NURSING CARE PREPARATION



NURSING CARE PREPARATION

Student Name: Daniel GaudetteDG, SN Date of Care: January 20, 2015

|Unit/Room Number: REU 259 |Date of Admission: 01-14-2015 |

|Age:95 |Ethnic/Cultural Preferences: Non-Hispanic/ Latin |

|Gender:M |Allergies: NKA |

|Erikson’s Developmental Level: Integrity Vs. Despair |Code Status: DNR |

Primary Diagnosis: Temporal stroke

Co-morbidities:

1. Progressive obtundation/coma.

2. Severe aspiration pneumonia with acute respiratory distress/respiratory

failure.

3. Acute right frontal stroke with dysphagia/left hemiparesis.

4. Non-ST elevation myocardial infarction/acute coronary syndrome.

5. Acute renal insufficiency.

6. Fever/leukocytosis, probable aspiration pneumonia.

Discharge Plan (add day of clinical): Comfort measures provided to transition to end of life.

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): NPO |IV (Fluid type, rate, access type): Yes, Peripheral IV, hand right, 22G, |

| |dressing: Sorbaview. FS-SODIUM CHLORIDE 0.9% flush IV PRN IV access. |

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

|Fall Risk/Safety Precautions (Yes/No): yes. High risk for falls, as of 01-19-15 |Activity (What is the patient activity level): As tolerated. HOB 0-15 degrees |

|Braden score 10, Morse fall risk 80. |x24hrs. |

|Wound Care (Yes/No): Yes, coccyx preadmission. |Oxygen (Yes/No, Delivery method, how much): yes, O2 NC at 1 - 4 Lpm to keep O2 |

| |sats greater than or equal to 95%. |

|Drains (Yes/No, Type): |Last BM: Prior to admit, will inquire during shift. |

|Yes, Foley | |

|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. |Neck is symmetrical and larynx and trachea seem hard and swollen. Thyroid and |

|Extremities were cool to touch and capillary refill occurred at less than 3 |lymph nodes are difficult to detect but appear to be normal in size. Alopecia on |

|seconds on pointer finger and great toe. |the head. No lice noted. Range of motion for the neck is limited. No JVD noted. |

|Wound previous to admit, Redness on tailbone, 3cm in length 2cm in width. Not | |

|open wound, no bandage, open to air. Multiple bruises on extremities. | |

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

|Pupils 2mm equal, round, and reactive to light. Eyes were not tracking pen light |Chest cavity is symmetrical and slightly barrel chested. Respirations at 16 per |

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

|the ocular cavity noted. Ears have no tenderness to palpitation objectively. Ears|presented in the upper lobes were clear inspiratory and expiratory wheezes. Lower|

|are symmetrical. Nose is midline and symmetrical, nasal mucosa pink, dry, and not|lobes bilaterally had diminished lung sounds. Pleural rubs heard in all lobes. |

|draining. Oral mucosa is pink, intact, and dry. No bleeding or lesions evident, | |

|teeth were absent. | |

|Tongue is pink, dry and free of lesions. Dysphagia noted from previous charting. | |

|Cardiac: |Musculoskeletal: |

|Dorsal pedal and radial pulses were irregular and thready bilaterally, |Appears to be a well developed adult. Generalized weakness and left sided |

|Extremities were warm to touch and capillary refill occurred at less than 3 |weakness noted in chart. Not able to assess strength or ROM because of comatose |

|seconds on pointer finger and great toe. No chest pain reported. S1, S2 heard at |state. |

|right and left base and Erb’s point. Irregular rate and rhythm no murmurs, | |

|gallops, or rubs. | |

|Genitourinary: |Gastrointestinal: |

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

|output of 340mL on bedside Foley bag. Pink and hazy without foul odor. |percussion not performed per comfort care. Abdomen was soft to palpitation. No |

| |gastric reflux noted. |

|Neurological/Psychosocial: |Other: BP=122/88 Temp=98.2 Pulse=62 Res= 16 O2= 93% |

|Patient is comatose, and in pain. Family at bedside part of the day, wife |Pain: objectively ranged from 0-2 through shift |

|continually at bedside. Wife continues to speak with patient and make physical |Frequency: N/A |

|contact. Comfort care measures in place. |Description: N/A |

| |Tolerable Level: N/A |

| | |

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 |side effect) | |

| | | | |taking med? | | |

|LORAZEPAM INJ |benzodiazepines |0.5-1 MG IV Q6H PRN |15-30min/60-90min |Anxiety |Shortness of Breath |Monitor for mental/mood changes (such as hallucinations, |

|(ATIVAN INJ) | |AGITATON, AFTER | | | |agitation, confusion), muscle weakness. Loss of |

| | |HALDOL for 7 Days | | | |consciousness, shortness of breath, slow/shallow |

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

|MORPHINE |Analgesic |2-8 MG IV Q2H PRN |Rapid/ 20min |Extreme Pain relief |Respiratory depression |Monitor for slowed, labored breathing, and a decreased |

| | |SHORTNESS OF | | | |respiratory rate. |

| | |BREATH/PAIN for 5 | | | | |

| | |Days | | | | |

|ACETAMINOPHEN |Antipyretic |650 MG = 1 SUPP |0.5-1hr/10-60min |Lower Temperature |Liver damage |Monitor for signs and symptoms or liver damage (dark |

|(TYLENOL) | |RECTAL Q4H PRN FEVER| | | |urine, persistent nausea/vomiting, stomach/abdominal pain,|

| | |= OR > 100.4 F | | | |extreme tiredness, or yellowing eyes/skin). |

|ASPIRIN |salicylate |300 MG = 1 TAB |Unknown/ 15min-2hr |Prevent blood clots how? |Difficulty hearing |Monitor for easy bruising/bleeding, difficulty hearing, |

| | |rectally daily | | | |ringing in the ears, change in the amount of urine, |

| | | | | | |persistent or severe nausea/vomiting, unexplained |

| | | | | | |tiredness, dizziness, dark urine, yellowing eyes/skin. |

|ATROPINE |anticholinergic |1% EYE DROP U/D 2 |Rapid/ 5-10 min |Suppress salivation |CNS changes |Monitor for mental mood changes, drowsiness, fatigue, |

| | |DROP = 2 DROP | | | |weakness, mental depression, and confusion. |

| | |MISCELLANEOUS Q4H | | | | |

| | |First Dose Now | | | | |

|SCOPOLAMINE PATCH |Anticholinergic |1 PATCH = 1 PATCH | |Sedation dry secretions |Respiratory depression |Monitor for slowed, labored breathing, and a decreased |

|1.5 MG/72 HR | |TRANSDERMAL Q72H | | | |respiratory rate. |

|(TRANSDERM-SCOP 1.5 | | | | | | |

|MG/72 HR) | | | | | | |

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 | |

|1-17 |Sodium |140 |N/A |

| |135 – 145 mEq/L | | |

|1-17 |Potassium |3.8 |N/A |

| |3.5 – 5.0 mEq/L | | |

|1-17 |Chloride |106 |N/A |

| |97-107 mEq/L | | |

|1-17 |Co2 |21 |N/A |

| |23-29 mEq/L | | |

|1-17 |Glucose |162H |Elevation could be due to recent cerebrovascular accident. |

| |75 – 110 mg/dL | |(Van Leeuwen, 2011). Pg.735 |

|1-17 |BUN |31H |Elevation due to muscle wasting and decreased renal blood flow. |

| |8-21 mg/dL | |(Van Leeuwen, 2011). Pg.1297 |

|1-17 |Creatinine |1.65H |Increase related to decreased renal excretion, muscle wasting. |

| |0.5 – 1.2 mg/dL | |(Van Leeuwen, 2011). Pg.533 |

|1-17 |Calcium |8.6 |N/A |

| |8.2-10.2 mg/dL | | |

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

| |2.5-4.5 mg/dL | | |

|1-17 |Total Bilirubin |1.9H |Elevated due to heme released from RBC destruction. |

| |0.3-1.2 mg/dL | |(Van Leeuwen, 2011). Pg.188 |

|1-17 |Total Protein |5.8L |Decrease related to malnutrition |

| |6.0-8.0 gm/dL | |(Van Leeuwen, 2011). Pg.1098 |

|1-17 |Albumin |2.9L |Low albumin levels are due to inadequate production, inadequate intake, |

| |3.4-4.8gm/dL | |or excessive loss. |

| | | |(Van Leeuwen, 2011). |

|N/A |DBIL |N/A |N/A |

|1-17 |GLOBULIN |2.9 |N/A |

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

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