NURSING CARE PREPARATION



NURSING CARE PREPARATION

Student Name: DG, SN Date of Care: March 3, 2015

|Unit/Room Number: APU 351 |Date of Admission: 02-27-2015 |

|Age:41 |Ethnic/Cultural Preferences: White, Single, no religion |

|Gender:M |Allergies: NKA |

|Erikson’s Developmental Level: Generativiy vs. Stagnation |Code Status: Full Code |

Primary Diagnosis: Depression with suicidal ideations

Co-morbidities: Bipolar I disorder, current episode manic with psychosis.

Discharge Plan (add day of clinical): Patient is to go to Josephine county for court date tomorrow 3-4-15. The plan is to return to bay area until he is stabilized and will then be discharged to a home that is specialized for his needs.

Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any assessment/elaboration should be made on the assessment sheet):

|Diet (Type): Regular, Isolation No Caffeine Regular diet, NO caffeine, isolation |IV (Fluid type, rate, access type): no |

|I&O (MD order/Nursing Order/Frequency): No |CBG (Yes/No, frequency): no |

|Fall Risk/Safety Precautions (Yes/No): yes. Low risk for falls, as of 03-01-15 |Activity (What is the patient activity level): no physical restrictions |

|Braden score 23, Morse fall risk 0. | |

|Wound Care (Yes/No): No |Oxygen (Yes/No, Delivery method, how much): no |

|Drains (Yes/No, Type): |Last BM: 3-1-15 10:15 |

|NO | |

|Other Tubes: N/A | |

ASSESSMENTS

(Include Subjective & Objective Data)

|Integumentary: |Head and Neck: |

|Skin was uniform in color. |Head is symmetrical, facial movement is symmetrical. |

|Skin had good turgor, no tenting on back of hand or clavicle. Extremities were |Neck is symmetrical and larynx and trachea rise with swallowing. Thyroid and |

|warm to touch and capillary refill occurred at less than 3 seconds on pointer |lymph nodes are normal in size. No alopecia on the head, but very poor haircut. |

|finger and great toe. Wound on left foot from possible fungal infection. Wound |No lice noted. Range of motion for the neck is not limited. 45 degree rotation |

|observed due to application of anti-fungal cream. Stage 2 1cm wide, 1cm long, |from center on either side. No JVD noted. |

|epidermis depth, white colored skin surrounding it. No drainage from wound noted.| |

|Eyes/Ear/Nose/Throat: |Thorax/Lungs: |

|Pupils 2mm equal, round, and reactive to light. Eyes were tracking pen light |Chest cavity is symmetrical and slightly barrel chested. Respirations at 18 per |

|through all six fields. Eyes are symmetrical. No tenderness to palpation around |min. Chest is not sensitive to palpitation. Lung sounds presented were clear |

|the ocular cavity. Ears have no tenderness to palpitation. Hearing is not |inspiratory and expiratory sounds in all lobes. No complaints of labored |

|diminished and equal bilaterally. Ears are symmetrical. Nose is midline and |breathing or shortness of breath. Cough was not productive of sputum in the |

|symmetrical, nasal mucosa pink, moist, and not draining. Oral mucosa is pink, |morning. Heavy nose breather that sometimes whistles. |

|intact, and dry. No bleeding or lesions evident, all Teeth were present and | |

|slightly yellow, mild gingivitis. Tongue is pink, moist and free of lesions. | |

|Cardiac: |Musculoskeletal: |

|Dorsal pedal and radial pulses were regular and strong bilaterally, extremities |Left and right arm strength was equal bilaterally. Left and right dorsal |

|are warm to touch, and cap refill at less than 3 second on pointer finger and |extension and flexion strength was equal bilaterally. Pt. was able to ambulate |

|great toe bilaterally. No chest pain reported. S1, S2 heard at right and left |with no restrictions but was wobbly and unsteady when arising from his nap. |

|base and Erb’s point. Regular rate and rhythm no murmurs, gallops, or rubs. | |

|Hypertension noted. | |

|Genitourinary: |Gastrointestinal: |

|No redness, swelling or drainage noted from Penis, anus or perianal area. No |Bowel sounds normoactive in all four quadrants, no sensitivity to palpitation, |

|reported pain from urination, passing flatus, or bowel movements. Last BM |percussion reveals no diminished sounds in the four quadrants. Abdomen was not |

|reported 3-1-15. Urine output was yellow clear with no foul odor. |obese or distended, and soft to palpitation. Last BM was on 3-1-15 and is |

| |currently passing gas. No gastric reflux noted. |

|Neurological/Psychosocial: |Other: BP= 143/89 Temp= 98.2 Pulse= 93 Res= 18 O2= 99% |

|Patient is alert and oriented to place. His thought content had command |Pain: 0/10 |

|hallucinations, grandiose delusions, paranoid delusions, persecutory delusions, |Frequency: N/A |

|and religious delusions. Speech is pressured, slurred, rambling and full of |Description: N/A |

|obscenities. He has flight of thought and is tangential. He was on the phone |Tolerable Level: 0/10 |

|leaving messages for family and girlfriend several times during the shift and he | |

|was waiting for a call back when I left. | |

CURRENT MEDICATIONS

List ALL regularly scheduled and prn medications scheduled on your client.

(Due morning of clinical)

|Generic & Trade Name|Classifi-cation |Dose/Route/ |Onset/Peak |Intended Action/Therapeutic |Adverse reactions (1 major |Nursing Implications for this client. (No more than one) |

| | |Rate if IV | |use. Why is this client taking|side effect) | |

| | | | |med? | | |

|CLOTRIMAZOLE 1% |azole antifungal |1 EACH TOPICAL DAILY|30min/ 3hrs |Prevents growth of fungus |Stinging |Monitor for agitation at the administration site |

|CREAM 15 GM | | | | | | |

|(LOTRIMIN 1%) | | | | | | |

|LITHIUM CARBONATE |antidepressant |600 MG = 2 CAP PO |30min/ 3hrs |Decrease manic episodes |GI disturbance |Monitor for N/V/D and abdominal cramping. |

| | |BID | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|OLANZAPINE ZYDIS |antipsychotic |10 MG = 1 TAB PO BID|15min/ 6hr |Decrease hallucinations and |Tardive dyskinesia |Monitor for unusual/uncontrolled movements (especially of |

|(ZYPREXA ZYDIS) | |First Dose Now | |think more clearly | |the face, lips, mouth, tongue, arms or legs). |

|QUETIAPINE |anti-psychotic |400 MG = 2 TAB PO |30min/ 1.5hrs |Prevents manic episodes |Tardive dyskinesia |Monitor for unusual/uncontrolled movements (especially of |

|(SEROQUEL) | |BID | | | |the face, lips, mouth, tongue, arms or legs). |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|ACETAMINOPHEN |Anti-inflammatory |650 MG = 2 TAB PO |0.5-1hr/ 10-60min |Lowers temp relieves mild pain |Liver damage |Monitor for signs and symptoms or liver damage |

|(TYLENOL) | |Q4H PRN MILD PAIN | | | | |

|DIPHENHYDRAMINE |Antihistamine |50 MG = 2 TAB PO HS |15-30min/ 1-4hr |Itching |Mental mood changes |Monitor for mental/mood changes (such as restlessness, |

|(BENADRYL) | |PRN INSOMNIA | | | |confusion), difficulty urinating, fast/irregular heartbeat|

|DOCUSATE SODIUM |Stool softner |100 MG = 1 CAP PO |30-60min/ 2-6hrs |Constipation relief |Rectal bleeding |Monitor bowel movements for signs of bleeding like frank |

|(COLACE, DOSS) | |BID | | | |blood |

|LORAZEPAM (ATIVAN) |benzodiazepines |1-2 MG PO Q2H PRN |15-30min/60-90min |Anxiety |Shortness of Breath |Monitor for mental/mood changes (such as hallucinations, |

| | |ANXIETY for 7 Days | | | |agitation, confusion), muscle weakness. Loss of |

| | | | | | |consciousness, shortness of breath, slow/shallow |

| | | | | | |breathing, seizures. |

|MAG HYDROX/AL |Laxative/ antacid |30 ML = 30 ML PO Q2H|30min/ 3-6hr |Laxative due to higher dose |Electrolyte imbalance |Monitor for persistent nausea/vomiting/diarrhea, muscle |

|HYD/SIMETH 30 ML | |PRN GI DISTRESS | | | |cramps/weakness, irregular heartbeat, and dizziness |

|(MAG-AL PLUS, | | | | | | |

|MAALOX) | | | | | | |

|MAGNESIUM HYDROXIDE |Laxative |30 ML = 30 ML PO |3-6hr/4hr |Constipation |Electrolyte imbalance |Monitor for persistent nausea/vomiting/diarrhea, muscle |

|(MILK OF MAGNESIA) | |DAILY PRN | | | |cramps/weakness, irregular heartbeat, and dizziness |

| | |CONSTIPATION | | | | |

|NICOTINE TRANSDERMAL|Smoking deterrent |21MG/24HR 1 PATCH = |30min/ 8-9hrs |Tobacco craving |Mental/ mood changes |Monitor for mental/mood changes (e.g., irritability, |

| | |1 PATCH TRANSDERMAL | | | |trouble sleeping, vivid dreams), |

| | |DAILY PRN CRAVINGS | | | | |

| | |(TOBACCO) | | | | |

|OLANZAPINE ZYDIS |antipsychotic |10 MG = 1 TAB PO Q8H|30min/ 6hr |Depression or bipolar episodes |Tardive dyskinesia |Monitor for unusual/uncontrolled movements (especially of |

|(ZYPREXA ZYDIS) | |PRN AGITATION | | | |the face, lips, mouth, tongue, arms or legs). |

DIAGNOSTIC TESTING

Include pertinent labs [ABGs, INRs, cultures, etc.] & other diagnostic reports [X-rays, CT, MRI, U/S, etc.]

NOTE: Adult values indicated. If client is newborn or elder, normal value range may be different.

|Date |Lab Test |Patient Values/ |Interpretation as related to Pathophysiology –cite reference & pg. # |

| |Normal Values |Date of care | |

|N/A |Sodium |N/A |N/A |

| |135 – 145 mEq/L | | |

|N/A |Potassium |N/A |N/A |

| |3.5 – 5.0 mEq/L | | |

|N/A |Chloride |N/A |N/A |

| |97-107 mEq/L | | |

|N/A |Co2 |N/A |N/A |

| |23-29 mEq/L | | |

|N/A |Glucose |N/A |N/A |

| |75 – 110 mg/dL | | |

|N/A |BUN |N/A |N/A |

| |8-21 mg/dL | | |

|N/A |Creatinine |N/A |N/A |

| |0.5 – 1.2 mg/dL | | |

|N/A |Calcium |N/A |N/A |

| |8.2-10.2 mg/dL | | |

|N/A |Phosphorus |N/A |N/A |

| |2.5-4.5 mg/dL | | |

|N/A |Total Bilirubin |N/A |N/A |

| |0.3-1.2 mg/dL | | |

|N/A |Total Protein |N/A |N/A |

| |6.0-8.0 gm/dL | | |

|N/A |Albumin |N/A |N/A |

| |3.4-4.8gm/dL | | |

|N/A |Cholesterol |N/A |N/A |

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