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

Student : Maggie Fabry Date of Care: 10/11/13 Room Number: 340

Patient Data Admitting Diagnosis : R humeral head fracture Age: 64 Spiritual Focus: Hindu Culture: Hindu Patient Initials: DJ Gender: F Height : 5 ft 1 in Weight: 159 lbs Admitting Date: 10/09 POD: 1 Vital Signs: T: 36.6 P: 89 R: 18 B/P: 141/78 O2 Sat: 99 Pain Scale: 9 Past Medical History: DM type 2, HTN, hyperlipidemia, nonalcoholic fatty liver disease Surgical History: R shoulder, rotator cuff surgery Diet: NPO pre-surgery, vegetarian diet post-surgery Activity: bedrest. Up with one person assist Foley: Y NG/Feeding Tube: N Advance Directives: No Drains/ Tubes: 2 L NC Code Status: Full VS Freq: Q6hr Glucose Monitoring: Y TEDs/SCDs: N Vascular Access: PCA/Epidural: N Telemetry: Y IV Site: 22 gauze IV in L forearm IV Solution: NS 1000mL Safety Considerations: Fall risk Dressing Change: N Labs to be drawn: none scheduled Scheduled Procedures: R humeral head surgery 10/10/13 Notes on pathophysiology: Type 2 diabetes: Diabetes is a problem with your body that causes blood glucose (sugar) levels to rise higher than normal. This is also called hyperglycemia. Type 2 diabetes is the most common form of diabetes. If you have type 2 diabetes your body does not use insulin properly. This is called insulin resistance. At first, your pancreas makes extra insulin to make up for it. But, over time it isn't able to keep up and can't make enough insulin to keep your blood glucose at normal levels. HTN: High blood pressure. The force of blood against artery walls is too high and can cause health problems. The more blood your heart pumps and the narrower the arteries, the higher the blood pressure

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

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

Lab and Diagnostic Test Data Test

type(date) Normal Range Patient Results Trend

↓↑ Rationale

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

teaching Glucose 74-118 10/09 0119: 158

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

↑ Monitoring blood glucose levels

because pt is a type ll diabetic. Also

monitoring because many drugs the pt is taking can alter blood

glucose levels. Levels are controlled

by insulin and glucagon.

Pt blood glucose levels are slightly above normal limits. Monitor glucose levels closely for further increases.

Administer prescribed Insulin as needed and as dictated by the sliding scale. Signs of hyperglycemia include

frequent urination, increased thirst, blurred vision and headache. Signs of hypoglycemia include confusion, abnormal behavior, vision disturbances, shakiness,

anxiety and sweating.

BUN 8-26 10/09 0119: 20 10/09 0422: 23 10/10 0400: 20

↓ Used to monitor kidney function. This

test also monitors liver function. Pt has an elevated BP and

chronic htn. This can

Pt is within normal limits. A decrease could indicate malnutrition. Could also be due to her high BP. Monitor s/s of kidney malfunction such as nausea, vomiting, or

abdominal pain. Monitor other electrolyte levels to ensure nutrition. An increase could indicate dehydration

or GI bleeding.

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Test type(date)

Normal Range Patient Results Trend ↓↑

Rationale (specific to pt.)

Nursing Implications related to patient care & teaching

cause kidney disease, so function must be monitored.

Creatinine 0.44-1.00 10/09 0119: 0.84 10/09 0422: 1.11 10/10 0400: 0.90

↓ Used to monitor kidney function/

diagnose impaired function. Pt has an

elevated BP and chronic htn can cause kidney

disease, so function must be monitored.

Pt is slightly above normal limits. Will closely monitor for changes. An increase in levels could indicate kidney

disease or dehydration. Monitor s/s such as low output, low appetite, nausea and vomiting, and persistent fatigue.

A decrease could indicate malnutrition or severe liver disease or muscle dystrophy. Monitor s/s such as

nausea, vomiting, abdominal pain or jaundice or frequent falls or waddling gait.

eGFR >60 10/09 0119: >60 10/09 0422: 49 10/10 0400: >60

↑ Used to monitor kidney function and evaluate stages of

kidney failure.

Pt is now WNL. If levels fall consistently, kidney failure could be indicated. However, antibiotic treatment can

sometimes alter labs. Use creatinine levels to confirm. Watch for s/s of kidney disease such as low output, low appetite, nausea and vomiting, and persistent fatigue.

Note that age, gender, height, race and weight can influence the glumerular filtration rate.

Sodium 136-145 10/09 0119: 130 10/09 0422: 132 10/10 0400: 136

↑ Used to monitor fluid and electrolyte

balance. This pt has DM and HTN which

can both effect sodium.

Pt levels slightly low, but slowly increasing. Watch for a decrease (hypoatremia) and s/s such as weakness,

fatigue, headache, nausea and vomiting, muscle cramps, irritability, and confusion. Low sodium levels can indicate dehydration or low sodium intake. This pt was NPO pre

surgery, so this may have caused the low levels. Pt teaching about how hydrating can prevent low sodium

levels. Potassium 3.6-5.1 10/09 0119: 4.6

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

↓ Used to ensure electrolyte balance. Hold meds if levels

are abnormal or nearly abnormal. This

is electrolyte is important to cardiac

function and is especially important

in patients taking diuretics or digoxin.

Pt WNL. An increase in these levels could indicate kidney disease. Monitor s/s such as low output, low

appetite, nausea and vomiting, and persistent fatigue. A decrease in levels could indicate excessive potassium

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

hyperaldosteronism. Monitor s/s such as muscle aches, abnormal weakness, arrhythmias, diarrhea, and nausea and vomiting. Know which meds to hold if levels are not

WNL.

Chloride 101-111 10/09 0119: 99 10/09 0422: 100 10/10 0400: 105

↑ Used to monitor electrolyte balance.

Chloride follows

Pt levels slightly low. Decreased levels could indicate over hydration, CHF, vomiting, diarrhea, chronic

respiratory alkalosis, hypokalemia, or burns. Monitor for

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Test type(date)

Normal Range Patient Results Trend ↓↑

Rationale (specific to pt.)

Nursing Implications related to patient care & teaching

sodium, and water moves with both electrolytes. As a

result, chloride effects water

balance. It also helps the acid base

balance in the body. Chloride is controlled

by the kidneys, so abnormal levels can

indicate renal problems.

s/s of hypochloremia such as hyperexcitability of the nervous system and muscles, shallow breathing,

hypotension and tetany. Hyperchloremia can be indicated through s/s such as lethargy, weakness and deep

breathing. Monitor for these signs and symptoms and continue to check lab values for changes

Carbon Dioxide 22-32 10/09 0119: 23 10/09 0422: 25 10/10 0400: 25

↑ Used to monitor acid base balance in the body as well as to assist in evaluating

the pH.

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 pt’s over all LOC. Monitor levels for any dramatic increases because it could lead to respiratory arrest. S/s of low

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

Anion Gap 5.0-15.0 10/09 0119: 12.6 10/09 0422: 12.1 10/10 0400: 10.6

↓ Used to monitor acid base balance

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

chest pain as well as kidney disease s/s. A decrease could indicate a low sodium blood level or bone marrow

cancer. Calcium 8.9-10.3 10/09 0119: 9.4

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

↓ Used to monitor parathyroid function

and calcium metabolism. Also used to monitor kidney function.

Pt is WNL. Low levels may be a result of malabsorption syndrome, hypoalbumenia, end stage kidney disease,

post thyroidectomy, hypoparathyroidism, vitamin D deficiency, inadequate intake, pancreatitis, low

phosphate, meds that block parathyroid function prevent absorption of Ca. S/s of progressing hypocalcemia would include tingling in hands, feet or lips, muscle spasms or slow uneven heart beat. An increase in levels may be caused by hyperparathyroidism, metastatic tumor to

bone, prolonged immobilization, vitamin D intoxication, lymphoma, acromegaly. Symptoms of hypercalcemia are

usually not significant, unless severe hypercalcemia results, which may cause generalized symptoms such as

GI disturbances, fatigue, and like with hypocalcemia, muscle twitching.

Total Protein 6.1-7.9 10/09 0119: 7.1 Used to diagnose, Pt WNL. A decrease in levels could indicate malnutrition.

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Test type(date)

Normal Range Patient Results Trend ↓↑

Rationale (specific to pt.)

Nursing Implications related to patient care & teaching

evaluate and monitor disorders such as liver dysfunction, impaired nutrition,

and protein-wasting states.

S/s to watch for would include weight loss, weakness or muscle fatigue, increased susceptibility to infections, or delayed healing of even small wounds. An increase in

levels could indicate dehydration or inflammatory disease. Inflammatory diseases are characterized by

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

globulin levels to confirm any abnormalities. Albumin 3.5-4.8 10/09 0119: 4.0 Just like the total

protein test, this test is used to diagnose, evaluate and monitor

disorders such as liver dysfunction, impaired nutrition,

and protein-wasting states.

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

levels could indicate dehydration or inflammatory disease. Inflammatory diseases are characterized by

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

and globulin levels to confirm any abnormalities. Globulin 2.3-3.5 10/09 0119: 3.1 Just like the total

protein test and albumin, this test is used to diagnose,

evaluate and monitor disorders such as liver dysfunction, impaired nutrition,

and protein-wasting states.

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

levels could indicate dehydration or inflammatory disease. Inflammatory diseases are characterized by

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

total protein levels to confirm any abnormalities.

ALB/GLOB ratio 0-35 10/09 0119: 1.3 Used in the evaluation of pts that are expected to have

hepatocellular diseases

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

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

output, low appetite, nausea and vomiting, and persistent fatigue

Alkaline Phosphatase

38-126 10/09 0119: 66 Used to detect and monitor diseases of

the liver or bone.

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

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

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

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

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Test type(date)

Normal Range Patient Results Trend ↓↑

Rationale (specific to pt.)

Nursing Implications related to patient care & teaching

of even small wounds. AST/SGOT 15-41 10/09 0119: 53 Test primarily used in

the evaluation of pts with suspected hepatocellular diseases. The amount of AST

elevation is directly related to the number of cells affected by a

disease or injury. Because this enzyme

is found in skeletal muscle and because

this pt just had a bone fracture, the test was indicated.

Pt levels above normal. This is mostly like due to her recent skeletal muscle trauma. Levels should decrease as the fracture heals. Monitor pt for healing progress and check lab value regularly to assess progression. If levels

were low, acute renal disease or diabetic ketoacidosis could be indicated.

ALT/SGPT 14-54 10/09 0119: 59 Used to identify hepatocellular

diseases of the liver or to monitor the improvement or

worsening states of these diseases

Pt levels are above normal. This could indicate cirrhosis, hepatic tumor or obstructive jaundice. A further increase could indicate hepatitis. Signs to watch for include loss of

appetite, loss of energy, weight loss, jaundice, or fluid retention. Another set of labs was not completed for this

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

Bili Total 0.4-2.0 10/09 0119: 0.8 This is yet another test to evaluate liver

function.

Pt WNL. An increase in this level could indicate liver disease. S/s would include loss of appetite, loss of

energy, weight loss, jaundice, or fluid retention. Will watch for s/s and monitor pt closely.

White Blood Cell Count

4.8-10.8 10/09 0119: 14.2 10/09 0422: 15.5 10/10 0400: 9.4

↓ Used to help in the evaluation of

infection, neoplasm, allergy or

immunosuppression.

Pt was above normal levels pre-surgery, but levels have lowered since the surgery was performed. An increase

could indicate infection, dehydration, allergy or immunosuppression. S/s would include malaise or fever.

Will monitor pt for s/s of infection and will assess new labs as they come. A decrease could indicate drug

toxicity, bone marrow failure, or a dietary deficiency. S/s would include bleeding or bruising.

Red Blood Cell Count

3.80-5.40 10/09 0119: 4.13 10/09 0422: 4.04 10/10 0400: 3.33

↓ Measurement of the amount of red blood

cells in peripheral blood. Closely related

to hemoglobin and

Pt levels were WNL pre-surgery and slightly low post-op. This decrease could simply indicate blood loss due to

surgery. In general, a decrease could indicate anemia, renal disease, or bone marrow failure. S/s would depend

on the disease process being indicated. An increase

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Test type(date)

Normal Range Patient Results Trend ↓↑

Rationale (specific to pt.)

Nursing Implications related to patient care & teaching

hematocrit levels. Conducted as a routine part of a complete blood

count. Also used to check for anemia.

could indicate severe COPD of severe dehydration. S/s of increased severity of COPD include an ongoing cough that produces a lot of sputum, SOB, wheezing or chest

tightness.

Hemoglobin 11.5-15.5 10/09 0119: 12.5 10/09 0422: 12.3 10/10 0400: 10.3

↓ Used to monitor the oxygen-carrying

capacity of the blood

Pt WNL. A high number could indicate congenital heart disease, COPD, or dehydration. Symptoms of high levels

include dysfunctional cognition, dizziness, mental confusion, peripheral cyanosis, slow blood clotting times,

swelling and sudden numbness. A decrease could indicate anemia, renal disease, or bone marrow failure. Low levels are seen as pale skin, nail beds and gums,

shortness of breath, cardiac symptoms like palpitations, chest pain and aggravation of heart problems. I will

monitor labs for changes. Hematocrit 35-47 10/09 0119: 38.4

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

↓ This test closely reflects the

hemoglobin values. Used as a rapid,

indirect measurement of RBC number and volume, integral part

of evaluation of anemic patients.

Pt shows drop in levels post-op. This drop indicates a loss of blood during the surgery. Normally, a drop in levels could indicate anemia, renal disease, or bone

marrow failure. S/s would include constant fatigue and tiredness, pale skin, shortness of breath, hair loss,

worsening heart problems, and faster heart palpitations. An increase could indicate severe COPD or severe

dehydration or CHF.

Red Cell Distribution

Width

11.5-15.5 10/09 0119: 13.0 10/09 0422: 13.1 10/10 0400: 12.8

↓ This is an indication of the variation of

RBC size. Used to classify anemias.

Pt is within normal limits. When values are normal the anemia is said to be normochromic (hemolytic anemia).

An increase level in RDW could indicate a large variety of different kinds of anemia. S/s would include easy fatigue

and a loss of energy, SOB, dizziness and pale skin. Platelet Count

Auto 130-400 10/09 0119: 209

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

↓ Used to monitor platelet number in the blood. Used in this pt

to monitor risk for bleeding because they are receiving

heparin and because she is post-op.

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

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

destroying the body’s platelets, bleeding or infection. Monitor for s/s such as easy or excessive bruising,

superficial bleeding into the skin, or blood in urine or stools. Will monitor levels for changes and look for s/s

associated with abnormal levels Neutrophils % 42-75 10/09 0119: 83.3

10/09 0422: 78.5 ↑ Neutrophils primarily

fight acute bacterial Pt levels are high. High levels can suggest acute

bacterial infection as well as fungal infections. Levels

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Test type(date)

Normal Range Patient Results Trend ↓↑

Rationale (specific to pt.)

Nursing Implications related to patient care & teaching

10/10 0400: 84.2 infections and fungal infections. This pt

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

may be high due to the pt’s recent fracture and then a corrective surgery that followed. Will continue to monitor

labs to ensure that levels return to normal in a timely fashion. Pt being prescribed Ancef. Low levels could indicate sepsis or radiation therapy, aplastic anemia,

chemotherapy and influenza. Lymphocytes % 16-50 10/09 0119: 10.2

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

↓ Lymphocytes primarily fight chronic infection and acute viral infections. This

pt had a bone fracture and is

therefore at risk for infection.

Pt levels slightly low. Low levels can suggest immunosuppression, leukemia, sepsis, immunodeficiency

diseases, later stages of HIV infection, drug therapy (aderenocorticosteroids, antineoplastics), and radiation

therapy. S/s would depend on the disease being indicated. Elevated levels indicate chronic bacterial

infection, viral infection, lymphocytic leukemia, multiple myeloma, infectious mononucleosis, radiation, and

infectious hepatitis. Will monitor levels for improvements or for a worsening condition.

Neutrophils # 1.4-6.5 10/09 0119: 11.8 10/09 0422: 12.2 10/10 0400: 7.9

↓ Neutrophils primarily fight acute bacterial infections and fungal

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

Pt levels are high but decreasing. High levels can suggest acute bacterial infection as well as fungal

infections. Levels may be high due to the pt’s recent fracture and then a corrective surgery that followed. Will

continue to monitor labs to ensure that levels return to normal in a timely fashion. Pt being prescribed Ancef. Low levels could indicate sepsis or radiation therapy,

aplastic anemia, chemotherapy and influenza. NRBC # 0 10/09 0119: 0

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

This is a tool used to indicate a situation in

which a serious underlying disease could be present.

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

marrow replacement, anemia, asplenia, hypoxia or extramedullary hematopoiesis.

Medication Allergies: NONE Medications

Generic & Trade Name Drug classification

(Therapeutic & Pharmacologic)

dose/Route Frequency

Action of drug and Rationale (specific to Pt)

Significant Side Effects Nursing Implications related to patient care and teaching

Atorvastatin Calcium 10mg/PO/Q48HR Inhibits HMG-CoA reductase and

cholesterol synthesis in the liver and

increases the number

Diarrhea, arthralgia, myalgia, UTI, nasopharyngitis, pain in extremity, increased liver enzymes, systemic lupus, rhabdomyolysis, rupture of

tendon, hemorrhagic cerebral infarction

May be taken at any time of the day with or without food. Monitor lipid panel 2 to 4

weeks after initiation and 2 to 4 weeks after dose adjustment. Monitor liver

function tests. Instruct pt to report s/s of

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of hepatic LDL receptors on the cell-surface to enhance

uptake and catabolism of LDL,

thus lowering plasma lipoprotein and

cholesterol levels.

Used to lower pt’s cholesterol due to her

history of hyperlipidemia.

myopathy or rhabdomyolysis such as muscle pain, tenderness, weakness, and

fever. Counsel pt to avoid excessive quantities of alcohol to reduce risk of

hepatotoxicity. Instruct pt not to consume grapefruit or grapefruit juice

with this drug. Provide pt teaching about alternate ways to lower cholesterol such as dietary changes and to incorporate

omega- 3 fatty acids regularly.

Normal Saline (NaCl 0.9%)

Electrolyte replacement; sodium salt

1,000mL/IV/Q12H PRN

Replaces sodium and chloride and

maintains levels

To help with IV patency and to

promote hydration.

Aggravation of heart failures, hypernatremia, pulmonary edema, local tenderness, tissue necrosis at injection

site, abscess

Monitor electrolytes. Teach pt to report any reverse reactions. Monitor for signs

of edema. Monitor injection site.

Normal Saline Add

Cefazolin Sodium (Ancef)

Antiinfective; cephalosporin

100mL/IVPB Two doses post-

op

Inhibits bacterial cell wall synthesis leading

to cell death.

Used to prevent infection in pt’s

fracture post-op.

Headache, dizziness, weakness, seizures, fever, chills, diarrhea,

anorexia, pain, bleeding, increased AST, ALT, bilirubin,

pseudomembranous colitis, proteinuria, increased BUN, renal failure,

nephrotoxicity, leukopenia, neutropenia, lymphocytosis, hemolytic anemia,

dyspnea, serum sickness, superinfection, Stevens-Johnson

syndrome

Assess for sensitivity to penicillin and other cephalosporins. Assess for

nephrotoxicity symptoms like increased BUN and urine output. Assess for

anaphyalxis and bleeding (ecchymosis, bleeding gums, hematuria, stool guaiac daily). Check I&O daily, blood studies (AST, ALT, CBC, Hct, LDH, asl phos, Evaluate for decreased symptoms of infection. Perform teaching on eating

yogurt or buttermilk to maintain intestinal flora/decrease diarrhea. Pt teaching

about taking medication as prescribed and about finishing entire regimen.

Instruct pt to report sore throat, bruising, bleeding or joint pain. Know that this

drug may cause diarrhea, nausea, vomiting or thrombocytopenia. After

reconstitution, shake well. Administer drug immediately after reconstitution.

Dilute reconstituted solution in 50 to 100 mL NS. Infuse drug over 30 minutes.

Losartan Potassium (Cozarr)

50mg/PO/daily Deters vasoconstriction and

Chest pain, hypotension, hypoglycemia, diarrhea, anemia, asthenia, dizziness,

Drug may be taken with or without food. Monitor BP and HR during treatment

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Angiotensin ll receptor

agonist; antihypertensive

aldosterone-secreting effects by specifically

intercepting the binding of angiotesin

ll to the AT(1) receptor.

Used to manage pt’s

hypertension.

cough, fatigue, hepatotoxicity, rhabdomyolysis, acute renal failure,

angioedema.

especially if or when dose is adjusted. Monitor renal function and electrolyte panel. Be aware that drug can cause hypoglycemia, so concurrent use with

insulin requires careful consideration. Pt should avoid activities requiring

coordination until drug effects are realized. Instruct pt to report s/s of

hypotension such as dizziness,blurry vision, confusion, weakness, fatigue or

nausea. Advise pt against sudden discontinuation of the drug. Provide pt teaching on lifestyle changes such as a diet low in salt and high in vegetables as

well as implementation of an exercise regimen. Pt should consult dr before

using potassium supplements or potassium-containing salt substitutes.

Escitalopram Oxalate (Lexapro)

Selective serotonin reuptake inhibitor;

antidepressant

10mg/PO/QAM Enhances serotonergic activity

in the CNS as a result of its inhibition of serotonin reuptake

in CNS neurons.

Used for anxiety.

Diaphoresis, abdominal pain, constipation, diarrhea, indigestion,

nausea, vomiting, xerostomia, dizziness, headache, insomnia, reduced libido, fatigue, worsening depression or

suicidal thoughts.

Monitor pt closely for clinical worsening, suicidality, or unusual changes in

behavior. Family and caregivers should be advised of the need for close

observation and communication with prescriber. Advise pt not to drink alcohol while taking medication. Use precaution when withdrawing medication. Gradual

withdraw should be used whenever possible. Monitor for s/s of resolution

which would indicate drug efficacy. Counsel pt to report s/s of serotonin

syndrome such as high fever, agitation, confusion, hallucinations, hyperreflexia, nausea, vomiting or diarrhea. Advise pt that concomitant use of aspirin, NSAIDS

or heparin can increase the risk of bleeding. May take med without regard to

meals. Docusate Sodium (Colace)

Laxative, emollient, stool

softener; anionic surfactant

40mg/PO/daily Increases water, fat penetration in

intestine; allows for easier passage of

stool.

Used to prevent

Bitter taste, throat irritation, nausea, anorexia, cramps, diarrhea, rash

Assess for the cause of constipation in the pt. Assess for therapeutic effect

(decrease in constipation, increase in BMs). Monitor pt for cramping, rectal

bleeding, nausea, vomiting. Discontinue use if these effects occur. Advise pt that med may take up to three days to soften

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constipation caused by use of analgesics

and opioids. Pt’s immobility can also cause constipation.

stools. Instruct pt not to use in the presence of abdominal pain, nausea or

vomiting. Take with a full glass of water, may be diluted in milk or juice, do not

admin within 2 hours of another laxative. Assess for abdominal distension, bowel

sounds, and usual pattern of bowel function. Advise pt to only use for short

term therapy because long term can result in electrolyte imbalances and

dependence. Pantopazole Sodium

(Protonix)

Antiulcer agents; proton-pump inhibitors

40mg/PO/daily Binds to an enzyme in the presence of acidic gastric pH,

preventing the final transport of hydrogen ions into the gastric

lumen.

Used to prevent ulcers and irritation

due to use of excessive meds at

one time. Commonly given to pts staying at

hospital.

Headache, abdominal pain, diarrhea, flatulence, hyperglycemia,

hypoglycemia, C-diff diarrhea, Stevens-Johnson syndrome

Watch for s/s of anaphylactic reaction such as rash or hives, angioedema, and

SOB. These reactions are more common when giving med IV. Assess pt routinely for epigastric or abdominal pain

and for frank or occult blood in stool, emesis, or gastric aspirate. Warn pts to report diarrhea that does not improve.

Oral tablets may be taken with or without food. If using delayed-release, swallow whole and do not split, crush or chew.

Influenza Virus Vaccine (Fluvirin)

Vaccine

0.5mL/IM/once Live attenuated influenza vaccine viruses replicate primarily in the

ciliated epithelial cells of the

nasopharyngeal mucosa to induce

immune responses (via mucosal

immunoglobulin [Ig]A, serum IgG

antibodies, and cellular immunity),

but LAIV viruses do not replicate well at

the warmer temperatures found

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

erythema at injection site or tenderness.

Inject into the deltoid muscle. EMC protocol: MAKE SURE DOCTOR HAS ORDERED VACCINE AND THAT PT

HAS SIGNED AN INFORMED CONSENT DOCUMENT! Explain

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

needle from protector and expel any air from the syringe. Inject needle into skin at 90 degree angle. Do not aspirate with

deltoid muscle injections. Withdraw needle and activate safety device.

Massage area gently and inform pt that they may experience muscle soreness for a few days following the injection.

Advice pt to report any unusual or severe reactions following the vaccination.

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in the lower airways and lung. During the course of replication, all LAIV viral proteins would be presented

to the immune system in their native conformation and in

the context of histocompatibility

proteins.

Given to prevent this pt from getting the

influenza virus. Dextrose 50%- water

(Glutose)

Monosaccharide; carbohydrate caloric

nutritional supplement

12.5 GM/IVP PRN Prevents protein and nitrogen loss;

promotes glycogen deposition and

ketone accumulation.

Venous thrombosis, heart failure, hyperosmolar coma, pulmonary edema, hyperglycemia, hypertension, flushing.

Infuse concentrations above 10% through central vein. Do not infuse

rapidly, doing so may cause hyperglycemia and fluid shifts. Never stop infusion abruptly. Monitor infusion

site frequently to prevent irritation, tissue sloughing, necrosis, and phlebitis.

Check blood glucose at regular intervals. Monitor I&O. Monitor weight regularly

and assess patient for confusion. Teach pt how to recognize s/s of hypo and

hyperglycemia. Insulin Reg Human

(Humulin)

Pancreatic hormone; hypoglycemic

SS/SC/Q6HR

SLIDING SCALE

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

Promotes glucose transport and

promotes phosphorylation of

glucose in liver.

Used in this pt because she is a type

ll diabetic. Used to maintain glucose

levels throughout the day, especially after

mealtime.

Hypokalemia, sodium retention, hypoglycemia, rebound hyperglycemia, utricaria, rash, edema, lipodystrophy,

anaphylaxis.

• Perform pt teaching regarding proper subQ injection techniques if pt wishes to give their own injections. This includes teaching on proper sites for injection and rotating injection sites to prevent lipodystrophy. Monitor glucose levels frequently to assess drug efficacy and appropriateness of dosage. Monitor for s/s of hypoglycemia. These include trembling, clammy skin, palpitations (pounding or fast heart beats), anxiety, sweating, hunger, and irritability. S/s of severe hypoglycemia can include difficulty thinking, confusion, headache, seizure and coma. Monitor for s/s of hyperglycemia such as polydipsia,

13

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

Diphenhydramine HCl

(Benadryl)

Ethanolamine derivative, nonselective histamine-

receptor antagonist; antihistamine, antitussive,

antiemetic, antivertigo agent, antidyskinetic

50mg/IV/Q6H PRN Acts as an antihistamine by competing with

histamine or receptor sites on effector cells.

Used for itchiness

associated with Dilaudid.

Xerostomia, dizziness, dyskinesia, somnolence, dry nasal mucosa,

pharyngeal dryness, thick sputum, anaphylaxis, photosensitivity

Administer IV at a rate not exceeding 25mg/min. Don’t give drug within 14

days of MOA inhibitors. Monitor cardiovascular status. Supervise pts

during ambulation. Advise pts to avoid alcohol and other depressants such as sedatives while taking this drug. Advise

pt to avoid activities requiring coordination until drug effects are

realized. Instruct pt that drug may cause sleepiness.

Ibuprofen 600mg/PO/Q6H PRN

Exhibits analgesic and antipyretic

activities by inhibiting prostaglandin

synthesis.

Given to this pt to reduce inflammation related to humeral

fracture.

Hypotension, rash, hypernatremia, hypoalbuminemia, hypoproteinemia,

flatulence, heartburn, nausea, vomiting, thrombocytosis, bacteremia, dizziness,

headache, elevated BUN, urinary retention, CHF, hypertension, Stevens-

Johnson syndrome, hearing loss, depression, acute renal failure, Reye’s

syndrome.

Know that NSAIDs increase the risk of serious cardiovascular thrombotic

events, MI and stroke. They can also increase the risk of GI adverse events. Medication may be given with food or

milk to reduce GI upset. Monitor for relief of pain or reduction in fever. Monitor renal and liver function tests with long term use. Advise pt to avoid use of additional NSAIDs or aspirin during therapy. Instruct pt to report s/s of

serious GI events such as bleeding, ulceration or perforation

Ondansatron HCl (Zofran)

Antiemetic; serotonin type 3 antagonist;

4mg/IV/Q6H PRN Blocks serotonin a 5-HT receptor sites in

vagal nerve terminals by disrupting CNS

chemoreceptor

Headache, fatigue, chest pain, hypotension, constipation,

bronchospasm, anaphylaxis

Monitor GI status. Auscultate bowel sounds and palpate for tenderness.

Watch for hypotension and bronchospasm. Instruct pt to

immediately report symptoms of allergic

14

trigger zone.

To reduce nausea related to

administration of analgesics and other

medications.

reaction such as rash or hives. Give undiluted by direct IV and administer slowly over 2 to 5 minutes. Flush SL

before and after administration with 5mL of water. Know that drug van cause

anaphylaxis and bronchospasm. Instruct pt to report s/s of hypersensitivity

reactions such as fever, chills, rash or breathing problems. Monitor ECG in pts

with electrolyte imbalances. Acetaminophen 650mg/PO/Q4H

PRN Pain reducing ability

may be due to an inhibition of COX 2 and an elevation of

the pain threshold. It reduces fever by

inhibiting the formulation and

release of prostaglandins in the

CNS.

Used for mild pain associated with her fractured humeral bone. Prescribed

PRN in case of infection related fever post-surgery as well.

Puritus, constipation, nausea, vomiting, headache, agitation, atelectasis, liver failure, pneumonitis, Stevens Johnson

syndrome

Know that drug may cause hepatic toxicity at high doses. S/s of hepatic

toxicity include dark urine, clay-colored stools; yellowing of skin; abdominal pain;

fever or diarrhea. Monitor hepatic and renal lab values if long-term therapy is

anticipated. Advise pt that it is unsafe to take more than 4 grams of this drug in a

24 hr period. Watch for s/s of chronic poisoning such as rapid, weak pulse; dyspnea; cold, clammy extremities.

Monitor pt for s/s of allergic reaction such as rash or urticaria. Instruct pt not to use this med with alcohol. Take medication

with a full glass of water.

Pantoprazole Sodium (Protonix)

Antiulcer agents; proton-

pump inhibitors

40mg/IV/daily PRN Binds to an enzyme in the presence of acidic gastric pH,

preventing the final transport of hydrogen ions into the gastric

lumen.

Used to prevent ulcers and irritation

due to use of excessive meds at

one time. Commonly given to pts staying at

hospital.

headache, abdominal pain, diarrhea, flatulence, hyperglycemia,

hypoglycemia, C-diff diarrhea, Stevens-Johnson syndrome

IV administration should be discontinued as soon as an oral route is possible.

Flush before and after administration with either 5% Dextrose injection, 0.9%

sodium chloride injection, or Lactated ringer’s injection. Injection is NOT

compatible with midazolam and may not be compatible with products containing

zinc. Reconstitute the appropriate number of vials with 10mL of 0.9%

sodium chloride injection for each vial for a final concentration of approximately

4mg/mL. Administer IV over a period of at least 2 minutes. Watch for s/s of

anaphylactic reaction such as rash or

15

hives, angioedema, and SOB. These reactions are more common when giving

med IV. Assess pt routinely for epigastric or abdominal pain and for

frank or occult blood in stool, emesis, or gastric aspirate. Warn pts to report

diarrhea that does not improve. Monitor for injection site reactions such as

thrombophlebitis.

Heparin Sodium (Hep-Lock)

Antithrombotic; Anticoagulant

5,000 units/SC/Q8HR

Inhibits the mechanisms that

induce the clotting of blood and the

formation of stable fibrin clots at various sites in the normal

coagulation system. When heparin is combined with antithrombin lll,

thrombosis is blocked through inactivation of activated Factor X

and inhibition of prothrombin’s conversion to

thrombin. This also prevents fibrin formation from

fibrinogen during active thrombosis.

Used as a

prophylactic to prevent postoperative venous thrombosis.

Pt is inactive and Heparin will help reduce the risk of

clots.

Thrombocytopenia, increased liver aminotransferase level, hemorrhage,

hep-induced thrombocytopenia, immune sensitivity reaction, non-

traumatic spinal subdural hematoma, hyperkalemia

Draw baseline blood sample for clotting studies before starting drug. Inject deep subQ (slowly into fat layer between iliac crests in lower abdomen). Leave needle

in place for ten seconds before withdrawing. Instruct patient to report s/s

of thrombocytopenia such as easy bruising (can be in the form of petechiae

which are red, flat spots on the skin), prolonged bleeding, excessive bleeding

of the mouth while brushing teeth or flossing, black stools, dark or red urine. Instruct pt to avoid taking aspirin during

therapy unless approved by a health care professional. Check hematocrit, PTT, and platelet count frequency. Monitor potassium level in pts with diabetes or

renal disease. Urge pts to avoid activities that can cause injury. Pt should

be urged to use soft bristle toothbrush and an electric razor. Use with extreme caution in this pt because of her history

of hypertension.

Hydromorphone (Dilaudid)

Opioid agonist; opioid

0.5mg/IV/Q3H PRN

Acts primarily as an analgesic agent. It is

believed that CNS

Flushing, pruritus, sweating, constipation, nausea, vomiting, asthenia, dizziness, headache,

Hydromorphone is a potent schedule ll opioid agonist which has the highest

potential for abuse and risk of producing

16

analgesic, antitussive opioid receptors that are specific for endogenous

substances with opioid-like properties

play a role in the drug’s analgesic

effects.

This drug is prescribed PRN so

that the pt can use it for MODERATE TO

SEVERE pain related to her humeral

fracture. May be useful post-surgery

as well.

hypotension, seizure, resp depression, drug withdrawl.

resp depression. Alcohol, other opioids and CNS depressants potentiate the resp

depressant effects of hydromorphone, increasing the risk of respiratory

depression that may result in death. This drug is contraindicated for use with

Probable. Reconstitute drug immediately prior to use with 25 mL sterile water for injection to a concentration of 10mg/mL.

Administer slowly over at least 2 to 3 minutes. Assess vital signs. Assess

pain levels before and after administration. Do not give if respirations are less than 10/min. Monitor for signs of

respiratory depression. Monitor for adverse effects especially during initial

dosing. Pts should avoid activities requiring mental alertness or

coordination until drug effects are realized. Instruct pt to report

constipation, absence of pain relief, hypotension and s/s of resp depression

such as SOB, apnea and increased effort with breathing. Advise pt against sudden discontinuation of the drug. Have second

practitioner verify dosage. Hydrocodone BIT/ACE

(Norco)

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

This medication binds to opiate receptors in the CNS. It alters the

perception and response to painful

stimuli.

This will help with MILD TO

MODERATE pain after surgery and allow for healing.

Confusion, dizziness, sedation, hypotension, constipation, dyspepsia,

nausea

Know that this drug has been associated with cases of acute liver failure, at times resulting in liver failure and death. Most

injuries are the result of excess acetaminophen. Monitor liver function

tests accordingly. Assess vitals. Respiration less than 10/min; hold medication and assesses sedation,

assess pain, have second practitioner verify dosage. Advise pt that drug that

may cause drowsiness. Give with food to reduce nausea. Pts should avoid

activities requiring mental alertness or coordination until drug effects are

realized. Advise pt that med contains acetaminophen and to not take additional drugs containing acetaminophen. Advise pt to report s/s of respiratory depression

17

such as SOB, apnea and increased effort with breathing. Monitor pt for s/s of drug

overdose including nausea, vomiting, blurred vision, cool and clammy skin,

dizziness, confusion, dyspnea, respiratory depression, bradycardia, hearing loss, headache or mood or

behavior changes. Promethazine HCl (Prorex)

Laxative; Stimulant

12.5mg/IV/Q6H PRN

Completely blocks histamine H(1)

receptors without blocking the secretion

of histamine. The drug has sedative,

anti-motion sickness, antiemetic, and

anticholinergic effects but it has no

dopaminergic action due to a structural

difference with other phenothiazines.

For pt’s constipation

related to surgery and administration of

opioids.

Abdominal colic, abdominal discomfort, diarrhea, proctitis, atony of colon,

xerostomia, apnea, respiratory depression

Monitor pt for decreased abdominal pain. Monitor for BM which should take place 15-60 minutes after administration. Also monitor hydration level and mental status

during therapy. Reassess pt if rectal bleeding occurs or if no BM occurs after

laxative is given. Advise pt that drug may cause diarrhea or abdominal pain, discomfort and cramping. Instruct pt to

report rectal bleeding or failure to have a BM within 12 hrs. Drug should not be

taken for longer than 7 days. This drug must be administered IV with caution

because risk of perivascular extravasion and severe tissue damage is high. Dilute in 10 to 20 mL of NS and administer over 10 to 15 minutes. Insure patency of site

before administration. Instruct pt to immediately report any burning or pain

during or after the injection and stop administration immediately. Advise pt to avoid excessive sun exposure because drug can cause photosensitivity. Advise pt not to consume alcohol while taking

this drug.

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LA8/2011 19

Concept Mapping

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

ND # 1: Acute Pain Data to support: R humeral head fracture Recent surgery for fracture (POD 1) Guarded behavior Pt reports pain Pain upon movement of R arm Prescribed pain medication

ND # 2: Risk for bleeding Data to support: Pt being administered Heparin Pt POD 1 R humeral fracture Fall risk/impaired physical mobility

ND # 3: Risk for constipation Data to support: Immobility Pt being administered opioids for pain Pt was NPO pre-surgery

ND # 4: Impaired physical mobility Data to support: Physician order of bed rest. R humeral fracture and surgery (POD 1) Pt report of pain with movement Administration of opioids (decreased awareness and coordination)

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

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

8. Pt Education Meds Wound Care Recovery Process Pain management Immobility

ND # 5: Risk for Impaired Skin Integrity Data to support: Immobility/ Bedrest Recent fracture Recent surgery Altered nutritional state (overweight) Pt taking Heparin

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

LA8/2011 20

Concept Mapping

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

1. ND/Nursing Care: Acute Pain

Nursing Actions(NIC)

• Determine if client is experiencing pain at the time of initial interview. • Assess pain level using 1-10 scale • Assess the client for pain presence routinely and frequently (when vital signs are taken, during activity, and during rest) • Ask pt to describe previous experiences with pain medications or therapy. What worked? What didn’t? • Identify pt’s comfort-function goal for pain • Prevent pain during any procedures or mobility • Administer opioids as ordered • Assess pain level, sedation level, and respiratory status at regular intervals during pain management with opioid

administration. • Assess for effectiveness of medication • Assess for constipation related to use of opioids. • Assess for adverse reactions closely and frequently and especially during the first dose. • Assess for influence of cultural beliefs on pain management and perception of pain.

Patient response: Initially, pt reported no pain and complained of numbness at the site of injury. As the nerve block worse off, pt did complain of pain and rated it at a 3/10 but noted that it was quickly increasing. Pt expressed fear of pain coming back. Pt vital signs were taken and were normal. Pt administered Norco. Assessed effectiveness of medication and reassessed pain level routinely following administration. Pt reported that Norco and Dilaudid both worked well at relieving her pain since admittance. Pt expressed her comfort-function goal as being a 1 or a 0. Pt was immobile throughout entire day, so no pre-ambulatory pain medication was needed. Vital signs were normal following administration of medications. Pt reports last BM two days prior. Pt reports no worry and claims it is only because she wasn’t allowed to eat before the surgery. Pt status was monitored closely following administration. Pt is Hindu, but expressed no hesitance about taking pain medication and communicated her pain levels often and clearly.

LA8/2011 21

2. ND/Nursing Care: Risk for Bleeding

Nursing Actions(NIC)

• Monitor for signs of bleeding in the urine, stool, sputum, vomitus. • Watch for nose bleeds, petechiae, purpura, or bruising. • Monitor laboratory values (hemoglobin, hematocrit, RBC, INR) • Implement safety precautions (Fall risk protocol, soft bristle tooth brush) • Acquire additional help when moving pt to prevent falls • Check bandaging regularly for saturation and bleeding • Check vital signs frequently and regularly (watch for low BP, elevated HR, and respiratory rate) • Before administering heparin, check APTT • Have protamine sulfate close by as a precaution for Heparin OD. • L&L bed at lowest position and put side rails up x3 before leaving room • Explain bleeding risk to pt and assess for understanding • Perform teaching on reducing risk of bleeding including elimination of risky behaviors

Patient response: no signs of bleeding visible. No bruising, petechiae or purpura visible or noted by patient. RBC high and being monitored continually and closely. All other lab values WNL. Pt successfully labeled as a fall risk pt. Pt had already brushed her teeth before my arrival, but stated that soft bristle brush was used. Pt was not ambulated throughout the entire day, so no additional help was required. Bandage monitored and checked for bleeding a saturation regularly. Vital all WNL with the exception of BP which was initially low. It was determined that the BP was low due to administrating Losartan. BP began to rise towards normal limits so no intervention was needed. No APTT was ordered. Planned to inquire as to the reasoning, but never followed through. Bed L&L each time I exited the room. Side rails up x3. Pt demonstrates good working knowledge regarding her increased risk for bleeding as well as the actions of Heparin.

3. ND/Nursing Care: Risk for constipation

Nursing Actions(NIC)

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

LA8/2011 22

• Review clients current medications • If client is constipated and taking medications that can cause constipation, consult a health care provider about switching

the medications • Palpate for abdominal distention • Inquire about discomfort or abdominal pain • Assess for effectiveness of laxatives • Assess for any adverse reactions of laxatives • Assess for pt’s desire to take additional laxatives to promote GI motility

Patient response: Pt reports normally producing two BMs per day. However, pt reports last BM two days prior. Pt is a vegetarian and reports eating a variety of vegetables with each meal. Pt admits to having a poor fluid intake at home. Pt is taking opioids for pain which contribute greatly to constipation. When weighing risks and benefits, keeping the pt’s pain at a low level is a priority to both the patient and the staff, so no adjustment was made to opioid prescription. However, additional laxatives were prescribed. No distention palpable. Pt reports no abdominal pain or discomfort. Pt has not yet had a BM since the beginning of her laxative therapy. Will continue to inquire about pt’s BMs. Pt reports no diarrhea or vomiting or other side effects of laxatives. Pt reports a lack of concern about constipation and claims it is because she was required not to eat proceeding the surgery.

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

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

LA8/2011 23

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

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

• Monitor skin condition at least once a day for color and texture • Instruct pt to avoid harsh cleaning agents, hot water, and too frequent cleansing • Minimize exposure of the site of skin impairment to moisture, perspiration or wound drainage • Monitor condition of skin covering bony prominences • Implement prevention plan • Assess client’s nutritional status • Perform teaching to the client regarding skin assessment and ways to monitor for impending skin breakdown • Determine pt’s risk by using the Braden Scale.

Patient response: Skin integrity, color and texture appear and feel normal. Pt used warm rather than hot water while performing self cleansing as well as mild soap. Wound bandaging is tight and free of moisture or damage. Skin surrounding and covering pt’s bony prominences is without breakdown. Inquired about the need to rotate the pt’s positions regularly and was told that the brief nature of her visit was not cause for rotation. Also, pt is able to sit herself up which decreased her risk of developing any ulcers or areas of breakdown. Client electrolytes are normal which indicated good nutritional status. Pt is now eating her entire meals and is being hydrated via IV NS. Calculated pt’s Braden Scale risk at a 17 which puts her at mild risk for skin breakdown.

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

LA8/2011 24

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

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