Danielle Young Bear Pharm. Documentation Assignment PDF

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Pharmacology Scenario 3: Danielle Young Bear Documentation Assignments 1. Document your initial assessment data of Danielle Young Bear, including orientation, level of consciousness, pain assessment (including indicators of chronic pain), and vital signs. 



Awake Alert and Oriented X3 o

Person

o

Place

o

Time

Glasgow Coma Scale o



Score 15

Level of consciousness o

The patient is conscious; awake and alert

o

Muscle strength, sensation and deep tendon reflexes are normal.

o

No signs of clonus

o

Pasero Opioid-Induced Sedation Scale 

o

Pupils are 6mm 

o 



Score 1

Equal and react bilaterally to light

Eye extra ocular movement

Legs o

Normal elasticity of the skin

o

Skin is cool and very sweaty

Vital Signs o

Respiratory Rate – 21

From vSim for Nursing | Pharmacology. © Wolters Kluwer.



o

SpO2 – 98 on room air

o

Pulse – 89

o

Blood Pressure – 110/74

o

Temperature – 99°

Pain o

Patient Pain was a 6 on the numeric pain scale

o

Dull achy pain 

Sometimes becomes a sharp pain when she moves

o

The pain is located in her lower back

o

Pain medicine helps to relieve the pain

o

Pain gets worse when she tries to lift heavy stuf

2. In the nurses’ notes, document the medication reconciliation information for Danielle Young Bear. Include all prescription medications, OTC medications, herbal supplements, and dietary supplements. Note any drug–drug interactions. 





Prescription Medication: o

Cyclobenzaprine 5mg X 3 daily

o

Duloxetine 60mg X 1 daily

o

Tramadol 50mg X 4-6 daily

o

Hydrocodone 5mg/ acetaminophen 325mg X 4 daily

Over the Counter Medication: o

Nyquil 3 Tablespoons daily

o

Acetaminophen 500mg X 4 daily

Herbal Supplements: o

1 cup willow bark tea

From vSim for Nursing | Pharmacology. © Wolters Kluwer.



Drug Interactions: o

Hydrocodone & Tramadol 

o

Hydrocodone containing acetaminophen, Nyquil & Acetaminophen 

o

Cause seizures

OTC medications caused Mrs. Young Bear to exceed the prescribed daily dose of acetaminophen. (Damaging to the liver)

Acetaminophen & Duloxetine 

Causes liver damage

3. Document the information you provided to Danielle Young Bear regarding adverse drug efects when combining medications.  The total amount of acetaminophen exceeds more than 4g per day. You should choose over the counter medications that don’t include acetaminophen and consult you doctor or pharmacist about over the counter medication. 4. Document the total amount of acetaminophen Danielle Young Bear ingested in the 24 hours before the scenario. 

Mrs. Young Bear ingested 4,275mg of acetaminophen in 24 hours

5. Document any referrals for Danielle Young Bear. Include who the patient was referred to and why. 

Mrs. Young bear was referred to the Pain clinic



The pain clinic is going to help Mrs. Young manage her learn techniques to manage her pain without use of medication. o

Guided imagery

o

Breathing training

o

Relaxation techniques

From vSim for Nursing | Pharmacology. © Wolters Kluwer.

From vSim for Nursing | Pharmacology. © Wolters Kluwer....