General Appearance/Mental State: Male, 76 years old. Grey hair cut very short and balding. Blue eyes. Pleasant demeanour and smiles often. Rarely makes eye contact. Usually dressed in button down shirts and jeans. Slouches in wheelchair and keeps head down. Constantly fidgeting. Keeps right arm flexed at the elbow and held close to the abdomen. Limited facial expressions but looks relaxed. Cooperative with care. Understands speech but is unable to respond verbally. Nods or shakes his head to answer yes or no questions. Unable to determine orientation. GCS of 11 and suffers from dementia. Cardiovascular System: Diagnosed with hypertension and hyperlipidemia BP: 120/82 lying flat taken on left arm Radial pulse 64 weak and irregular Apical pulse 64 strong and irregular S1 & S2 heart sounds heard at all cardiac sites with no additional sounds Heart sounds are muffled No edema noted in peripheral extremities, all extremities are pink and warm to touch Radial, ulnar, carotid, brachial pulses palpable Capillary refill <2 seconds No cyanosis noted in nail beds or extremities Respiratory System: Diagnosed with Chronic Obstructive Pulmonary Disease 14 respirations per minute shallow and unlaboured SPO2 of 92% on room air Decreased air entry Lung sounds clear in upper lobes bilaterally. Unable to assess lung sounds in right middle and left and right lower lobes bilaterally due to client not breathing through his mouth Symmetrical chest expansion Occasional productive cough with clear viscous mucous, usually approximately dime sized Gastrointestinal System: Bowel sounds in all 4 quadrants Umbilical hernia with protrusion mid abdomen Has bowel incontinence and wears a large brief Often constipated but usually relieved with the use of suppository Poor fluid intake approximately 500ml per shift Client eats well, usually >75% of meals Appears hydrated, no tenting noted, mucous membranes and lips pink and moist Abdominal distension but soft on palpation BMI is 21.56 (healthy weight)
it may not be enough to meet the requirements of the body cells or the body may be unable to use the insulin produced. This means that the body’s many cells are not receiving the food source they need to function. Impaired gas exchange related to decreased oxygenation of alveoli secondary to COPD as evidenced by SPO2 of 92% on room air. Client goal: Client will have adequate oxygenation. Client outcome: Client will have an adequate oxygen/carbon dioxide exchange as evidenced by SPO2 of >92%, no evidence of cyanosis and unlabored respirations between 12-20. Administer bronchodilator medications to maintain a patent airway and improve alveolar ventilation. (Day, Paul, Williams, Smeltzer & Bare, 2014, p. 652) Monitor sputum for any signs of infection including a change in colour, character, consistency or amount and take temperature daily. (Day et. al., 2014, p. 660) Monitor and report any signs or symptoms of hypoxia or dyspnea including cyanosis, a SPO2 of < 92% or 1) Goal partially met. I was able to administer ventolin and atrovent to client for AM meds but the client refused to inhale the atrovent after administering the ventolin during noon meds. The client’s respirations were 16 breaths a minute, shallow and unlabored upon 0730 vital signs and after lunch respirations were 12 breaths a minute, deep and unlabored. Will continue with this intervention throughout care and new ways to encourage the client to accept the inhalers. 2) Goal met. Upon mucous productive coughs during lunchtime I noted sputum was
Risk for aspiration related to impaired swallowing secondary to CVA. Client goal: Client will not aspirate. Client outcome: Client will demonstrate effective swallowing free of aspiration as evidenced by absence of coughing while eating and drinking. Encourage the client to eat slowly and chew all food well before attempting to swallow to aid in the passage of the bolus from the esophagus to the stomach. (Day et. al., 2014, p. 1098) Ensure that the client remains in semi or high fowlers position with the chin tucked down while eating and at least 30 minutes afterwards to avoid food remaining in the esophagus. (Day et. al., 2014, p. 1098) Provide fluids to client during and between meals to aid in the passage of food from the esophagus to the stomach. (Potter & Perry, 2014, p. 1073) Goal partially met. I have not been able to be present with the client during all meal times but when I am present I ensure that the client spends approximately 10-15 seconds chewing each bite to make swallowing more effective. I will continue with this intervention and attempt to be present for more meals to encourage this practice. Goal met. I have positioned the client’s wheelchair at an approximate 60 degree angle during meal times and have positioned his chin accordingly throughout feeding. I have also rescheduled his afternoon nap to 1300 to accommodate the time needed for food to pass through the esophagus. I will
continue with this intervention. Risk for falls related to Levodopa Carbidopa medication for Parkinson’s disease. Client goal: Client will not fall. Client outcome: Client will not fall within the next two in my care. Ensure that the clients wheelchair remain in a semi-fowlers position at all times (Potter & Perry, 2014, p. 801) Always keep the side rails of the bed in the upright position when the client is in bed Goal met. I have positioned the client’s wheelchair at an approximate 60-degree angle prior to transferring in the AM and it remains at that angle throughout the day. A fall has not
(Potter & Perry, 2014, p. 798) Provide the client with non-slip to wear when out of bed (Potter & Perry, 2014, p. 798) occurred. I will continue this intervention. Goal met. When the client is transferred into bed the side rails are always upright to maintain the clients safety and a fall has not occurred. I will continue with this intervention. Goal met. The client wears non-slip footwear at all times while in his wheelchair and a fall has not occurred. I will continue with this intervention. Medication Research Record Ensure you relate the medication information to the appropriate medical diagnosis. Please use lay terms as if you were teaching a patient.
Medication/Reason for Medication Order Dosage/Safe Dose Action as Related to Medical Diagnosis Common Side Effects Nursing Implications Generic: Levodopa/Carbidopa 200/50mg Trade: Levocarb CR Class: Dopamine agonist (antiparkinson agent) Dose ordered: 200/50mg PO QID Safe dose: Yes. 25 mg carbidopa/100 mg levodopa 3 times daily. May be increased every 1–2 days until desired effect is achieved (max = 8 tablets of 25 mg carbidopa/100 mg levodopa/day). Levodopa is converted into active dopamine in the central nervous system and acts as the neurotransmitter, resulting in a relief in tremors. Carbidopa prolongs the time that Levodopa is active in the central nervous system. Involuntary movements, anxiety, dizziness, hallucinations, memory loss, blurred vision, nausea, vomiting, diarrhea, dark urine or sweat, orthostatic hypotension. Administer on a regular schedule, eating after administration may decrease GI upset but foods high in protein may alter the effect of the drug, reposition slowly to avoid orthostatic hypotension, rinse mouth and provide oral hygiene regularly to decrease dry mouth. Assess for signs of toxicity (involuntary muscle twitching, protrusion of tongue, spasmodic eye winking, facial grimacing). Generic: Levothyroxine Sodium Trade: Synthroid Class: thyroid preparation (hormones) Dose ordered: 75mcg PO daily Safe dose: Yes. 50 mcg as a single dose initially, then can be increased q 2-3 weeks by 25mcg a day, maintenance dose is usually 75mcg/day. Replaces or supplements the thyroid hormones. Increases the metabolic rate of body tissues (the function of thyroid hormone in the body). Headache, insomnia, irritability, angina, arrhythmias, tachycardia, abdominal cramps, diarrhea, vomiting, sweating, hyperthyroidism. Administer before breakfast with a full glass of water, patients with dysphasia may take tablet crushed, watch for signs and symptoms of hyperthyroidism (toxicity, including: tachycardia, chest pain, diaphoresis, tremors)
Generic: Ipratropium Bromide Trade: Atrovent Class: Bronchodilator (anticholinergic) Dose ordered: 20mcg/dose, 2 puffs via chamber 4 times a day Safe dose: Yes. 2 inhalations 4 times daily (not to exceed 12 inhalations/24 hours or more frequently than q 4 hour). For acute exacerbations, 4–8 puffs using a spacer device as needed. Dilates the airways in the bronchi and lungs to promote effective breathing and decreases mucous secretions. Atrovent blocks the action of a natural chemical we have in our bodies that causes the muscles in our airways to narrow. The blocking of this chemical is what causes the airway dilation. Onset: 1-3 minutes Dizziness, headache, blurred vision, sore throat, paradoxical bronchospasm, hypotension, palpitations, GI irritation, nausea, rash Assess respiratory status prior to administration and at peak. When used concurrently with other inhalation medications, administer adrenergic bronchodilators first, then ipratropium, then corticosteroids with 5 minutes in between. Rinse mouth following administration. Generic: Salbutamol Trade: Ventolin Class: Bronchodilator Dose ordered: 2 puffs via chamber 4 times a day Safe dose: Yes. 2 inhalations q 4-6 hours Ventolin acts in the lungs on receptors called When these receptors are stimulated, it causes the muscles of the airway to relax. This promotes effective breathing. Onset: 5-15 minutes Nervousness, tremors, restlessness, insomnia, chest pain, palpitations, arrhythmias, hypertension, hyperglycemia, nausea, vomiting, hypokalemia Assess lung sounds, BP and pulse before administration and during peak of medication, note amount and color of sputum produced. Prime the inhaler prior to administration, allow one minute between inhalations, rinse mouth after administration. Use first when used concurrently with other inhalation meds,
allow 5 minutes in between medications. Generic: 0.3% ciprofloxacin + 0.1% dexamethasone Trade: Ciprodex Class: anti-infectives and anti-inflammatory (steroidal) Dose ordered: 3 drops to affected ear PRN Safe dose: Yes. 3mg/ml of ciprofloxacin and 1mg/ml of dexamethasone Ciprofloxacin: Prevents bacteria from multiplying by altering the DNA. Once the DNA is mutated, it cannot reproduce effectively and eventually will die off. Dexamethasone: suppresses inflammation and the natural immune response by acting on the cells that release inflammatory response chemicals. Dexamethasone inhibits the cells from releasing these immune response chemicals and thereby reduces inflammation. Ciprofloxacin: elevated intracranial pressure, seizures, hallucinations, headache, dizziness, tremor, peripheral neuropathy Dexamethasone: hallucinations, headache, increased intraocular pressure, hypertension, edema, nausea, vomiting. Warm solution in hands before administering to avoid vertigo, encourage fluids, position client in lateral recumbent position to administer ear drops and ensure they remain in that position for 5 minutes following administration.
Generic: Hydrocortisone cream Trade: Uremol HC Class: corticosteroid (anti-inflammatory) Dose ordered: 1% apply sparingly BID Safe dose: Yes. Apply sparingly to affected area 2-4 times daily Hydrocortisone works by inhibiting the body cells from releasing immune response chemicals. The inhibition of these chemicals being released slows down the inflammatory response causing a decrease in redness, swelling and pain. Burning, dryness, edema, folliculitis, hypersensitivity reactions, adrenal suppression. Wear gloves while applying, avoid eyes, and apply sparingly.