Documente Academic
Documente Profesional
Documente Cultură
DATE: 2/24/2015
DATE OF ADMISSION:
5/5/2006
AGE:
74
WT: 152
CODE STATUS:
Chandra Carr
CLIENT INITIALS:
MS
HT:
53
RACE/ETHNICITY:
DNR
CULTURAL CONSIDERATIONS:
Hispanic
RELIGION/SPIRITUAL CONSIDERATIONS:
Catholic
OCCUPATION/HOBBIES/RECREATIONAL ACTIVIES:
Home Maker
LIVING SITUATION/WITH WHOM: (home, assisted living, LTC, etc)
Assisted Living
SOCIAL HISTORY: (tobacco, ETOH, illicit drugs, family dynamics)
Tobacco
ALLERGIES:
Fish and apisol
Common signs/symptoms:
Dyspnea, fluid retention
Definition:
Decreased function and strength of heart muscle
Etiology/pathophysiology:
CAD, MI, Cardiomyopathy, valve diseases, hypertension, DM, thyroid or kidney
disease, birth defects
Common signs/symptoms:
Congestion in lungs, fluid retention, weakness
None
CONSULTS: (include date and reason for consult)
2/5/2015 Routine follow up
DIAGNOSTIC TESTS: (CT, MRI, CXR, U/S, EKG, etc.; include date, reason for test,
and results)
LABS:
Lab Test
Purpose
Normal Values
Client Results
*CBC* Complete Blood Count - evaluate hematologic system ad possible health problems
White Blood
Cell Count
4.1-10.4
8.7 Normal
Hemoglobin
Hgb (g/dL)
11.8-15.1
12.3 Normal
Hematocrit Hct
(%)
34.0-44.0
38.8 Normal
Platelet count
(L)
150-450
228 Normal
WBC (L)
40-100
Eos
100-300
Monos
40-100
Neutro
2,500-7,000
Lymph
1,700-3,500
*CMP* Complete Metabolic Panel-organ function/damage, electrolyte levels
Glucose (mg/dl)
74-106
Urea Nitrogen
(mg/dL)
7-18
Creatinine (mg/
dL)
0.6-1.3
1.1 Normal
Sodium (mEq/L)
136-145
139 Normal
Potassium
(mEq/L)
3.5-5.1
4.2 Normal
Chloride (mEq/
L)
98-107
104 Normal
CO2 (mEq/L)
21.0-32.0
28.0 Normal
Albumin (g/dL)
3.4-5.0
Protein (Total)
(g/dL)
6.4-8.2
6.5 Normal
Bilirubin (mg/
dL)
0.2-1.0
0.30 Normal
Lab Test
Purpose
Normal Values
Client Results
Calcium (mEq/
L)
8.5-10.1
9.0 Normal
Alkaline
phosphatase
(ALP) (unit/L)
50-136
AST (SGOT)
(unit/L)
15-37
ALT (SGPT)
(unit/L)
12-78
28 Normal
GFR
52^2
Anion Gap
(mEq/L)
2-12
Osmolarity
(mOsm/kg)
280-300
7 Normal
298 Normal
Other Pertinent Labs
HbA1C
4.3-6.3
MEDS:
Medication (Brand
and Generic
Prescribed
Classification
Names)
Benzonatate
Dose, Freq,
Route
anti-tussive
Tessalon Perles
100mg one by
mouth twice
daily as
needed for
cough
Mechanism of
Action
Patient
Specific
Indications
Suppresses
cough through
a peripheral
action,
anesthetizing
cough
receptors also,
may suppress
transmission of
the cough
reflex
Cough
Depression
Side effects/Nursing
Implications
drowsiness, nausea,
constipation
Lung sounds, sputum
amount, swallow whole
Citalopram
SSRI
20mg one by
Inhibits CNS
Hydrobromide
Antidepressant
mouth once
neuronal
daily
reuptake of
serotonin
Celexa
Clonidine HCL
Anti-
0.1mg one by
Duraclon
hypertensive,
mouth three
analgesic
stimulates
Hypertension
alphaadrenoceptors
in the brain
stem. This
action results in
reduced
sympathetic
outflow from
the CNS
stimulates
enteric nerves
to cause
colonic mass
movements
Propionate
Temovate
Corticosteroid
0.05% applied
to be
administered if
systolic
pressure is
constipation, drowsiness
Monitor BP, I&O, weight,
and for depression. Hold
OTC, do not consume
alcohol, stay hydrated
below 110
Dulcolax
Stimulant
10mg
Bisacodyl
laxative
suppository
one every 24
hours as
Constipation
electrolyte disturbances
Evaluate need, monitor for
Vitamin K absorption in pts
needed for
on anticoagulants, increase
constipation
Fentanyl patch
Analgesic,
50mcg/hour
Duragesic
narcotic
one patch
every 72 hours
applied to skin
as needed for
pain
management
Guaifenesin-
Expectorant
Binds with
Pain
stereospecific
receptors at
many sites
within the CNS,
increases pain
threshold,
alters pain
reception,
inhibits
ascending pain
pathways.
Sedation, circulatory
depression, cardiac arrest,
N/V respiratory depression
Monitor VS, closely monitor
respirations
0.5-3(2.5)mg/
Arovent
antimuscarinic,
3mL one
broncodilator
inhalation
codeine
Robitussin Ac
every 6 hours
as needed for
inhibit vagallymediated
reflexes by
antagonizing
the action of
acetylcholine
COPD
COPD
Lantus
Antidiabetic,
100u/mL
Insulin glargine
long acting
35units
insulin
injected SQ
every morning
lower blood
Diabetes
glucose levels
by stimulating
peripheral
glucose
uptake, and by
inhibiting
hepatic glucose
production.
inhibits lipolysis
in the
adipocyte, and
proteolysis,
and enhances
protein
synthesis.
Hypoglycemia, hypokalemia
Monitor for hypoglycemia,
withhold if hypokalemic,
monitor fasting glucose and
HbA1C
Lasix
Diuretic,
40mg one by
Furosemide
inhibits water
reabsorption in
the nephron by
blocking the
sodiumpotassiumchloride
cotransporter
Edema
Circulatory collapse,
hypokalemia, leukopenia,
aplastic anemia,
agranulocytosis, diuresis,
water and electrolyte
depletion
Monitor BP and vitals,
monitor for hypokalemia,
muscle cramps diziness,
I&O, glucose, monitor
weight, LABS - CBC, serum
and urine electrolyte, BUN,
glucose, uric acid
Lorazpam
Benzodiazepine
0.5mg one by
Ativan
sedative-
mouth every 8
hypnotic
hours as
anxiolytic
needed for
prophylaxis of
anxiety
Losartan
Angiotensin
100mg one by
Cozaar
receptor
mouth once
agonist,
daily
antihypertensive
binds to an
Anxiety
allosteric site
on GABA-A
receptors,
which
potentiates the
effects of the
inhibitory
neurotransmitte
r GABA, which
opens the
chloride
channel in the
receptor,
allowing
chloride influx
and causing
hyperpolerizati
on of the
neuron.
competitively
Hypertension
inhibits the
binding of
angiotensin II
to AT1 in many
tissues Inhibits
angiotensin II
vasoconstrictiv
e and
aldosteronesecreting
effects and
results in
decreased
vascular
resistance and
blood pressure.
hyper or hypotension
Supervise
ambulation,monitor for
mood alterations, CBC and
LFT, do not consume
alcohol, do not drive while
taking medication
UR infection, cough
Monitor BP at trough,
monitor CBC, electrolytes,
hepatic and renal function,
Black box warning for
pregnancy
Milk of Magnesia
Antacid, saline
30ml by mouth
Magnesium
cathartic
every 48 hours
Hydroxide
as needed for
constipation
Nitroglycerin
Nitrate
Nitrostat
vasodilator
the osmotic
force of the
magnesia
suspension
acts to draw
fluids from the
body and to
retain those
already within
the lumen of
the intestine,
stimulating
nerves within
the colon wall,
inducing
peristalsis.
Constipation
Angina
20meq one by
Hypopotasse
ER
mouth twice
mia
paralysis, respiratory
Klor-Con
replacement
daily
Potassium is
the major
cation of
intracellular
fluid and is
essential for
the conduction
of nerve
impulses;
maintenance of
normal renal
function, acidbase balance,
carbohydrate
metabolism,
and gastric
secretion
Headache, orthostatic
hypotension, circulatory
collapse, dizziness, N/V,
anaphylaxis, palpitations,
tachycardia
Monitor LOC and heart
rhythm, supervise
ambulation, baseline BP
and HR
distress, cardiac
depression, arrhythmia, or
arrest, EKG changes in
hyperkalemia, VFib, Death
Monitor I&O, monitor for GI
ulceration, monitor cardiac
status, Frequent serum
electrolytes
Prednisone
Adrenal
5mg one by
Rayos
Corticosteroid
mouth once
daily
Spiriva
Bronchodilator,
18mcg inhale
one cap per
day
anticholinergic
metabolizes in
the liver to its
active form,
then crosses
cell membrane
and binds to
cytoplasmic
receptors
resulting in
inhibition of
leukocyte
infiltration,
interference of
inflammatory
response,
suppression of
immune
responses, and
reduction in
edema or scar
tissue.
COPD
acts mainly on
M3 muscarinic
receptors
located in the
airways to
produce
smooth muscle
relaxation, thus
producing a
bronchodilatory
effect
Chronic
airway
pharyngitis, rhinitis,
obstruction
sinusitis, UR infection,
cataracts, hypokalemia,
headache, insomnia,
delayed wound healing
Baseline BP, I&O, weight,
fasting glucose, and sleep
pattern, monitor bone
density, monitor withdrawal
symptoms, watch for
changes in mood LABSglucose, electrolytes, and
routine labs
Symbicort
Adrenal
160-4.5mcg/
Budesonide and
corticosteroid,
formoterol
glucocorticoid,
twice daily
antiinflammatory
stimulation of
intracellular
adenyl cyclase,
the enzyme
that catalyzes
the conversion
of (ATP) to
(cyclic AMP).
Increased
cyclic AMP
levels cause
relaxation of
bronchial
smooth muscle
and inhibits the
release of proinflammatory
mast-cell
mediators
Obstructive
Headache, infections,
chronic
dizziness, palpitations,
bronchitis
with
hypokalemia, N/V/D
exacerbation
Vital Signs
1000
Temp
1200
1600
98.2
Oral/Auxiliary/Rectal
Pulse
80
Apical/Radial/Pedal/Rhythm
Respirations
18
Rate & Quality
Blood Pressure
137/98
Oxygen Saturation
amount/Method
95%
Intak
0700
0800
090
1000
1100
1200
1300
1400
1500
25
50
IV
Tube Feed
PEG
Other
Outp
ut
Void
Foley
Bowel
Movement
Emesis
Other
Total
s
Dietary
Intake %
PO
Totals
50
Normal
Abnormal
General Survey
Level of
Consciousness
PERRLA
Pupils:
Equal:
Round:
Reaction:
Reactive to light:
Accommodation:
Yes
Yes
Yes
Yes
Yes
Yes
Yes Bilaterally
Pain
Pain None
Scale
Pain Goal
Location:
Onset:
Variation:
Quality:
Aggravates:
Problem
Yes/No
Relieves:
P (Provocate/
Palliative)
Q (Quality/
Quantity)
R (Region/
Radiation)
S (Severity
Scale)
T (Timing)
Pain Intervention
PCA/PCE:
None
Location
Dressing
PO Intervention:
Non
Pharmacological:
Sleep/Rest
Quality &
Rested
Quantity of Sleep
Assistive
Devices
none
Safety
Sepsis Screen
Interventions
HEENT
Head/Face
Normocephalic/symmetrical
Eye
Pupil size
R 4mm
L 4mm
"
Ear
No drainage or pain
Nose
Septum midline
Throat
Moist
Color Pink color
Trachea Midline
Present
Teeth
Hearing Aid
Missing teeth
Yellow/discolored
Mouth
Intact Moist
Color of Mucous Pink
Membranes
Odor No
Tongue
Neck
Respirations Symmetric
Pattern Even & Unlabored
Respiratory Rate: 18
Respiratory Regular
Rhythm:
Breath Sounds: Clear throughout bilaterally
Location:
Cough: None
Sputum/ None
Secretions:
Color:
Oxygen: Room air
Pulse ox: 95%
Use of accessory No
muscles
Pain No
Other
Respiratory
Treatment
Cardiac
Heart Rhythm Regular Rate
Heart Rate 80
Heart Sounds Normal S3 S2
S1 Murmur III
Peripheral
Edema Absent
Neurovascular
Pulses
Present
Radial
Pedal
Apical
VTE Screening:
Interventions
Access/Monitoring Devices
Type of Line:
None
Insertion Site:
IV Fluids:
none
TPN/PPN:
Blood glucose:
Coverage:
Blood glucose
ranges:
None
Gastrointestinal
Abdominal shape
Bowel Sounds
Last Bowel
Movement
How often
Consistency
Continent
Nausea/Vomiting
Symmetrical flat
Bowel Sounds present in all
four quadrants
2/21/2015 at 9:40am Regular
daily BMs
Formed brown
Continent
No Nausea No Vomiting
Palpation
Soft/Non tender
Interventions
None
Tubes Insertion
Site:
Tube feeding
none
Ostomy
None
Stoma
Stoma status
Nutrition
Diet
Regular diet
Breakfast % Ate 25
Lunch % Ate 50
Dinner % Ate 50
Genitourinary
Continent
Yes
Urine color
Yellow
Urine
characteristics
Clear
Male
Surgical History:
Hysterectomy
Musculoskeletal
Activity Ad Lib
Posture
Ambulation
History of Falls
Interventions
Walker /Wheelchair
Strength
LEFT
ARM
LEG
Absent =A
Weak & thread= W
Normal
Full
Bounding =B
0
1+
2+
3+
4+
No Edema
Barely discernible depression, 2mm
A deeper depression (<5 mm) w/ normal foot &
leg contours
Deep depression (5-7 mm) w/foot & leg swelling
Deeper depression (>8 cm) w/severe foot and leg
swelling
Skin
Color Color appropriate for race/pink
Intact Intact
Temperature
Moisture
Skin turgor
Capillary refill
Nail beds (color &
angle)
Hair
Other:
Warm
Dry
No tenting
Regular < 2 seconds
Hygiene
Shower
Wounds/Incision
Signs/symptoms
of inflammation/
infection
none
!
Interventions
Coping
Interventions Cooperative
NURSING
DIAGNOSIS
STATEMENT:
Priority 1 of 3
NURSING
OUTCOMES
OBJECTIVE:
S.T. Goals:
LE pitting edema
1.
Decreased O2 sat
Decreased fluid
retention - edema by
next week
Hypertension
Weight gain
SUBJECTIVE:
SOB
Polydipsia
2.
INTERVENTIONS
NIC: fluid
management and
monitoring
RATIONALEs
EVALUATION
management and
monitoring fluid
will assist in
decreasing
overload
Short Term Goal:
1a Weigh daily
to monitor fluid
retention
1b Activity to
Exercises to
promote
prevent pooling of
movement of fluids fluid in legs
1c Implement fluid
and sodium
restriction as
ordered
to prevent further
retention of fluid
1a O2 therapy PRN
as ordered
to provide
adequate oxygen
at a higher
concentration
Increase O2 sat to 95 by
next week
L.T. Goal:
Ericksons: Maturity
1bAdminister
diuretic as ordered
to rid body of
excess fluid
1c provide sodium
restricted diet
prevent fluid
retention in lungs
1a reduce fluid in
lungs with
diuretics as
prescribed
to allow more
surface area for
oxygen exchange
in lungs
1b patient must
have
understanding of
necessity for
ordered therapy
and restrictions
to promote
compliance with
interventions
1c provide
scheduled rest
periods
to allow patient to
recover from
activities and take
slower deeper
breaths
NURSING
DIAGNOSIS
STATEMENT:
Constipation RT inactivity
Priority 2 of 3
NURSING
Assessment focused
on NSG DIAGNOSIS
OUTCOMES
OBJECTIVE:
S.T. Goals:
No formed stool in 2
days
SUBJECTIVE:
Slight abdominal
pain, feeling of
fullness
INTERVENTIONS
NIC:Bowel
management and
training
Ericksons: Maturity
RATIONALES
Management will
decrease
discomfort felt by
patient as well as
additional
complication that
may result due to
constipation
1a Administer
laxative and/or
suppository as
ordered
to
pharmacologically
initiate a BM
1b Increase fluid
intake
prevent
constipation due
to lack of fluid
1c Provide a fiber
filled diet
promote regular
stools
2. Patient will
1a Educate patient
demonstrate knowledge on prophylactic
medications
of prevention methods
by end of day
to allow patient
knowledge and
access to
preventative
measures
1b Educate patient
on need for
hydration and
activity
encourage activity
and promote
patient
participation
1c Explain side
effects of
medications that
may decrease
bowel activities
to possibly
consider
alternatives or limit
PRN or
medications that
may not be 100%
medically
necessary
L.T. Goal:
1a Provide
to engage activity
physical therapy or that will encourage
ROM exercises to
BM
1. Constipation will
become a risk for by the promote activity
end of the month
1b Have a stable
allow for hydration
intake of fluid and
and dietary needs
fiber
to prevent
constipation
1c Attempt to limit
need for narcotic
medication
EVALUATION
To prevent
pharmacological
causes of
constipation
NURSING
DIAGNOSIS
STATEMENT:
Priority 3 of 3
NURSING
OUTCOMES
OBJECTIVE:
S.T. Goals:
1.Patient will
demonstrate use safe
ambulation and transfer
techniques by end of
day
INTERVENTIONS
NIC:body
mechanics
promotion,
exercise therapy,
fall prevention
EVALUATION
Knowledge and
practice of better
mechanics and
strengthening will
help to prevent
future falls
to allow patient to
have knowledge in
safety and why it is
important to have
assistance with
ambulation
1c Be sure proper
footwear is
provided for
patient
to prevent slipping
or stumbling due
to inadequate
footwear
2. Patient will
1a Padded corners
demonstrate knowledge of hard surfaces
of injury prevention by
next week
1b Teach how to
avoid head trauma
with fall
RATIONALES
SUBJECTIVE:
L.T. Goal:
Ericksons: Maturity
1c Instruct patient
to wear her
prescription
glasses when
ambulating
1a Physical
therapy for
strengthening
to allow patient to
participate in her
own ambulation
1b assist with
ambulation
to allow pt to
ambulate without
risk or fall
Safe ambulation is
verbally and
physically
demonstrated by
patient
1c Make frequently
in use objects
easily accessible
and minimize
clutter
to prevent patient
from reaching or
requiring
unnecessary
movement that
may lead to falls
References
Beckerman, J. (2014). Heart disease and congestive heart failure. Retrieved February 21, 2015 from http://www.webmd.com/
heart-disease/guide-heart-failure?page=7
Mayo Clinic. (2014). Diseases and conditions COPD. Retrieved February 24, 2015 from http://www.mayoclinic.org/diseasesconditions/copd/basics/definition/con-20032017
McLeod, S. (2007). Maslows hierarchy of needs. Retrieved February 24, 2015 from http://www.simplypsychology.org/
maslow.html
Wilkinson, J. (2014). Nursing Diagnosis Handbook. United States of America. Pearson Education.