Patient Care Plan

7/24/2019 Patient Care Plan

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CSU, STANISLAUS B.S.N.CLINICAL PLAN OF CARE

Student: Maggie Fabry Date of Care: 09-19-13 Room Number: 325

Patient Data

Admitting Diagnosis: Acute chronic alcohol intox Age: 47 Spiritual Focus: None Culture: CaucasianPatient Initials: PM Gender: F Height: 5 2 Weight: 109 lbs Admitting Date: 9/17/13 POD: NAVital Signs: T: 36.8 P: 74 R : 18 B/P: 148/88 O2Sat: 96 Pain Scale: 0Past Medical History: Asthma, COPD, bronchitis, anxiety, arthritis, alcoholism, fibromyalgia, smoking !pack/day

Surgical History: bilateral hip replacement, cataract

Diet: Regular Activity: Progressive gait; ambulates with assistance Foley: N NG/Feeding Tube: NAdvance Directives: No Drains/ Tubes: NCode Status: DNAR VS Freq: Q6H Glucose Monitoring: N TEDs/SCDs: NVascular Access: PCA/Epidural: N Telemetry: YIV Site: peripheral IV L antecubital space, 22 gauze IV Solution: SL Safety Considerations: Fall risk; latex precautionsDressing Changes: N Labs to be drawn: N Scheduled Procedures: N

Notes on pathophysiology:

Alcohol dependency: If you continue to abuse alcohol, it can lead to alcohol dependence. Alcohol dependence is also called alcoholism. You are physically ormentally addicted to alcohol. You have a strong need, or craving, to drink. Alcoholism is a long-term (chronic) disease. It's not a weakness or a lack of willpower. Likemany other diseases, it has a course that can be predicted, has known symptoms, and is influenced by your genes and your life situation.

Asthma: Chronic lung disease that inflames and narrows the airways. Asthma causes recurring periods of wheezing, chest tightness, shortness of breath, andcoughing. The coughing often occurs at night or early in the morning. People who have asthma have inflamed airways. This makes them swollen and very sensitive.They tend to react strongly to certain inhaled substances. When the airways react, the muscles around them tighten. This narrows the airways, causing less air toflow into the lungs. The swelling also can worsen, making the airways even narrower. Cells in the airways might make more mucus than usual. Mucus is a sticky, thick

liquid that can further narrow the airways. This chain reaction can result in asthma symptoms. Symptoms can happen each time the airways are inflamed.http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/

COPD: progressive disease that makes it hard to breath over time. Symptoms include coughing that produces large amounts of mucus, wheezing, shortness ofbreath, chest tightness. Cigarette smoking is number one cause. The airways and air sacs lose their elastic quality. The walls between many of the air sacs aredestroyed. The walls of the airways become thick and inflamed. The airways make more mucus than usual, which can clog them. This makes gas exchange

impaired. COPD consists of emphysema and chronic bronchitis. http://www.nhlbi.nih.gov/health/health-topics/topics/copd/

Bronchiitis: the lining of the airways is constantly irritated and inflamed. This causes the lining to thicken. Lots of thick mucus forms in the airways, making it hard to

breathe.


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Anxiety: characterized by excessive, exaggerated anxiety and worry about everyday life events with no obvious reasons for worry. People with symptoms ofgeneralized anxiety disorder tend to always expect disaster and can't stop worrying about health, money, family, work, or school. In people with anxiety, the worry isoften unrealistic or out of proportion for the situation. Daily life becomes a constant state of worry, fear, and dread. Eventually, the anxiety so dominates the person'sthinking that it interferes with daily functioning, including work, school, social activities, and relationships. http://www.webmd.com/anxiety-panic/guide/generalized-anxiety-disorder

Arthritis: Arthritis is inflammation of one or more of your joints. The main symptoms of arthritis are joint pain and stiffness, which typically worsen with age. The twomost common types of arthritis are osteoarthritis and rheumatoid arthritis. Osteoarthritis is usually just caused by the normal wear and tear of life.

Fibromyalgia: Fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Researchersbelieve that fibromyalgia amplifies painful sensations by affecting the way your brain processes pain signals. Symptoms sometimes begin after a physical trauma,surgery, infection or significant psychological stress. In other cases, symptoms gradually accumulate over time with no single triggering event.

http://www.mayoclinic.com/health/fibromyalgia/DS00079/DSECTION=treatments-and-drugs

Lab and Diagnostic Test DataTest

type(date)Normal Range Patient Results Trend

"#Rationale

(specific to pt.)Nursing Implications related to patient care &

teachingGlucose 74-118 120 Monitoring blood

glucose levels that

could be altered due

Pt blood glucose levels are ever so slightly above normallimits. Monitor glucose levels closely for further increases.

Signs of hyperglycemia include frequent urination,


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Testtype(date)

Normal Range Patient Results Trend"#

Rationale(specific to pt.)

Nursing Implications related to patient care &teaching

to meds the pt istaking.

increased thirst, blurred vision and headache. Signs ofhypoglycemia include confusion, abnormal behavior,vision disturbances, shakiness, anxiety and sweating.

BUN 8-26 6 Used to monitorkidney function. Pt

has an elevated BPand chronic htn can

cause kidneydisease, so functionmust be monitored.

Pt has below normal levels. This decrease could indicatemalnutrition associated with this pts alcoholism and

withdrawal. Could also be due to her high BP. Monitors/s of kidney malfunction such as nausea, vomiting, or

abdominal pain. Monitor other electrolyte levels toensure nutrition.

Creatinine 0.44-1.00 0.65 Used to monitorkidney function. Pthas an elevated BPand chronic htn can

cause kidneydisease, so functionmust be monitored.

Pt is WNL. An increase in levels could indicate kidneydisease or dehydration. Monitor s/s such as low output,

low appetite, nausea and vomiting, and persistent fatigue.A decrease could indicate malnutrition or severe liver

disease or muscle dystrophy. Monitor s/s such asnausea, vomiting, abdominal pain or jaundice or frequent

falls or waddling gait.

eGFR >=60 >60 Used to monitorkidney function andthe stage of kidney

failure.

Pt is WNL. If levels fall below 60, kidney failure could beindicated. Use creatinine levels to confirm. Watch for s/s

of kidney disease such as low output, low appetite,nausea and vomiting, and persistent fatigue. Note thatage, gender, height, race and weight can influence the

glumerular filtration rate.

Sodium 136-145 135 Used to monitor fluidand electrolyte

balance.

Pt levels slightly low. Watch for a decrease (hypoatremia)and s/s such as weakness, fatigue, headache, nauseaand vomiting, muscle cramps, irritability, and confusion.Low sodium levels can indicate dehydration. Pt teaching

about how hydrating can prevent low sodium levels.

Potassium 3.6-5.1 3.7 Used to ensureelectrolyte balance.

Pt came in for adetox so nutritional

status and hydrationcould be

compromised. Holdmeds if levels are

abnormal or nearlyabnormal. Also, pH

imbalance can effectK levels. Since this pt

is a smoker, pH

Pt WNL. An increase in these levels could indicate

kidney disease. Monitor s/s such as low output, lowappetite, nausea and vomiting, and persistent fatigue. Adecrease in levels could indicate excessive potassium

loss in the urine. This could be due to a large variety ofissues such as GI disorders, renal tubular acidosis, or

hyperaldosteronism. Monitor s/s such as muscle aches,abnormal weakness, arrhythmias, diarrhea, and nausea

and vomiting.


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Testtype(date)




levels as well as Klevels must be

monitored.

Chloride 101-111 99 Used to monitorelectrolyte balance.

Chloride followssodium, and watermoves with bothelectrolytes. As a

result, chlorideeffects water

balance. It also helpsthe acid base

balance in the body.Chloride is controlled

by the kidneys, soabnormal levels can

indicate renalproblems.

Pt slightly below normal limits. Monitor for s/s ofhypochloremia such as hyperexcitability of the nervous

system and muscles, shallow breathing, hypotension andtetany. Hyperchloremia can be indicated through s/s such

as lethargy, weakness and deep breathing. Monitor forthese signs and symptoms and continue to check lab

values for changes

Carbon Dioxide 22-32 26 Used to monitor acidbase balance in thebody as well as toassist in evaluatingthe pH. This pt has

COPD, monitoring forCO2 retention.

Pt is WNL. Watch levels to ensure they do not increase.s/s include rapid respiration, rapid pulse rate, and SOB.

As CO2 levels increase, there could be a reduction in ptsover all LOC. Monitor levels for any dramatic increasesbecause it could lead to respiratory arrest. S/s of low

CO2 levels (respiratory alkalosis) include confusion, handtremor, light headedness or nausea and vomiting.

Anion Gap 5.0-15.0 13.7 Used to monitor acidbase balance.

Pt is WNL. An increase could indicate lactic acidosis orkidney failure. S/s would include headache, palpitations,

chest pain as well as kidney disease s/s. A decrease

could indicate a low sodium blood level or bone marrowcancer.

Calcium 8.9-10.3 8.2 Used to monitorparathyroid function

and calciummetabolism. Alsoused to monitorkidney function.

Pt slightly below normal limits. S/s of progressinghypocalcemia would include tingling in hands, feet or lips,

muscle spasms or slow uneven heart beat. Watch forthese symptoms and continue to monitor labs. A calciumsupplement may be needed is levels continue to decline.

WBC Count 4.8-10.8 7.2 Used to help in theevaluation of

infection, neoplasm,allergy or

Pt WNL. A decrease could indicate drug toxicity, bonemarrow failure, or a dietary deficiency. S/s would includebleeding or bruising. An increase could indicate infectionor dehydration. S/s would include malaise or fever. Will


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Testtype(date)




immunosuppression.This pt is a smoker

and an alcoholic so atest to spot an

infection or a low

immune system isnecessary.

monitor pt for s/s of infection and will assess new labs asthey come.

RBC Count 3.80-5.40 3.86 Closely related tohemoglobin and

hematocrit levels.Conducted as aroutine part of acomplete blood

count. Also used tocheck for anemia.

Pt levels WNL. A decrease could indicate anemia, renaldisease, or bone marrow failure. S/s would depend on

the disease process being indicated. An increase couldindicate severe COPD of severe dehydration. S/s of

increased severity of COPD include an ongoing coughthat produces a lot of sputum, SOB, wheezing or chest

tightness.

Hemoglobin 11.5-15.5 13.0 Used to monitor theoxygen-carrying

capacity of the blood.In this pt, used to

monitor the severityof her COPD.

Pt WNL. An increase could indicate severe COPD. S/swould include severe SOB upon little activity, a cough

that wont go away, and possibly mucous being coughedup. A decrease could indicate anemia, renal disease, orbone marrow failure. S/s would depend on the disease

process being indicated. I will monitor labs for anincrease which would indicate an escalation in the pts

COPD.

Hematocrit 35-47 38.6 This test closelyreflects the

hemoglobin values.Used to further

evaluate the ptsCOPD status.

Pt WNL. A drop in levels could indicate anemia, renaldisease, or bone marrow failure. S/s would depend on

the disease process being indicated. An increase couldindicate severe COPD or severe dehydration. S/s of

increased severity of COPD include an ongoing coughthat produces a lot of sputum, SOB, wheezing or chest

tightness.Red Cell

DistributionWidth

11.5-15.5 15.6 This is an indicationof the variation of

RBC size. Used toindicate a conditioncalled amisocytosis.

Pt is very slightly above normal limits. An increase levelin RCDW could indicate a large variety of different kindsof anemia. S/s would include easy fatigue and a loss of

energy, SOB, dizziness and pale skin.

Platelet CountAuto

130-400 233 Used to monitorplatelet number in theblood. Used in this pt

to monitor risk forbleeding.

Pt WNL. An increase could indicate anything frommalignant disorder like leukemia or lymphoma to

rheumatoid arthritis. A decrease could indicate immunethrombocytopenia in which antibodies would be

destroying the bodys platelets. Monitor for s/s such aseasy or excessive bruising, superficial bleeding into the


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Testtype(date)




skin, or blood in urine or stools. Will monitor levels forchanges and look for s/s associated with abnormal levels.

NRBC# 0 0.0 This is a tool used toindicate a situation in

which a serious

underlying diseasecould be present.

Pt at normal limit. The presence of nucleated red bloodcells could indicate a variety of problems such as bone

marrow replacement, anemia, asplenia, hypoxia or

extramedullary hematopoiesis.

Total Protein 6.1-7.9 6.5 Used to diagnose,evaluate and monitor

disorders such asliver dysfunction,impaired nutrition,

and protein-wastingstates. For this pt itis most likely beingused to monitor her

nutrition and to check

for impairment.

Pt WNL. A decrease in levels could indicate malnutrition.S/s to watch for would include weight loss, weakness ormuscle fatigue, increased susceptibility to infections, ordelayed healing of even small wounds. An increase in

levels could indicate dehydration or inflammatorydisease. Inflammatory diseases are characterized by

episodes of inflammation that result in fever, rash or jointswelling. Will monitor lab values and use albumin and

globulin levels to confirm any abnormalities.

Albumin 3.5-4.8 3.9 Just like the totalprotein test, this testis used to diagnose,evaluate and monitor

disorders such asliver dysfunction,impaired nutrition,

and protein-wastingstates. For this pt itis most likely beingused to monitor her

nutrition and to checkfor impairment.



episodes of inflammation that result in fever, rash or jointswelling. Will monitor lab values and use total protein

and globulin levels to confirm any abnormalities.

Globulin 2.3-3.5 2.6 Just like the totalprotein test and

albumin, this test isused to diagnose,

evaluate and monitordisorders such asliver dysfunction,impaired nutrition,

and protein-wastingstates. For this pt it



episodes of inflammation that result in fever, rash or jointswelling. Will monitor lab values and use albumin and

total protein levels to confirm any abnormalities.


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Testtype(date)




is most likely beingused to monitor her

nutrition and to checkfor impairment.

ALB/SGOT 15-41 124 Used in theevaluation of pts thatare expected to have

hepatocellulardiseases such as this

pt who abusesalcohol use regularly.

Pt levels are significantly above normal. This increase

could indicate liver disease. Signs to watch for includeloss of appetite, loss of energy, weight loss, jaundice, orfluid retention. Another set of labs was not completed forthis pt. This leads me to believe that these levels mightbe expected from a pt who is admitted for detox. Plan towatch for these signs and symptoms and inquire about

the test during my next trip to the hospital.

AST/GLOB ratio 0-35 1.5 Used in theevaluation of pts thatare expected to have

hepatocellulardiseases such as this

pt who abusesalcohol use regularly.

Pt WNL. An increase could indicate liver disease. Signsto watch for include loss of appetite, loss of energy,

weight loss, jaundice, or fluid retention. A decrease couldindicate renal disease. S/s to watch for will include low

output, low appetite, nausea and vomiting, and persistentfatigue.

Alkalinephosphatase

38-126 64 Used to detect andmonitor diseases of

the liver or bone.

Pt WNL. An increase in these levels could indicateprimary cirrhosis or bone disease. S/s of cirrhosis

include loss of appetite, loss of energy, weight loss,jaundice, or fluid retention. S/s of bone disease would

include pain, weakness or tingling in the affected area. Adecrease in levels could indicate malnutrition. These s/s

include weight loss, weakness or muscle fatigue,increased susceptibility to infections, or delayed healing

of even small wounds.

ALT/SGPT 14-5471

Used to identifyhepatocellular

diseases of the liveror to monitor theimprovement or

worsening states ofthese diseases.

Because this pt is analcoholic, liver

function must bemonitored for

damage.

Pt levels are significantly above normal. This couldindicate cirrhosis, hepatic tumor or obstructive jaundice.

A further increase could indicate hepatitis. Signs to watchfor include loss of appetite, loss of energy, weight loss,jaundice, or fluid retention. Another set of labs was not

completed for this pt. This leads me to believe that theselevels might be expected from a pt who is admitted for

detox. Plan to watch for these signs and symptoms andinquire about the test during my next trip to the hospital.

Bili Total

0.4-2.0 1.5This is yet another Pt WNL. An increase in this level could indicate liver


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Testtype(date)




test to evaluate liverfunction.

disease. S/s would include loss of appetite, loss ofenergy, weight loss, jaundice, or fluid retention. Will

watch for s/s and monitor pt closely.

Medication Allergies: Penicillin, Latex

MedicationsGeneric & Trade Name

Drug classification(Therapeutic &Pharmacologic)

dose/RouteFrequency

Action of drugand Rationale(specific to Pt)

Significant Side Effects Nursing Implications related topatient care and teaching

Thiamine HCL (Biamine)

Vit B1; Water Soluble

100mg/PO/daily Water-solublevitamin; combines

with adenosinetriphosphate and

thiaminediphosphokinase to

form thiaminepyrophosphate, a

coenzyme essentialfor normal growth

and aerobicmetabolism, nerve

impulse transmission,and acetylcholine

synthesis.

Used to preventWernicke syndrome

which involves a

deficiency of thiaminewhich most often

results fromalcoholism. Given tothis patient for heralcohol abuse and

dependence.

Cyanosis, pulmonary edema, GI tracthemorrhage, cardiovascular collapse,

angioedema, anaphylactic shock, death

Instruct pt to watch for signs andsymptoms of serious allergic reaction

which can include rash, itching orswelling, severe dizziness, or troublebreathing. Instruct pt to not crush orchew enteric-coated tablets. Upon

discharge, perform pt teaching aboutfood that are rich in thiamine. Thesefoods include yeast, pork, beef, liver,

wheat and other whole grains, nutrient-added breakfast cereals, fresh

vegetables, especially peas and driedbeans.

Metoprolol Tartrate(Lopressor)

Beta-adrenergic blocker;cardiovascular agent

50 mg/PO/BID Selective activity onbeta-1

adrenoreceptorslocated mainly in

cardiac muscles. At

Bronchospasm, bradyarrhythmia, heartblock, heart failure, hypotension,constipation, diarrhea, nausea,

dizziness, headache, depression,dyspnea.

Instruct pt to take with or immediatelyfollowing meals. Swallow tab whole withglass of water. Monitor BP regularly and

especially near the end of the dosinginterval to confirm 24-hr hypertension


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higher doses, it mayinhibit beta-2

adrenoreceptors ofbronchial and

vascular smoothmuscles. Possible

mechanisms of

antihypertensioneffects include:competitive

antagonism ofcatecholamines at

peripheral andcardiac adrenergicreceptors, a central

effect leading toreduced sympathetic

outflow, andsuppression of rennin

activity.

Given to this pt tolower her BP which

was high onadmission andsteadily high

throughout visit.

control. Monitor BP, HR and ECG inearly treatment to assess for MI.

Regularly monitor HR and rhythm duringtherapy. Pt teaching regarding the

avoidance of activities requiringcoordination until drug effects arerealized. Advise pt to report s/s of

cardiac failure such as pulmonaryedema, dyspnea, cyanosis, peripheraledema, hepatomegaly. Be aware thatdurg may mask s/s of hypoglycemia.

Advise pt to take ER tabs after meals.DO NOT ABRUPTLY STOP TAKING

MED. The dosage should be graduallyreduced over a period of 1 to 2 weeks.

Folic Acid (Folvite)

Vit B Complex group; water-soluble vitamin

1 mg/PO/daily Stimulates productionof red and whiteblood cells and

platelets in some

megaloblasticanemias.

Given to this patientbecause folatedeficiency is

accelerated byalcohol consumption

Confusion, depression, excitability,irritability, anorexia, nausea, rash,pruritus, erythema, bronchospasm,

anaphylaxis

Assess for signs of megaloblastic anemiawhich can include anemia, fatigue,

dyspnea or weakness. Evaluate pt to seeif therapeutic response is indicated

through increased orientation andabsence of fatigue. Perform pt teachingabout replacing folic acid supplements

with foods rich in folic acid such as organmeats, vegetables and fruit.

Amlodipine (Norvasc)

Calcium Channel blocker;dihydropyridine

5mg/PO/daily Blocks thetransmembrane influx

of calcium ions intocardiac and vascularsmooth muscles. It

Acute MI, angina, angioedema,flushing, peripheral edema, nausea,

dizziness, fatigue

Pt should avoid activities requiringcoordination until drug effects arerealized as drug may cause dizziness.

Assess pt regularly for peripheraledema. Assess heart sounds and ECG


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also reducesperipheral vascular

resistance and lowersBP by causing directvasodilation in the

peripheral arteries ofthe vascular

smoother muscle.

Given to this pt toreduce her BP

(antihypertensive)

for palpitations. Instruct pt to notify youif experiencing adverse effects such asfatigue, headaches, abdominal pain,nausea. Instruct pt to report s/s of MIsuch as pain, fullness, and/or squeezingsensation of the chest, jaw pain,toothache, headache, SOB, nausea,

vomiting, and/or general epigastric(upper middle abdomen) discomfort,sweating, heartburn and/or indigestion,arm pain (more commonly the left arm,but may be either arm) or upper backpain. When increasing dose, useespecial precaution in COPD becausethere is an increased risk of worseningangina

Influenza Virus (Fluvirin)

Vaccine

0.5mL/IM/once Live attenuatedinfluenza vaccine

viruses replicateprimarily in theciliated epithelial cells

of thenasopharyngeal

mucosa to induceimmune responses

(via mucosalimmunoglobulin [Ig]A,

serum IgGantibodies, and

cellular immunity),but LAIV viruses donot replicate well at

the warmertemperatures foundin the lower airwaysand lung. During thecourse of replication,all LAIV viral proteinswould be presented

to the immunesystem in their nativeconformation and in

the context of

Stevens-Johnson syndrome,anaphylaxis, fatigue, fever, headache,

erythema at injection site or tenderness.

Inject into the deltoid muscle. EMCprotocol: MAKE SURE DOCTOR HAS

ORDERED VACCINE AND THAT PTHAS SIGNED AN INFORMEDCONSENT DOCUMENT! Explain

procedure to pt. Prepare medication andselect an appropriately sized needle.Cleanse skin with antiseptic. Remove

needle from protector and expel any airfrom the syringe. Inject needle into skinat 90 degree angle. Do not aspirate with

deltoid muscle injections. Withdrawneedle and activate safety device.

Massage area gently and inform pt thatthey may experience muscle sorenessfor a few days following the injection.

Advice pt to report any unusual or severereactions following the vaccination.


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histocompatibilityproteins.

Given to prevent thispt from getting the

influenza virus.

Oxybutynin Chloride(Ditropan)

Antimuscarinic; urinaryantispasmodic

5mg/PO/BID Causes relaxation ofthe bladder smoothmuscle by reducing

the muscarinic effectof acetylcholine onsmooth muscle. Inpts with involuntary

bladder contractions,oxybutyin chlorideincreases bladder

capacity, reduced the

frequency ofuninhibited

contractions of thedetrusor muscle, and

slows the initialdesire to void leading

to a decrease inurgency and

frequency of bothincontinent episodes

and voluntaryurination.

Given to this pt toimprove her bladder

incontinence.

Confusion, seizure, psychotic disorder,angioedema, mycosis, constipation,gastroenteritis, nausea, dizziness,

headache, somnolence

Instruct pt to swallow ER tabs whole andto take med with liquid; do not crush,divide or chew. This medication may begiven with or without meals. Assessregularly for symptomatic improvement.Pt should avoid activities requiringmental alertness until drug effects arerealized as drug may cause drowsinessor blurred vision. Monitor I&O becausedrug can cause urinary retention.Instruct pt to immediately report s/s of

angioedema such as Large, thick, firmwelts, swelling of the skin, pain orwarmth in the affected areas, difficultybreathing or swallowing, in severe cases.

Advise pt to report s/s of severe CNSeffects including hallucinations, agitation,and confusion. Advise pt thatconcomitant use of alcohol may enhance

drowsiness.

Metoclopramide (Reglan)

Antiemetic; dopamineantagonist

10mg/PO/daily Promotes motility inthe upper

gastrointestinal tractby sensitizing tissues

to the action ofacetylcholine. Ithastens gastricemptying and

Neuroleptic malignant syndrome,tardive dyskinesia, body fluid retention,nausea, vomiting, asthenia, headache,

somnolence, fatigue

Advice pt to administer 30 minutesbefore each mean and at bedtime or as a

single dose. Administer on an emptystomach and do not repeat dose if takenwith food. Discard tablet if it breaks orcrumbles. Monitor hydration level and

BP. Assess for s/s of extrapyramidal sideeffects and parkinsonian-like symptoms.


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intestinal transit byincreasing tone andamplitude of gastric

contractions.

Given for nausea anddehydration for this

pt.

Teach pt to avoid activities requiringmental alertness until drug effects are

realized. Instruct pt to report s/s oftardive dyskinesia which include jerkymuscle movements, tongue thrusting,

facial grimacing/ticks, and randommovements of extremities. This disorder

is serious and often irreversible so knowthat risk is increased with duration oftreatment and total cumulative dose.Instruct pt to not drink alcohol while

taking this drug.

Gabapentin (Neurontin)

Anticonvulsant; gammaaminobutyric acid

600mg/PO/TID Structurally related tothe neurotransmitter

GABA, however,gabapentin and itsmetabolites do notbind to GABA or

GABA B receptors or

influence thedegradation oruptake of GABA.

The mechanism inwhich gabapentin

exerts its analgesicand anticonvulsanteffects is unknown.

For pts arthritis andfibromyalgia related

pain in this pt.

Stevens-Johnson syndrome, drughypersensitivity syndrome, drug-induced coma, seizure, suicidal

thoughts, peripheral edema, nausea,vival diease, ataxia, dizziness,nystagmus, hostile behavior

Advise pt to immediately report a rash orother s/s of hypersensitivity such as feveror lymphadenopathy. Instruct pt to report

new or worsening depression, suicidalideation or unusual changes in behavior.

Advise pt against sudden discontinuationof drug, as this may increase seizure

frequency. Pt should avoid alcohol whiletaking this drug.

Tiotropium Bromide(Spiriva)

Antimuscarinic;bronchodilator.

18 mcg INHcap/rt daily Long-actingantimuscarinic agent,which isoften referred

to as ananticholinergic.It

exhibitspharmacologicaleffects throughinhibition of M3-receptors at thesmooth muscle

leading tobronchodilation.

Bowel obstruction, hypersensitivityreaction, cerebrovascular accident,constipation, upper respiratory infection,

pharyngitis, sinusitis, xerostomia

Readvise pt on proper method ofmedication administration; place capsuleinto the center of chamber, close

mouthpiece; press and release thepiercing button only once; exhale

completely then inhale med powder andhold breath for as long as is comfortable;

repeat exhalation and inhalation oncemore before discarding. Advise pt that

drug is not indicated for acutebronchospasm. Instruct pt to report s/s

of acute narrow-angle glaucoma such aseye pain or discomfort, blurred vision, or


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For pts COPD andasthma.

vision halos.

LORazepam (Lorazepam)

Sedative, hypnotic; anti-anxiety; benzodiazepine,

short acting.

1mg/IV/Q2HR Potentiates theactions of GABA,especially in the

limbic system and the

reticular formation.

Used in this pt tocombat symptoms ofalcohol withdrawal.

Dizziness, drowsiness, confusion,depression, orthostatic hypotension,ECG changes, tachycardia, apnea,

cardiac arrest, blurred vision,

constipation.

Observe pt for changes in mental status.Monitor for drowsiness, dizziness, andsuicidal tendencies. Asses for physicaldependency and withdrawal symptoms

such as headache, nausea, vomiting,muscle pain, weakness, tremors,seizures. Assist pt with ambulationduring beginning of therapy since

dizziness can occur. Perform pt andfamily teaching that med must be takenwith food. Instruct pt not to take med formore than 4 mo unless directed. Instruct

pt to avoid alcohol while takingmedication. Finally, instruct pt not to

discontinue med abruptly after long-termuse and to rise slowly because fainting

can occur. Dilute med with an equalvolume of NS immediately prior to useand mix thoroughly by gently. Give over

a period of 1 to 2 minutes.

Ondansetron HCL (Zofran)

Antiemetic; serotonin type 3antagonist;

4mg/IV/Q4H PRN Blocks serotonin a 5-HT receptor sites in

vagal nerve terminalsby disrupting CNS

chemoreceptortrigger zone.

To reduce nausea

related to long termabuse of alcohol andalcohol withdrawal.

Headache, fatigue, chest pain,hypotension, constipation,

bronchospasm

Monitor GI status. Auscultate bowelsounds and palpate for tenderness.

Watch for hypotension andbronchospasm. Instruct pt to

immediately report symptoms of allergicreaction such as rash or hives. Giveundiluted by direct IV and administerslowly over 2 to 5 minutes. Flush SL

before and after administration with 5mLof water.


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LA8/2011 15

Concept Mapping

Step 2. List clinical manifestations under each nursing diagnosis and other relevant data to support each diagnosis, including labdata, medications, interventions, and assessment findings. All medical & nursing interventions should be found in one or more of theboxes.

ND #1: Risk for Injury

Data to support:

Excessive drinking which impairscognition.

Pt has a latex allergy which puts her at

great risk every time she is in the

hospital.

Pt requires help when ambulating

Pt lives alone.

ND #2: Anxiety

Data to support:

Administration of LORazepam for anxiety.Anxiety due to living alone.

Pt expresses need for medication when anxiety

become unbearable for her.

Admission of having an anxiety disorder.

High BP since admission.

ND # 3: Risk for loneliness

Data to support:

Pt lives alone.Pt alcoholism makes her

behavior socially unacceptable.

Pt expresses need to be around

others.

Pt has repeatedly tried to get

into a care home but is

continually denied.

ND #4: Risk-prone health

behavior

Data to support:Smoking

Alcoholism

Living alone and becoming

intoxicated.

Pt recent fall while

intoxicated

Chief Medical Diagnosis: Acute Chronic

Alcohol Intox

Priority Assessments: Assess mental state.Assess lab values related to nutrition and

hydration status and liver disease.

7. Discharge

Speak to discharge nurse

about at home care or carehome placement.

8. Pt Education

Education on dangers of

smoking.

Education on dangers of

drinking

Education on self

maintenance.

ND # 5: Knowledge Deficit

Data to support:

Unaware of the consequences

of having COPD.

Pt continually smoking and

drinking as health problems

become more severe.


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Concept Mapping

Evaluate Effects of Nursing Actions- Patient Outcomes, Documentation (Done During Clinical)

1. ND/Nursing Care: Risk for Injury

Nursing Actions(NIC)

Make sure nonslip socks are on before ambulating.

Make sure bed is in lowest position with side rails up x3

Encourage assisted ambulation to increase muscle strength and stability.

Make sure bed alarm is on and call light is within pt reach

Monitor pt carefully when anxiety medication levels are low and before next administration to prevent injury.

Perform pt teaching about alcohol abuse and the increased risk of injury associated with intoxication.

Assess pt readiness to acquire help at home or be placed in a care home to reduce risk of fall or any other kind of injury

Always double check that nonlatex gloves are worn when assessing or touching pt Inform all staff of latex allergy

Replace latex gloves in room with nonlatex gloves

Inform pt about all medication and their side effects

Monitor pts mental status regularly.

Patient Response: Pt is A&O x4. Nonslip socks are on properly and continually. I encouraged pt to take a walk down the hall withme at some point during the day but pt refused and was noticeable anxious when the topic was brought up. Bed alarm was up and ptwas instructed on how to use the call light. Pt had a tendency to try and get out of bed during anxiety attacks. Talked through areasof concerns with pt during these times and checked MAR for time of next available dose. Pt expressed a readiness to quit drinking

and an awareness of the implications of her drinking. Pt also expressed a desire to be placed in a care home in Patterson where shelives. The discharge nurse talked with the pt about in home nursing care until care home placement can be initiated. Pt agreed.Nonlatex gloves placed in pts room.Pt was informed that nonlatex gloves are blue in color and to be aware than anyone makingcontact with the pt should not be wearing any other colored gloves. Pt is aware of all drugs being taken and their side effects.

2. ND/Nursing Care: Anxiety



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LA8/2011 17

Assess pts level of anxiety and her physical reactions to anxiety.

Assess the role that alcohol withdrawal plays in pts anxiety

Use empathy to encourage the pt to interpret the anxiety

Offer the pt accurate information regarding her anxious thoughts

Provide backrubs or massage for the client to decrease anxiety.

Use therapeutic touch and healing touch techniques Monitor the client for depression

Observe for changes and improvements when anxiety meds are taken

Assess pts response to taking anxiety medication

Teach the clients family to recognize the s/s of anxiety

Patient Response: During the two anxiety attacks, pt described her anxiety as being severe. Pts HR rose to 92 during the attackand pt repeatedly tried to get out of bed. Pt believes that her anxiety attacks have become worse wince she started drinking moreheavily and since she started to live alone. Pt was anxious that she was not going to be able to get to the bank in time and that shewouldnt be able to have enough money to pay for the cab that she needed to get home. I informed pt about the times that thebanks closed and reassured her that we would get her home safely. I held the pts hand during the attack and this kept the pt fromgetting out of bed until the medication could be administered. Pts symptoms were significantly decreased after the administrationof the medication. The pt acknowledges her need for anxiety medication and takes it very willingly. Family teaching was notperformed because none of the pts family came to visit her during the day.

3. ND/Nursing Care: Ineffective CopingNursing Actions(NIC)

Assess for contributing factors of ineffective coping such as lack of support or a recent change in life situation

Use verbal and nonverbal therapeutic communication approaches including empathy, active listening and confrontation toencourage the pt to express her emotions


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LA8/2011 18

Encourage the pt to describe previous stressors and coping mechanisms used

Assist the pt in setting realistic goals

Offer instruction regarding alternate coping strategies

Encourage the use of social resources

Actively listen to complaints and concerns

Engage the client in reminiscence.

Patient Response: Pt lives alone and has no close friends or companions to keep her company or to offer her help at home.Recently the pt moved here from Philadelphia. Pt moved here in hopes to spend more time with her family, but reports hardlyseeing her family at all. It is unclear to be whether the family does not see her more often because of her drinking or whether sheis drinking because the family will not see her. Pt was hesitant to talk about her family for a period of time, but then started to openup as I began to listen more intently. I discussed in home care with the pt. I encouraged her to take the in home care that is beingoffered to her until she can secure a spot in the care home she is interested in.

4. ND/Nursing Care: Risk-prone health behavior


Allow the client adequate time to express feelings about health status

Use open-ended questions to allow the client free expression Discuss the clients current goals

Provide assistance with activities as needed

Maintain consistency and continuity in daily schedule

Refer to community resources

Assess pts willingness to quit smoking

Asses pts willingness to quit drinking


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Patient Response: Pt is unhappy with living alone, not seeing her family regularly, about her drinking habit and about otheraspects of her life. Pt wishes to stop drinking and to live in a care home. I discussed with pt the fact that living in a care homewill prevent her from consuming alcohol and possibly from smoking. Pt seemed to welcome the idea and expressed readinessfor this change in her lifestyle. I helped the pt ambulate to the bathroom and encouraged a walk down the hall which the ptdeclined. I tried to be as dependable as I could for the pt. When she made a request, I fulfilled it as soon as I could. I did thisin an attempt to establish trust with the client so that she could maybe feel more comfortable in disclosing information with me.

Pt expressed an unwillingness to quit smoking. Pt expressed a willingness and desire to quit drinking and improve her lifestyle.

5. ND/Nursing Care: Knowledge Deficit

Consider clients ability and readiness to learn

Pt teaching on COPD

Pt teaching on consequences of smoking

Pt teaching on consequences of drinking

Pt teaching on current medications

Family teaching to reinforce information

Patient Response: I advised pt about her current diagnosis of COPD. I also advised pt that her continuing to smoke would makethe inevitable progression of the disease accelerate. I used the pts goal of seeing her family as an incentive to stop smoking. Ialso informed the pt that getting intoxicated increases her risk of injury and therefore time in the hospital which would further keepher from spending time with her family. Pt expressed desire to quit drinking. I went over pts med list with her and her knowledgeof the medications was good. I was unable to perform family teaching because the family was not present during the day.

Patient Care Plan

Documents

Transcript of Patient Care Plan