CRITICAL THINKING SUMMARY



CRITICAL THINKING SUMMARY

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|Student ___Kelli Howland_ Client Dx__Subdural Hematoma___ Age _87_ Allergies __Wool, Brilinta___ |

|The MEDICAL DIAGNOSIS that brought the client to the hospital is: |

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|Subdural Hematoma after a fall. |

|PATHOPHYSIOLOGY of diagnosed disease: (From text) |

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|A collection of blood that develops between the surface of the brain and the dura mater, the brain’s tough outer covering, usually due to stretching and tearing of|

|veins on the brain’s surface. These veins rupture when a head injury suddenly jolts or shakes the brain. |

|SYMPTOMS typically seen with this diagnosis include (as identified in your text): |

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|Confusion, difficulty walking/balancing, headache, lethargy, confusion, loss of consciousness, nausea, vomiting, numbness, seizures, slurred speech, visual |

|disturbances, and weakness. |

|CLIENTS’ SYMPTOMS of the diagnosed disease include: |

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|Weakness, balance issues, and headache. |

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|NUTRITIONAL ASSESSMENT: |

|Height (actual or estimated) __162.5cm__ Weight (actual or estimated) __70kg____ |

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|Estimate Ideal Body Weight ( Male: 105lb + 6 lb/inch > 5’. Female: 100lb + 5lb/inch > 5’) __59kg____ |

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|Does this client have characteristics of a well-nourished person? Yes __x__ No ______ |

|Explain your answer. |

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|Patient has bright and clear eyes, teeth are intact and white, clear strong nails, no broken bones, good skin color, and even though he has diabetes, he has no |

|negative side effects of the disease because it is well managed. |

|PSYCHOSOCIAL STAGE OF DEVELOPMENT |

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|What is the client’s developmental stage? |

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|Lake Adult: Integrity vs. despair |

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|Has he/she met the necessary accomplishments? Yes __x__ No _____ |

|Explain |

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|The patient has met accomplishments by being married, having multiple kids, overcoming illnesses like diabetes and living with an ileostomy, and retiring from |

|work. |

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|How is this illness affecting the client’s ability to meet these necessary accomplishments? |

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|This illness is affecting the patient’s ability to fully meet these accomplishments because the illness happened so quick and severe causing him to be ventilated |

|and unconscious so he is not able to reflect back on his life. He isn’t able to feel if his life has been fulfilled or feel regret. |

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|STRESS MANAGEMENT: Identify coping mechanisms used by this client during stress. |

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|Family support at bedside while patient is sedated and intubated. |

|NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS |

|Indicate below the 2 priority nursing diagnosis that are most relevant for your client. |

|#1 NURSING DIAGNOSIS (problem r/t) |

|Risk for infection related r/t craniotomy |

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|DEFINING CHARACTERISTICS (S/S) that support this diagnosis: |

|Long incision on top of patients head with no dressing covering. Increasing temperature. Abnormal lab values. |

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|OBJECTIVE/CLIENT OUTCOME for this diagnosis: |

|Patient will stay free of infection. |

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|NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis: |

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|1. Monitor temperature closely and report if client has a low-grade temperature. Use a urinary bladder temperature. |

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|2. Use of appropriate hand hygiene and protective equipment like gloves when coming in contact with patient. |

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|3. Observe and report signs of infection of head incision such as drainage and swelling. |

|#2 NURSING DIAGNOSIS (problem r/t) |

|Risk for aspiration r/t presence of endotracheal tube. |

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|DEFINING CHARACTERISTICS (S/S) that support this diagnosis: |

|Dyspnea, cough, cyanosis, wheezing, adventitious breath sounds, fever. |

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|OBJECTIVE/CLIENT OUTCOME for this diagnosis: |

|Maintain patent airway and clear lung sounds. |

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|NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis: |

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|1. Auscultate lung sounds frequently noting any changes. |

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|2. Keep HOB elevated a minimum of 30 degrees. |

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|3. Keep airway clear of secretions by suctioning as needed. |

|COMPLICATIONS: |

|If this client’s condition were to worsen, what would be the most likely reason and why? |

|If the patient’s condition were to worsen, the most likely reason would be from infection because his WBC levels are low and he had craniotomy. This could go |

|undetected because his WBC’s are so low and he is not on any antibiotics. |

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|How would you know this is happening? |

|Because the patient’s WBC levels are so low, it would be hard to notice changes with lab values. However, the infection would be of the brain or of his incision |

|which could then travel to the brain which would cause many symptoms like increased intracranial pressure, a swollen or drainage at the incision site, vital sign |

|changes like increasing temperature, or seizures. |

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|What will you do if this happens? |

|If this were to happen, the first thing I would be to take vital signs to ensure the readings were right and assess his incision site for drainage and change in |

|appearance. Next I would look at labs to see if his WBC’s had increased from what they had been at, if everything was still indicating infection, I would notify |

|the physician immediately so that antibiotic could be ordered stat and started. I would make sure that seizure precautions were fully implemented. |

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|EVALUATION: |

|Was the patient able to achieve the objectives identified on the first clinical day? yes no |

|If no, list new objectives. |

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|The patient was able to meet some of the objectives but because he is intubated and under sedation, objectives are more long term then just for the day. He is not |

|consciously able to meet each objective. |

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|Did you choose the appropriate nursing diagnosis on the first clinical day? yes no |

|If no, list nursing diagnosis that would have been more appropriate. |

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|Were the interventions appropriate? yes no n/o |

|If no, list more appropriate interventions. |

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PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS

|MEDS/IV’S/TX/DIET |REASON PRESCRIBED |NURSING IMPLICATIONS FROM TEXT |PATIENT DATA FROM YOUR ASSESSMENT |

|(Include dose, route, frequency) |(Drug Classification |(Checking for adverse reactions, |(What data is important to know before & |

| |What is it treating?) |preparation & administration concerns) |after giving) |

| |Anti-thrombotics |Adverse Reactions are drug-induced |Assess for signs of bleeding and |

|Heparin- | |hepatitis, alopecia, rashes, urticaria, |hemorrhage; Notify health care |

|5000 Units, Subq, q8h |Prevention of thrombus formation. |bleeding, heparin-induced |professional immediately if occurs. Assess|

| | |thrombocytopenia, anemia, pain in |patient for additional or increased |

| | |injection sight, osteoporosis, fever, and |thrombosis. Monitor patient for |

| | |hypersensitivity. |hypersensitivity reactions. Monitor |

| | | |platelet count every 2-3 days throughout |

| | |Apply pressure to prevent bleeding or |therapy. If toxicity occurs, protamine |

| | |hematoma formation. |sulfate is the antidote. |

| |Mineral and electrolyte |Adverse Reactions: Arrhythmias, |Monitor serum calcium and phosphate |

|Calcium acetate- |replacement/supplement |hypercalcemia, constipation, calculi, |levels. |

|1334mg, 2 Cap, PO/Feeding tube, qid | |hypercalciuria. | |

| |To control hyperphophosphatemia in end- | | |

| |stage renal failure. |Administer on empty stomach before meals. | |

| |Anticonvulants |Adverse Reactions: diplopia, atrial |Asses location, duration, and |

|Lacosamide- | |fibrillation/flutter, bradycardia, PR |characteristics of seizure activity. |

|100MG, IVPB, q12h |Decrease incidence of seizures |interval prolongation, agranulocytosis, |Institute seizure precautions. |

| | |toxic epidermal necrolysis, steven-johnson|Assess ECG prior to therapy in patients |

| | |syndrome, drug reaction with eosinophilia |with pre-existing cardiac disease. |

| | |and systemic symptoms. |Assess patients skin for rash frequently. |

| | | |Monitor CBC and platelets periodically |

| | |Can be undiluted or diluted with normal |during therapy. |

| | |saline, D5W, or LR. Solution should be | |

| | |clear and colorless. Solution is stable at| |

| | |room temperature for 24 hours. | |

| |Laxatives |Adverse Reactions: mild cramps, diarrhea, |Assess for abdominal distention, presence |

|Docusate- | |rashes. |of bowel sounds, and usual pattern of |

|100mg, PO/Feeding tube, bid |Stool softener | |bowel function |

| | |Do not administer within two hours within |Assess color, consistency, and amount of |

| | |2 hours of other laxatives. |stool produced. |

| |Anticonvulsants |Adverse Reactions: dyskinesia, EPS, |Assess oral hygiene. Vigorous cleaning |

|Phenytoin- | |diplopia, nystagmus, hypotension, |beginning within 10 days of initiation of |

|200mg, IVPB, Q12hr |Prevention of seizures. |tachycardia, gingival hyperplasia, drug- |therapy. |

| | |induced hepatitis, stevens-johnson |Assess for phenytoin hypersensitivity |

| | |syndrome, hypertrichosis, rash, |reaction (usually begins within first 2 |

| | |agranulocytosis, aplastic anemia, |weeks of therapy). |

| | |osteomalacia, lymphadenopathy. |Observe for development of rash. |

| | | |Assess location, duration, and |

| | |Administer undiluted. Precipitate may form|characteristics of seizure activity. |

| | |if refrigerated, but dissolves after |Institute seizure precautions. |

| | |warming to room temperature. Discard |Assess BP, ECG, and respiratory function |

| | |solution that is not clear. |throughout therapy in patients with |

| | | |pre-existing cardiac disease. |

| | | |Monitor CBC, serum calcium, albumin, and |

| | | |hepatic function tests prior to and |

| | | |monthly during therapy. |

| |Laxatives |Adverse Reactions: electrolyte imbalances,|Assess for abdominal distention, presence |

|Senna- | |diarrhea, rashes, urine discoloration. |of bowel sounds, and usual pattern of |

|8.8mg, PO/Feeding tube, bid |Stool softener | |bowel function. |

| | |Do not administer within two hours within |Assess color, consistency, and amount of |

| | |2 hours of other laxatives. Administer |stool produced. |

| | |preferably in evening. | |

| |Lipid Lowering Agent |Adverse Reactions: Peripheral edema, |Evaluate serum cholesterol and |

|Simvastatin- | |abdominal cramps, heart burn, increased |triglyceride levels before therapy, after |

|20mg, PO/Feeding Tube, bid |Manage high cholesterol |liver enzymes, Pancreatitis, rash, Drug |4-6 weeks of therapy, and periodically |

| | |induced hepatitis, rhabdomyolosis, |thereafter. |

| | |hyperglycemia, dyspepsia, |Monitor liver function tests. |

| | |hypersensitivity, arthralgiamyopathy. |(May also increase alkaline phosphate and|

| | | |bilirubin levels) |

| | |Administer once a day in the evening. |Monitor CPK levels. |

| |Anticonvulsant |Adverse Reactions: increased seizures, |Assess location, duration, and |

|Topiramate- | |diplopia, nystagmus, constipation, dry |characteristics of seizure activity. |

|25mg, PO/Feeding tube, qhs |Prevention of seizures |mouth, encephalopathy, hyperammonemia, |Institute seizure precautions. |

| | |kidney stones, oligohydrosis, |Monitor CBC with differential, liver |

| | |hyperchloremia metabolic acidosis, |function tests, and platelet count before |

| | |leukopenia, tremor, fever. |and throughout therapy. |

| | | | |

| | |Capsules (not XR) can be opened. | |

| |Antiulcer agents |Ad verse Reactions: arrhythmias, |Assess for frank or occult blood in the |

|Famotidine- | |constipation, gynecomastia, |stool, emesis, or gastric aspirate. |

|20mg, Feeding tube, Daily |Prevention of GI ulcers |agranulocytosis, aplastic anemia, anemia, |Monitor CBC with differential periodically|

| | |neutropenia, thrombocytopenia, |throughout treatment. |

| | |hypersensitivity reactions. | |

| | | | |

| | |Administer with meals or after and at | |

| | |bedtime to prolong effect. If liquid, | |

| | |shake before administration. | |

| |Antiulcer agent |Adverse Reactions: edema, gastric |Assess fluid balance throughout therapy, |

|Sodium Bicarbonate- | |distention, metabolic acidosis, |Report symptoms of overload. |

|650mg, Feeding tube, daily |Prevention of GI ulcer |hypernatremia, hypocalcemia, hypokalemia, |Assess patient for signs of acidosis. |

| | |sodium and water retention, irritation at |alkalosis, hypernatremia, or hypokalemia |

| | |IV site, tetany, cerebral hemorrhage. |throughout therapy. |

| | | |Observe IV site closely. |

| | |May be administered 1 to 3 hours after |Assess patient for frank or occult blood |

| | |meals and at bedtime. |in the stool, emesis, or gastric aspirate.|

| | | | |

| | | |Monitor serum sodium, potassium, calcium, |

| | | |bicarbonate, osmolarity, acid-base |

| | | |balance, and renal function throughout |

| | | |therapy, |

| | | |Obtain arterial blood gases frequently |

| | | |during parenteral therapy. |

| |Anti-diabetic Hormones |Adverse Reactions: hypoglycemia, Allergic |Assess for signs and symptoms of |

|Insulin regular- | |reactions (anaphylaxis), lipodystrophy, |hypoglycemia (anxiety, restlessness, |

|100 units, IV, Continuous drip |Glucose Control |swelling, pruritus, erythema, Swelling. |tingling in hands and feet, chills, cold |

| | | |sweats, confusion, cool pale skin, |

| | |Do not use it cloudy, discolored, or |weakness, and tremors) |

| | |unusually viscous. May be diluted with | |

| | |normal saline in polyvinyl chloride | |

| | |infusion bag. | |

| |Sedative/Hypnotics |Adverse Reactions: Apnea, laryngospasm, |Assess level of sedation throughout |

|Midazolam- 100MG, IV, Continuous | |respiratory depression, cardiac arrest, |therapy and for 2-6 hours following |

|drip |Short-term sedation and control |arrhythmias, rash, phlebitis at iv site. |administration. |

| |seizures. | |Monitor BP, pulse, and respiration |

| | |Do not administer medication with any |continuously during IV administration. |

| | |other liquids. | |

| |General anesthetics |Adverse Reactions: bradycardia, |Assess respiratory status, pulse, and BP |

|Propofol- | |hypotension, involuntary muscle movements,|continuously throughout therapy. |

|1000mg, IV, Continuous drip |Sedation while intubated. |flushing, perioperative myoclonia, |Assess level of sedation and level of |

| | |discoloration of urine (green), fever. |consciousness throughout and following |

| | | |therapy. |

| | |Dose is titrated to patient response. |For ICU; wake-up and assessment of CNS |

| | |Administered undiluted but if diluted use |function during maintenance to determine |

| | |D5W. Shake well before using. When used |minimum dose required for sedation. |

| | |for sedation, discard unused medication |Monitor for propofol infusion syndrome |

| | |after 12 hrs. Do not administer with |(severe metabolic acidosis, hyperkalemia, |

| | |filter less than 5 micron pore size. |lipemia, rhabdomyolysis, hepatomegaly, |

| | | |cardiac and renal failure). |

| |Mineral electrolyte replacement |Adverse Reactions: Arrhythmias, ECG |Monitor Potassium levels. Symptoms of |

|Potassium Chloride- |supplement |changes, abdominal pain, diarrhea, |toxicity are those of hyperkalemia (slow |

|20mEq, Feeding tube, PRN | |flatulence, and vomiting. |heartbeat, fatigue, muscle weakness, |

| |Control Potassium level | |parathesia, confusion, dyspnea, peaked T |

| | |Administer with or after meals. Dissolve |waves, depressed ST segments) |

| | |effervescent tablets and powder in 3-8oz | |

| | |of cold water. | |

|Paricalcitol- |Vitamin |Adverse Reactions: conjunctivitis, |Assess for symptoms of vitamin deficiency |

|4mcg, PRN (with dialysis) | |rhinorrhea, arrhythmias, edema, |prior to and periodically during therapy. |

| |Prevent hyperparathyroidism and improve |hypertension, palpitations, constipation, |Assess patient for bone pain and weakness |

| |calcium and phosphate homeostasis. |increased liver function test, polydipsia,|prior to and during therapy. |

| | |albuminuria, rash, gout, and hyperthermia.|Observe patient carefully of hypocalcemia.|

| | | | |

| | | |Monitor serum calcium and phosphate |

| | |Administer by rapid injection through the |levels. |

| | |catheter at the end of a hemodialysis | |

| | |period. | |

Analysis of Diagnostic Tests

DIRECTIONS:

1. List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical treatments (i.e. medications) and provide the patient values for each test. Explain why they are pertinent for this patient.

2. List any screening diagnostic and laboratory tests that are not within normal limits. Explain why these tests are increased or decreased in relation to your patient's medical condition.

|Diagnostic/Lab Test |Patient Values |Analysis of Values |

| | | |

|WBC |3.71- Low |Low level because patient had blood loss during surgery |

| | |and is on many medications that can lower WBC. |

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|Hgb |6.8- Critically low |Low level because of blood loss during surgery. |

| | | |

|Hct |21.5- Low |Low level because of blood loss during surgery. |

| | | |

|RBC |2.0- Low |Low level because of blood loss during surgery. |

| | | |

|MCV |107.5- High |High level because of lack of iron and b12 because of |

| | |lack of nutrition and liver function may be altered. |

| | | |

|MCH |34.0- High |High level because of lack of iron and b12 because of |

| | |lack of nutrition and liver function may be altered. |

| | | |

|MCHC |31.6- Low |Low level because of blood loss during surgery. |

| | | |

|RDW |16.1- High |High level because of lack of iron and liver function may|

| | |be altered. |

| | | |

|Platelet |97- Low |Low level because patient had blood loss during surgery |

| | |and is on many medications that can lower platelet count.|

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| | | |

|Lymphs Man |6- Low |Low level because patient had blood loss during surgery |

| | |and is on many medications that can lower these values. |

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|EOS Man |10- Low |Low level because patient had blood loss during surgery |

| | |and is on many medications that can lower these level. |

| | | |

|Meta Man |1- High |High level because of medications and other blood cells |

| | |deficiency. |

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|Pco2 |34- Low |Low level due to patient being on ventilator and on |

| | |medications (like antiulcer) that can affect levels. |

| | | |

|HCO3 |20- Low |Low level due to patient being on ventilator and on |

| | |medications (like antiulcer) that can affect levels. |

| | | |

|Base Excess |-5.2- Low |Low level due to patient being on ventilator and on |

| | |medications (like antiulcer) that can affect levels. |

| | | |

|Chloride |114- High |High level because patient has renal failure and an |

| | |ileostomy in the right upper quadrant so it is not being |

| | |absorbed. |

| | | |

|Urea Nitrogen |51- High |High level due to patient’s renal failure. |

| | | |

|Creat |5.77- High |High level due to patient’s renal failure and antiulcer |

| | |medication. |

| | | |

|MDRD eGFR |9- Low |Low level because patient’s renal failure. |

| | | |

|Glucose |132- High |High level because patient is diabetic and on medications|

| | |that can increase glucose. |

| | | |

|Calcium lvl total |8.0- Low |High level because patient has renal failure and an |

| | |ileostomy in the right upper quadrant so it is not being |

| | |absorbed. |

| | | |

|Iron Binding Capacity |174- Low |High level because patient has renal failure, isn’t able |

| | |to consume iron since under sedation. |

Narrative Charting Sample

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