes. Primary hyperlipidemia is usually due to genetic causes (such as a mutation in a receptor protein), while secondary hyperlipidemia arises
due to other underlying causes such as diabetes. Lipid and lipoprotein abnormalities are common in the general population, and are regarded as a modifiable risk
factor for cardiovascular disease due to their influence on atherosclerosis. In addition, some forms may predispose to acute pancreatitis.

Nonalcoholic fatty liver diease: Non-alcoholic fatty liver disease (NAFLD) is the build up of extra fat in liver cells that is not caused by alcohol. It is normal for the liver
to contain some fat. However, if more than 5% - 10% percent of the livers weight is fat, then it is called a fatty liver (steatosis). NAFLD tends to develop in people who
are overweight or obese or have diabetes, high cholesterol or high triglycerides. Rapid weight loss and poor eating habits also may lead to NAFLD.

Lab and Diagnostic Test Data

Test
type(date)

Normal Range

Glucose

74-118

BUN

8-26

Patient Results

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &

teaching

10/09 0119: 158

10/09 0422: 135
10/10 0400: 152

Pt blood glucose levels are slightly above normal limits.

Monitor glucose levels closely for further increases.
Administer prescribed Insulin as needed and as dictated
by the sliding scale. Signs of hyperglycemia include
frequent urination, increased thirst, blurred vision and
headache. Signs of hypoglycemia include confusion,
abnormal behavior, vision disturbances, shakiness,
anxiety and sweating.

10/09 0119: 20
10/09 0422: 23
10/10 0400: 20

Monitoring blood
glucose levels
because pt is a type ll
diabetic. Also
monitoring because
many drugs the pt is
taking can alter blood
glucose levels.
Levels are controlled
by insulin and
glucagon.
Used to monitor
kidney function. This
test also monitors
liver function. Pt has
an elevated BP and
chronic htn. This can

Pt is within normal limits. A decrease could indicate

malnutrition. Could also be due to her high BP. Monitor
s/s of kidney malfunction such as nausea, vomiting, or
abdominal pain. Monitor other electrolyte levels to
ensure nutrition. An increase could indicate dehydration
or GI bleeding.

Test
type(date)

Normal Range

Patient Results

Trend

Rationale
(specific to pt.)
cause kidney
disease, so function
must be monitored.
Used to monitor
kidney function/
diagnose impaired
function. Pt has an
elevated BP and
chronic htn can
cause kidney
disease, so function
must be monitored.
Used to monitor
kidney function and
evaluate stages of
kidney failure.

Creatinine

0.44-1.00

10/09 0119: 0.84

10/09 0422: 1.11
10/10 0400: 0.90

eGFR

>60

10/09 0119: >60

10/09 0422: 49
10/10 0400: >60

Sodium

136-145

10/09 0119: 130

10/09 0422: 132
10/10 0400: 136

Used to monitor fluid

and electrolyte
balance. This pt has
DM and HTN which
can both effect
sodium.

Potassium

3.6-5.1

10/09 0119: 4.6

10/09 0422: 5.1
10/10 0400: 4.6

Chloride

101-111

10/09 0119: 99
10/09 0422: 100
10/10 0400: 105

Used to ensure
electrolyte balance.
Hold meds if levels
are abnormal or
nearly abnormal. This
is electrolyte is
important to cardiac
function and is
especially important
in patients taking
diuretics or digoxin.
Used to monitor
electrolyte balance.
Chloride follows

Nursing Implications related to patient care &

teaching

Pt is slightly above normal limits. Will closely monitor for

changes. An increase in levels could indicate kidney
disease or dehydration. Monitor s/s such as low output,
low appetite, nausea and vomiting, and persistent fatigue.
A decrease could indicate malnutrition or severe liver
disease or muscle dystrophy. Monitor s/s such as
nausea, vomiting, abdominal pain or jaundice or frequent
falls or waddling gait.
Pt is now WNL. If levels fall consistently, kidney failure
could be indicated. However, antibiotic treatment can
sometimes alter labs. Use creatinine levels to confirm.
Watch for s/s of kidney disease such as low output, low
appetite, nausea and vomiting, and persistent fatigue.
Note that age, gender, height, race and weight can
influence the glumerular filtration rate.
Pt levels slightly low, but slowly increasing. Watch for a
decrease (hypoatremia) and s/s such as weakness,
fatigue, headache, nausea and vomiting, muscle cramps,
irritability, and confusion. Low sodium levels can indicate
dehydration or low sodium intake. This pt was NPO pre
surgery, so this may have caused the low levels. Pt
teaching about how hydrating can prevent low sodium
levels.
Pt WNL. An increase in these levels could indicate
kidney disease. Monitor s/s such as low output, low
appetite, nausea and vomiting, and persistent fatigue. A
decrease in levels could indicate excessive potassium
loss in the urine. This could be due to a large variety of
issues such as GI disorders, renal tubular acidosis, or
hyperaldosteronism. Monitor s/s such as muscle aches,
abnormal weakness, arrhythmias, diarrhea, and nausea
and vomiting. Know which meds to hold if levels are not
WNL.
Pt levels slightly low. Decreased levels could indicate
over hydration, CHF, vomiting, diarrhea, chronic
respiratory alkalosis, hypokalemia, or burns. Monitor for

Test
type(date)

Normal Range

Carbon Dioxide

22-32

Anion Gap

Patient Results

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &

teaching

sodium, and water

moves with both
electrolytes. As a
result, chloride
effects water
balance. It also helps
the acid base
balance in the body.
Chloride is controlled
by the kidneys, so
abnormal levels can
indicate renal
problems.
Used to monitor acid
base balance in the
body as well as to
assist in evaluating
the pH.

s/s of hypochloremia such as hyperexcitability of the

nervous system and muscles, shallow breathing,
hypotension and tetany. Hyperchloremia can be indicated
through s/s such as lethargy, weakness and deep
breathing. Monitor for these signs and symptoms and
continue to check lab values for changes

10/09 0119: 23
10/09 0422: 25
10/10 0400: 25

5.0-15.0

10/09 0119: 12.6

10/09 0422: 12.1
10/10 0400: 10.6

Used to monitor acid

base balance

Calcium

8.9-10.3

10/09 0119: 9.4

10/09 0422: 9.5
10/10 0400: 8.3

Used to monitor
parathyroid function
and calcium
metabolism. Also
used to monitor
kidney function.

Total Protein

6.1-7.9

10/09 0119: 7.1

Used to diagnose,

Pt is WNL. Watch levels to ensure they do not increase.

s/s include rapid respiration, rapid pulse rate, and SOB.
As CO2 levels increase, there could be a reduction in pts
over all LOC. Monitor levels for any dramatic increases
because it could lead to respiratory arrest. S/s of low
CO2 levels (respiratory alkalosis) include confusion, hand
tremor, light headedness or nausea and vomiting.
Pt is WNL. An increase could indicate lactic acidosis or
kidney failure. S/s would include headache, palpitations,
chest pain as well as kidney disease s/s. A decrease
could indicate a low sodium blood level or bone marrow
cancer.
Pt is WNL. Low levels may be a result of malabsorption
syndrome, hypoalbumenia, end stage kidney disease,
post thyroidectomy, hypoparathyroidism, vitamin D
deficiency, inadequate intake, pancreatitis, low
phosphate, meds that block parathyroid function prevent
absorption of Ca. S/s of progressing hypocalcemia would
include tingling in hands, feet or lips, muscle spasms or
slow uneven heart beat. An increase in levels may be
caused by hyperparathyroidism, metastatic tumor to
bone, prolonged immobilization, vitamin D intoxication,
lymphoma, acromegaly. Symptoms of hypercalcemia are
usually not significant, unless severe hypercalcemia
results, which may cause generalized symptoms such as
GI disturbances, fatigue, and like with hypocalcemia,
muscle twitching.
Pt WNL. A decrease in levels could indicate malnutrition.

Test
type(date)

Normal Range

Patient Results

Albumin

3.5-4.8

10/09 0119: 4.0

Globulin

2.3-3.5

10/09 0119: 3.1

ALB/GLOB ratio

0-35

10/09 0119: 1.3

Alkaline
Phosphatase

38-126

10/09 0119: 66

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &

teaching

evaluate and monitor

disorders such as
liver dysfunction,
impaired nutrition,
and protein-wasting
states.

S/s to watch for would include weight loss, weakness or

muscle fatigue, increased susceptibility to infections, or
delayed healing of even small wounds. An increase in
levels could indicate dehydration or inflammatory
disease. Inflammatory diseases are characterized by
episodes of inflammation that result in fever, rash or joint
swelling. Will monitor lab values and use albumin and
globulin levels to confirm any abnormalities.
Pt WNL. A decrease in levels could indicate malnutrition.
S/s to watch for would include weight loss, weakness or
muscle fatigue, increased susceptibility to infections, or
delayed healing of even small wounds. An increase in
levels could indicate dehydration or inflammatory
disease. Inflammatory diseases are characterized by
episodes of inflammation that result in fever, rash or joint
swelling. Will monitor lab values and use total protein
and globulin levels to confirm any abnormalities.
Pt WNL. A decrease in levels could indicate malnutrition.
S/s to watch for would include weight loss, weakness or
muscle fatigue, increased susceptibility to infections, or
delayed healing of even small wounds. An increase in
levels could indicate dehydration or inflammatory
disease. Inflammatory diseases are characterized by
episodes of inflammation that result in fever, rash or joint
swelling. Will monitor lab values and use albumin and
total protein levels to confirm any abnormalities.

Just like the total

protein test, this test
is used to diagnose,
evaluate and monitor
disorders such as
liver dysfunction,
impaired nutrition,
and protein-wasting
states.
Just like the total
protein test and
albumin, this test is
used to diagnose,
evaluate and monitor
disorders such as
liver dysfunction,
impaired nutrition,
and protein-wasting
states.
Used in the
evaluation of pts that
are expected to have
hepatocellular
diseases
Used to detect and
monitor diseases of
the liver or bone.

Pt WNL. An increase could indicate liver disease. Signs

to watch for include loss of appetite, loss of energy,
weight loss, jaundice, or fluid retention. A decrease could
indicate renal disease. S/s to watch for will include low
output, low appetite, nausea and vomiting, and persistent
fatigue
Pt WNL. An increase in these levels could indicate
primary cirrhosis or bone disease. S/s of cirrhosis
include loss of appetite, loss of energy, weight loss,
jaundice, or fluid retention. S/s of bone disease would
include pain, weakness or tingling in the affected area. A
decrease in levels could indicate malnutrition. These s/s
include weight loss, weakness or muscle fatigue,
increased susceptibility to infections, or delayed healing

Test
type(date)

Normal Range

Patient Results

Trend

Rationale
(specific to pt.)

AST/SGOT

15-41

10/09 0119: 53

ALT/SGPT

14-54

10/09 0119: 59

Bili Total

0.4-2.0

10/09 0119: 0.8

White Blood Cell

Count

4.8-10.8

10/09 0119: 14.2

10/09 0422: 15.5
10/10 0400: 9.4

Used to help in the

evaluation of
infection, neoplasm,
allergy or
immunosuppression.

Red Blood Cell

Count

3.80-5.40

10/09 0119: 4.13

10/09 0422: 4.04
10/10 0400: 3.33

Measurement of the
amount of red blood
cells in peripheral
blood. Closely related
to hemoglobin and

Test primarily used in

the evaluation of pts
with suspected
hepatocellular
diseases. The
amount of AST
elevation is directly
related to the number
of cells affected by a
disease or injury.
Because this enzyme
is found in skeletal
muscle and because
this pt just had a
bone fracture, the
test was indicated.
Used to identify
hepatocellular
diseases of the liver
or to monitor the
improvement or
worsening states of
these diseases
This is yet another
test to evaluate liver
function.

Nursing Implications related to patient care &

teaching
of even small wounds.
Pt levels above normal. This is mostly like due to her
recent skeletal muscle trauma. Levels should decrease
as the fracture heals. Monitor pt for healing progress and
check lab value regularly to assess progression. If levels
were low, acute renal disease or diabetic ketoacidosis
could be indicated.

Pt levels are above normal. This could indicate cirrhosis,

hepatic tumor or obstructive jaundice. A further increase
could indicate hepatitis. Signs to watch for include loss of
appetite, loss of energy, weight loss, jaundice, or fluid
retention. Another set of labs was not completed for this
pt. Plan to watch for these signs and symptoms and
inquire about the test during my next trip to the hospital.
Pt WNL. An increase in this level could indicate liver
disease. S/s would include loss of appetite, loss of
energy, weight loss, jaundice, or fluid retention. Will
watch for s/s and monitor pt closely.
Pt was above normal levels pre-surgery, but levels have
lowered since the surgery was performed. An increase
could indicate infection, dehydration, allergy or
immunosuppression. S/s would include malaise or fever.
Will monitor pt for s/s of infection and will assess new
labs as they come. A decrease could indicate drug
toxicity, bone marrow failure, or a dietary deficiency. S/s
would include bleeding or bruising.
Pt levels were WNL pre-surgery and slightly low post-op.
This decrease could simply indicate blood loss due to
surgery. In general, a decrease could indicate anemia,
renal disease, or bone marrow failure. S/s would depend
on the disease process being indicated. An increase

Test
type(date)

Normal Range

Patient Results

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &

teaching

hematocrit levels.
Conducted as a
routine part of a
complete blood
count. Also used to
check for anemia.
Used to monitor the
oxygen-carrying
capacity of the blood

could indicate severe COPD of severe dehydration. S/s

of increased severity of COPD include an ongoing cough
that produces a lot of sputum, SOB, wheezing or chest
tightness.

Hemoglobin

11.5-15.5

10/09 0119: 12.5

10/09 0422: 12.3
10/10 0400: 10.3

Hematocrit

35-47

10/09 0119: 38.4

10/09 0422: 37.3
10/10 0400: 31.0

Red Cell
Distribution
Width

11.5-15.5

10/09 0119: 13.0

10/09 0422: 13.1
10/10 0400: 12.8

Platelet Count
Auto

130-400

10/09 0119: 209

10/09 0422: 220
10/10 0400: 152

Used to monitor
platelet number in the
blood. Used in this pt
to monitor risk for
bleeding because
they are receiving
heparin and because
she is post-op.

Neutrophils %

42-75

10/09 0119: 83.3

10/09 0422: 78.5

Neutrophils primarily
fight acute bacterial

This test closely

reflects the
hemoglobin values.
Used as a rapid,
indirect measurement
of RBC number and
volume, integral part
of evaluation of
anemic patients.
This is an indication
of the variation of
RBC size. Used to
classify anemias.

Pt WNL. A high number could indicate congenital heart

disease, COPD, or dehydration. Symptoms of high levels
include dysfunctional cognition, dizziness, mental
confusion, peripheral cyanosis, slow blood clotting times,
swelling and sudden numbness. A decrease could
indicate anemia, renal disease, or bone marrow failure.
Low levels are seen as pale skin, nail beds and gums,
shortness of breath, cardiac symptoms like palpitations,
chest pain and aggravation of heart problems. I will
monitor labs for changes.
Pt shows drop in levels post-op. This drop indicates a
loss of blood during the surgery. Normally, a drop in
levels could indicate anemia, renal disease, or bone
marrow failure. S/s would include constant fatigue and
tiredness, pale skin, shortness of breath, hair loss,
worsening heart problems, and faster heart palpitations.
An increase could indicate severe COPD or severe
dehydration or CHF.
Pt is within normal limits. When values are normal the
anemia is said to be normochromic (hemolytic anemia).
An increase level in RDW could indicate a large variety of
different kinds of anemia. S/s would include easy fatigue
and a loss of energy, SOB, dizziness and pale skin.
Pt WNL. An increase could indicate anything from
malignant disorder like leukemia or lymphoma to
rheumatoid arthritis. A decrease could indicate immune
thrombocytopenia in which antibodies would be
destroying the bodys platelets, bleeding or infection.
Monitor for s/s such as easy or excessive bruising,
superficial bleeding into the skin, or blood in urine or
stools. Will monitor levels for changes and look for s/s
associated with abnormal levels
Pt levels are high. High levels can suggest acute
bacterial infection as well as fungal infections. Levels

Test
type(date)

Normal Range

Patient Results

Trend

10/10 0400: 84.2

Rationale
(specific to pt.)

Nursing Implications related to patient care &

teaching

infections and fungal

infections. This pt
had a bone fracture
and is therefore at
risk for infection.

may be high due to the pts recent fracture and then a

corrective surgery that followed. Will continue to monitor
labs to ensure that levels return to normal in a timely
fashion. Pt being prescribed Ancef. Low levels could
indicate sepsis or radiation therapy, aplastic anemia,
chemotherapy and influenza.
Pt levels slightly low. Low levels can suggest
immunosuppression, leukemia, sepsis, immunodeficiency
diseases, later stages of HIV infection, drug therapy
(aderenocorticosteroids, antineoplastics), and radiation
therapy. S/s would depend on the disease being
indicated. Elevated levels indicate chronic bacterial
infection, viral infection, lymphocytic leukemia, multiple
myeloma, infectious mononucleosis, radiation, and
infectious hepatitis. Will monitor levels for improvements
or for a worsening condition.
Pt levels are high but decreasing. High levels can
suggest acute bacterial infection as well as fungal
infections. Levels may be high due to the pts recent
fracture and then a corrective surgery that followed. Will
continue to monitor labs to ensure that levels return to
normal in a timely fashion. Pt being prescribed Ancef.
Low levels could indicate sepsis or radiation therapy,
aplastic anemia, chemotherapy and influenza.
Pt at normal limit. The presence of nucleated red blood
cells could indicate a variety of problems such as bone
marrow replacement, anemia, asplenia, hypoxia or
extramedullary hematopoiesis.

Lymphocytes %

16-50

10/09 0119: 10.2

10/09 0422: 15.2
10/10 0400: 10.0

Lymphocytes
primarily fight chronic
infection and acute
viral infections. This
pt had a bone
fracture and is
therefore at risk for
infection.

Neutrophils #

1.4-6.5

10/09 0119: 11.8

10/09 0422: 12.2
10/10 0400: 7.9

Neutrophils primarily
fight acute bacterial
infections and fungal
infections. This pt
had a bone fracture
and is therefore at
risk for infection.

NRBC #

10/09 0119: 0
10/09 0422: 0
10/10 0400: 0

This is a tool used to

indicate a situation in
which a serious
underlying disease
could be present.

Medication Allergies: NONE

Medications
Generic & Trade Name
Drug classification
(Therapeutic &
Pharmacologic)
Atorvastatin Calcium

dose/Route
Frequency

Action of drug
and Rationale
(specific to Pt)

Significant Side Effects

Nursing Implications related to

patient care and teaching

10mg/PO/Q48HR

Inhibits HMG-CoA
reductase and
cholesterol synthesis
in the liver and
increases the number

Diarrhea, arthralgia, myalgia, UTI,

nasopharyngitis, pain in extremity,
increased liver enzymes, systemic
lupus, rhabdomyolysis, rupture of
tendon, hemorrhagic cerebral infarction

May be taken at any time of the day with

or without food. Monitor lipid panel 2 to 4
weeks after initiation and 2 to 4 weeks
after dose adjustment. Monitor liver
function tests. Instruct pt to report s/s of

of hepatic LDL
receptors on the cellsurface to enhance
uptake and
catabolism of LDL,
thus lowering plasma
lipoprotein and
cholesterol levels.

Normal Saline (NaCl 0.9%)

1,000mL/IV/Q12H
PRN

Electrolyte replacement;
sodium salt

Normal Saline
Add
Cefazolin Sodium (Ancef)

100mL/IVPB
Two doses postop

Antiinfective;
cephalosporin

Losartan Potassium
(Cozarr)

50mg/PO/daily

Used to lower pts

cholesterol due to her
history of
hyperlipidemia.
Replaces sodium and
chloride and
maintains levels

myopathy or rhabdomyolysis such as

muscle pain, tenderness, weakness, and
fever. Counsel pt to avoid excessive
quantities of alcohol to reduce risk of
hepatotoxicity. Instruct pt not to
consume grapefruit or grapefruit juice
with this drug. Provide pt teaching about
alternate ways to lower cholesterol such
as dietary changes and to incorporate
omega- 3 fatty acids regularly.

Aggravation of heart failures,

hypernatremia, pulmonary edema, local
tenderness, tissue necrosis at injection
site, abscess

Monitor electrolytes. Teach pt to report

any reverse reactions. Monitor for signs
of edema. Monitor injection site.

Used to prevent
infection in pts
fracture post-op.

Headache, dizziness, weakness,

seizures, fever, chills, diarrhea,
anorexia, pain, bleeding, increased
AST, ALT, bilirubin,
pseudomembranous colitis, proteinuria,
increased BUN, renal failure,
nephrotoxicity, leukopenia, neutropenia,
lymphocytosis, hemolytic anemia,
dyspnea, serum sickness,
superinfection, Stevens-Johnson
syndrome

Deters
vasoconstriction and

Chest pain, hypotension, hypoglycemia,

diarrhea, anemia, asthenia, dizziness,

Assess for sensitivity to penicillin and

other cephalosporins. Assess for
nephrotoxicity symptoms like increased
BUN and urine output. Assess for
anaphyalxis and bleeding (ecchymosis,
bleeding gums, hematuria, stool guaiac
daily). Check I&O daily, blood studies
(AST, ALT, CBC, Hct, LDH, asl phos,
Evaluate for decreased symptoms of
infection. Perform teaching on eating
yogurt or buttermilk to maintain intestinal
flora/decrease diarrhea. Pt teaching
about taking medication as prescribed
and about finishing entire regimen.
Instruct pt to report sore throat, bruising,
bleeding or joint pain. Know that this
drug may cause diarrhea, nausea,
vomiting or thrombocytopenia. After
reconstitution, shake well. Administer
drug immediately after reconstitution.
Dilute reconstituted solution in 50 to 100
mL NS. Infuse drug over 30 minutes.
Drug may be taken with or without food.
Monitor BP and HR during treatment

To help with IV
patency and to
promote hydration.
Inhibits bacterial cell
wall synthesis leading
to cell death.

aldosterone-secreting
effects by specifically
intercepting the
binding of angiotesin
ll to the AT(1)
receptor.

Angiotensin ll receptor
agonist; antihypertensive

cough, fatigue, hepatotoxicity,

rhabdomyolysis, acute renal failure,
angioedema.

Used to manage pts

hypertension.

Escitalopram Oxalate
(Lexapro)

10mg/PO/QAM

Selective serotonin
reuptake inhibitor;
antidepressant

Enhances
serotonergic activity
in the CNS as a
result of its inhibition
of serotonin reuptake
in CNS neurons.

Diaphoresis, abdominal pain,

constipation, diarrhea, indigestion,
nausea, vomiting, xerostomia,
dizziness, headache, insomnia, reduced
libido, fatigue, worsening depression or
suicidal thoughts.

Used for anxiety.

Docusate Sodium (Colace)

Laxative, emollient, stool
softener; anionic surfactant

40mg/PO/daily

Increases water, fat

penetration in
intestine; allows for
easier passage of
stool.

Bitter taste, throat irritation, nausea,

anorexia, cramps, diarrhea, rash

Used to prevent

10

especially if or when dose is adjusted.

Monitor renal function and electrolyte
panel. Be aware that drug can cause
hypoglycemia, so concurrent use with
insulin requires careful consideration. Pt
should avoid activities requiring
coordination until drug effects are
realized. Instruct pt to report s/s of
hypotension such as dizziness,blurry
vision, confusion, weakness, fatigue or
nausea. Advise pt against sudden
discontinuation of the drug. Provide pt
teaching on lifestyle changes such as a
diet low in salt and high in vegetables as
well as implementation of an exercise
regimen. Pt should consult dr before
using potassium supplements or
potassium-containing salt substitutes.
Monitor pt closely for clinical worsening,
suicidality, or unusual changes in
behavior. Family and caregivers should
be advised of the need for close
observation and communication with
prescriber. Advise pt not to drink alcohol
while taking medication. Use precaution
when withdrawing medication. Gradual
withdraw should be used whenever
possible. Monitor for s/s of resolution
which would indicate drug efficacy.
Counsel pt to report s/s of serotonin
syndrome such as high fever, agitation,
confusion, hallucinations, hyperreflexia,
nausea, vomiting or diarrhea. Advise pt
that concomitant use of aspirin, NSAIDS
or heparin can increase the risk of
bleeding. May take med without regard to
meals.
Assess for the cause of constipation in
the pt. Assess for therapeutic effect
(decrease in constipation, increase in
BMs). Monitor pt for cramping, rectal
bleeding, nausea, vomiting. Discontinue
use if these effects occur. Advise pt that
med may take up to three days to soften

constipation caused
by use of analgesics
and opioids. Pts
immobility can also
cause constipation.

Pantopazole Sodium
(Protonix)

40mg/PO/daily

Antiulcer agents; protonpump inhibitors

Influenza Virus Vaccine

(Fluvirin)
Vaccine

0.5mL/IM/once

Binds to an enzyme
in the presence of
acidic gastric pH,
preventing the final
transport of hydrogen
ions into the gastric
lumen.
Used to prevent
ulcers and irritation
due to use of
excessive meds at
one time. Commonly
given to pts staying at
hospital.
Live attenuated
influenza vaccine
viruses replicate
primarily in the
ciliated epithelial cells
of the
nasopharyngeal
mucosa to induce
immune responses
(via mucosal
immunoglobulin [Ig]A,
serum IgG
antibodies, and
cellular immunity),
but LAIV viruses do
not replicate well at
the warmer
temperatures found

Headache, abdominal pain, diarrhea,

flatulence, hyperglycemia,
hypoglycemia, C-diff diarrhea, StevensJohnson syndrome

Stevens-Johnson syndrome,
anaphylaxis, fatigue, fever, headache,
erythema at injection site or tenderness.

11

stools. Instruct pt not to use in the

presence of abdominal pain, nausea or
vomiting. Take with a full glass of water,
may be diluted in milk or juice, do not
admin within 2 hours of another laxative.
Assess for abdominal distension, bowel
sounds, and usual pattern of bowel
function. Advise pt to only use for short
term therapy because long term can
result in electrolyte imbalances and
dependence.
Watch for s/s of anaphylactic reaction
such as rash or hives, angioedema, and
SOB. These reactions are more
common when giving med IV. Assess pt
routinely for epigastric or abdominal pain
and for frank or occult blood in stool,
emesis, or gastric aspirate. Warn pts to
report diarrhea that does not improve.
Oral tablets may be taken with or without
food. If using delayed-release, swallow
whole and do not split, crush or chew.

Inject into the deltoid muscle. EMC

protocol: MAKE SURE DOCTOR HAS
ORDERED VACCINE AND THAT PT
HAS SIGNED AN INFORMED
CONSENT DOCUMENT! Explain
procedure to pt. Prepare medication and
select an appropriately sized needle.
Cleanse skin with antiseptic. Remove
needle from protector and expel any air
from the syringe. Inject needle into skin
at 90 degree angle. Do not aspirate with
deltoid muscle injections. Withdraw
needle and activate safety device.
Massage area gently and inform pt that
they may experience muscle soreness
for a few days following the injection.
Advice pt to report any unusual or severe
reactions following the vaccination.

in the lower airways

and lung. During the
course of replication,
all LAIV viral proteins
would be presented
to the immune
system in their native
conformation and in
the context of
histocompatibility
proteins.

Dextrose 50%- water

(Glutose)

12.5 GM/IVP PRN

Monosaccharide;
carbohydrate caloric
nutritional supplement

Insulin Reg Human

(Humulin)

SS/SC/Q6HR
SLIDING SCALE

Pancreatic hormone;
hypoglycemic

70-130 = 0 units
131-180 = 2 units
181-240 = 4 units
241-300 = 6 units
301-350 = 8 units
351-400 = 10 units

Given to prevent this

pt from getting the
influenza virus.
Prevents protein and
nitrogen loss;
promotes glycogen
deposition and
ketone accumulation.

Promotes glucose
transport and
promotes
phosphorylation of
glucose in liver.

Venous thrombosis, heart failure,

hyperosmolar coma, pulmonary edema,
hyperglycemia, hypertension, flushing.

Hypokalemia, sodium retention,

hypoglycemia, rebound hyperglycemia,
utricaria, rash, edema, lipodystrophy,
anaphylaxis.

Used in this pt
because she is a type
ll diabetic. Used to
maintain glucose
levels throughout the
day, especially after
mealtime.

12

Infuse concentrations above 10%

through central vein. Do not infuse
rapidly, doing so may cause
hyperglycemia and fluid shifts. Never
stop infusion abruptly. Monitor infusion
site frequently to prevent irritation, tissue
sloughing, necrosis, and phlebitis.
Check blood glucose at regular intervals.
Monitor I&O. Monitor weight regularly
and assess patient for confusion. Teach
pt how to recognize s/s of hypo and
hyperglycemia.
Perform pt teaching regarding proper
subQ injection techniques if pt wishes to
give their own injections. This includes
teaching on proper sites for injection and
rotating injection sites to prevent
lipodystrophy. Monitor glucose levels
frequently to assess drug efficacy and
appropriateness of dosage. Monitor for
s/s of hypoglycemia. These include
trembling, clammy skin, palpitations
(pounding or fast heart beats), anxiety,
sweating, hunger, and irritability. S/s of
severe hypoglycemia can include
difficulty thinking, confusion, headache,
seizure and coma. Monitor for s/s of
hyperglycemia such as polydipsia,

polyphagia, polyuria, and diabetic

ketoacidosis (as shown by blood and
urinary ketones, metabolic acidosis,
extremely elevated blood glucose level).
Teach pt about life style changes that
can help to control glucose levels and
may help to reduce insulin intake.
Perform pt teaching on tight glucose
control. Maintaining tight glucose control
may help pt to manage their htn and
reduce other problems that can result
from DM. Have another nurse verify
dosage!
Diphenhydramine HCl
(Benadryl)

50mg/IV/Q6H PRN

Ethanolamine derivative,
nonselective histaminereceptor antagonist;
antihistamine, antitussive,
antiemetic, antivertigo
agent, antidyskinetic
Ibuprofen

Acts as an
antihistamine by
competing with
histamine or receptor
sites on effector cells.
Used for itchiness
associated with
Dilaudid.

600mg/PO/Q6H
PRN

Exhibits analgesic
and antipyretic
activities by inhibiting
prostaglandin
synthesis.
Given to this pt to
reduce inflammation
related to humeral
fracture.

Ondansatron HCl (Zofran)

Antiemetic; serotonin type 3
antagonist;

Xerostomia, dizziness, dyskinesia,

somnolence, dry nasal mucosa,
pharyngeal dryness, thick sputum,
anaphylaxis, photosensitivity

4mg/IV/Q6H PRN

Blocks serotonin a 5HT receptor sites in

vagal nerve terminals
by disrupting CNS
chemoreceptor

Hypotension, rash, hypernatremia,

hypoalbuminemia, hypoproteinemia,
flatulence, heartburn, nausea, vomiting,
thrombocytosis, bacteremia, dizziness,
headache, elevated BUN, urinary
retention, CHF, hypertension, StevensJohnson syndrome, hearing loss,
depression, acute renal failure, Reyes
syndrome.

Headache, fatigue, chest pain,

hypotension, constipation,
bronchospasm, anaphylaxis

13

Administer IV at a rate not exceeding

25mg/min. Dont give drug within 14
days of MOA inhibitors. Monitor
cardiovascular status. Supervise pts
during ambulation. Advise pts to avoid
alcohol and other depressants such as
sedatives while taking this drug. Advise
pt to avoid activities requiring
coordination until drug effects are
realized. Instruct pt that drug may cause
sleepiness.
Know that NSAIDs increase the risk of
serious cardiovascular thrombotic
events, MI and stroke. They can also
increase the risk of GI adverse events.
Medication may be given with food or
milk to reduce GI upset. Monitor for relief
of pain or reduction in fever. Monitor
renal and liver function tests with long
term use. Advise pt to avoid use of
additional NSAIDs or aspirin during
therapy. Instruct pt to report s/s of
serious GI events such as bleeding,
ulceration or perforation
Monitor GI status. Auscultate bowel
sounds and palpate for tenderness.
Watch for hypotension and
bronchospasm. Instruct pt to
immediately report symptoms of allergic

trigger zone.
To reduce nausea
related to
administration of
analgesics and other
medications.

Acetaminophen

Pantoprazole Sodium
(Protonix)
Antiulcer agents; protonpump inhibitors

650mg/PO/Q4H
PRN

40mg/IV/daily PRN

Pain reducing ability

may be due to an
inhibition of COX 2
and an elevation of
the pain threshold. It
reduces fever by
inhibiting the
formulation and
release of
prostaglandins in the
CNS.
Used for mild pain
associated with her
fractured humeral
bone. Prescribed
PRN in case of
infection related fever
post-surgery as well.
Binds to an enzyme
in the presence of
acidic gastric pH,
preventing the final
transport of hydrogen
ions into the gastric
lumen.

Puritus, constipation, nausea, vomiting,

headache, agitation, atelectasis, liver
failure, pneumonitis, Stevens Johnson
syndrome

headache, abdominal pain, diarrhea,

flatulence, hyperglycemia,
hypoglycemia, C-diff diarrhea, StevensJohnson syndrome

Used to prevent
ulcers and irritation
due to use of
excessive meds at
one time. Commonly
given to pts staying at
hospital.

14

reaction such as rash or hives. Give

undiluted by direct IV and administer
slowly over 2 to 5 minutes. Flush SL
before and after administration with 5mL
of water. Know that drug van cause
anaphylaxis and bronchospasm. Instruct
pt to report s/s of hypersensitivity
reactions such as fever, chills, rash or
breathing problems. Monitor ECG in pts
with electrolyte imbalances.
Know that drug may cause hepatic
toxicity at high doses. S/s of hepatic
toxicity include dark urine, clay-colored
stools; yellowing of skin; abdominal pain;
fever or diarrhea. Monitor hepatic and
renal lab values if long-term therapy is
anticipated. Advise pt that it is unsafe to
take more than 4 grams of this drug in a
24 hr period. Watch for s/s of chronic
poisoning such as rapid, weak pulse;
dyspnea; cold, clammy extremities.
Monitor pt for s/s of allergic reaction such
as rash or urticaria. Instruct pt not to use
this med with alcohol. Take medication
with a full glass of water.

IV administration should be discontinued

as soon as an oral route is possible.
Flush before and after administration with
either 5% Dextrose injection, 0.9%
sodium chloride injection, or Lactated
ringers injection. Injection is NOT
compatible with midazolam and may not
be compatible with products containing
zinc. Reconstitute the appropriate
number of vials with 10mL of 0.9%
sodium chloride injection for each vial for
a final concentration of approximately
4mg/mL. Administer IV over a period of
at least 2 minutes. Watch for s/s of
anaphylactic reaction such as rash or

hives, angioedema, and SOB. These

reactions are more common when giving
med IV. Assess pt routinely for
epigastric or abdominal pain and for
frank or occult blood in stool, emesis, or
gastric aspirate. Warn pts to report
diarrhea that does not improve. Monitor
for injection site reactions such as
thrombophlebitis.
Heparin Sodium (Hep-Lock)

5,000
units/SC/Q8HR

Antithrombotic;
Anticoagulant

Hydromorphone (Dilaudid)
Opioid agonist; opioid

0.5mg/IV/Q3H
PRN

Inhibits the
mechanisms that
induce the clotting of
blood and the
formation of stable
fibrin clots at various
sites in the normal
coagulation system.
When heparin is
combined with
antithrombin lll,
thrombosis is blocked
through inactivation
of activated Factor X
and inhibition of
prothrombins
conversion to
thrombin. This also
prevents fibrin
formation from
fibrinogen during
active thrombosis.
Used as a
prophylactic to
prevent postoperative
venous thrombosis.
Pt is inactive and
Heparin will help
reduce the risk of
clots.
Acts primarily as an
analgesic agent. It is
believed that CNS

Thrombocytopenia, increased liver

aminotransferase level, hemorrhage,
hep-induced thrombocytopenia,
immune sensitivity reaction, nontraumatic spinal subdural hematoma,
hyperkalemia

Draw baseline blood sample for clotting

studies before starting drug. Inject deep
subQ (slowly into fat layer between iliac
crests in lower abdomen). Leave needle
in place for ten seconds before
withdrawing. Instruct patient to report s/s
of thrombocytopenia such as easy
bruising (can be in the form of petechiae
which are red, flat spots on the skin),
prolonged bleeding, excessive bleeding
of the mouth while brushing teeth or
flossing, black stools, dark or red urine.
Instruct pt to avoid taking aspirin during
therapy unless approved by a health care
professional. Check hematocrit, PTT,
and platelet count frequency. Monitor
potassium level in pts with diabetes or
renal disease. Urge pts to avoid
activities that can cause injury. Pt should
be urged to use soft bristle toothbrush
and an electric razor. Use with extreme
caution in this pt because of her history
of hypertension.

Flushing, pruritus, sweating,

constipation, nausea, vomiting,
asthenia, dizziness, headache,

Hydromorphone is a potent schedule ll

opioid agonist which has the highest
potential for abuse and risk of producing

15

analgesic, antitussive

opioid receptors that

are specific for
endogenous
substances with
opioid-like properties
play a role in the
drugs analgesic
effects.

hypotension, seizure, resp depression,

drug withdrawl.

This drug is
prescribed PRN so
that the pt can use it
for MODERATE TO
SEVERE pain related
to her humeral
fracture. May be
useful post-surgery
as well.

Hydrocodone BIT/ACE
(Norco)

5/325mg (1 tab)
PO/Q4H PRN

This medication binds

to opiate receptors in
the CNS. It alters the
perception and
response to painful
stimuli.

Confusion, dizziness, sedation,

hypotension, constipation, dyspepsia,
nausea

This will help with

MILD TO
MODERATE pain
after surgery and
allow for healing.

16

resp depression. Alcohol, other opioids

and CNS depressants potentiate the resp
depressant effects of hydromorphone,
increasing the risk of respiratory
depression that may result in death. This
drug is contraindicated for use with
Probable. Reconstitute drug immediately
prior to use with 25 mL sterile water for
injection to a concentration of 10mg/mL.
Administer slowly over at least 2 to 3
minutes. Assess vital signs. Assess
pain levels before and after
administration. Do not give if respirations
are less than 10/min. Monitor for signs of
respiratory depression. Monitor for
adverse effects especially during initial
dosing. Pts should avoid activities
requiring mental alertness or
coordination until drug effects are
realized. Instruct pt to report
constipation, absence of pain relief,
hypotension and s/s of resp depression
such as SOB, apnea and increased effort
with breathing. Advise pt against sudden
discontinuation of the drug. Have second
practitioner verify dosage.
Know that this drug has been associated
with cases of acute liver failure, at times
resulting in liver failure and death. Most
injuries are the result of excess
acetaminophen. Monitor liver function
tests accordingly. Assess vitals.
Respiration less than 10/min; hold
medication and assesses sedation,
assess pain, have second practitioner
verify dosage. Advise pt that drug that
may cause drowsiness. Give with food to
reduce nausea. Pts should avoid
activities requiring mental alertness or
coordination until drug effects are
realized. Advise pt that med contains
acetaminophen and to not take additional
drugs containing acetaminophen. Advise
pt to report s/s of respiratory depression

Promethazine HCl (Prorex)

Laxative; Stimulant

12.5mg/IV/Q6H
PRN

Completely blocks
histamine H(1)
receptors without
blocking the secretion
of histamine. The
drug has sedative,
anti-motion sickness,
antiemetic, and
anticholinergic effects
but it has no
dopaminergic action
due to a structural
difference with other
phenothiazines.

Abdominal colic, abdominal discomfort,

diarrhea, proctitis, atony of colon,
xerostomia, apnea, respiratory
depression

For pts constipation

related to surgery
and administration of
opioids.

17

such as SOB, apnea and increased effort

with breathing. Monitor pt for s/s of drug
overdose including nausea, vomiting,
blurred vision, cool and clammy skin,
dizziness, confusion, dyspnea,
respiratory depression, bradycardia,
hearing loss, headache or mood or
behavior changes.
Monitor pt for decreased abdominal pain.
Monitor for BM which should take place
15-60 minutes after administration. Also
monitor hydration level and mental status
during therapy. Reassess pt if rectal
bleeding occurs or if no BM occurs after
laxative is given. Advise pt that drug
may cause diarrhea or abdominal pain,
discomfort and cramping. Instruct pt to
report rectal bleeding or failure to have a
BM within 12 hrs. Drug should not be
taken for longer than 7 days. This drug
must be administered IV with caution
because risk of perivascular extravasion
and severe tissue damage is high. Dilute
in 10 to 20 mL of NS and administer over
10 to 15 minutes. Insure patency of site
before administration. Instruct pt to
immediately report any burning or pain
during or after the injection and stop
administration immediately. Advise pt to
avoid excessive sun exposure because
drug can cause photosensitivity. Advise
pt not to consume alcohol while taking
this drug.

18

Concept Mapping
Step 2. List clinical manifestations under each nursing diagnosis and other relevant data to support each diagnosis, including lab
data, medications, interventions, and assessment findings. All medical & nursing interventions should be found in one or more of the
boxes.
ND # 1: Acute Pain
Data to support:

ND # 2: Risk for bleeding

Data to support:

R humeral head fracture

Recent surgery for fracture (POD 1)
Guarded behavior
Pt reports pain
Pain upon movement of R arm
Prescribed pain medication

Pt being administered Heparin

Pt POD 1
R humeral fracture
Fall risk/impaired physical mobility

ND # 3: Risk for constipation

Data to support:
Immobility
Pt being administered opioids
for pain
Pt was NPO pre-surgery

ND # 4: Impaired physical mobility

Data to support:
CMD: R Humeral fracture
Priority Assessments:
Pain!
BM inquiry
Vital signs and labs
Pt understanding
Assess injured area closely

Physician order of bed rest.

R humeral fracture and surgery (POD 1)
Pt report of pain with movement
Administration of opioids (decreased
awareness and coordination)

ND # 5: Risk for Impaired Skin Integrity

Data to support:
8. Pt Education

Immobility/ Bedrest
Recent fracture
Recent surgery
Altered nutritional state (overweight)
Pt taking Heparin

Meds
Wound Care
Recovery Process
Pain management
Immobility
LA8/2011

19

7. Discharge
Pt teaching prior
Provide information about
medications
PT inquiry

ND # 6: Knowledge Deficit
Data to support:
Knowledge of surgery
Knowledge of post-op lifestyle
changes
Knowledge of medications.

Concept Mapping
Evaluate Effects of Nursing Actions- Patient Outcomes, Documentation (Done During Clinical)
1. ND/Nursing Care:
Nursing Actions(NIC)

Acute Pain

Determine if client is experiencing pain at the time of initial interview.

Assess pain level using 1-10 scale
Assess the client for pain presence routinely and frequently (when vital signs are taken, during activity, and during rest)
Ask pt to describe previous experiences with pain medications or therapy. What worked? What didnt?
Identify pts comfort-function goal for pain
Prevent pain during any procedures or mobility
Administer opioids as ordered
Assess pain level, sedation level, and respiratory status at regular intervals during pain management with opioid
administration.
Assess for effectiveness of medication
Assess for constipation related to use of opioids.
Assess for adverse reactions closely and frequently and especially during the first dose.
Assess for influence of cultural beliefs on pain management and perception of pain.
Patient response: Initially, pt reported no pain and complained of numbness at the site of injury. As the nerve block
worse off, pt did complain of pain and rated it at a 3/10 but noted that it was quickly increasing. Pt expressed fear of pain
coming back. Pt vital signs were taken and were normal. Pt administered Norco. Assessed effectiveness of medication
and reassessed pain level routinely following administration. Pt reported that Norco and Dilaudid both worked well at
relieving her pain since admittance. Pt expressed her comfort-function goal as being a 1 or a 0. Pt was immobile
throughout entire day, so no pre-ambulatory pain medication was needed. Vital signs were normal following
administration of medications. Pt reports last BM two days prior. Pt reports no worry and claims it is only because she
wasnt allowed to eat before the surgery. Pt status was monitored closely following administration. Pt is Hindu, but
expressed no hesitance about taking pain medication and communicated her pain levels often and clearly.

LA8/2011

20

2. ND/Nursing Care:
Risk for Bleeding
Nursing Actions(NIC)

Monitor for signs of bleeding in the urine, stool, sputum, vomitus.

Watch for nose bleeds, petechiae, purpura, or bruising.
Monitor laboratory values (hemoglobin, hematocrit, RBC, INR)
Implement safety precautions (Fall risk protocol, soft bristle tooth brush)
Acquire additional help when moving pt to prevent falls
Check bandaging regularly for saturation and bleeding
Check vital signs frequently and regularly (watch for low BP, elevated HR, and respiratory rate)
Before administering heparin, check APTT
Have protamine sulfate close by as a precaution for Heparin OD.
L&L bed at lowest position and put side rails up x3 before leaving room
Explain bleeding risk to pt and assess for understanding
Perform teaching on reducing risk of bleeding including elimination of risky behaviors
Patient response: no signs of bleeding visible. No bruising, petechiae or purpura visible or noted by patient. RBC high
and being monitored continually and closely. All other lab values WNL. Pt successfully labeled as a fall risk pt. Pt had
already brushed her teeth before my arrival, but stated that soft bristle brush was used. Pt was not ambulated
throughout the entire day, so no additional help was required. Bandage monitored and checked for bleeding a saturation
regularly. Vital all WNL with the exception of BP which was initially low. It was determined that the BP was low due to
administrating Losartan. BP began to rise towards normal limits so no intervention was needed. No APTT was ordered.
Planned to inquire as to the reasoning, but never followed through. Bed L&L each time I exited the room. Side rails up
x3. Pt demonstrates good working knowledge regarding her increased risk for bleeding as well as the actions of
Heparin.

3. ND/Nursing Care:
Risk for constipation
Nursing Actions(NIC)

LA8/2011

Assess usual pattern of defecation (time of day, amount and frequency of stool, consistency of stool)
Assess for diet patterns including fiber and fluid intake
21

Review clients current medications

If client is constipated and taking medications that can cause constipation, consult a health care provider about switching
the medications
Palpate for abdominal distention
Inquire about discomfort or abdominal pain
Assess for effectiveness of laxatives
Assess for any adverse reactions of laxatives
Assess for pts desire to take additional laxatives to promote GI motility
Patient response: Pt reports normally producing two BMs per day. However, pt reports last BM two days prior. Pt is a
vegetarian and reports eating a variety of vegetables with each meal. Pt admits to having a poor fluid intake at home. Pt
is taking opioids for pain which contribute greatly to constipation. When weighing risks and benefits, keeping the pts
pain at a low level is a priority to both the patient and the staff, so no adjustment was made to opioid prescription.
However, additional laxatives were prescribed. No distention palpable. Pt reports no abdominal pain or discomfort. Pt
has not yet had a BM since the beginning of her laxative therapy. Will continue to inquire about pts BMs. Pt reports no
diarrhea or vomiting or other side effects of laxatives. Pt reports a lack of concern about constipation and claims it is
because she was required not to eat proceeding the surgery.

4. ND/Nursing Care:
Impaired Physical Mobility
Nursing Actions(NIC)

LA8/2011

Screen for measures of physical function to assess strength of muscle groups

Assess for cause of impaired mobility
Monitor and record clients ability to tolerate activity.
Before activity, treat with pain as necessary
Evaluate impact that pain has on immobility
Acquire additional help before ambulating
Consult with PT for further evaluation
Obtain any assistive devices needed for activity.
Perform ROM exercises at least twice a day
Help pt to achieve motility and start walking as soon as possible unless contraindicated.

22

Patient response: Significantly decreased R hand and arm strength noted. Pt is immobile because she is recovering from
her recent humeral surgery. Pt reports pain during even the slightest movement of her right arm. Planned to treat her pain
before ambulating but pt did not ambulate throughout my time with her. Pain is the largest reason why this patient is
immobile. She expresses fear of pain and is guarded. Planned to consult PT about starting therapy, but upon arriving, I was
informed that the pt is no have a second surgery on her shoulder on 10/11. Pt is unable to perform ROM exercises with her
R arm while it is still healing. Plan to start ambulating pt after her next surgery is complete.

5. ND/Nursing Care:
Risk for Impaired Skin Integrity
Nursing Actions(NIC)

Monitor skin condition at least once a day for color and texture
Instruct pt to avoid harsh cleaning agents, hot water, and too frequent cleansing
Minimize exposure of the site of skin impairment to moisture, perspiration or wound drainage
Monitor condition of skin covering bony prominences
Implement prevention plan
Assess clients nutritional status
Perform teaching to the client regarding skin assessment and ways to monitor for impending skin breakdown
Determine pts risk by using the Braden Scale.
Patient response: Skin integrity, color and texture appear and feel normal. Pt used warm rather than hot water while
performing self cleansing as well as mild soap. Wound bandaging is tight and free of moisture or damage. Skin
surrounding and covering pts bony prominences is without breakdown. Inquired about the need to rotate the pts
positions regularly and was told that the brief nature of her visit was not cause for rotation. Also, pt is able to sit herself
up which decreased her risk of developing any ulcers or areas of breakdown. Client electrolytes are normal which
indicated good nutritional status. Pt is now eating her entire meals and is being hydrated via IV NS. Calculated pts
Braden Scale risk at a 17 which puts her at mild risk for skin breakdown.

6. ND/Nursing Care:
Knowledge Deficit
Nursing Actions(NIC)
LA8/2011

23

Consider pts ability and readiness to learn

Assess personal context and meaning of injury
Assess family involvement and ability to assist with learning
Perform family and pt teaching
Pt teaching about medications
Pt teaching about recovery process
Pt teaching regarding safe mobility
Pt teaching regarding proper care and maintenance of injury and bandaging
Assess for understanding.

Patient response: Pt A&O x4 and has a good ability and readiness when it comes to learning. Pt reports anxiety regarding
injury because it has stopped her from caring for and seeing her four grandchildren. For her, this injury means not spending
time with her family, which she reports as being a very high priority. Pts husband and son are both physicians. The
husband was at the bed side off and on throughout the entire day and was very helpful about providing information to the
client. Pt demonstrated a good knowledge of the medications she was receiving as shown by her questioning nature during
administration and by her concerns about receiving Losartan when her BP was low. Pt demonstrated good knowledge
about surgery dates and the process of recovery. Pt and husband were very careful while pt is adjusting positions or when
moving the HOB. Planned to perform teaching about proper care and maintenance of injury, but since pt was due to have
another surgery the next day, it was no longer a priority.

LA8/2011

24