N223 Weekly Clinical Paperwork

Name: Sarah Zerbst

Date: 10/3/20

Client’s Initials/age/gender/room number_________________

Admission problem/disease process diagnosis:

SR arrived to the hospital with severe complaints of severe abdominal pain around 2300 on
9/29/20. She underwent numerous different tests and was eventually found to have
choledocholithiasis, which is the presence of stones in the bile duct. Typically, these stones are
formed in the gallbladder or the ducts themselves. Subsequently, the stones cause biliary colic,
biliary obstruction, gallstone pancreatitis, or cholangitis (bile duct infection).

Pathophysiology of problem/disease process:

Bile is made by the liver and then stored in the gallbladder. This storage process allows bile to
remain in the gallbladder for extended periods of time, thus causing a buildup of bile in the
gallbladder. This buildup of bile increases the risk of developing stones. These stones then are
able to pass from the gallbladder through the cystic duct and then into the common bile duct
(CBD). The most common cases of choledocholithiasis are secondary to the gallstones’ passage
from the gallbladder into the CBD where they get stuck. Primary choledocholithiasis is the
formation of stones within the common bile duct. This occurs in the setting of bile stasis, which
results in intraductal stone formation. When the body senses the need to secret bile, the
gallbladder contract forcing a stone or sludge against the cystic duct opening, leading to an
increase in intra-gallbladder pressure. As the gallbladder relaxes, the stone often falls back from
the cystic duct [ CITATION Zak20 \l 1033 ].

As an individual age, the diameter of the bile duct increase. Therefore, older adults with dilated
bile ducts and biliary diverticula are at an increased risk for the formation of primary dibble duct
stones. Less common sources of this include complicated Mirizzi syndrome or hepatolithiasis.
Either way bile flow is obstructed by stones within the CBD, which leads to obstructive jaundice
and possible hepatitis. The stagnant bile can lead to bactibilia and ascending cholangitis.
Cholangitis and sepsis are more common in patients with choledocholithiasis than other sourced
of bile duct obstruction because a bacterial biofilm typically covers common bile duct stones.
The pancreatic duct joins the common bile duct near the duodenum, and therefore, the pancreas
may also become inflamed by the obstruction of the pancreatic enzymes. This is called gall
stone pancreatitis [ CITATION McN20 \l 1033 ].

Pancreatitis is an uncommon disease characterized by the acute inflammatory process of the

pancreases, usually accompanied by abdominal pain and elevation of serum pancreatic enzymes.
Clinically an individual who has acute pancreatitis will present with severe abdominal pain and
elevated levels of panarctic enzymes in the blood. As discussed above, SR was diagnosed with
gallstones which predisposed her to pancreatitis[ CITATION Vegry \l 1033 ].

What diagnostics are significant to this disease:

Typically, the first imaging study completed is the transabdominal ultrasound. However,
additional testing my include may include magnetic resonance cholangiopancreatography
(MRCP), endoscopic ultrasound (EUS) and /or endoscopic retrograde cholangrapancreatography
(ERCP). The aim of diagnostic evaluation is to confirm the presences of CBD stones using the
lease invasive, most accurate and most cost-effective imaging modality. Additionally, patient
will present with elevated liver enzymes in a primarily cholestic patter there will be a
disproportionate elevation of alkaline phosphatase, gamma-glutamyl transferase and bilirubin.
Additionally, a complete blood count (CBC) to look for leukocytosis, that may suggest acute
cholangitis and pancreatic enzymes[ CITATION Ara20 \l 1033 ].

Typically, patients with leukocytosis will have an increased number of bands from, ie. A left
shift). An elevation in the serum total bilirubin and alkaline phosphatase concentration are not
common in uncomplicated acute cholecystitis since obstruction is usually limited to the
gallbladder, if present they should rise concerns about biliary obstruction and conditions such as
choledocholithiasis. Mild elevation in serums aminotransferase and amylase, along with
hyperbilirubinemia and jaundice have been reported in the absence of these complication and
may be due to passage of sludge or pus[ CITATION Zak18 \l 1033 ].

The initial imaging study of choice in patient with suspected CBD stones is a transabdominal
ultrasound of the right upper quadrant. This can evaluate cholelithiasis, cholelithiasis, and
common bile duct dilation. However, there is poor sensitivity for stones in distal common bile
duct because the distal common bile duct is often obscured by bowel gas in the imaging field. A
dilated common bile duct on an ultrasound is suggestive of, but not specific for
choledocholithiasis. Thus, the need for additional testing to determine the severity and/or the
need for removal of the gallbladder[ CITATION McN20 \l 1033 ]. SR underwent an ultrasound
when she was still in the emergency room.

The next diagnostic test completed would be MRCP is noninvasive. The MRCP is used to
evaluate for concurrent choledocholithiasis in patients with acute cholecystitis and elevations of
liver transaminase, total bilirubin, or evidence of CBD dilation an ultrasound. The role of MRCP
is the diagnosis of choledocholithiasis [ CITATION Zak18 \l 1033 ]. After the results of the
ultrasound came back, SR underwent the MRCP to confirm the presence of gallstones and the
need for removal of the gallbladder.

The next test which would be completed would be a total ERCP which can be used as both a
diagnostic and therapeutic procedure in patients with suspected choledocholithiasis. The ERCP
is invasive and requires technical expertise and is associated with complication such as
pancreatitis, bleed, and perforation. Due to the invasive nature of this test, it is usually the last
test preformed[ CITATION Ara20 \l 1033 ]. Based on SR’s continued increasing liver function
tests, the doctors wanted to perform this test to determine the continued cause despite the
removal of SR’s gallbladder.

Signs/symptoms of problem/disease process (on admission):

Typically, biliary colic is the classic symptom of choledocholithiasis. This is the dull discomfort
located in the right upper quadrant, epigastrium or substernal area that can radiate to the back
(particularly to the right shoulder blade). The pain is often associated with diaphoresis, nausea
and vomiting. This pain has a characteristic pattern and timing for an individual, usually after
eating a fatty meal, the gallbladder contacts which forces the gallstone into the CBD, producing
the pain. Additionally, squatting, bowel movements and passage of flatus also cause the pain.
The pain typically peaks around 30 minutes, plateauing within an hour, then beginning to
subside, with an entire attack usually lasting less than six hours. While pain can occur after
eating, it can also occur at night[ CITATION Zak20 \l 1033 ]. While it was never fully
discussed, SR presented to the ER around 2300, thus leading one to believe that her pain was
related to the time not to what she’d eaten hours ago for dinner.

Describe past medical history, including a description of the health condition, causes or risk
factors, treatments, and potential complications for each.
Health Description Causes/Risk Factors Treatments Complications
Condition
Hypoxia Oxygenation is Risk factors Possible Hypoxia can also
the process of associated with hospitalization lead to a
oxygen hypoxemia are high for condition called
diffusing altitude, asthma, or supplemental hypercapnia.
passively from heart disease. oxygen. Complications
the alveolus to Additionally, Outpatient include
the pulmonary common causes: treatment may depression
capillary, where Anemia, acute include an and/or other
it binds to respiratory disease inhaler or mood disorders,
hemoglobin in syndrome (ARDS), asthma fatigue,
RBCs or asthma, congenital medicine by headaches,
dissolves into heart defects, mouth to easy confusion, high
the plasma. chronic obstructive breathing, blood pressure
Insufficient pulmonary disease steroids to (HTN),
oxygenation is (COPD) decrease pulmonary
known as exacerbation, inflammation in hypertension,
hypoxemia[ CIT emphysema, your lungs increased heart
ATION interstitial lung and/or rate, heart
The20 \l 1033 ]. disease, medication antibiotics to failure,
(narcotics, treat any secondary
anesthetics, etc.), underlying polycythemia,
pneumonia, infection. If the which is an
pneumothorax, hypoxia id abnormal
pulmonary edema, severe enough increase in the
pulmonary and life is in number of red
embolism, danger, other blood cells
pulmonary fibrosis, treatment may (RBCs)
and/or sleep apnea [ be needed such [ CITATION
CITATION as mechanical The20 \l 1033 ].
The20 \l 1033 ]. ventilation
[ CITATION
The20 \l 1033 ].
Osteopenia Osteopenia is a Bone loss is a Lifestyle The main
condition that condition when the changes complication
begins as soon body gets rid of including: associated with
as bone loss more bone than it exercise, which osteopenia is the
begins. can create. Thus, as strengthen the risk that an
Typically, it an individual age bones the more individual
causes bone to their bone density you use it, diet progress to
become weaker will decrease. changes osteoporosis.
than normal, Typically, women including eating Osteoporosis
thus increasing are a greater risk for a diet rich in increased the
the risk for bone loss than calcium and risk of bone
fractures women, due to vitamin D (dairy fracture,
[ CITATION hormone changes products— typically of the
Ros20 \l 1033 ]. that happen during yogurt, low-fat spin or hip. Hip
menopause and men milk and fractures
with lower cheese), green typically result
testosterone levels. vegetables in falls. In some
Medical causes, (broccoli and cases, fractures
such as eating collard greens), can occur due to
disorders (anorexia sardines/salmon, weaken of the
and bulimia) that and/or tofu. bones
starve the body of Typically, the [ CITATION
nutrients. Untreated body make its Lew19 \l 1033 ].
celiac disease which own vitamin D
causes damage to when the
their small intestine sunlight hits the
by eating food with skin, therefore
gluten in them, spend a few
overactive thyroid, minutes
chemotherapy, outdoors in the
certain medication sunshine each
(steroids day boosts
(hydrocortisone or vitamin D
prednisone) production.
antiseizure meds Additionally,
(carbamazepine, good food
gabapentin, or choices for
phenytoin). Lastly, vitamin D
lifestyle causes include: fish
include lack of (salmon, tuna,
exercise, lack of and mackerel),
calcium intake or fish liver oils,
vitamin D, beef liver,
smoking, too much cheese egg
alcohol and/or yolks, fortified
carbonated breakfast
beverages cereals, juices,
[ CITATION milk produces,
Lew19 \l 1033 ]. yogurt and
margarine. Quit
smoking and
drink alcohol in
moderation
because both
can deplete the
body of
calcium. Cut
back on salt and
caffeine—both
of which
increase your
body’s loss of
calcium.

Medications to
treat osteopenia
include
bisphosphonates
(alendronic acid
(Fosamaz),
ibandronic acid
(Boniva),
risedronic acid
(Actonel) and
zoledric acid
(Reclas).
Hormone
replacement
therapy
(however this
can increase
blood clots).
Teriparatide
(Forteo) acts
like a hormone
made by your
parathyroid
glands that may
help the body to
make new
bones.
Raloxifen
 (Evista) which
can prevent
osteoporosis
(may increase
the risk of breast
cancer)
[ CITATION
Ros20 \l 1033 ].
Pulmonary Emphysema is a The main cause of Treatment Complication
Emphysema lung condition emphysema is long- depends on the include:
that causes term exposure to severity of the pneumothorax—
shortness of airborne irritants, symptoms. collapsed lung,
breath (SOB). including tobacco Bronchodilators heart problems
The alveoli are smoke, marijuana which can help —increased
damaged over smoke, air pollution relieve pressure in the
time, the they and/or chemical coughing, SOB, arteries that
weaken and fumes and/or dust. and breathing connects the
rupture, creating Rarely emphysema problems by heart a lungs
larger air spaces is caused by an relaxing (cor pulmonale,
instead of inherited deficiency airways, inhaled a section of the
smaller ones— of a protein that steroids heart expands
thus reducing protect the elastic (corticosteroids) and weakens),
the surface are structures in the as an aerosol and/or bullae
of the lungs and lungs—alpha-1- spray which which are empty
in turn, the antitrysin further reduce spaces in the
amount of deficiency[ CITATI inflammation lungs, which can
oxygen that ON Kin20 \l 1033 ]. and may help be as large as
reaches your relieve SOB half the lung,
bloodstream. and/or which increases
When you antibiotics the risk of a
exhale, the which treat pneumothorax
damaged alveoli bacterial [ CITATION
don’t work infections such Kin20 \l 1033 ].
properly and old as bronchitis or
air becomes pneumonia.
trapped, leaving Therapy,
no room including
oxygen-right air pulmonary
to enter rehabilitation
[ CITATION which can teach
Kin20 \l 1033 ]. you breathing
exercises and
techniques that
may reduce
breathlessness
and improve the
 ability to
exercise,
nutritional
therapy—in the
early stages of
emphysema,
many people
need to lose
weight, while
people with late-
stage
emphysema
often need to
gain weight,
and/or
supplemental
oxygen due to
the low blood
oxygen levels.
Surgery, such
as: Lung volume
reduction
surgery in which
a small wedge
of damaged lung
tissue is
removed—
removal of the
diseased tissue
helps the
remaining lung
tissue expand
and work more
efficiently and
helps improve
breathing, lung
transplant—
which is only an
option if severe
lung damage has
occurred and
other treatments
have failed
[ CITATION
Kin20 \l 1033 ].
Peripheral Inadequate Risk Factors Treatment is Complications of
Vascular muscle pump include advancing based on clinical PVD if
Disease function, age, family history severity— undiagnosed or
(PVD) incompetent of venous disease, asymptomatic: untreated can be
venous valves ligamentous laxity sclerotherapy serious or life-
(reflux), venous (ex. Hernia, flat and surface laser threatening.
thrombosis, or feet), prolonged therapy of They include
nontherrombotic standing, increased telangiectasias tissue death
venous body mass index, and reticular (limb
obstruction are smoking, lower veins are amputation),
cases of extremity trauma, generally impotence, pale
elevated venous prior venous considered skin, pain at rest
pressure thrombosis (post- cosmetic and and with
(venous thrombotic), some not typically movement,
hypertension), hereditary covered through severe pain that
which initiates a conditions (Klippel- insurance. restricts
sequence of Trenaunay mobility,
anatomic, Syndrome), high Symptomatic— wounds that will
physiologic and estrogen states, and initially not heal and/or
histologic pregnancy. Obese nonoperative life-threatening
changes lead to patient are more measures are infection of the
vein dilation, likely to be recommended bone and/or
skin changes, symptomatic as a for most blood stream
and/or skin result of their symptomatic [ CITATION
ulcerations venous disease. patients and Kab20 \l 1033 ].
[ CITATION The prevalence rate may include
Kab20 \l 1033 ]. appears to be lower skin care, leg
in non-Wester elevation,
population, strong exercise, and
familial component. compression
Venus wall therapy.
degeneration
(Venus aneurysm), Chronic
arteriovenous (AV) Symptoms—
shut (Traumatic AV Depends upon
fistula, AV the response to
malformation), and conservative
non-thrombotic iliac measure,
vein obstruction ongoing
(May-Thurner symptoms,
syndrome). extent of disease
Telangiectasias presence of
associated with reflux
cutaneous (superficial,
pigmentation and deep, perforator)
atrophy can result patient
form radiation trats expectations,
 of sequelae and likelihood
[ CITATION that treatment
Kab20 \l 1033 ]. would provide a
durable benefit [
CITATION
Kab20 \l 1033 ].
Hypertension The general Lifestyle and diet: Treatment Complication of
(HTN) definition of overweight, initially hypertension is
hypertension is increased salt involves associated with a
based upon the intake, heavy lifestyle significant
relationship alcohol use modification: increase in risk
between blood dietary salt of adverse
pressure and the Medication: restriction cardiovascular
incidence of Nonsteroidal anti- (moderate and renal
cardiovascular inflammatory drugs sodium outcomes. Left
events. When (NSAIs) (celeoxib) reduction is a ventricular
evaluating an selective fall in blood hypertrophy
individual and cyclooxygenase-2 pressure in HTN (LVH), heart
making the (COX-2) inhibitor, and failure, both
diagnosis of sympathomimetics normotensive reduced ejection
hypertension is (diet pills, individuals), fraction
complex and decongestants, potassium (systolic) and
requires amphetamine-like supplementation preserved
integration of stimulants), (dietary ejection fraction
repeated blood glucocorticoids, modification), (diastolic),
pressure herbal preparations, weight loss (can ischemic stroke,
measurements, estrogen containing decreased blood intracerebral
using contraceptives, pressure), hemorrhage,
appropriate calcineurin DASH diet, ischemic heat
technique, both inhibitors and/or exercise disease,
in and out of the antidepressants. (Aerobic including
office exercise and myocardial
[ CITATION Extracellular possible infraction and
Bas20 \l 1033 ]. volume expansion resistance coronary
—underlying renal training can interventions,
insufficiency, decreased chronic kidney
sodium retention systolic BP, disease and end
due to therapy with limit alcohol stage renal
vasodilators and/or intake. disease
a high salt diet [ CITATION
(assessed by Pharmacologic Bas20 \l 1033 ].
measuring sodium Therapy:
exerted in a 24-hour Thiazide-like or
urine collection). thiazide-type
diuretics, long-
Secondary causes: acting calcium
 primary channel
aldosteronism, renal blockers
artery stenosis, (amlodipine),
chronic kidney angiotensin-
disease, obstructive Converting
sleep apnea, Enzyme (ACE)
pheochromocytoma, inhibitors,
Cushing’s Angiotensin II
Syndrome and/or receptor
aortic coarctation blockers
[ CITATION (ARBs)
Tow20 \l 1033 ]. [ CITATION
Bas20 \l 1033 ].
Obstructive Is a disorder that Older age— The main goal Drowsiness
Sleep Apnea is characterized increased from of OSA therapy while
by obstructive young adulthood is to resolve driving/operating
apneas, through the 60-70, signs and motor vehicle
hypopneas, then appears to symptoms of and crashes—
and/or plateau; Male OSA, improve Three times
respiratory gender—2 to 3 sleep quality, more common
effort-related times more and normalize with patient with
arousals caused common in males, the apnea- OA;
by repetitive although the risk hypopnea index Neuropsychiatric
collapse of the appears to be (AHI) and dysfunction—
upper airway similar once women oxyhemoglobin Worsening
during sleep are postmenopausal; saturation inattention,
[ CITATION obesity—the risk of levels. memory,
Kli20 \l 1033 ]. OSA correlates with cognitive
body mass index Behavior deficits, which
(BMI); craniofacial medication: result in
and upper airway Overweight/ impaired
abnormalities— obese patient executive
maxillary or short should be function and
mandibular six, a encouraged to increase in errors
wide craniofacial lose weight; and accident,
base, and tonsillar change their moodiness and
and adenoid sleep position; irritability as
hypertrophy; avoid alcohol; well as
smoking; family avoid depression,
history of snoring or medication such psychosis, and
OSA; nasal as sexual
congestion, alcohol, benzodiazepine, dysfunction.
benzodiazepines, which can Cardiovascular
narcotics, possibly worsen OSA. and
gabapentinoids; cerebrovascular
obesity Positive Airway morbidity—
hypoventilation Pressure increased risk for
(OHS); congestive Therapy: systemic
heart failure, (CPAP) hypertension,
hypertension— involved coronary artery
Cardiovascular maintenance of disease, cardiac
disease, atrial a positive arrhythmias,
fibrillation and pharyngeal heart failure and
pulmonary transmural stroke;
hypertension; end- pressure so that pulmonary
stage renal; type 2 intraluminal hypertension or
diabetes mellitus, pressure right sided heart
chronic lung disease exceeded the failure—obesity
—asthma, chronic surround hypoventilation
obstructive pressure, while syndrome or an
pulmonary disease also stabilizing alternative cause
(COPD), and the upper airway of daytime
idiopathic through hypoxemia
pulmonary fibrosis; increased end- (chronic lung
stroke and transient expiratory lung disease), severe
ischemic attacks; volume. hypoxemia may
pregnancy; also cause
acromegaly; Alternative secondary
hypothyroidism; Therapies: oral polycythemia.
polycystic ovary appliance Metabolic
syndrome; Parkin’s (mandibular syndrome and
disease; folly eyelid advancement type 2 diabetes
syndrome; devices, tongue —increased
fibromyalgia; retaining prevalence of
gastroesophageal devices). Upper insulin resistance
reflux disease airway surgery as well as type 2
(GERD); secondary including diabetes and
polycythemia; tonsillar diabetic
Down’s Syndrome; hypertrophy, complication;
pos-traumatic stress adenoid nonalcoholic
disorder[ CITATIO hypertrophy, or fatty liver
N Kli20 \l 1033 ]. craniofacial disease
abnormalities. (NAFLD)—2-
Hypoglossal 3fold increased
nerve prevalence of
stimulation via NAFLD; gout
an implantable [ CITATION
neurostimulator Kli20 \l 1033 ].
device.

Pharmacologic:
medication that
 might act to
stimulate
respiratory drive
direction
(theophylline)
or indirectly
(oxybutynin) or
noradrenergic
agents
(atomoxetine);
persistent
sleepiness—
modafinil or
armodafinil may
be beneficial as
adjunctive
therapy for
expressive
daytime
sleepiness
persists and
successful
conventional
therapy (eg.
Positive airway
pressure/oral
appliances)
[ CITATION
Kry20 \l 1033 ].
Diverticulosis A diverticulum Aging, obesity, Treatment An abscess,
is a sac-like smoking, lack of depends on the which occurs
protrusion of the exercise, diet high severity of the when pus collets
colon wall, in animal fats and disease. in the
whereas low in fiber, and/or Uncomplicated diverticula. A
diverticulosis is medication diverticulitis blockage in the
defined by the (steroids, opioids, may be treated bowel caused by
presence of and nonsteroidal at home with scarring. An
divertivula— anti-inflammatory antibiotics for abnormal
which may be drugs (NSAIDS) infection and a passageway
asymptomatic. [ CITATION liquid diet to (fistula) between
Diverticular Pem19 \l 1033 ]. rest the bowel. sections of the
disease is bowel or bowel
defined as Complicated and other organs.
clinically diverticulitis: Lastly
significant or possible peritonitis,
symptomatic intravenous which can occur
diverticulosis antibiotics and if the infected of
due to the insertion of inflamed pouch
diverticular an nasogastric ruptures, spilling
bleeding, tube to drain intestinal
divertuliitis, abdominal contents into the
segmental abscess and rest abdominal
colitis the bowel. cavity.
associated with Peritonitis is a
diverticula. Surgery: should medical
Diverticulitis is complication emergency that
defined as the such as a bowel requires
inflammation of abscess, fistula, immediate care [
the diverticulum obstruction, or CITATION
that can be perforation of Pem19 \l 1033 ].
complicated by the bowel wall,
a diverticular multiple
abscess, fistula, episodes of
bowel uncomplicated
obstruction or diverticulitis
free perforation and/or a
[ CITATION weakened
Pem19 \l 1033 ]. immune system.
There are two
main types of
surgery:
Primary bowel
resection—
which the
diseased
segments of the
intestine is
removed and
then reconnects
(anastomosis)
the two
segments. A
bowel resection
with colostomy
—if there is too
much
inflammation
that it
impossible to
rejoin the colon
and rectum, the
surgeon will
 preform a
colostomy. Or
an opening
(stoma) in your
abdominal
wi[ CITATION
Pem19 \l 1033 ]l
l that is
connected the
healthy part of
the colon that
stool can pass
through into
colostomy bag.
This may be
reversed once
inflammation
has eased
[ CITATION
Pem19 \l 1033 ].

How does the client’s medical history impact the present problem/disease process:

This patient has a complex medical history, which

Allergies, their drug classifications and food allergies, and client’s reaction:

SR’s allergies include colchicine which produced gastrointestinal (GI) problems, typically
diarrhea for this patient; environmental allergies which include watery eyes and naproxen which
also produced GI distress including nausea and vomiting.

Client Medications/IV Solutions (Medications given during scheduled shift including PRN
medications)
Generic Name: Is this a new medication?

Albuterol inhaler Based on this patient’s history, this is not a new medication.

Classification: Any pertinent teaching about this medication?

Ther. Class.
Bronchodilators
Pharm. Class. Adrenergic
How does this medication
Instruct the patient about side effects, the risk of paradoxical
bronchospasms and/or the loss of effectiveness of medication.
Instruct the patient to contact health care professional
immediately if shortness of breath is not relieved by the
medication or is accompanied by diaphoresis, dizziness,
palpitations, or chest pain. Instruct the patient on how to prime
a new medication with 4 sprays before using and to discard the
work?
The medication binds to the
beta2-adrenergic receptors
in the airway smooth
muscle, leading to
activation of adenyl cyclase
and increased levels of
cyclase and increased levels
of of cyclic 3’, 5’-adenosine
monophosphate (cAMP).
Increases in cAMP activate
kinases, which inhibit the
phosphorylation of myosin
and decrease intracellular
calcium. Decreased
intracellular calcium relaxes
smooth muscle airways.
Relaxation of airway
smooth muscle with
subsequent bronchodilation.
Relatively selective for
beta2 (pulmonary)
receptors.
Medication order:
2 puffs every four hours as
needed for shortness of
breath
Is this a safe dose?
Yes
canister after 200 sprays. Instruct the patient to notify health
care professionals of all medication, including over the counter,
vitamins, and/or herbal products and to consult health care
professionals before taking any over the counter medications.
Caution the patient to avoid smoking and other respiratory
irritants. Advise the patient to use albuterol first if using other
inhalation medication and to allow five minutes to elapse before
administering another inhalants medication unless otherwise
directed. Advise patient to rinse their mouth with water after
each inhalation dose to minimize dry mouth and clean the
mouthpiece with water at least once a week. Instruct the patient
to notify health care professional if there is no response to the
usual dose or if contents of one canister are used in less than
two weeks. Asthma and treatment regimen should be evaluated,
and corticosteroids should also be considered.
Why is this medication prescribed?
This medication is prescribed to treat or prevent bronchospasm
in asthma or chronic obstructive pulmonary disease (COPD).
Additionally, it can be used to treat exercise-induced
bronchospasm.
What pertinent pre- and post- assessments are necessary?
Assess lung sounds, pulse, and blood pressure before
administration and during peak of medication. Note amount,
color, and character of sputum produced. Monitor pulmonary
function tests before initiating treatment and throughout
therapy. Additionally, observe for paradoxical bronchospasm
(prolonged wheezing). If condition occurs, the medication will
need to be withheld and the HCP notified immediately.
What labs if any would need to be monitored and why?
This medication may cause a transient decrease in serum
potassium concentration with nebulization or higher-than-
recommended doses.
List reasons why this medication may need to be held (lab,
VS, assessment findings)

Generic Name:
Atorvastatin
Classification:
Ther. Class. Lipid-lowering
agents
Pharm. Class. Hmg Coa
reductase inhibitors
How does this medication
work?
This medication works by
inhibiting 3-hydroxy-
3methylglutaryl-coenzyme
A (HMG-CoA) reductase,
an enzyme which is
responsible for catalyzing
an early step in the
synthesis of cholesterol.
Medication order:
40mg by mouth every night
Being that this medication has the tendency to increase heart
rate, the nurse would want to hold this medication of
tachycardia. Additionally, this increased heart rate can cause
chest pain, palpitation, nervousness, restlessness, and/or
tremors, should these symptoms become problematic, the nurse
would need to hold the medication. Should there be an increase
in serum potassium, the nurse would also want to hold this
medication.
Lastly, this medication should be used cautiously in people with
heart disease, hypertension, hyperthyroidism, diabetes,
glaucoma, and/or seizure disorders.
Is this a new medication?
No. This medication is usually used for long-term management
of high cholesterol.
Any pertinent teaching about this medication?
Instruct the patient to take as directed, avoid missing doses, take
the misses dose as soon as remember, however, if it has been
more than 12 hours since the missed dose, omit and take during
the next scheduled time. Avoid consuming more than one quart
of grapefruit juice daily due to the risk of toxicity. Additionally,
the patient would need to be taught that the medication does not
cure elevated sodium levels, however, it does help to control
them. Instruct the patient on a diet that is low in fat, cholesterol,
carbohydrates and/or alcohol. Exercise, alcohol consumption,
and smoking cessation would also need to be discussed. The
nurse would want to advices patient to notify health care
professionals of medication regimen prior to treatment or
surgery.
Why is this medication prescribed?
This medication is used to lower total and LDL cholesterol and
triglycerides. It also reduces lipids/cholesterol reduces the risk
of myocardial infarction and stroke sequelae. Additionally, it
slows the progression of coronary atherosclerosis with resultant
decrease in coronary heart disease—related events.
Is this a safe dose? What pertinent pre- and post- assessments are necessary?

Yes The nurse would need to obtain a diet history, especially with
regard to fat consumption. May be given without regard to
food. However, avoid grapefruit juice during therapy as it may
increase the risk of toxicity.

What labs if any would need to be monitored and why?

The nurse would need to evaluate serum cholesterol and

triglyceride levels before initiating, after two to four weeks of
therapy, and periodically thereafter. The nurse would want to
monitor liver function tests prior to initiation of therapy and as
clinically indicated. If symptoms of serious liver injury,
hyperbilirubinemia, or jaundice occurs discontinue the
medication. It may also cause an increase in alkaline
phosphatase and bilirubin levels. If the patient develops muscle
tenderness during therapy, CPK levels should be monitored. If
CPK levels are greater than 10 times the upper limit of normal
or myopathy occurs, therapy should be discontinued.

List reasons why this medication may need to be held (lab,

VS, assessment findings)

Monitor for signs and symptoms of immune-mediated

necrotizing myopathy without (IMNM) (proximal muscle
weakness and increased serum creatine kinase), persisting
despite discontinuation of statin therapy. Perform muscle
biopsy to diagnose; shows necrotizing myopathy without
significant inflammation.

Generic Name: Is this a new medication?

Fluticasone propionate It does not appear that this medication is new.

Classification: Any pertinent teaching about this medication?

Ther. Class. Anti- Instruct patient in correct technique for administering nasal
inflammatories (Steroidal) spray. Shak well before use. Before frist time use, prime unit
Pharm. Class. by spraying 6 times. If not used for at least 7 days or if cap is
Corticosteroid left off for more than 5 days, reprime the unit. Warn patient that
temporary nasal stinging may occur. Instruct the patient to
How does this medication gently blow their nose to clear the nostrils prior to administering
work? dose. Instruct the patient to notify Health care professional if
symptoms do not improve within 1 month or symptoms worsen.
Potent, locally acting anti-
inflammatory and immune
modifier.
Medication order:
50mcg/act
1 spray two times daily to
each nostril as needed for
allergy symptoms
Is this a safe dose?
yes
Generic Name:
Hydralazine
Classification:
Ther. Class.
Antihypertensives
Pharm. Class. Vasodilators
How does this medication management). Instruct the patient on proper technique for
work?
This medication has a direct should also monitor for swelling in the legs/feet and weigh
acting on the peripheral
arteriolar vasodilator. There The nurse should advise that it may cause drowsiness, therefore,
Why is this medication prescribed?
The medication is used to decrease symptoms of allergic and
nonallergic rhinitis.
What pertinent pre- and post- assessments are necessary?
Monitor degree of nasal stuffiness, amount and color of nasal
discharge and frequency of sneezing. Patient on long-term
therapy should have periodic otolaryngologic examinations to
monitor nasal mucosa and passages for infection or ulceration.
Monitor for s/s of hypersensitivity reaction (rash, pruritis,
swelling of fac and neck, dyspnea.
What labs if any would need to be monitored and why?
Periodic adrenal function tests may be ordered to assess degree
of hypothalamic-pituitary-adrenal (HPA) axis suppression in
chronic therapy.
List reasons why this medication may need to be held (lab,
VS, assessment findings)
Instruct the patient to stop fluticasone and notify health care
professional immediately if s/s of anaphylaxis (rash, hives,
difficulty breathing, swollen lips or throat) occur.
Is this a new medication?
It is unclear if this is a new medication or if this is an older
medication.
Any pertinent teaching about this medication?
Encourage the patient to comply with additional intervention for
hypertension (weight reduction, low-sodium diet, smoking
cessation, moderate alcohol intake, regular exercise and stress
blood pressure monitoring. Educate the patient that this
medication does not cure high blood pressure. The patient
themselves daily, wearing the same clothes, at the same time.
by lower blood pressure.
Medication order:
Inject via IV 10mg every
6hrs as needed for increased
blood pressure >160 SBP
Is this a safe dose?
Yes
Generic Name:
Morphine sulfate
Classification:
Ther. Class. Opioid
analgesics
Pharm. Class. Opioid
agonists
Controlled substance
schedule II
the patient should be encouraged to avoid driving or tasks that
require a lot of mental focus. Sudden position changes should
be avoided. Lastly, follow up appointment should be
emphasized to evaluate the effectiveness
Why is this medication prescribed?
This medication is used to decrease blood pressure and decrease
afterload in patients with heart failure.
What pertinent pre- and post- assessments are necessary?
Monitor blood pressure and pulse frequently during initial dose
adjustment and periodically during therapy. Monitor frequency
of refills to determine adherence.
What labs if any would need to be monitored and why?
Monitor CBC, electrolytes, LE cell prep, and ANA titer prior to
and periodically during prolonged therapy.
List reasons why this medication may need to be held (lab,
VS, assessment findings)
This medication would need to be held if the patient had a
hypersensitivity reaction, the blood pressure/pulse were not in
the parameters for administration. If this patient develops
generalized tiredness, muscle/joint aching, chest pain, skin rash,
sore throat, numbness, tingling, pain, or weakness of hands/feet.
Is this a new medication?
The IV form of this medication is new for this patient. It is
unclear if she has ever been on this medication before.
Any pertinent teaching about this medication?
 Assess type, location, and intensity of pain prior to and 1
hr following When titrating opioid doses, increases of
25–50% should be administered until there is either a
50% reduction in the patient's pain rating on a numerical
or visual analogue scale or the patient reports
satisfactory pain relief. When titrating doses of short-
How does this medication
work?
Binds to opiate receptors in
the CNS. Alters the
perception of and response
to painful stimuli while
producing generalized CNS
depression.
Medication order:
Inject 2mg via IV every two
hours as needed for severe
pain
Is this a safe dose?
Yes.
Why is this medication prescribed?
What pertinent pre- and post- assessments are necessary?
acting morphine, a repeat dose can be safely
administered at the time of the peak if previous dose is
ineffective and side effects are minimal.
 Patients on a continuous infusion should have additional
bolus doses provided every 15–30 min, as needed, for
breakthrough pain. The bolus dose is usually set to the
amount of drug infused each hr by continuous infusion.
 Patients taking extended-release morphine may require
additional short-acting opioid doses for breakthrough
pain. Doses of short-acting opioids should be equivalent
to 10–20% of 24 hr total and given every 2 hr as needed.
 Assess bowel function routinely. Institute prevention of
constipation with increased intake of fluids and bulk and
with laxatives to minimize constipating effects.
Administer stimulant laxatives routinely if opioid use
exceeds 2-3 days, unless contraindicated. Consider drugs
for opioid-induced constipation.
 Assess risk for opioid addiction, abuse, or misuse prior
to administration. Abuse or misuse of extended-release
preparations by crushing, chewing, snorting, or injecting
dissolved product will result in uncontrolled delivery of
morphine and can result in overdose and death.
 High Alert: Assess LOC, BP, Pulse, and respirations
before and periodically during administration. <10/min,
assess level of sedation. Physical stimulation may be
sufficient to prevent significant hypoventilation.
 Severe pain (the 20 mg/mL oral solution concentration
should only be used in opioid-tolerant patients).
 Pain severe enough to require daily, around-the-clock
long-term opioid treatment and for which alternative
treatment options are inadequate (extended-release).
 Assess type, location, and intensity of pain prior to and 1
hr following PO, subcut, IM, and 20 min (peak)
following IV administration. When titrating opioid
doses, increases of 25–50% should be administered until
there is either a 50% reduction in the patient's pain rating
on a numerical or visual analogue scale or the patient
reports satisfactory pain relief. When titrating doses of
short-acting morphine, a repeat dose can be safely
 administered at the time of the peak if previous dose is
ineffective and side effects are minimal.
 Patients on a continuous infusion should have additional
bolus doses provided every 15–30 min, as needed, for
breakthrough pain. The bolus dose is usually set to the
amount of drug infused each hr by continuous infusion.
 Patients taking extended-release morphine may require
additional short-acting opioid doses for breakthrough
pain. Doses of short-acting opioids should be equivalent
to 10–20% of 24 hr total and given every 2 hr as needed.
 An equianalgesic chart (see equianalgesic dosing
guidelines) should be used when changing routes or
when changing from one opioid to another.
 High Alert: Assess level of consciousness, BP, pulse,
and respirations before and periodically during
administration. If respiratory rate is <10/min, assess
level of sedation. Physical stimulation may be sufficient
to prevent significant hypoventilation. Subsequent doses
may need to be decreased by 25–50%. Initial drowsiness
will diminish with continued use. Geri:  Assess geriatric
patients frequently; older adults are more sensitive to the
effects of opioid analgesics and may experience side
effects and respiratory complications more frequently
 Prolonged use may lead to physical and psychological
dependence and tolerance. This should not prevent
patient from receiving adequate analgesia. Patients who
receive morphine for pain rarely develop psychological
dependence. Progressively higher doses may be required
to relieve pain with long-term therapy.
 Assess bowel function routinely. Institute prevention of
constipation with increased intake of fluids and bulk and
with laxatives to minimize constipating effects.
Administer stimulant laxatives routinely if opioid use
exceeds 2–3 days, unless contraindicated. Consider
drugs for opioid-induced constipation.
 Assess risk for opioid addiction, abuse, or misuse prior
to administration. Abuse or misuse of extended-release
preparations by crushing, chewing, snorting, or injecting
dissolved product will result in uncontrolled delivery
of morphine and can result in overdose and death.

What labs if any would need to be monitored and why?

May ↑ plasma amylase and lipase levels.

 List reasons why this medication may need to be held (lab,
VS, assessment findings)

This medication would need to be with-held for

toxicity/overdose, decrease respirations and pulse, severe CNS
depressant, drug-drug interaction, etc.

Generic Name: Is this a new medication?

Lorazepam The IV form of this medication is new for this patient. It is

unclear if she has ever been on this medication before.
Classification:
Any pertinent teaching about this medication?
Ther. Class. Analgesic
adjuncts, antianxiety agents,
sedative/hypnotics Why is this medication prescribed?

Pharm. Class. This medication was used to treat the patient anxiety.
Benzodiazepines
What pertinent pre- and post- assessments are necessary?
Controlled Substance
Schedule: IV Geri: Assess geriatric patients carefully for CNS reactions as
they are more sensitive to these effects. Assess falls risk.

How does this medication
work?
Depresses the CNS,
probably by potentiating
GABA, an inhibitory
neurotransmitter.
What labs if any would need to be monitored and why?
Patients on high-dose therapy should receive routine evaluation
of renal, hepatic, and hematologic function.
List reasons why this medication may need to be held (lab,
VS, assessment findings)

Therapeutic Effect(s): This medication would need to be held for suspected overdose

Sedation.
Decreased anxiety.
Decreased seizures.

Medication order:

Inject 0.5mg via IV every

four hours as needed for
anxiety/agitation.
 Is this a safe dose?

Yes

How does it Nursing

Lab Normal Trends Today’s relate to your Intervention/
Range (i.e. Yesterday, Value patient’s disease Assessment/Follow
(Bryant & day prior) process? up: What do you
Stratton) do about it?
WBC 5-10,000 11.6 9.9 Initially, this The nurse would
patient’s WBCs want to determine
would be the cause of
elevated in infection—which is
relation to having why they ordered
acute the chest x-ray.
cholecystitis. Therefore, the nurse
would want to
continually monitor
WBCs to determine
if they were
trending upward.
Assess for other
origins of infection
(wounds/skin, urine,
etc.)
RBC F: 4.2-5.4 3.85 3.9 The patient’s Monitor for blood
M: 4.7- RBCs have loss—checking
6.1 remained stable wound dressing at
throughout least every shift,
hospitalization. encourage a diet
high in iron, and/or
discuss the need for
supplement with the
doctor.
Hgb F: 12-16 11.3 11. As with RBC’s The nurse would
M: 14-18 4 this patient was want to continue to
not losing blood monitor for any
either before or blood loss, however,
after surgery, her hgb has remain
therefore, there stable, the nurse
should not be a would want to
significant drop continue to verify its
 in Hgb. stability.
Hct F: 34-47 34.6 34. As with RBCs While the nurse
M: 42-57 3 and Hgb this continues to monitor
patient was not the hct, the nurse
losing blood would want to
either before or educate SR on the
after surgery, need to increase her
therefore, there iron levels
should not be a beginning by the
significant drop most non-invasive
in Hct. practices. This
would include
increasing her
dietary intake of
iron, including red
meat, beans, egg
yolk, whole-grain
products, nuts, and
seafood.
Platelet 150-400 239 238 This patient does The nurse would
not currently want to assess for
have an areas of any s/s of bleeding
acute blood loss, and educate SR on
with clotting the decreased
needed, platelets and the
therefore, increased risk for
platelets would bleeding.
remain normal. Accordingly, SR’s
count is not
dangerously low,
therefore and order
of a unit of platelets,
medications
(corticosteroids),
surgical intervention
(splenectomy)
and/or a plasma
exchange are not
indicated at this
time.
Na 136-145 140 144 144 This patient’s
sodium level is
expected to
remain within the
normal limits, as
she’s receiving
 IV fluids,
therefore
maintaining
hydration and
therefore sodium
level.
K 3.5-5.0 3.8 3.8 3.6 Potassium has
also remained
within the normal
limits as there
was not a
significant
Cl 98-106 101 104 106 The chloride Kidneys play an
level is within the important role in
normal range. regulation of
chloride in the body,
so an imbalance
may be related to a
problem with the
kidneys. Being that
SR’s level is WNL,
therefore, it should
continue to be
monitored.
Mg 1.3-2.1
Ca 9-10.5 9.2 9.4 Being that this pt The nurse would
has a hx want to continue to
significant for monitor this
low calcium patient’s calcium
levels, having a level, encourage Ca
normal is the supplements and/or
goal. prescription
medication
necessary to
increase Ca levels.
Phos 3-4.5
BUN 10-20 27 25 The BUN is The nurse would
elevated, which want to continue to
could be in monitor this,
relation to acute encourage proper
kidney injury hydration to
secondary to maintain adequate
cholestasis. blood flow to the
kidneys.
Additionally,
dehydration and/or
 heart failure also
decreased blood
flow to the kidneys,
thereby increasing
BUN.
CR F: 0.5-1.1 0.21 0.8 The creatinine Therefore, the nurse
M: 0.6- level is within the would want to
1.2 normal range, continue to monitor
adding proof that the level while
dehydration rehydrating the
caused the patient.
elevated BUN
versus significant
kidney injury.
GFR
Cholesterol <200 156 Cholesterol is Being that this is a
within the normal normal level, the
range. nurse would want to
Cholesterol is a continue to monitor
waxy, fat-like this level.
substance that is Additionally, the
found in call cells nurse would want to
of the body—and educate on ways to
needed for the decrease
production of cholesterol,
hormones, including reducing
vitamin D, and saturated fats,
substances that eliminating trans
help to digest fats, eat foods rich
foods. in omega-3 fatty
acids, and increase
soluble fiber,
exercise, quit
smoking, weight
loss, and/or drink
alcohol in
moderation.
Triglyceride F: 35-135 71 Triglycerides are As listed above, the
M: 40- a type of fat nurse would want to
160 found in the educate the SR on
blood. When the ways to decreased
body converts her triglycerides.
calories, it does
not need right
way, it does so
 into triglycerides,
which are stored
in your fat cells.
They are later
released for
energy between
meals.
HDL F: >55 64 HDL stand for Being that SR’s
Cholesterol M: >45 high-density gallbladder was
lipoproteins damaged, it would
(good not have surprised
cholesterol) the nurse should this
because it carries be decreased due to
cholesterol from the damage.
other part of the However, it should
body back to the again normalize
liver. The liver once the tissue
then removes the injury to the liver
cholesterol from has resolved.
the body. Therefore, the nurse
would want to
continue to monitor
this level, educate
the patient on foods
that would increase
this level, including
olive oil,
beans/legumes,
whole grains, high-
fiber fruit, fatty fish,
flax seeds, nuts,
and/or chia seeds.
BNP <100
CK-MB 5-25
Myoglobin <90
Troponin I <0.03 Throughout SR’s While this level is
hospitalization, not acutely elevated
this level has nor is the level
remained the increasing, the nurse
same, while would want to
elevated. This continue to monitor
means there was this level—should it
no acute concerns continue to rise, the
of a heart attack. nurse would want to
update the MD and
request further
 intervention.
Additionally, the
nurse would want to
educate SR on s/s of
cardiac
involvement.
Lactic Acid 0.5-1
Procalcitonin <0.15
INR 0.8-1.1
aPTT 30-40
UA Upon arrival, the This patient’s
(Urinalysis) pt had a UA urinalysis is
complete to rule relatively
out any kidney unremarkable,
concerns, which therefore, there was
could be no concerns of
contributing to kidney involvement
SR’s severe as the cause of her
abdominal pain. abdominal pain.
Throughout SR’s
hospitalization, the
nurse would want to
monitor her urine
output, to make sure
she was producing
adequate amount of
urine and to verify
that she’s free from
s/s of urinary tract
infection.
Specific 1.005- 1.02
Gravity 1.030 0
pH 5.0-7.0 60
Bilirubin Negative (--)
Blood Negative LG
Glucose Negative (--)
Ketones Negative (--)
Leukocyte Negative SM
Esterase
Nitrite Negative (--)
Protein Negative 100
How does it Nursing
Lab Normal Trends Today’ relate to your Intervention/
Range (i.e. Yesterday, s patient’s disease Assessment/Follow
 (Bryant & day prior) Value process? up: What do you
Stratton) do about it?
ABGs
pH 7.35-7.45
paO2 80-100
paCO2 35-45
HCO3 22-26
O2 93-100%
Glucose 70-100
non-
diabetic
Hgb A1c Goal <7%
for
diabetics
TSH 0.4-4.0
without
thyroid
disorder
T3 70-205
T4 4-12
LFTs Liver function
tests signify liver
damage.
albumin 3.5-5g/dl 4.1 3.4 3.5 Albumin is The nurse would
within the normal want to educate the
range. Albumin patient on foods that
is a protein made retain a lot of
in the liver. protein include nuts,
eggs, and dairy
products, all of
which may increase
the albumin levels.
aLT 4-36 IU 55 64 (Aspartate The nurse would
aminotransferase) want to teach SR
is an enzyme about different
released by the ways to decrease
liver. In SR’s ALT, including
case, it is drinking coffee,
elevated in exercising
relation to her regularly, losing
liver involvement excess weight,
with the and/or increase folic
gallbladder acid intake.
becomes infected
and
 dysfunctional.
AST 0- 100 57 118 Like (aLT) AST The nurse would
35units/L (alkaline want to educate the
phosphatase) is a patient about ways
liver enzyme— to decrease AST,
again in SR’s including: limiting
case it is elevated alcohol intake,
secondary to gall and/or losing
bladder weight via a low-
dysfunction. calorie diet.
Alkaline 30- 0.2 95 118
Phosphatase 120units/L
(ALP)
Total 0.3- 6.2 0.4 Bilirubin is a The nurse would
Bilirubin 1.0mg/dl waste product want to determine
made by the the cause of the
liver. SR’s was increased bilirubin
initially elevated, and make the
however, as her associated lifestyle
hospital stay changes as
progressed, it too mentioned above.
normalized.
Direct 0.1- 0.3
Bilirubin 0.3mg/dl

Indirect 0.2- <2

Bilirubin 0.8mg/dl
Ammonia 10-80
Amylase 30-220 74 56 Initially this level
was elevated d/t
liver involvement
in relation to
gallbladder
dysfunction
and/or cystic duct
swelling.
Lipase 0-160 18
Misc:
 Diagnostic Test (i.e. CXR, CT, MRI, Doppler, ECHO, ECG, etc.)
Date Test Type Results Significance

Describe all abnormal assessment findings, what each one means and what you did about
each one. Indicate with a check in the box if it is related to admission diagnosis, sign client
is improving or sign client is worsening in their admission diagnosis.
Abnormal Significance Nursing Unrelated Sign of Sign of
Assessment (what does Interventions to potential worsening
the abnormal (what did you diagnosis improvement condition
finding mean) do about the
abnormal
finding)

VS trends (include your 2 sets and hospitalization trends):

Vitals: Temperature Pulse Respiratory Rate Blood Pressure Pulse Oximetry
Previous Shift:
Current:
 Assessment Data Diagnosis Desired Outcomes
Objective: Acute Anxiety (What will the client do?)

Subjective:

Priority:

Nursing Interventions Supporting Rationale Evaluation Data

(What will the nurse do?) (Reference/Source) Date:

Outcome Summary:

Revision:
 Assessment Data Diagnosis Desired Outcomes
Objective: Problem Statement: (What will the client do?)

Etiology:

Subjective:

Signs and Symptoms:

Priority:

Nursing Interventions Supporting Rationale Evaluation Data

(What will the nurse do?) (Reference/Source) Date:

Outcome Summary:

Revision:
Medical interventions used to treat admission problem/diagnosis (Consults, pharmacology,
surgery, treatments, therapy, etc.).

Throughout SR’s admission, she was met with many different people. The nurse

Nutrition (diet orders, supplements, tube feeding, restrictions, etc.) and why are they ordered:
List 5 examples of foods that should be restricted and/or encouraged based on ordered diet.
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Discharge plan for care (Case Management) **Discharge Plan starts on day 1:
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Discuss client teaching provided (include client barriers to teaching):
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STUDENT EVALUATION OF CLINICAL PERFORMANCE (please list specific examples
for each clinical experience):

Explain how you met a QSEN competency during your clinical experience:
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After reflecting on your clinical performance today, what critical thinking did you utilize and
how can you improve on that in your next clinical day?
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