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complete NURSING CARE PLAN assignment...

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N206 Medications

S: Patient is a 72 y/o male. Patient is here for suspected diagnosis of rhabdomyolysis. He is a full code with NKA.

B: Patient has history of hypertension and osteoarthritis, and no past pertinent surgical history. Patient lives alone and was found on the floor by his daughter. A: (for assessment) – define what the med does, state why the patient needs the med. R: (for recommendation)- state if you would give or hold med. If you choose to hold the med, state why and that you would alert the patient care provider.

Generic Name: Acetaminophen Trade Name: Tylenol Therapeutic Class: Analgesics

Dosage: 650 mg Safe dose: total dose NTE 3g / 24 hr Frequency: every 6 hours prn Route: PO Time: prn (last dose 4 hours ago)

A: Acetaminophen is metabolized by the liver (Nursing Central, 2014). It reduces production of prostaglandins in the brain, which elevates a person’s pain threshold. It also reduces fever through action on the heat-regulating center of the brain. Patient’s vitals revealed a febrile state and patient reported pain and severe cramps in lower back and legs

Dosage: 12.5 mg Safe dose: Frequency: q 6 hours prn Route: IV Time: prn, last dose 4 hours ago

A: Promethazine woks as an antihistamine, having an inhibitory effect on the chemoreceptor trigger zone in the medulla, resulting in antiemetic properties, and also produces CNS depression by decreasing stimulation of the CNS reticular system (Nursing Central, 2014). Patient reports nausea and vomiting, and this medication is effective in controlling the feeling of nausea, and thus controls vomiting.

Pharmacologic Class: Antipyretics

R: I would recommend giving this medication. Patient’s very high fever, 40.1 degrees Celcius, needs to be decreased. The patient is also experiencing severe discomfort in lower back and legs with movement, and this medication would relieve that discomfort. I would check the patients fever and BP q 4 hours and once the fever is controlled, hold medication so HR is not decreased unnecessarily as pt vitals revealed a low systolic (80).

Rationale for use: pain Expected therapeutic effect: relieve pain Action: Inhibits synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. (Nursing Central, 2014) Generic Name: Promethazine Trade Name: Phenergan Therapeutic Class: Tricyclic

R: If the patient reports feelings of nausea and vomiting, then this medication should be given. This pt should not vomit due to current dehydration and electrolyte imbalance. I would check patient’s symptoms at least q 4 hours, should be evaluated for effectiveness within 30 mins of administration. Also check IV inser-

tion site q 4 hours for patency as medication can be damaging to tissue when administered via IV.

Pharmacologic Class: Phenothiazine Rationale for use: nausea / vomiting Expected therapeutic effect: reduce nausea and cease vomiting Action: Antihistamine Generic Name: Zolpidem extended release Trade Name: Ambien Therapeutic Class: sedative Pharmacologic Class: hypnotics Rationale for use: for sleep Expected therapeutic effect: Sedation and induction of sleep Action: CNS depressor

Dosage: 6.25 mg Safe dose: Frequency: prn Route: PO Time: pro 4 hours ago

A: Produces CNS depression by binding to GABA receptors (Nursing Central, 2014). R: If patient is unable to sleep, and BP and RR are WNL, then I would recommend giving this medication. Vital signs showed a low systolic BP (80) which could be further decreased with administration of CNS depressants. Call MD for reevaluation of medication administration.

Generic Name: Trade Name: Therapeutic Class: Pharmacologic Class: Rationale for use: Expected therapeutic effect: Action:

Dosage: Safe dose: Frequency: Route: Time:

A: R:

N206 Laboratory Review Laboratory test Results Normal Range

Interpretation Why is the result abnormal in this patient & what is your recommendation for re(WNL/high/low) sponding to the value? (A: includes what the test measures & hx, assessment findings, etc. pertinent to the test.)

S: Patient is a 72 y/o male. Patient is here for suspected diagnosis of rhabdomyolysis. He is a full code with NKA. B: Patient has history of hypertension and osteoarthritis, and no past pertinent surgical history. Patient lives alone and was found on the floor by his daughter. A: (for assessment) – define the lab, state why the lab is abnormal (use your assessment findings.) R: (for recommendation)- state you will trend every time, every entry! What are you going to assess for and report to the patient care provider. Be patient specific!

WBC 4.8 - 10.8

7.9

WNL

A: White blood cells are the body’s defense against foreign antibodies. This lab would be drawn to assess for infection and inflammation (Nursing Central, 2014.). Patient’s temperature has been elevated. Patient's skin has no sign of break down other than stage II pressure ulcer evaluated on coccyx. R: Continue to trend and evaluate for WBC elevation, particularly because patient has a pressure ulcer and other infection risk factors (Foley catheter) that could become infected. Notify Provider for elevated WBC count and other signs of infection: fever, tachycardia, tachypnea, etc

Hgb 12.4 - 17.4

11.4

low

A: Hgb is the iron-containing pigment of RBCs that carries oxygen from the lungs to the tissues. (Nursing Central, 2014.). R: Hgb results not within lower range critical level (145), meaning the Pt has hypernatremia. IV hypotonic electrolyte solutions should lower Na+ levels, but continue to monitor sodium serum levels until they reach WNL range. Monitor for fever, tachycardia, decreased BP, and orthostatic hypotension. Pt at risk for seizures. Notify Physician if levels do not lower or continue to rise.

K+ 3.5-5

6.5

High

A: Extracellular potassium is increased in renal failure; in destruction of cells with release of intracellular potassium in burns, crush injuries, or severe infection; in adrenal insufficiency; in over-treatment with potassium salts; and in metabolic acidosis (Nursing Central, 2014.) R: This lab result is high, meaning the Pt has hyperkalemia. The Saline IV solution should lower the pt K+ levels, due to the dilution effect of the Normal Saline, but continue to monitor K+ labs until they reach WNL range. Monitor cardiac: peaked T waves and ventricular fibrillation. Notify Physician if levels do not lower or continue to rise, sodium bicarbonate or calcium gluconate may be needed.

Cl97-107

114

High

A: Chloride is the major extracellular anion and contributes to many body functions including the maintenance of osmotic pressure, acid-base balance, muscular activity, and the movement of water between fluid compartments (Nursing Central, 2014.). R: This lab result is high, meaning the Pt has Hyperchloremia, which could indicate metabolic acidosis, edema, or hyperatremia. IV hypotonic electrolyte solutions should lower Cl- levels, but continue to monitor Chloride serum levels until they reach WNL range. Assess daily weights and urinary intake/output. Monitor for dyspnea, fatigue, muscle weakness, and tachycardia. Electrolyte balance should be restored through IV and dehydration should be monitored. Notify Physician if levels do not lower or continue to rise.

Glucose < 100 mg/dl

110

High

A: Glucose is the end product of carbohydrate digestion, and serves as a primary energy source for living organisms(Nursing Central, 2014.). Hyperglycemia is a primary indication of diabetes mellitus, occurring when the pancreas does not produce sufficient insulin levels, and can induce vascular damage (Contemporary Clinic, 2016). R: This lab result is high, indicating hyperglycemia, but is not of critical level (>400). Assess for altered mental status, abnormal BP levels, fluid volume deficit and dehydration. Also monitor strict I&O: in spite of the state of dehydration, the urine may not appear concentrated (Nursing Central, 2014).

Laboratory test Results Normal Range

Interpretation Why is the result abnormal in this patient & what is your recommendation for re(WNL/high/low) sponding to the value? (A: includes what the test measures & hx, assessment findings, etc. pertinent to the test.) Blood glucose levels should continue to be monitored every 4 hours. Notify Physician if levels do not lower or continue to rise.

BUN 8-31

36

High

A: BUN levels are utilized for assessing for kidney function toward diagnosing disorders such as kidney disease and dehydration (Nursing Central, 2014.). R: This lab result is high, but is not of critical level (>100). Administration of IV bicarbonate will normalize pt glucose levels, and levels should be monitored until returning to WNL. Assess peripheral pulses and capillary refill. Monitor blood pressure and check for orthostatic changes. Assess respiratory rate, breath sounds, and orthopnea, level of consciousness, skin color, temperature and urinary intake/output. Notify physician if levels do not decrease or rise.

Creatinine 0.61 - 1.21

6.5

High

A: Creatinine is a normal alkaline constituent of urine and blood and is a source of energy for muscle contraction. Increased quantities of creatinine are found in advanced stages of renal disease (Nursing Central, 2014.), acromegaly, dehydration, kidney disease, acute kidney injury and CKD, and shock. R: This lab is very high, but not of critical level (>7.4). Monitor for weak peripheral pulses, slow capillary refill (>2 sec), decreased urinary output, tachypnea, abnormal heart sounds, hypoxia, SOB, edema, and distended neck veins. Notify Physician if levels do not lower or continue to rise.

Bicarbonate 22-26 14

Low

A: The amount of bicarbonate present in blood is an indicator of the body’s alkali reserve Nursing Central, 2014.), and low levels can indicate metabolic acidosis. R: Monitor for low RR or fast HR. Notify Physician if levels do not rise or continue to lower.

Calcium 8.2 - 10.2

4.2

Low

A: Calcium is important for blood clotting, enzyme activation, and acid-base balance. Blood levels of calcium are regulated by parathyroid hormone; deficiency of this hormone produces hypocalcemia. Low blood calcium causes tetany. Blood deprived of its calcium will not clot. (Nursing Central, 2014.). This low lab level indicates hypocalcemia. R: Assess for neuromuscular excitability with twitching and irritability and laryngospasm (the most common sx of severe hypocalcemia). Assess airway, breathing, and circulation. Monitor for dysrhythmias (ventricular fibrillation / heart block). Check for Trousseau sign and Chvostek sign, and inspect the patient's skin to see if it is dry, coarse, or scaly (Nursing Central, 2014.). Also assess for confusion. Notify Physician if levels do not rise or continue to lower.

Creatinine Kinase (CK) 22 - 198

14,118

High

A: CK An enzyme that catalyzes the reversible transfer of high-energy phosphate between creatine and phosphocreatine and between adenosine diphosphate (ADP) and adenosine triphosphate (ATP). Serum levels of CK-MB are also increased in progressive muscular dystrophy, in myocarditis, and fol-

Laboratory test Results Normal Range

Interpretation Why is the result abnormal in this patient & what is your recommendation for re(WNL/high/low) sponding to the value? (A: includes what the test measures & hx, assessment findings, etc. pertinent to the test.) lowing trauma to skeletal muscle(Nursing Central, 2014.). R: Assess for weak peripheral pulses; slow capillary refill; decreased urinary output; cool, clammy skin; tachypnea; dyspnea; altered level of consciousness; abnormal heart sounds; fatigue; hypoxia; ECG changes; increased jugular venous distention, increased BP/HR, SOB, pallor, and chest pain. Notify Physician if levels do not lower or continue to rise.

Urinalysis: specific gravity 1.002 and 1.030

1.038

High

A: Specific gravity is a reflection of the concentration ability of the kidneys. Results above 1.010 can indicate mild dehydration. The higher the number, the more dehydrated one is.

Urinalysis: pH 4.5 - 8.0

5.8

WNL

A: Urine pH is an indication of the kidneys' ability to help maintain balanced hydrogen ion concentration in the blood(Nursing Central, 2014.).

Urinalysis: protein 0

1+

High

A: Moderate proteinuria occurs in various renal diseases or in diseases in which renal failure is a late complication (diabetes mellitus, heart failure). Levels are also increased in diabetic nephropathy, glomerulonephritis, and nephrosis.(Nursing Central, 2014.).

R: Notify Physician if levels do not lower or continue to rise.

R: This lab is WNL, signifying no abnormality in pt urine pH. It does not require further monitoring.

R: Pt at risk for increased risk of death from cardiovascular diseases and potential need for dialysis. Notify Physician if levels do not lower or continue to rise. Urinalysis: glucose negative

Negative

WNL

A: Glucose is not supposed to be in urine, if glucose test is positive, indicates blood in urine. The main cause of this is diabetes.

Urinalysis: ketones Negative

Negative

WNL

A: The presence of urinalysis ketones indicates impaired carbohydrate metabolism. Positive lab result is increased with diabetes, fasting, fever, high-protein diets, isopropanol intoxication, starvation, vomiting (Nursing Central, 2014.).

R: This lab is WNL, signifying no glucose in pt urine. It does not require further monitoring.

R: This lab is WNL, signifying no ketones in pt urine. It does not require further monitoring. Urinalysis: blood negative

Negative

WNL

A: Positive hemoglobin in a urinalysis indicates the presence of blood, which is associated with kidney disease. Positive results due to hemolysis, bladder diseases, malignancy, and traumav(Nursing Central, 2014.). R: This lab is WNL, signifying no blood in the pt urine. It does not require further monitoring.

Laboratory test Results Normal Range Urinalysis: casts Negative

Positive

Interpretation Why is the result abnormal in this patient & what is your recommendation for re(WNL/high/low) sponding to the value? (A: includes what the test measures & hx, assessment findings, etc. pertinent to the test.) High

A: Casts are the result of solidification of material (protein) in the lumen of the kidney tubules. Casts in urine are a symptom of kidney disease (Ringsrud. Casts in the Urine Sediment, 2019.). R: Continue monitoring presence of casts in urine. Notify Physician if levels do not lower or continue to rise.

Urinalysis: bacte- None ria None

WNL

A: Nitrites and leukocytes are used to test for bacteriuria and other sources of urinary tract infections (UTIs). R: This lab is WNL, signifying no bacteria in pt urine. It does not require further monitoring.

N206 NURSING FUNDAMENTALS WORKSHEET

STUDENT'S NAME_____Emma Orosz_________ DATE_____11-18-2019________ PATIENT'S INITIALS__OL__ ROOM #_____11_____

AGE___72__

SEX__M__

ADMISSION DATE____11-18-2019___

PRIMARY LANGUAGE____English_______

ALLERGIES__NKDA___

ADMITTING DIAGNOSIS_________Rhabdomyolysis______________________ HISTORY OF PRESENT ILLNESS: [Include risk factors, smoking, ETOH use, & precipitating event to admission.] Precipitating event: heat exhaustion; nausea/vomiting/anorexia for the past 6 or 7 days Pre-diagosed gastrointestinal virus by PCP and was told to be on clear liquid diet Risk factors: Living alone, high fall risk No ETOH use / smoking reported

CURRENT & PAST MEDICAL PROBLEMS: [eg. HTN, DM, Angina, physical limitations to include hearing loss, blindness, amputations, etc] Hx of hypertension and osteoarthritis

PATHOPHYSIOLOGY OF _____Rhabdomyolysis, dehydration, malnutrition________________________________ TEXTBOOK DESCRIPTION OF PATHOPHYSIOLOGIC PROCESS Rhabdomyolysis is an acute, sometimes fatal disease in which the by-products of skeletal muscle destruction accumulate in the renal tubules and produce acute renal failure, other internal organ injury, and, occasionally, death. Kidney failure caused by rhabdomyolysis may produce life-threatening hyperkalemia and metabolic acidosis (Nursing Central, 2014).

CLINICAL MANIFESTATION (Sx) Elevated levels (five times the upper limit of normal) of creatine kinase (CK) (Nursing Central, 2014). ETIOLOGY Rhabdomyolysis may result from crush injuries, the toxic effect of drugs or chemicals on skeletal muscle, extremes of exertion, heatstroke, sepsis, shock, electric shock, and severe hyponatremia. Lipid-lowering drugs such as statins (pravastatin, simvastatin) and/or fibrates (gemfibrozil) are among the commonly prescribed drugs that put patients at risk for rhabdomyolysis (Nursing Central, 2014). SURGERY 1. PREVIOUS SURGERY [PLEASE LIST DATES & SURGICAL PROCEDURES] N/A 2. CURRENT SURGERY A. DATE & TYPE OF SURGERY

B. NUMBER OF DAYS POST OP______________________

C. PROVIDE A GENERAL DESCRIPTION OF THE SURGICAL PROCEDURE

DIAGNOSTIC TESTS & RESULTS [eg. X-rays, biopsy, UGI series, occult blood tests, paracentesis, etc.] LIST ALL TESTS BELOW. TEST

DATE & RESULT

REASON FOR TEST

N/A

TREATMENT KARDEX [INCLUDE ALL INFORMATION FROM KARDEX & PROVIDE DETAILED RATIONALES. BE PREPARED TO EXPLAIN NURSING CARE ASSOCIATED WITH EACH INTERVENTION PRIOR TO ASSUMING CARE OF THE PATIENT.] PLEASE LIST ALL INTERVENTIONS - eg. Dressing changes, Drains & tubes, (chest tubes, foleys, NG tubes, T-tubes, etc), Respiratory TXs, Finger stick glucose, special equipment (eg. special beds, walkers, heating pads, etc.) etc. INTERVENTION ACTIVITY LEVEL:

RATIONALE

Complete bed rest

Pt weak: movement is weak in all four extremities, muscle pain and severe cramps in legs and lower back when extremities are moved; high fall risk

2 g sodium diet

low sodium diet bc electrolyte imbalance

. DIET:

IV SOLUTION & RATE: Normal Saline at rate of 1.5 L/hr TYPE OF VASCULAR ACCESS DEVICE:

Raise systolic BP greater than 110

TUBES: [list all tubes, drains, etc.] Indwelling urinary catheter IV normal saline . OTHER Cooling blanket Incentive Spirometry

Pt incontinent, need strict I&O Pt admitted with dehydration and electrolyte imbalance, used for replenishing hydration and electrolytes

Pt admitted with fever, use until temperature is less than 38.3C Pt ahas low Hgb levels, monitoring adequate perfusion, use every hour while awake

N206: Head to Toe Assessment Patient Initials: __OL__ Room #__11__ Most Recent Diagnosis:__________________Rhabdomyolysis________________________________________ Time of Assessment____730__ Vitals 0800

1200 HR 118 BP 80/60 RR 22 Temp 40.1C

Labs WBC 11.4 Hct 39.6% Hgb 11.4 Plt 380

Na 150 Cl 114 BUN 36 Gluc 110 K 6.5 CO2 — Creat 6.5

IV

Medications Due

Site #1: Date Inserted:11-18-2019 Location: R forearm Solution/Rate: 20G IV normal saline at rate of 1.5 L/hr Site Assessment: □aClear □Redness □Pain □Warmth □Swelling □Drainage Site patency for a lock device: ___________

0730 0800 0830 0900 0930 1000 1030 1100 1130 1200 12...