POC & CONCEPT MAPS WEEK 12 1

Clinical Plan of Care and Concepts Maps

Valerie M. Ganley WNCSN

Western Nevada College

Professor Debi Ingraffia-Strong PhD©, MSN, RN

Instructor Lisa Dunkelberg, MSN, RN

Instructor Raylene Stiehl MSN, RN

Instructor Heather Reardon MSN, RN

Clinical Week 12

April 16, 2019

 POC & CONCEPT MAPS WEEK 12 2

Pain/Mobility Elimnation Genitourinary

Full active movements x4. Up self,
SBA with IV Pole PRN. No swelling
or tenderness in joints. Fall risk due to
Oxycodone (PRN q4hrs) & weakness
r/t pain. Pain 7/10 prior to pain med
administration. Pain upon palpation of
abd. Enlarging psuedocyst. Pain 3/10,
30 minutes after, during reassessment.
Neurological/Thermoregulation
Self void, urinal. Yellow, clear, 300 mLs. UA:
Alert and oriented x4. PERRLA 3mm. normal except 4+ glucose.
Normal speech. Temp: 98.2. Gag reflex
present (cough). Gaslow score 15.
Purposeful motor response x4.

57-Year-Old- Male. Full code. No known allergies.

Not married. Lives at home with mother.
Metabolism
Active bowel sounds x 4. Soft, tender, mild
distention. LBM: 4/16/19, UTA. Given
Admitting Diagnosis: Docusate-Senna, Pepcid for gastric
Oxygenation “Diabetic Issues” secretions, Fenofibrate for hyperlipidemia.
Glucose 61 upon admission. Hypoglycemia. A1c: 5.9: Insulin subq. Agressive fluids:
Respirations 18/ O2 Sat: 95 RA. Clear, LR 1000mL. Lipase elevated: 203.
symmetrical breath sounds bilaterally. Triglycerides: 89. Smoker, denies alcohol
Capillary refill < 3 seconds. Denies chest use. Na+ low: 132. Cl: 97. Alb 2.5: wasn't
pain and SOB. eating & experienced N/V/D. Full liquid
Past Medical History: diet upgraded to Reg diet Dys III.
Type 2 DM, Hyperlipidemia, Hypertension, CAD,
Anxiety, Current Smoker. Previous visit DKA.
Pancreatic pseudocyst. Heavy drinker and
recreational drug user in the past. Stopped in the
80s.
Perfusion
Regular rate and rhythm. HR 88.
Capillary refil < 3 seconds. Radial and
pedal pulse 2+. BP: 99/72. Lisinopril Psychsocial
held 0900 med pass. BP 107/75 1200
VS. INR: 1.2, will continue to monitor. Tissue Integrity Calm, cooperative. Mood appropiate
Enoxaparin for anticoagulation. Alb for situation except knowledge deficit
Warm, dry, intact, pink with no concerning disease process. Actively
low: 2.5. WBC elevated:14.9. Hgb: abnormal color. Turgor returns < 3
15.8. Plt: 523 elevated, Thrombocytosis participates. Denial of disease
seconds. Braden score: 23. 20 g PIV process. Family in life. Tobacco
due to elevated state. Monitor fluids. in Lt UA. dependent. Nicotine patch refused.
 POC & CONCEPT MAPS WEEK 12
Nursing Interventions:
• Explan the causes of chronic
pancreatitis.
• Evaluate understanding of dietary
needs and restrictions.
• Maintain pain management PRN.
• Reassess pain throughout shift.
• Monitor for s/s of hypovolemia
and shock: Increasing PR, normal
or slightly decreased BP,
increasing RR, urine output <5
ml/kg/hr, restlessness, agitation,
change in mentation, dimished
peripheral pulses, cool, pale, or
cyanotic skin.
• Monitor for respiratory
complications: Hypoxemia,
Atelectasis, Pleural effusion.
• Monitor for SIRS.
• Monitor for metabolic
complications: Hypokalemia,
hiccups.
• Monitor hematologic
complications.
• Monitor coagulation profiles,
H&H, hypoalbuminemia.
• Evaluate whether or not pt abuses
alcohol.
• Monitor thrombocytosis.
• Idenify patient's current
knowledge and adjust teaching
accordingly.
Nursing Goals:
• Patient will relate satisfactory
relief after pain-relief
interventions.
• Patient will relate effective
interventions to relieve pain.
• Patient will rate pain level lower
after measures.
• The patient will acknowledge
alcohol problem (if he is denying).
• Patient will demonstrate
understanding of disease process
and understand that low blood
sugar can kill him.
• Patient will describe daily food and
fluid intake that meets therapeutic
goals.
• Patient will describe scheduling of
medications that meet therapeutic
goals.
• Patient will verbalize ability to
manage therapeutic regimens.
• Patient will collaborate with health
professionals to decide on a
therapeutic regimen that is
congruent with health goals and
lifestyle.
• Patient will demonstrate interest in
smoking cessation.
• Patient will use IS 10x/hr.
3
Patient Education &
Health Promotion:
• Teach patient about all aspects of
the therapeutic regimen, providing
as much knowledge as the patient
is willing to accept.
• Educate patient on self-
management of the medical
regimen.
• Teach patient importance of
smoking cessation.
• Teach patient importance of
glucose monitoring, and the need
to monitor BS at home.
• Teach patient to report early
worsening symptoms of: clay
colored stools, increase in pain in
upper left side, mid abd, and or
radiating to back, persistent
gastritis, N/V, weight loss, and
elevated temperature.
• Teach deeping breathing exercises
in times of pain.
• Teach patient the use of incentive
spirometry.
 POC & CONCEPT MAPS WEEK 12 4

Nursing Diagnosis:
Acute pain related to irritation and edema
of inflamed pancreas as evidence of patient
rating pain as 7/10 and stating "it hurts
above my stomach."

Evaluation:
• Patient rated pain relief of 3/10 after pain Subjective:
med administration at 1000. Patient rated pain 7/10 and stated, "it hurts
• Patient demonstrated little to no interest above my stomach."
about disease process. Objective:
• Patient joked about his disease process. Pointed to stomach, mid-abd, upper left
side. Winced during palpation.

Teaching: Goals/Outcomes
• Teach patient importance of BS monitoring. Short Term:
• Explain causes of chronic pancreatitis.
• Educate patient on self-management of the Patient will relate satisfactory relief after
medical regimen. pain med administration by lunch.
• Advise patient to call when he is in pain. Long Term:
• Teach patient importance of smoking Patient will state an acceptable rate of painor
cessation. no pain by discharge.
Interventions:
• Maintain pain management PRN.
• Reassess pain throughout shift.
• Monitor IV fluids.
• Monitor urine output.
 POC & CONCEPT MAPS WEEK 12 5

Nursing Diagnosis:
Ineffective Health Maintenance related to
deficient knowledge concerning diet,
disease process (DM type 2), smoking, and
stating "you can't die from low blood
sugar."

Evaluation: Subjective:
• Patient joked about the need to check his Patient stated, "you can't die from low
BS. blood sugar."
• Patient demonstrated little to no interest Objective:
about disease process and smoking 4 Units sliding scale insulin given. A1c:
cessation. 5.9. Admission glucose of 61.

Teaching: Goals/Outcomes
• Teach patient about all aspects of the Short Term:
therapeutic regimen, providing as much Patient will demonstrate importance of
knowledge as the patient is willing to monitoring BS by end of shift.
accept.
Long Term:
• Teach patient about disease process and
explan that low blood sugar can kill him. Patient will verbalize ability to manage
Interventions: therapeutic regimens by discharge.
• Idenify patient's current knowledge and
adjust teaching accordingly.
• Explan the causes of chronic
pancreatitis.
• Evaluate whether or not patient abuses
alcohol.
• Evaluate understanding of dietary needs
and restrictions.
 POC & CONCEPT MAPS WEEK 12 6

Labs & Diagnostics (from prior care plan example) Must show trending…i.e. increasing, decreasing, stabilized, baseline)
[include all relevant normal & abnormal tests and analyze the results as related to this patient]
Test Date Result Trending Analysis
4/15/19 14.9 Normal Range WBC count indicates the possible presence and severity of
WBC-Leukocytes (4.5-11 x 103 cell/ infection or inflammatory response. Performed with CBC to
uL) evaluate a specific problem.
WBC 4/17/19 13.6 ^^^ Trending down. Patient has chronic pancreatitis.
4/15/19 5.0 Normal Range RBC may be part of routine CBC or may be repeated as a single
(Male: 4.6-6.0 x test when the patient’s health condition includes an abnormal
RBC- Red Blood Cells 106/uL) altered RBC. Also used to evaluate anemia and polycythemia.
(Female: 4.0-5.4 x
106/uL)
RBC 4/17/19 4.7 ^^^
4/15/19 15.8 Normal Range Used to measure the severity of anemia or polycythemia, and it
(Male: 14.0-18.0 monitors the response to treatment of anemia. An elevated Hgb
g/dL) value may be a result of either excess production of erythrocytes
HGB-Hemoglobin (Female: 12.0-15.0 by the bone marrow or dehydration which the patient was
g/dL) experiencing. In dehydration, the RBC counts and Hgb are
relatively high because of the normal number and quality of cells
that are concentrated in a smaller amount of fluid.
4/17/19 13.6 ^^^ Patient experienced episodes of N/V/D which results in
HGB
dehydration.
4/15/19 47.2 Normal Range Is useful in evaluation of blood loss, anemia, hemolytic anemia,
(36-50) polycythemia, and dehydration. Hct rises if the number or size of
the erythrocytes increases or when the plasma fluid volume is
HCT-Hematocrit
reduced. When fluid volume is decreased, the RBC become
concentrated in the smaller fluid volume. Blood is thicker or has
increased viscosity.
4/17/19 40.9 ^^^ Trending down. Patient experienced N/V/D and was NPO which
HCT
resulted in dehydration.
PLT - Platelets 4/15/19 523 Normal Range Used to assess the ability of the bone marrow to produce platelets
 POC & CONCEPT MAPS WEEK 12 7

(150-450 x 109/L) and to identify the destruction or loss of platelets in the
circulation. Also used to evaluate the untoward effects of
chemotherapy or radiation treatment. Platelets function to initiate
the process of coagulation.
4/17/19 439 ^^^ Trending down. Thrombocytosis with elevated platelets due to
PLT
inflammatory state. Patient receiving Lovenox for coagulopathy.
4/15/19 132 Normal Range Sodium level is used to monitor electrolyte balance, water
(135-145 mEq/L) balance, and acid-base balance. It is used for evaluation of
Na+ - Sodium
disorders of the CNS, musculoskeletal disorders, or disease of the
kidneys or adrenal glands.
4/17/19 134 ^^^ Hyponatremia. Mildly low. Patient was recently admitting for
Na+
DKA, experienced N/V.
4/15/19 4.1 Normal Range Potassium levels are used to evaluate electrolyte balance, acid-
(3.5-5 mEq/L) base balance, hypertension, renal disease, or renal failure, and
K+ - Potassium endocrine disease. It is used to monitor patients receiving
treatment for ketoacidosis, hyperalimentation, dialysis, diuretic
therapy, or IV fluid and electrolyte replacement.
K+ 4/17/19 4.0 ^^^ Patient’s K+ fluctuated because of dehydration.
4/15/19 98 Normal Range Chloride is used in evaluation of electrolyte levels, water
Cl -Chloride
(95-105 mEq/L) balance, and acid-base balance, and anion gap.
Cl- 4/17/19 101 ^^^ Patient was recently admitting for DKA, experienced N/V.
4/15/19 8.4 Normal Range Are used to assist in the diagnosis of acid-base imbalance,
Ca - Calcium (8.8-10.2 mg/ dL) coagulation disorders, pathologic bone disorders, endocrine
disorders, cardiac arrhythmia, and muscle disorders.
4/17/19 8.3 ^^^ Decreased calcium levels indicates hypocalcemia and vitamin D
deficiency, and malnutrition to name a few. Patient was
Ca+
previously not eating and had a poor diet. He had been NPO and
would not eat because pain would occur an hour after .
4/15/19 26 Normal Range Is used to help evaluate acid-base balance and the bicarbonate
CO2-Carbon Dioxide (23-29 mEq/L) buffer system. The concentration of CO2 is controlled by the lungs
and the concentration of bicarbonate is controlled by the kidneys.
CO2 4/17/19 23 ^^^ Decreased CO2 values can be caused diarrhea and dehydration
 POC & CONCEPT MAPS WEEK 12 8

which the patient experienced.
GLUC-Glucose 4/15/19 61 Normal Range Glucose is evaluated to diagnose and manage patients with
(79-160 mg/dL) diabetes mellitus.
GLUC 4/17/19 87 ^^^ Patient has knowledge deficit regarding disease process. Poor
DM management.
BUN- Blood Urea Nitrogen 4/15/19 27 Normal Range BUN is used to evaluate renal function and used to monitor
(7-20mg/dL) patients in renal failure or patients receiving dialysis therapy.
Decreased values may indicate overhydration, starvation, IV
therapy, low-protein diet, acromegaly, severe liver damage.
BUN 4/17/19 10 ^^^ Trending down, patient was not eating.
Cr-Creatinine 4/15/19 0.57 Normal Range Serum creatinine is to evaluate renal function and to estimate the
(0.6-1.2 mg/ dL) effectiveness of glomerular function.
Cr 4/17/19 0.54 ^^^ Indicator of possible muscle wasting from not eating.
Mg-Magnesium 4/15/19 Not Tested Normal Range Is used to evaluate renal function and to stage chronic renal
(130 mL/min) disease.
4/17/19 Not Tested
PT-Prothrombin time 4/15/19 15.2 Normal Range Helps to evaluate electrolyte disorders, hypocalcemia,
(10- 14 Seconds) hypokalemia, and acid-base imbalance.
4/17/19 Not Tested ^^^ Elevated values indicate hepatobiliary or pancreatic obstruction.
INR-Int. Normalized Ratio 4/15/19 1.2 Normal Range Helps diagnose kidney disorders and acid-base imbalance. Also
(2.8-4.5 mg/dL) used to detect disorders of calcium, bone, and endocrine origin.
4/17/19 Not Tested ^^^ Patient has poor management of DM.
AST-Aspartate 4/15/19 20 Normal Range Is used to detect hepatocellular injury or necrosis. Most specific
Aminotransferase Female 60-90: to detect acute hepatitis from a viral, toxic, or drug-induced
(10-28 IU/L) caused. It is used to help determine the source of jaundice.
AST 4/17/19 Not Tested ^^^
ALT-Alanine 4/15/19 55 Normal Range Is used as a nonspecific indicator of liver disease, biliary tract
Aminotransferase (Females 20-50: obstruction, bone disease, or hyperparathyroidism. It is part of a
42-98 U/L) battery of tests that evaluate liver function. Also serves as a tumor
 POC & CONCEPT MAPS WEEK 12 9

(Females 60 & Up: marker by indicating rapid cell growth or accelerated function
53-141 U/L) caused by malignancy of the liver or bone.
ALT 4/17/19 Not Tested ^^^ Trending down. According to CTH the first value was elevated
which may indicate liver disease. The patient’s labs are
appearing to indicate issues with liver, renal, or endocrine
systems.
Protein 4/15/19 5.1 Normal Range Provides general information about patient’s nutritional status
(6.4-8.3 g/dL) and the severity of diseases of the liver, bone marrow, and
kidneys. Also used to investigate cause of edema.
Pr 4/17/19 5.5 ^^^ Patient was not eating prior to admission. Decreased levels
indicate malnutrition.
Albumin 4/15/19 2.5 Normal Range Is used in detection of hepatobiliary disease and monoclonal
(3.5-5.0) gammopathy, and in the evaluation of nutritional status.
Alb 4/17/19 2.0 ^^^ Patient was not eating. Indicates moderate protein calorie
malnutrition.
Lipase 4/15/19 203 Normal Range Lipase is a pancreatic enzyme needed to help digest fatty acids. In
(< 200 units/L) pancreatic inflammation, this enzyme cannot flow into the
intestine because of inflammation or blockage in the pancreas,
pancreatic duct, common bile duct, or intestine. Once there is
obstruction, the lipase is secreted into the blood and the serum
level rises.
Li 4/17/19 186 ^^^ Elevated lipase indicated chronic pancreatitis.
Lipid Profile (Triglycerides) 4/15/19 89 Normal Range Lipid levels are used to identify individuals at risk for CAD and
(< 150 mg/dL) as an evaluation tool to determine the effectiveness of “heart
healthy” changes in lifestyle.
Lipid Not tested ^^^ Patient has a history of CAD.
EKG 4/15/19 Showed sinus rhythm at 88 bpm with normal R-wave progression,
normal T-waves, normal intervals.
Radiology (CT Scan) 4/15/19 CT of abdomen and pelvis showed pancreatic calcification
consistent with chronic pancreatitis. There is an enlarging cystic
collection at the anterior aspect of the pancreatic body,
measuring 11.3 x 6.6 x 7.5 (pancreatic pseudocyst).
 POC & CONCEPT MAPS WEEK 12
PEPCID
Trade Name
Generic Name
Drug Class
Route(s)
Drug Indications
Mechanism of Action
Onset of Action
Duration of Action
Contraindications
Drug Interactions
Adverse Effects
Nursing Considerations
(Before giving this drug, I
will…)
10
Medications – Current Medications and all PRN’s
Davis Pages: 637-639
Pepcid
Famotidine
Histamine H2 Receptor Antagonists/ Antiulcer
PO: 40 mg/daily at bedtime or 20 mg twice daily, for up to 8 weeks initially (Maintenance dose: 20 mg/daily). IV: 20 mg q
12 hours, diluted and given over 2 minutes.
Treatment of active duodenal ulcers and GERD. Management of gastric hypersecretory states (Zollinger-Ellison Syndrome).
IV: Prevention and treatment of upper GI bleed.
Inhibit the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of
gastric acid secretion.
Within 60 Minutes
8-15 Hours
Hypersensitivity; Some products contain alcohol and should be avoided in patients with known intolerance; Some products
contain aspartame and should be avoided in patients with phenylketonuria. Use caution with patient with renal impairment.
Famotidine, nizatidine, and ranitidine have a much smaller and less significant effect on the metabolism of other drugs
CNS: Confusion, dizziness, drowsiness, hallucinations, headache. CV: Arrhythmias. GI: Constipation, diarrhea, nausea,
drug-induced hepatitis. GU: Decreased sperm count, impotence. Endo: Gynecomastia. HEMAT: Agranulocytosis, aplastic
anemia. MISC: Hypersensitivity reactions.
Before giving this drug, I will check the CBC and differential counts daily. Advise patient that other medications may be
less effective because of increased stomach pH. I will teach the patient to take the medication as directed for the full course
of therapy. Notify HCP if difficulty swallowing occurs if abdominal pain persists. Smoking interferes with the action of
histamine receptor antagonists. Avoid alcohol, products containing aspirin or NSAIDs, excessive amounts of caffeine, and
foods that may cause an increase in GI irritation. Report immediately signs of bone marrow suppression, such as bleeding,
purpura, and sore throat. Report confusion or hallucinations immediately.
 POC & CONCEPT MAPS WEEK 12
FENOFIBRATE
Trade Name
Generic Name
Drug Class
Route(s)
Drug Indications
Mechanism of Action
Onset of Action
Duration of Action
Contraindications
Drug Interactions
Adverse Effects
Nursing Considerations
(Before giving this drug, I
will…)
11
Davis Pages: 543-544
Antara, Fenoglide, Lipofen, Lofibra, Ticor,
Fenofibrate
Lipid-lowering agent/Fibric Acid Derivative
PO: 145 mg/day
Management of type IIb hyperlipidemia (decreased HDL, increased LDL, increased triglycerides) in patients who do not yet
have clinical CAD and have failed therapy diet, exercise, weight loss, or other agents (niacin, bile acid sequestrants).
Inhibits peripheral lipolysis. Decreased triglyceride carrier protein. Increased HDL.
Unknown
Unknown
Hypersensitivity; Hepatic impairment (including primary biliary cirrhosis), severe renal impairment, concurrent use of
HMG-CoA reductase. Use cautiously with concurrent use of warfarin.
Increased anticoagulant effects of warfarin. HMG-CoA reductase inhibitors increases risk of rhabdomyolysis (concurrent
use should be avoided). Absorption is decreased by bile acid sequestrants (fenofibrate should be given 1 hour before or 4 – 6
hours after). Increased risk of nephrotoxicity with cyclosporine. Concurrent use with colchicine may increase risk of
rhabdomyolysis.
CNS: Dizziness, headache. EENT: Blurred vision. GI: Abdominal pain, D/N/V, epigastric pain, flatulence, gallstones,
heartburn. DERM: Alopecia, rash, urticaria. HEMAT: Anemia, leukopenia. MS: Myositis.
Before giving this drug, I will assess lipid panel, LFT, CBC, and electrolytes at baseline, and periodically while on
medication. Administration of these drugs with HMG-CoA reductase inhibitors increases the risk for rhabdomyolysis that
can result in renal failure. This medication should be used in conjunction with dietary restrictions, exercise, and cessation of
smoking.
 POC & CONCEPT MAPS WEEK 12 12

HUMALOG Davis Pages: 691. Mosby’s Pages: 671-674
Trade Name Humalog (Rapid-Acting Insulin)
Generic Name Insulin Lispro, rDNA Origin
Drug Class Antidiabetic Agent, hormone/ Pancreatic Agents
Route(s) SC: 0.2-0.6 unit/kg/daily
Drug Indications Treatment of diabetes mellitus. Very rapid acting.
Mechanism of Action Lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Other
actions are inhibition of lipolysis and proteolysis.
Onset of Action 5-15 minutes. Peak 30-60 minutes.
Duration of Action 3-5 hours
Contraindications Hypersensitivity to protamine, creosol.
Drug Interactions Increase: Hypoglycemia-salicylate, alcohol, B-blockers, anabolic
steroids, phenylbutazone, sulfinpyrazone, guanethidine, oral hypoglycemics, MAOIs, tetracycline. Decrease: Hypoglycemia-
thiazides, thyroid hormones, oral contraceptives, corticosteroids, estrogens, Dobutamine, Epinephrine. Increase: VMA,
Decrease: K+, Ca. Interference: LFTS, thyroid function studies.
Adverse Effects DERM: Urticaria. ENDO: Hypoglycemia, rebound hyperglycemia (Somogyi effect). RESP: Bronchospasm with inhaled
insulin. LOCAL: Lipodystrophy, itching, redness, swelling. MISC: Allergic reactions, including anaphylaxis.
Nursing Implications Because of the higher error rate, two nurses should check the insulin type, dosage, and expiration date. Very rapid-
acting agents are called “dose and eat” for a reason. Memorize the peak time of these medications! Look for
hypoglycemia (Normal 70-120 mg/dL). Hypoglycemia resembles an anxiety attack, with the person having cold, clammy
skin. Teach: Use U-100 syringes with solutions 100 units/mL. If using a prefilled pen, prime with 2 units prior to dialing
dosage. Sick days require more monitoring. Carry a source of glucose. Wear a Medic-Alert bracelet. Recognize s/s of
hyperglycemia and hypoglycemia and be aware of self-treatment measures if these occur.
 POC & CONCEPT MAPS WEEK 12
OXYCODONE
Trade Name
Generic Name
Drug Class
Route (s)
Drug Indications
Mechanism of Action
Onset of Action
Duration of Action
Contraindications
Drug Interactions
Adverse Effects
Nursing Considerations
(Before giving this drug, I
will…)
13
HIGH ALERT!!! Mosby’s Pages: 943-945. Davis Pages: 940-942
Oxy IR
Oxycodone/Acetaminophen
Opioid analgesic/Opioid Agonists and nonopioid combinations.
10 mg PO q4 hours PRN Severe (7-10)
Management of moderate to severe pain.
Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli, while producing generalized
CNS depression.
10-15 minutes.
3-6 Hours.
Hypersensitivity. Some products contain alcohol or bisulfites and should be avoided in patients with known intolerance or
hypersensitivity, significant respiratory depression, paralytic ileus; Acute or severe bronchial asthma. Acute, mild,
intermittent, or postoperative pain (extended-release). Use Cautiously in: Head trauma, increase intracranial pressure, severe
renal or hepatic disease, hypothyroidism, adrenal insufficiency, alcoholism, seizure disorders; Undiagnosed abdominal pain,
prostatic hyperplasia, difficulty swallowing or GI disorders that may predispose patient to obstruction (increased risk for GI
obstruction).
Use with caution in patients receiving MAO inhibitors (may result in unpredictable reactions increase initial dose of
oxycodone to 25% of usual dose). Additive CNS depression with alcohol, antihistamines, and sedative/hypnotics.
Administration of partial-antagonist opioid analgesics may precipitate withdrawal in physically dependent patients.
Nalbuphine, buprenorphine, or pentazocine may decrease analgesia. Potent CYP3A4 inhibitors including erythromycin,
ketoconazole, itraconazole, voriconazole, or ritonavir may increase levels. Potent CYP3A4 inducers including rifampin,
carbamazepine, and phenytoin may decrease levels.
CNS: Confusion, sedation, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. EENT: Blurred
vision, diplopia, miosis. RESP: Respiratory depression. CV: Constipation, N/V. GU: Urinary retention. DERM: Sweating.
MISC: Physical dependence, psychological dependence, tolerance.
Before giving this drug, I will assess type, location, and intensity of pain prior to and 1 hour (peak) after 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 analog scale or the patient reports satisfactory pain relief. A repeat dose can be
safely administered at the time of the peak if previous dose is ineffective and side effects are minimal. Naloxone (Narcan)
is the antidote. Treatment of overdose: Narcan 0.2-0.8 mg IV, O2, IV fluids, vasopressors, caution in patients physically
dependent on opioids.
 POC & CONCEPT MAPS WEEK 12
DOCUSATE
Trade Name
Generic Name
Drug Class
Route(s)
Drug Indications
Mechanism of Action
Onset of Action
Duration of Action
Contraindications
Drug Interactions
Adverse Effects
Nursing Considerations
(Before giving this drug, I
will…)
14
Davis Pages: 443-444. Mosby’s Pages: 405-406
Colace, Senna
Docusate Calcium (OTC)
Laxative, Stool Softener
PO: 50-300 mg/day (sodium) or 240 mg (calcium)
Prevention of dry, hard stools
Promotes incorporation of water into stool, resulting in softer fecal mass. May also promote electrolyte and water secretion
into the colon.
12-72 Hours
Unknown
Hypersensitivity, obstruction, fecal impaction, nausea, vomiting.
Toxicity: Mineral Oil. Increase laxative action- flax, Senna.
EENT: Bitter taste, throat irritation. GI: Nausea, anorexia, cramps, diarrhea. DERM: Rash
This medication does not stimulate intestinal peristalsis; stimulant laxative may be required for constipation. PO:
Administer with a full glass of water or juice. May be administered on an empty stomach for more rapid results. Oral
solution may be diluted in milk, infant formula, or fruit juice to decrease bitter taste. Do not administer within 2 hr of other
laxatives, especially mineral oil. May cause increased absorption.
 POC & CONCEPT MAPS WEEK 12
LISINOPRIL
Trade Name
Generic Name
Drug Class
Route(s)
Drug Indications
Mechanism of Action
Onset of Action
Duration of Action
Contraindications
Drug Interactions
Adverse Effects
Nursing Considerations
(Before giving this drug, I
will…)
15
Davis Pages: 161-167
Lisinopril
Prinivil, Zestril
Antihypertensive agent/ACE Inhibitor
PO: 10-40 mg/day
Used alone or with other agents in the management of HTN. Reduction of death or development of CHF after MI. Slowed
progression of left ventricular dysfunction.
ACE Inhibitors block the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. They also inhibit the renin-
angiotensin-aldosterone (Body’s salt) in the bloodstream.
1 Hour
24 Hours
Hypersensitivity; History of angioedema with previous use of ACE inhibitors
Excessive hypotension may occur with concurrent use of diuretics.
Additive hypotension with other antihypertensive agents. Risk of hyperkalemia with concurrent use of potassium
supplements, potassium-sparing diuretics, or potassium-containing salt substitutes.
CNS: Dizziness, fatigue, headache, weakness. RESP: Cough. CV: hypotension, chest pain, tachycardia. GI: Taste
disturbances, anorexia, abdominal pain, N/V/D, hepatotoxicity (rare). GU: erectile dysfunction, impaired renal function.
DERM: Rashes. F and E: Hyperkalemia. MISC: ANGIOEDEMA, fever. HEMAT: BMS.
Before giving this drug, I will always take the BP prior to administration. Monitor BP and pulse frequently during
initial dose adjustment and periodically during therapy. Assess patient for signs of angioedema (dyspnea, facial
swelling). Monitor RFT, LFT, CBC, serum glucose, and K+ increase. May cause increase in BUN and serum creatinine.
Asses for signs of CHF. Monitor I&O and daily weight.
 POC & CONCEPT MAPS WEEK 12
LACTATED RINGERS
Trade Name
Generic Name
Drug Class
Route(s)
Drug Indications
Mechanism of Action
Onset of Action
Duration of Action
Contraindications
Drug Interactions
Adverse Effects
Nursing Considerations
(Before giving this drug, I
will…)
16
Lewis, Dirksen, Heitkemper, Butcher, Harding. Pg: 292
Lactated Ringers
Sodium Chloride, Sodium Lactate, Potassium Chloride & Calcium Chloride
Fluid and Electrolyte Balancer
Intravenous Solution, IV.
As a source of water and electrolytes or as an alkalinizing agent.
USP produces a metabolic alkalinizing effect. Lactate ions are metabolized ultimately to carbon dioxide and water, which
requires the consumption of hydrogen cations. Restores fluid and electrolyte balances and produces diuresis.
Rapid
Duration of infusion
Patients with liver dysfunction, hyperkalemia, and severe hypovolemia. History of hypersensitivity to sodium lactate. Other
calcium-containing infusion solutions must not be administered simultaneously with intravenous calcium-containing
solutions, including Lactated Ringer’s. Use cation in those with renal impairment.
Do not use with ceftriaxone (Rocephin) due to the significant risk of ceftriaxone and calcium precipitation. May increase the
risk of sodium and fluid retention in use with corticosteroids. Use caution in patients treated with agents or products that can
cause hyperkalemia or increase risk of hyperkalemia, such as potassium sparing diuretics, with ACE inhibitors, angiotensin
II receptor antagonists, or the immunosuppressants tacrolimus and cyclosporine. Renal clearance of acidic drugs may
increase and alkaline may decrease. May increase risk of hypercalcemia.
Chest pain, abnormal heart rate, decreased blood pressure, troubled breathing, cough, sneezing, rash, itching, and headache.
Infection at the site of injection, venous thrombosis or phlebitis at the site of injection, extravasation, and increased fluid
volume (hypervolemia) may also occur.
Before giving this drug, I will assess for allergies and stop infusion immediately if any signs or symptoms of a suspected
hypersensitivity reaction develop. I will evaluate the patient and initiate appropriate therapeutic countermeasures. Should not
be administered simultaneously with blood through the same administration set because of the likelihood of coagulation.
Monitor vital signs and for fluid retention.
 POC & CONCEPT MAPS WEEK 12
LOVENOX
Trade Name
Generic Name
Drug Class
Route(s)
Drug Indications
Mechanism of Action
Onset of Action
Duration of Action
Contraindications
Drug Interactions
Adverse Effects
Nursing Considerations
(Before giving this drug, I
will…)
17
HIGH ALERT! Davis Pages: 634-637 Mosby’s Pages:456-458
Lovenox
Enoxaparin
Anticoagulant, Antithrombotic. Low-Molecular-Weight Heparin
SC: 30-40 mg daily
Prophylaxis in knee replacement: 30mg q12 hours given12-24hrs postop for 7-10 days.
Prophylaxis DVT/PE: 20mg daily
Prevention of DVT, PE, in hip and knee replacement, abdominal surgery at risk for thrombosis, unstable angina, acute MI,
coronary artery thrombosis. Used in very low doses (10 – 100 units) to maintain patency of IV catheters (heparin flush).
Binds to antithrombin III inactivating factors Xa/IIa, thereby resulting in a higher ratio of anti-factor Xa to IIa.
3-5 Hours
12 Hours
Hypersensitivity to this med, heparin, pork, active major bleeding, hemophilia, leukemia with bleeding,
thrombocytopenic purpura, heparin-induced thrombocytopenia.
Increase: Enoxaparin action, anticoagulants, salicylates, NSAIDS, antiplatelets, thrombolytics, RU-486, SSRIs, Monitor
INR/PT. Drug/Lab: Increase in AST, ALT. Decrease in platelet count. Increase bleeding risk, feverfew, garlic, ginger,
ginkgo, green tea, horse chestnut.
CNS: Fever, confusion. GI: Nausea. HEMA: Hemorrhage from any site, hypochromic anemia, thrombocytopenia,
bleeding. DERM: Ecchymosis, injection site hematoma. META: Hyperkalemia in renal failure. MS: Osteoporosis. SYST:
Edema, peripheral edema, angioedema, anaphylaxis.
Monitor for hypersensitivity, CBC with platelets, D-dimers studies, and LFT. Assess for any signs of bleeding and
hemorrhage. Teach: Report any symptoms of unusual bleeding or bruising immediately. Do not concurrently take
antiplatelet agents. Use soft-bristle toothbrush and an electric razor. Wear Medic Alert bracelet at all times. Follow
instructions on proper method of injecting med. Lovenox is given in the “love handles.” Antidote is Protamine sulfate.
POC & CONCEPT MAPS WEEK 12 18

Clinical Manifestations Pathophysiology: Clinical

Patient S/S: Manifestations Labs &
The outlet of the pancreas may become blocked due Diagnostics:
• Severe midline to inflammation, mechanically (gallstones), or by the
abdominal pain that digestive enzymes being prematurely activated while • Elevated ALT and
radiates to the flank, they are still in the pancreas. Protease causes dilation AST, amylase, lipase,
spine, and back. and permeablility of the capillaries, allowing fluid to ALP, bilirubin, LDH,
• Pain is lessened by move from the pancreas to the retroperitoneal space. potassium, and
drawing the knees up If fluid loss is severe, shock may occur. Protease glucose.
and worsened with initiates a chain reaction that results in conversion of • Low blood pressure
extension of the legs or prothrombin to thrombin, causing DIC. and increase pulse
ingestion of food. indicates shock.
• Complications: Shock, • CT scan and US to
respiratory distress show infiltrates in the
• Renal failure retroperitoneal and
• Signs of hemorrhage: pleural spaces.
Turner's sign (a purple
discoloration in the
flanks) & Cullen's sign
(a purple discoloration Pancreatitis
around the umbilicus). Usual Treatments:
Meds, Vaccinations,
Treatments
IV infusion of fluids,
volume expanders, and
Nursing Considerations: PRBCs.
Anticipated Nursing
Diagnoses: • Monitor pain level and medicate as Oxygen
needed. IV analgesics
• Acute Pain • Assess vital signs for increased pulse
• Risk for Deficient Fluid (meperidine rather than
and decreased BP. morphine to lessen
Volume/Bleeding • Monitor amylase and lipase levels and spasm of the sphincter
• Risk for Unstable Blood F & E levels. of Oddi)
Glucose Level • Assess for Turner's or Cullen's sign.
• Imbalanced Nutrition: Antiemetics
• Teach patient chronic alcohol
Less than body ingestion is a causative factor in NPO to avoid
requirements pancreatitis and Cholelithiasis may worsening
• Risk for Infection cause mechanical obstruction. autodigestion.
 POC & CONCEPT MAPS WEEK 12
Clinical Manifestations
Patient S/S:
• Sedentary lifestyle
• Elevated fasting blood
glucose levels
• Elevated postprandial
glucose levels
• Weight loss
• Polyuria, Polydipsia,
Polyphagia
• Elevated
glycohemoglobin
levels
Anticipated Nursing
Diagnoses:
• Deficient
Knowledge
regarding disease
process
• Risk for unstable
blood Glucose Level • Monitor HgbA1c and serum glucose
• Risk for Infection
• Monitor glucose level before meals and
• Risk for Disturbed
Sensory Perception
19
Pathophysiology:
Type 2 diabetes increases in incidence
with obesity, poor diet, and sedentary Clinical Manifestations
lifestyle as the cells of the body Labs & Diagnostics:
become resistant to insulin. Genetic • Glucose, fasting, whole
link (10 new gene variants that affect blood
blood glucose and insulin levels have • Glycosylated
been identified). Type 2 diabetes is hemoglobin assay
affecting more children related to poor • Anion Gap
diet and obesity.
• Electrolytes, serum
• Ketone bodies, blood
• Ketones, urine
• Osmolarity, plasma
Diabetes
Mellitus
Type 2
Usual Treatments:
Meds, Vaccinations,
Treatments
• Oral hypoglycemic
agents and drugs to
Nursing Considerations: lower insulin resistance;
insulin may be required
levels; monitor for complications. if these meds are
ineffective or the
at bedtime. Learn the symptoms of low patient is ill (increases
blood glucose and report if it occurs. glucose levels).
• Teach patient to: • Nutritional consult and
• Follow dietary, exercise, and med exercise regimen.
regimen. • Assessment for cardiac
• Check feet for sores. status with stress
testing, lipid profile,
• Report sensation or vision changes. cardiac rhythm strip.
• Renal tests
 POC & CONCEPT MAPS WEEK 12 20

Pathophysiology:
CAD results in interruption of blood flow that can cause Clinical Manifestations
ischemia or infarction as a result of atherosclerosis. The
inflammation attracts low-density lioproteins (LDL) and Labs & Diagnostics:
binds them to the site. The triglyceride core of the LDLs is • Cardiac Catheterization
spilled into the underlayer of the intima. Macrophages • Cardiac markers
envelop these fats and are now termed "foam cells." This is
a "fatty streak" seen in early stages of stherosclerosis. As • Electrocardiogram
the area englarges, more LDL, macrophages, platelets, and • Stress testing, cardiac
smooth muscle fibers are drawn to the site and accumulate • Cholesterol, total, serum or
under the intima, narrowing the vessel. This causes reduced plasma
blood flow and higher blood pressure in the small coronary • C-reactive protein
vessels. • Homocysteine, plasma
• Lipids, serum
Clinical Manifestations • Ultrafast CT scan to dtect
Patient S/S: calcium deposits in the
• Shortness of breath ateries.
with activity in a Coronary
patient with risk factors Artery
for heart disease such
as history of elevated Disease
blood lipids, smoking,
poor dietary habits, (CAD)
sedentary lifestyle, and Usual Treatments:
obesity. Meds, Vaccinations,
Treatments
• Dietary changes
Nursing Considerations: • Lipid-lowering
Anticipated Nursing
Diagnoses: • Lifestyle changes can drugs.
reverse CAD. • Cardiac
• Risk for decreased catheterization with
cardiac output • Assess shortness of breath
with activity. balloon angiography
• Acute Pain and stent placement,
• Teach patients that CAD
• Risk for Activity may be genetic, but there depending on
Intolerance are modifiable risk factors severity.
• Risk for powerlessness (cessation of smoking, • CABG
• Risk for Imbalanced healthy diet, exercising).
Nutrition
 POC & CONCEPT MAPS WEEK 12 21

Pathophysiology:
Hyperlipidemia is a condition where a group of metabolic
abnormalities of lipoproteins resulting in elevations of fasting
total cholesterol concentration. Lipids are not soluble in plasma
but are transported by the lipoproteins. Primary cause of
hyperlipidemia is genetics including isolated cholesterol
Clinical Manifestations elevation, elevated cholesterol and triglycerides, and isolated
Patient S/S: triglyceride elevation. Secondary cause is diet which includes
satuated and trans fat, excess calories, alcohol, red meat, whole
• Usually asymptomatic milk, and high sugar beverages and foods. Primary risk factor Clinical
until significant target for atherosclerosis, coronary artery disease, and cardiovascular Manifestations Labs
organ damage is done disease. Hyperlipidemia is more common in people with & Diagnostics:
(chest pain, MI; TIA, hypertension. • Elevated serum
stroke). total cholesterol
• May be metabolic signs • Elevated low-
such as corneal arcus, density lipoprotein
xanthoma, xanthelasma, (LDL)
and pancreatitis.
• Elevated
• Intermittent claudication Triglycerides
• Arterial occlusion of Hyperlipidemia • Decreased high-
lower extremities. density lipoproteins
• Complications: Disability (HDL)
from MI, stroke, and
lower extremity ischemia.

Usual Treatments:
Nursing Considerations: Meds, Vaccinations,
• Monitor blood levels for HDL & Treatments
Anticipated Nursing
Diagnoses: LDL. • Lipid-lowering drug therapy
• Assess vital signs, especially BP & (statins).
• Risk for Ineffective auscultate breath sounds. • Lipid-lowering agents: Garlic,
Cerebral Tissue • Assess for PVD. flaxseed, niacin, Omega-3
Perfusion fatty acid, psyllium, plant
• Obtain medical & diet history.
• Ineffective Health sterols, red yeast rice, & soy.
Maintenance • Teach patients the importance of
diet, exercise, & weight loss. • Treatment also includes weight
• Imbalanced Nutrition: loss, decreased dietary fat and
more than body • Encourage patient of smoking
cessation & limiting alcohol. cholesterol intake, & increase
requirements in activity level.
 POC & CONCEPT MAPS WEEK 12 22

Pathophysiology:
Blood pressure is determined by cardiac output, Clinical Manifestations
which is determined by heart rate multiplied by the Labs & Diagnostics:
stroke volume. The heart rate can be affected by
stimulation of the SNS responding to artieral • Creatinine serum or
baroreceptors that measure BP and by plasma
chemoreceptors that measure CO2 levels. Other • Protein, urine
mechanisms that alter BP include renin- • Renal biopsy
angiotensin-aldosterone system, exercise, • Renin, plasma
emotions, and taking meds that cause • Urea nitrogen (BUN),
vasoconstriction. High BP damages the intima of serum or plasma
arteries, making way for infiltration of • Sodium, serum or plasma
macrophages, muscle fibers, cholesterol, and fatty Usual Treatments:
acids that form atherosclerotic plaque. PVR is the • Urine Analysis
Meds, Vaccinations,
resistance to blood flow through arterioles creating Treatments
a high afterload. • Diuretics
• Antihypertensives
• Lifestyle changes
Hypertension • Smoking cessation
Clinical Manifestations program
Patient S/S:
• Systolic BP >139 mm Hg
& Diastolic BP >89 mm Nursing Considerations:
Hg. • Assess BP carefully in the
• Patient may have no correct way with the correctly
symptoms (Silent Killer). Anticipated Nursing sized cuff, the patient seated,
• Most common: Fatigue, Diagnoses: and sphygmomanometer at heart
dizziness, palpitations, • Deficient Knowledge level. Take BP after 5 minute of
angina, & dyspnea. regarding condition, rest.
• In severe cases: headache, therapeutic regimen, & • Teach patients to change
nausea or vomiting, potential odifiable risk factors, avoid
confusion, visual changes complications. added salts, decrease caffeine
or nosebleed. • Risk for decreased intake, drink alcohol
Cardiac Output moderately, take prescribed
• Risk for Activity meds regularly, and manage
Intolerance stress through exercise or
meditative means.
• Acute Pain
POC & CONCEPT MAPS WEEK 12 23

Reference

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Leek, Valerie I. Deglin, Judith Hopfer. (2018) Pharm Phlash! Pharmacology flash cards. Philadelphia: F.A. Davis Company.

Lilley, L., Collins, S., Snyder, J. (2017). Pharmacology and the Nursing Process, 8th Edition.

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Lewis, Bucher, Heitkemper, Harding, Kwong, Roberts. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical

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