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Client Initials

MW

Admit Date 1/21/09

Date of Care 1/29/09-1/30/09

F Age 84

Marital Status S

Diagnosis weakness, dyspnea, plural effusion, sinus bradycardia, CHF Operation/Procedure (include date) thorocentisis (1/23/09), Advance Directives (what type): no

Reason for admission(chief complaint) SOB Significant History/Other pertinent information pneumonia (right lower lobe, 3 weeks PTA) , HTN, myocardial infarction, CHF, stent placement, dysrhythmias, lipidemia, diabetes mellitus, right lower lung lobe mass (nonmalignant),

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Report Data: (information obtained from RN, morning report, clarification of information obtained from clinical instructor)

• • • • • • • • • • • • •

Activity/Risk for Fall: up with assist, at risk for falls Allergies: NKA Vital signs(frequency): TID Code Status: full code Diet: Cardiac/ ADA 1800/ soft IV/Saline lock: SL right hand Telemetry: yes (sinus bradycardia) I/O (last void; last bowel movement): BRP , slight urine incontinence, urine yellow, clear; last BM 1/29. monitor I/O. Oxygen: RA Drains/Wounds: puncture wound, right middle upper back, skin intact, open to air; stage II DU, coccyx, Allevyn wound dressing and skin barrier cream applied 1/30/09 930; rt upper arm, ecchymotic. Procedures/specimens/medications: meds: 800, 900, 1200. Isolation: Contact precautions, hx MRSA (bronchial wash) 1/2/09. Scheduled Therapies/Other: PT

Plan of Care: 1. Obtain report from RN. 2. Review chart and MAR. 3. Introduce self to Pt. and complete assessment 4. Up-to-date pt on plan of care for the day 5. Assist with AM care 6. administer meds 7. Ambulate 8. gather holistic information 9. report off to RN at end of clinical

What are the client’s top priorities regarding his or her own care for today? -assessment/ meds-diuresis -ambulation, OOB for meals -AM care

MEDICATIONS: NAME DOSAGE ROUTE
Pantoprazole (Protonix) 40mg (1 tablet) PO

TIME DUE

INDICATION FOR
RECEIVING MEDICATION

NURSING CONSIDERATIONS ASSESSMENT RESULTS PRIOR TO
ADMINISTRATION

LAB RESULTS TO MONITOR PRIOR TO
ADMINISTRATION

ADVERSE REACTIONS/SIDE EFFECTS TO
ASSESS PRIOR TO ADMINSTRATION

900

To suppress gastric secretions

No nausea, no vomiting, no diarrhea, no constipation. No epigastric or abd pain. No bloody stools or emesis. No headache.

-may inc glucose, uric acid, and lipid levels -may inc/dec liver function BG:134 BUN:41 (elevated)

CNS: anxiety, dizziness, headache, insomnia. CV: chest pain, peripheral edema. EENT: rhinitis, sinusitis. GI: abd pain, constipation, diarrhea, dyspepsia, flatulence, gastroenteritis, GI disorder,

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Creatinine: 1.9 (elevated)

nausea, vomiting. GU: rectal disorder, urinary frequency, UTI. METAB: hyperglycemia, hyperlipidemia. MUSCSKEL: arthralgia, back pain, hypertonia, neck pain. RESP: bronchitis, dyspnea, inc cough, upper resp tract infection. INTEG: rash. Flulike symptoms, infections. METAB: hyperglycemia, hypoglycemia. RESP: dyspnea, inc cough, reduced pulmonary function, resp tract infection. INTEG: itching, rash, redness, stinging, swelling, urticaria, warmth at injection site. OTHER: anaphylaxis, hypersensitivity reactions, rash.

Insulin Regular (Novalin R vial) 5 units SubQ injection

800 1200

Antidiabetic

Injection site: no bleeding, no pain, no severe ecchymosis.

Blood glucose 830: 134 Urine ketones: wnl -may dec magnesium, and potassium levels

Insulin Regular (Novalin R vial) Sliding Scale SubQ injection

BG<150 151.199 200.249 250.299 300.349

0 units 2 units 4 units 6 units 8 units No GI bleed/distress, nausea, occult bleeding, vomiting. -may inc liver enzymes, BUN, serum creatinine, s. K, and may prolong bleeding times. -may dec WBC and platelet count. BUN and creatinine elevated. Plt count low (consistently decreasing). EENT: hearing loss, tinnitus GI: dyspepsia, GI bleeding, GI distress, nausea, occult bleeding, vomiting. GU: transient renal insufficiency HEMO: prolonged bleeding time, thrombocytopenia. METAB: HEPAT: hepatitis. INTEG: bruising, rash, urticaria. OTHER: angioedema, hypersensitivity reactions (anaphylaxis, asthma) Reye syndrome. GI: abd pain, diarrhea, nausea METAB: hypermagnesemia (hypotension, n/v, depressed reflexes, resp depression, coma)

Aspirin (Ecotrin 81 mg) 81mg (1 tablet) PO

900

>350 notify MD Antiplatelet, antipyretic

Magnesium Oxide (Mag-Ox 400mg)

900

Mg replacement

No abd pain, no diarrhea, no nausea.

-may inc mag levels

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400mg (1 tablet) PO Spironolactone (Aldactone) 25mg PO 900 Anti-HTN (diuretic) BP: 142/58 P: 69 No v/d/n/c. No edema. Monitor I/O Wt -may inc BUN, creatinine, K -may dec Na -may dec granulocyte count -may falsely inc digoxin level Na:137 K:4.6 Cl:100 Ca:8.1 (Low) PT: 11.3 INR:1.08 BUN:41 (elevated) Ramipril (Altace) 2.5mg PO 900 Anti-HTN (ACE inhibitor) No cough. No n/v/d/c. No headaches, lightheadedness. No chest pain, no edema. No abd pain. Creatinine: 1.9 (elevated) -may inc BUN, creatinine, bilirubin, liver enzyme, glucose, K. -may dec hgb and hct K: 4.6 Na:137 Ast: Alt: BG: 134 Hgb:10.6 (low) Hct: 33.2 CNS: amnesia, anxiety, asthenia, depression, dizziness, fatigue, headache, insomnia, syncope, lightheadedness, malaise, nervousness, neuropathy, seizures, tremors, vertigo . CV: angina, arrhythmias, chest pain, edema, MI, orthostatic hypotension, palpitations . EENT: epistaxis, tinnitus. GI: abd pain, anorexia, constipation, diarrhea, dry mouth, dyspepsia, gastroenteritis, nausea, vomiting. METAB: hyperkalemia, weight gain. MUSCSKEL: arthritis, myalgia. RESP: dry persistent, tickling, nonproductive cough. dyspnea. INTEG: dermatitis, inc diaphoresis, pruritis, rash. Bumetanide (Bumex) 1mg PO 900 Anti-HTN (diuretic) No dizziness, no headache. I/O balanced. BP:142/58 P: 69 Creatinine: 1.9 (elevated) BUN: 41 (elevated) BG: 134 K: 4.6 OTHER: andioedema. CNS: dizziness, headache . CV: ECG changes, orthostatic hypotension, volume depleteion and dehydration . EENT: transient deafness GI: nausea GU: freq CNS: ataxia, confusion, drowsiness, headache, lethargy. GI: cramping, diarrhea, gastric bleeding, gastric ulceration, vomiting. GU: impotence, menstrual disturbances. HEMO: agranuloctosis. METAB: dehydration, hyperkalemia, hyponatremia, mild acidosis. INTEG: erythematous rash, urticaria OTHER: anaphylaxis, angioedema, breast soreness, drug fever, gynecomastia.

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Lung sounds (rt. post. Lower lobe diminished) No peripheral edema

Mg: Na:137 Ca: 8.3 (low) Plt count: 86 (low)

urination, nocturia, oliguria, polyuria, renal failure HEMO: thrombocytopenia METAB: asymptomatic hyperuricemia, fluid and electrolyte imbalance, dilutional, hyponatremia/hypocalcemia/ hypomagnesemia, hyperglycemia, hypokalemia, impaired glucose tolerance. MUSCSKEL: muscle pain and tenderness. INTEG: rash CNS: dizziness, fatigue, fever, lethargy . CV: AV block, bradycardia, heart failure, hypotension, peripheral vascular disease. GI: diarrhea, nausea, vomiting. MUSCSKEL: arthralgia. RESP: bronchospasms, dyspnea. INTEG: rash

Metoprolol tartrate (Lopressor 50mg) 50mg PO

900

Anti-HTN (beta blocker)

BP: 142/ 58 P: 69

Diagnostic and/or Laboratory Test

Normal Values

Client’s Results
OnAdmission

Clinical Significance:
Reason this being monitored for this client. What nursing interventions and clinical decisions are essential for this client’s care as a result of their diagnostic and/or laboratory tests?

Current

HEMATOLOGY WBC

4.5-11.0 K/mm3

10.2

12.9

Evaluation of pt with infection, neoplasm, allergy or immunosuppression. Pt was recently hospitalized for pneumonia. Pt admitted SOB Used as a rapid indirect measurement of the red blood cell

Keep skin clean to avoid infections, cover open wounds, avoid aspiration pneumonia,

RBC HBG

3.90-5.20 L M/uL 11.2-15.0 g/dL

3.78 10.2

3.85 10.6

Monitor O2 sats.

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HCT

32.8-44.7 L%

32.7

33.2

count. Used as a rapid indirect measurement of the red blood cell count.

PLATELETS aPTT/PTT PT INR SED RATE BLOOD CHEMISTYRY POTASSIUM

125-400 K/mm3

115

86 33.8

11.3 1.08

3.5-5.1 mmol/L

4.2

Electrolyte is very important in the function of the heart and is part of routine evaluations for pt on diuretics or heart medications Routinely performed. Used to evaluate and monitor fluid and electrolyte balance and therapy.

Proper dietary intake

SODIUM

136-145 mmol/L

137

Monitor I/O for fluid balance

MAGNESIUM CALCIUM

8.5-10.1 mg/dL

8.3

To monitor Ca in relation to serum albumin levels. Also electrolyte imbalances are dangerous to the functioning of the heart

Increase weight bearing activity. Supplements.

PHOSPHORUS CHLORIDE

2.5-4.9 Mg/dL 98-107 mmol/L 101

4.0 100 In correlation with other electrolytes, Cl gives indication of acid-base balance and hydration status. Indirect and rough measurement of renal function and glomerular filtration rate. Used to diagnose impaired renal function 24 To evaluate liver function 6.4 2.3 To evaluate for hepatic Increase intake of protein to aid in tissue reconstruction and wound healing Monitor I/O

BUN

7-23 mg/dL

41

Adequate protein intake, monitor I/O to avoid overhydration

CREATININE BUN/CREATININ RATIO TOTAL BILIRUBIN TOTAL PROTEIN ALBUMIN

0.6-1.0 mg/dL 7-23 <1.0 mg/dL 6.4-8.2 g/dL 3.4-5.0 g/dL

2.0

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GLOBULIN ALBUMIN/ GLOBULIN RATIO TOTAL ALK PHOSPHATE CO2

1.4-4.8 g/dL 1.0-1.9 g/dL 50-136 U/L 21-32 mmol/L

malfunction and nutrition To evaluate for liver malfunction To distinguish between certain diseases of kidneys and liver To assist in evaluating the pH status of the pt and to assist in evaluation of electrolytes. Decreased levels can be contributed to medications administered. In evaluation of diabetic pt. Blood glucose levels rise as a response to stress and several types of medications.

GLUCOSE

70-99 mg/dL

134

Monitor intake, ambulate.

SERUM LIPIDS CHOLESTEROL TRIGLYCERIDES LDL’S HDL’S LIVER ENZYMES ALT AST

30-65 U/L 15-37 U/L

Used to identify hepatocellular disease of liver. Used to identify pt with suspected coronary artery occlusive disease or suspected hepatocellular disease.

CARDIAC MARKERS TROPONIN

<0.4

Cardiac enzyme which is measured for evidence of cardiac muscle injury.

MYOGLOBIN CK-MB Diagnostic and/or Laboratory Test

Normal Values

Client’s Results
OnAdmission

Clinical Significance:
Reason this is being monitored for this client. What nursing interventions and clinical decisions are essential for this client’s care as a result of their diagnostic and/or laboratory tests?

Current

BLOOD GASES

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Ph PCO2 PO2 HCO3 URINALYSIS COLOR GLUCOSE KETONE BLOOD PH PROTEIN UROBILINOGEN RBC WBC URINE OSMOLARITY SPECIFIC GRAVITY OTHERS CXR Lung US

Yellow Absent Absent Absent 4.6-8.0 0-8 Mg/dL <2 0-4

Yellow

5.0 15

9 66

Infection.

Increase fluids.

No pneumothorax Large left pleural effusion that is 3cm below skin surface. Small rt pleural effusion. Nonmalignant cells No evidence of renal stenosis. Mildly inc contical echogeniaty. Suggestive of

Lung biopsy Abd US

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renal parenchymal disease. Gallstones.

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NEUMAN’S VARIABLES OF ASSESSMENT (Plan of Care based on the Nursing Process) I. PSYCHOLOGICAL VARIABLES A. Interpersonal Communication Style Pt is quiet and very friendly, open about medical and personal history. B. Emotional status/Anxiety level Coping, current outlook is good, pt is looking forward being discharged. Pt is worried about the health status of her younger sister who is also hospitalized after a stroke. She has been keeping in tough with her and are planning to being discharge together soon. Pt has slight anxiety and irritation because she is not able to move about the same way she did before the previous admission in January. C. Stress/concerns related to hospitalization Pt’s concern is that she is unable to do self-care because she is weak, she is also concerned that after her discharge home she will have to stay alone overnight and she might fall with no help around. She does not want to go to an assisted living home but doesn’t not feel safe going home without the help of her sister, who will most likely not being discharged as soon as she is to be. D. Defense/coping mechanisms Pt expresses her feeling by talking to her family. She has realistic views of her health and her future and responds eagerly when discussing the importance of sitting in the chair for meals and throughout the day. II. SOCIOCULTURAL VARIABLES A. Living Arrangements/Dwelling Pt lives alone but recently, before her hospitalization, her sister has been staying with her. They live together in an apartment with easy access to the living quarters. She does not have to walk up stairs, she uses the elevator. Upon discharge, pt will be going back to live back at her apartment with her sister as they have previously been living together. She has a son visits her at home frequently throughout the week. Patient feels comfortable with this living arrangement as long as someone spends the night with her. B. Occupation/Retired/Student Pt is retired. C. Support Systems Pt is very independent. Just recently she has been relying on her sister more often. Her family is her support system. He is available to the patient throughout the day even during working hours. I did not observe any domestic violence behavior cues. I did not inquire about other support systems available to the patient. D. Educational Status n/a – specifics did not come up in conversation. I felt that the patient was very willing to learn how to maintain her health.

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E. Ethnic Heritage, Cultural Beliefs (other than spiritual), Customs and Health Practices n/a – did not come up in conversation F. Use of Complementary/Alternative Modalities of Treatment n/a – did not come up in conversation

III.DEVELOPMENTAL VARIABLES (Erikson’s Stage) A. Age 84 Older Adult

B. Life Stage C. Task •

Sense of Integrity vs. Despair

Has your assigned client achieved previous life stage tasks and is currently showing evidence of mastering current life stage task? Explain. Yes, pt is open about her life and her life experiences. She believes her life was lived to its

potential. She has a health self-esteem, she discusses her son as her great accomplishment for being a caring child that has taken her in to care for her. • Age related risks

Depression, deprived nutrition and fluid intake, decreased activity and exercise, alcohol abuse, Self-concept and self-image changes, change in roles and relationships, personal loss, coping strategies. IV. SPIRITUAL VARIABLES (Religious Affiliation/Activities/Use of Belief System as a Source of Hope and Support) Pt is a catholic who attends church weekly. She prays often. She states her prayers give her hope. Chart states that pt received spiritual support on 11/2/08. V. PHYSIOLOGIC VARIABLES A. Neurological 1. Mental Status a. LOC: alert b. Orientation: alert to time, place, person and situation

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c. Memory(short/long): no recent and remote memory deficits. Pt has no trouble recalling what she was doing yesterday. Pt recalls clearly that she has met me yesterday also. Pt can recall memories of when she was younger and where is lived. d. Judgment: Pt is acting in a logical and rational manner. She is calm and cooperative. She calls for assistance before getting up to go to the bathroom. 2. Appearance/Behavior Pt is wearing a hospital gown with visibly good personal hygiene. Pt is weak related to her condition. Pt is properly expressing her emotion in relation to her developmental stage. She is cooperative and interested in our conversation. She maintains a calm manner and does not express any feeling of anger. 3. Ability to communicate Pt communicates clearly, does not have any noticeable speech deficits and is can be clearly understood by the receiving party during a conversation. She maintains good eye contact and does not speak off on tangents. Pt uses glasses. She speaks English. 4. Neurosensory a. Vision: History of cataract removal. Eye movements are symmetrical and no amblyopia present. Eyebrows, eyelids, and lashes intact. Pt requires glasses. b. Hearing: Patient responds to normal speaking volume and tone. Patient does not wear hearing aids. No discharge or excessive cerumen in ears, skin of ears intact, pink, and warm. 5. Interventions: Fall precautions, up with assistance; assistance with ADLs. Make sure patient is wearing glasses while communicating with others or as needed. B. Musculoskeletal 1. Gait/Ambulation: Patient ambulates with a rolling walker . Patient is ambulating safely when walking with someone at her side to prevent falls, needs assistance of one. Gait is slightly leaning forward, steady, slow, small steps. No shuffling gait present. No significant weakness on either side of body. Patient has all four limbs, no prosthetic limbs.

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2. Alignment/Posture: Patient is slightly stooped over while walking (mainly curvature of upper spine and neck), able to maintain proper alignment while sitting in bed, chair or walking. Patient does not lean toward right or left side while sitting up in bed or during ambulation. 3. Immobilizing/Assistive Devices: Patient uses a rolling walker. Two side rails are up while patient is in bed and table is positioned in front of patient wile she is sitting in chair.

4. Motor Strength (moves all extremities) a. Symmetry: patient is moving all extremities symmetrically when prompted. Patient can move all ten fingers and toes. b. Strength: Lower and upper extremities are equally strong c. Range of Motion: all active. 5. Neurovascular integrity of extremities (CMS): Upper extremities and lower extremities skin equally slightly pale, warm and dry. Capillary refill of both upper and lower extremities 2-3 sec. Upper peripheral pulses palpable and equally strong, in lower extremities peripheral pulses not palpable. Patient senses light touch to extremities. No numbness, tingling or pain in any extremities. 6. Interventions: ; physical therapy to ambulate; activity every two hours ( up from bed and ambulate), up to chair for meals; assistance with ADLs. Bed mobility: moderate assist; Transfers: minimum assistance to stand; Gait: contact-guard assistance; Device: rolling walker; Activity with nursing: out of bed for meals and as tolerated; Ambulate in hallway. C. Respiratory Integrity 1. Respiration (rate, rhythm, and depth): unlabored breathing, regular rhythm, regular rate 18 breaths/minute. Eupnea. Nasal flaring absent. Pursed lips absent while breathing. Patient breathing comfortable while sleeping, sitting up in bed, sitting in chair. While walking patient increases breaths per minute to about 20, once activity decreased, breathing rate returns to normal at 18 in less than 5 minutes. No audible breathing sounds. 2. Lung sounds : clear except in right lower posterior lobe diminished. Pleural effusion. 3. Cough- patient is not coughing

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4. Sputum (color and amount)-patient is not expectorating any sputum 5. Assistive Respiratory Treatments/Interventions: Oxygen protocol initiated as needed: per nasal canula 2-4L LPM – currently patient 94% on room air, no supplemental O2 need.

D. Cardiovascular Integrity 1. Vital signs a. Peripheral pulses (rate, rhythm, quality): right arm 69 bpm; regular, strong peripheral pulse rhythm. In lower extremities, pulse non-palpable. Patient admitted with sinus bradycardia with symptoms and placed on remote telemetry. b. Apical pulse: 70 bpm. Regular and strong. No murmurs. PMI located in the left 4th or 5th intercostal space just medial to the midclavicular line. c. BP: 142/58 right arm (0800 1/29/09). Pt currently medicated for hypertension. d. Temperature: 97.9 degrees F, oral. e. Pulse oximetry: 94% on RA. 2. Color and warmth: Patients body is equally slightly pale and warm. 3. Capillary refill: 2-3 sec in both upper and both lower extremities. 4. Edema (peripheral): no peripheral edema present. 5. Interventions: Remote telemetry. E. Gastrointestinal 1. Weight, Height, BMI, Nutritional State : Ht: 5ft 6in; Wt: 132 lbs. BMI: 21.3 (healthy range) frail stature. 2. Note condition of mouth/teeth/gums and overall oral hygiene: Remaining teeth intact, inner mouth moist and pink. No scabbing, skin abrasion or lesion in mouth. 3. Mucous membranes (moist/dry): mouth moist. 4. Capillary Blood Glucose: 134 (800 1/30/09)

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5. Diet: Cardiac, ADA 1800, soft. Patient needs additional nutrients, currently in process of assessments and changes. 6. Ability to Feed Self, Chew/Swallow: Pt does not needs set up of meal trays, able to feed self. 7. Appetite: good appetite, breakfast 11/5/08: 80% 180cc. 8. Abdomen (LOOK, LISTEN, FEEL): bowel sounds present in all four quadrants: normoactive, no distention or abdomen, abdomen soft without pain; not tender. 9. Stool and Usual Bowel Characteristics, last BM (any changes in patterns): stools soft brown, decreased in frequency while institutionalized. Patient has full control over bowels. No unusual characteristics. 10. Perianal area/Rectal conditions: rectal area clean, no fissures, redness or external hemorrhoids, Stage II DU on coccyx. Allyven wound dressing applied. Perineal area slight redness and irritation, inner groin, Nystatin powder applied. 11. Intake/Output: intake by mouth. Output: BM with no unusual characteristics. 12. Interventions: monitor intake and output, encourage to eat during meals. Maximum assist with bathing. F. Genitourinary 1. Mode of elimination: Bathroom, walking and clean up with assist 2. Any changes in voiding pattern (pain/burning/frequency): no pain or burning while voiding, no feelings of urgency, increased frequency or incomplete bladder emptying; slight incontinence reported by pt, pt wears Depends at home. 3. Characteristics of urine: yellow, clear. 4. Intake/Output: breakfast 200cc. Output: 0800 1/30/09 – 300cc, slightly cloudy, yellow. 5. Interventions: monitor I/Os. Frequent perineal care to maintain genitalia clean and dry. Keep dressing clean and intact, change dressing. G. Integumentary (Skin)

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1. General condition (color, turgor, rashes, moisture, bruises): skin pinkish white (pt is Caucasian) and warm, no erythema, no jaundice, . Skin turgor is slightly elastic. No rashes on body. Skin is dry to touch, no diaphoresis, slight dryness or flakiness. Ecchymosis on rt upper lateral arm. 2. Check bony prominences/protective aids: DU stage II on coccyx, wound dressing applied. 3. Wound/Incisions/Dressing: coccyx pressure ulcer as noted above. 4. Interventions: moisturize skin with lotion to preserve elasticity and to aid in the prevent tears, dry skin well after bathing in skin to skin contact areas (genitalia, underarms, neck, under breasts and abdomen). Protective dressings to coccyx, elevate heels on pillow to avoid heel contact with bed to prevent possible skin breakdown. Measure and document all wounds and abrasion daily. Activity every 2 hrs while awake to promote circulation and skin integrity. Nutritional consult requested regarding skin integrity issues.

VI. Discharge Planning Assessment A. Anticipated date of discharge: patient is to be d/c home within couple of days. Date of potential discharge was not acquired from pt. B. Self care needs: mod assist with dressing and bathing. C. Educational needs/Health Promotion: discuss all of discharge planning and patient education with son who will be helping care for pt. D. Barriers to learning: diminished and slowed motor skills due to weakness. E. Equipment/environmental needs: rolling walker . Potentially a type of monitoring/emergency calling device to call for help when home alone. F. Resources for discharge: nurse to follow up with doctor Plan upon discharge: move back to own apartment with sister.

VI. Neuman Wheel

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Based on the holistic variables of the individual (physiological, psychological, sociocultural, developmental and spiritual) chart on the Neuman Wheel to depict the priority of needs based on your assessment of the client. Give reasons for depicted priorities. Pt is a 84 yo female. Admitted with SOB. Dx plural effusion, weakness, sinus bradycardia, dyspnea. Pt is a catholic who prays and attends church regularly. She has a son who she relies on mostly for emergencies. She lives alone in an apartment building which her sister also lives in. She is worried about her sister’s current medical condition and her ability to be potentially d/c soon. She states she is independent and able to complete her ADL independently with min assistance although she is quite weak and does need additional help. She relies on her family and friends for support and does not belong to any community groups. Spiritual
Developmental

Psychological

Sociocultural

Physiological

Complete the following regarding your assigned client: 1. Explain the pathophysiology as it relates to your client’s medical diagnosis. Transudative plural effusion is caused by some combination of increased hydrostatic pressure and decreased plasma oncotic pressure. Heart failure is the most common cause, followed by cirrhosis with ascites and hypoalbuminemia, usually from the nephrotic syndrome.

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2. What are the most important assessments (including lab values) for your client today? Auscultate and percuss lungs for abnormalities, BP, pulse, asses for dyspnea and tachypnea, 3. What complications may occur? What could go wrong? Large effusions could lead to respiratory failure. 4. What health promotion interventions and/or activities are essential to optimize your assigned client’s wellness potential or condition? Coughing and deep breathing exercises, ambulation, proper nutrition, frequent assessment to observe pt breathing pattern, oxygen sat, for evidence of improvement or deterioration. 5. Identify three pertinent actual or potential NANDA nursing diagnoses and list in order of priority. Ineffective breathing pattern related to collection of fluid in pleural space. Impaired gas exchange related to right lower lung lobe mass.

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Medication Administration: Nursing Process Focus** Classification/Prototype: proton pump inhibitor

Generic Name: Pantoprazole sodium Trade Name: Protonix, Protonix IV
Assessment* • Indication(s) for client receiving this medication • Route and dosage for this client Heartburn symptoms, increased stomach acid formation r/t stress of being institutionalized 40mg PO Therapeutic dosage ranges: 40mg PO Required: asses underlying Results of: no abd pain, no n/v. no condition; asses pt for complaints bloody stools or emesis. of epigastric or abd pain and for bleeding Serum lipid enzyme levels, liver function test. nka Abd pain, bloody stools or emesis, headache, pain, chest pain, peripheral edema, c/d,n/v, uti, dyspnea, increased cough, rash. Bloody stools or emesis, abd pain,n/v

Required assessments prior to administration with results of assessments Baseline data to consider prior to administration Allergies Reason(s) to hold medication Reason(s) to notify M.D.


• • •

In pt hypersensitive to the drug Any contraindications to the administration of this medication? Ampicillin esters, iron salts, ketoconazole, St.John’s wort, food delays • Drug-Drug or Drug-Herbal/Food absorption that may interact with this medication Diagnosis* Risk for imbalanced fluid volume related to drug-induced adverse • Identify actual/potential Nursing reactions. Diagnosis for the client receiving this medication Planning: Client Goals and Expected Outcomes* Pt maintains adequate hydration throughout therapy. • Identify expected outcomes related to the administration of this medication Implementation* Nursing Interventions and Administration Alerts Client/Family Education -can be given without regards to food. -instruct pt take exactly as prescribed and at approx the -monitor fluid intake same time every day. –drug can be taken with or without food. –table is to be swallowed whole. –instruct to report abd pain, or signs of bleeding, such as tarry stools. – not to drink etoh, eat food or take drugs that can cause gastric irritation. Evaluation (effectiveness of interventions, therapeutic effects, and adverse/side effects)* Decrease gastric secretions • Expected therapeutic effects achieved

Any occurrence of adverse/side effects

Abd pain, constipation, diarrhea, nausea, vomiting, urinary frequency, inc cough, rash.

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Need for further client/family education

As above

Any additional documentation required in the client’s chart besides the MAR? If so, where in the client’s chart would this data be documented? Allergies and diet. **Adams, M. P., Holland, L. N. and Bostwick, P. M. (2008). Pharmacology for nurses: A pathophysiologic approach (2nd ed.). Jersey: Pearson Prentice Hall. New

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