Documente Academic
Documente Profesional
Documente Cultură
Medication
Generic & Trade Name
Dose, Route, Frequency
Acetaminophen
Tylenol
650mg/PO/Q4H PRN
650mg/rectal/Q4H PRN
Mechanism of Action
Classification
Analgesic
Produce analgesia by
inhibiting
prostaglandin and
other substances that
sensitize pain
receptors
Albuterol
AccuNeb
2.5mg/oral inhalation/Q4H
PRN
Bronchodilator
Relaxes bronchial,
uterine, and vascular
smooth muscle by
stimulating beta 2
receptors
Bisacodyl
Dulcolax
10mg/rectal/daily prn
Laxative
Stimulant laxative that
increases peristalsis by
direct effect on smooth
muscle of the
intestines by irritating
the muscle or
stimulating the colonic
intramural plexus
Patient-Specific Rationale
Nursing Considerations
(Assessment implications, side effects, reasons to hold med,
administration rate, etc)
This medication is
administered due to patient
having a fever at 100.2 F
and non-pharmaceutical
measures (light clothing, no
blankets, and room
temperature adjusted) was
not successful. Due to pt
being NPO, if this medication
is given, it would be given
ng.
Treatment ordered in case
patient is experiencing
shortness of breath,
bronchospasm, or wheezing
which can be a result from
his injuries (gunshot wound
to chest). Due to pt being
intubated, pt will receive
treatment through
endotracheal tube.
Ordered for pt to prevent
constipation due to pt being
bedfast and on pain
medication which can cause
constipation. Held because pt
lacks bowel sounds. It is also
important that the pt does not
strain since pts abdominal
cavity is open after
exploratory laparoscopy.
Also, due to pt having a
gunshot wound to chest, it is
important pt doesnt strain
due to causing potential
internal bleeding from
injuries.
Cefoxitin IVPB
Mefoxin
1g/IV/Q8HR
Antibiotic
Inhibits cell-wall
synthesis, promoting
osmotic instability;
usually bacterialcidal
Fentanyl IV Drip
Sublimaze
2.5-10mL/hr/IV/titrate
Opioid Analgesic
Binds with opioid
receptors in the CNS,
altering perception of
and emotional
response to pain
Hydrocodone/Acetaminophen
Norco5, 10
1-2 tabs/PO/Q4H PRN
Narcotic
Hydrocodone blocks
the receptors on nerve
cells in the brain that
give rise to the
sensation of pain.
Acetaminophen is a
non-narcotic
analgesic and
antipyretic.
Administered to pt who
experiencing continuous pain
as evident by his injuries
(gunshot wound), surgical
procedures (opened
abdomen, opened sternum,
abdominal and chest
tubes/drains), behavior
(tearing, facial wincing, and
guarding), and scoring a 6/10
Hydromorphone
Dilaudid
0.2-2mg/IV/Q4H PRN
Magnesium Hydroxide
Milk of Magnesia
30mL/PO/daily PRN
Acetaminophen
works by elevating
the threshold to pain
in order for pain to be
felt, greater
stimulation of the
nerves responsible for
the sensation of pain
is necessary.
Opioid Analgesic
Binds with opioid
receptors in the CNS,
altering perception of
and emotional
response pain. Also
suppresses the cough
reflex by direct action
on the cough center in
the medulla
Laxative
Saline laxative that
produces an osmotic
effect in the small
intestine by drawing
water into the
intestinal lumen
Administered to pt who
experiencing continuous pain
as evident by his injuries
(gunshot wound), surgical
procedures (opened
abdomen, opened sternum,
abdominal and chest
tubes/drains), behavior
(tearing, facial wincing, and
guarding), and scoring a 6/10
on the Adult Nonverbal Pain
Scale.
Anxiolytic
May potentiate the
effects of GABA,
depress the CNS, and
suppress the spread of
seizure activity
Anxiolytic administered to pt
to decrease agitation and
promote sedation. These
behaviors include pt grabbing
and pulling at endotracheal
tube when not sedated.
Sedation will also help the pt
rest which will help the
healing/recovering process.
Pantoprazole
Protonix
20mg/PO/daily
Antiulcer
Inhibits proton pump
activity by binding to
hydrogen-potassium
adenosine
triphosphatase to
suppress gastric acid
secretion
Potassium Chloride
K-Dur
10 mEq/IV/PRN
Potassium Supplement
Replaces potassium
and maintains
potassium levels
Ondansetron
Zofran
4mg/IV/Q4H prn
Antiemetic
May block 5-HT3 in
the CNS in the
Enalaprilat
Vasotec
2.5mg/IV/Q6H PRN
Propofol
Diprivan
15mL/hr/IV/titrate
chemoreceptor trigger
zone and in the
peripheral nervous
system on nerve
terminals of the vagus
nerve
Antihypertensive
May inhibit ACE,
preventing conversion
of angiotension I to
angiotensis II, a potent
vasoconstrictor
Hypnotic
Unknown. Rapidacting IV sedative
hypnotic
aspirating.
Administered to pt due to
blood pressure being high at
141/82 and gradually
increasing.
LABORATORY DATA
LABS
Normal
Range
(Fill in Hospital
Norms)
(4/17, 0830)
CBC
WBC
RBC
4.0-11.0
4.4-6.0
9.3
3.24
10.9
3.66
Hemoglobin
13.5-18.0
9.9
11.1
Hematocrit
40.0-52.0
28.9
30.9
MCV
MCH
MCHC
RDW
PLT COUNT
WBC DIFF
NEUTROPHIL %
80-100
27.0-33.0
31.0-36.0
<16.4
89
30.6
34.7
13.5
84
30.3
35.9
14.6
82
81
49-74
(date &
time)
BANDS %
N4810 Clinical Paperwork Rev 11/6/13
LYMPHOCYTE%
26-46
MONOCYTE %
CHEMISTRY
Sodium
Potassium
136-145
3.5-5.1
145
5.5
142
3.5
Chloride
98-107
123
114
CO2(bicarb)venous
21-32
13
19
Glucose
70-90
148
90
Calcium
8.2-10.2
6.6
7.3
phosphorus
Magnesium
1.8-2.4
1.2
1.8
HDL
LDL
Cholesterol
Triglycerides
LIVER PANEL
Total protein
0-150
6.4-8.2
3.0
Albumin
3.2-4.7
1.6
Bilirubin Total
Alk phosphatase
AST
0.1-1.1
26-137
0-37
0.7
ALT
0-60
102
92
Normal
Range
(Fill in Hospital
Norms)
Troponin
Myoglobin
BNP
COAGULATTION
PT
INR ratio
PTT
Fibrin level
Bleeding time
D-Dimer
UA collection type
Urine color
12.1-15.3
21.4
17.7
0.9-1.1
2.0
1.5
Amber
yellow
dark
amber
light pink
Urine appearance
clear
Blood
clots
visible
1.020
Urine Ph
Urine glucose
1.0031.035
5.0-8.0
Negative
7
Trace
Urine bilirubin
Urine blood
Negative
Negative
Negative
Small
Urine Ketones
Urine Nitrites
Urine Protein
Negative
Negative
Negative
Negative
Negative
>500
Urine Leukocytes
URINE MICRO
WBC HPF
RBC HPF
Nitrate HPF
Epithelial
Bacteria
Mucous
Negative
Negative
Specific gravity
Blood
clots
visible
URINE CULTURE
CSF
WBC
RBC
Glucose
Protein
Culture
Blood Cultures
Stool Cultures
Nasal Cultures
ABG(FIO2 + device)
pH
7.3507.450
7.286
7.457
PO2
PCO2
80-100
35-45
488
27.3
102
27.6
Bicarbonate
20-26
12.7
19.1
Oxygen Saturation
Anion gap
Lactate
95-100
98
98
DIAGNOSTIC DATA
ECG
X ray
Angiography
NOTE: This outline of labs and diagnostics is to be organized by each student it is NOT all inclusive
you must decide what labs are important. Not all labs on this list will be found on each patient.
3. Electrolyte imbalance
Data to Support:
Pt experiencing possible hypervolemia
evident by general edema 1+
Pts chloride level high at 114
Pts albumin level is low at 1.6
Pts kidney function is decreased due to
laceration/hematoma to left kidney
Pt being administered D5W continuous
Pt having continuous bladder irrigation
pH slightly elevated at 7.457
PCO2 decreased at 27.6
Bicarbonate decreased at 19.1
Interventions:
Monitor vital signs
Monitor cardiac rhythm and rate
Monitor I/O
Monitor pts respiratory status
Review/monitor labs
Completed pain assessment
Monitor pts edema
Concept Mapping
1. Ineffective Airway Clearance
Data to Support:
Pt intubated
Pt sedated
Breath sounds diminished at bases
Pt only able to gag when experiencing excess
mucous/sputum
Interventions:
Pt suctioned prn
Yanker kept at pts bed side
Auscultate breath sounds q 1-4 hrs
Monitor respiratory patterns
Monitor blood gas values and O2 saturation
Position pt to optimize respiration
Make sure pt receives respiratory treatment such as
his Albuterol.
Problem Evaluation
Problem #
1
Wounds and surgical sites appeared to be pink, moist, and healing properly
Skin around wounds and surgical sites did not appear warm, red, or have any inflammation
Skin around tubes and drains appeared dry, intact, with no signs of infection
Pt showed no S&S of a UTI
Pts temperature was above normal limits and was being treated with Acetaminophen, light-weight
clothing, and room temperature control
WBCs were within normal limits
Pt tolerated administration of antibiotic (Cefoxitin) appropriately.
Professional Demeanor
Communication/rapport
Technical skills
Organized
Well-prepared
Comprehensive Assessment
Flexible
Coordinator of Care
Team Player
Educator
Ability to Prioritize
Knowledgeable
Good job one thing I would encourage you to keep working on labs and what they are
evaluating.
Instructions: Attach a copy of this form to the back of each of you Clinical Plan of Care/Maps for grading purposes.
Grading Rubric:
1.
2.
3.
Lab Diagnostics
a. Test
b. Results
c. Implications & Teaching
4.
5.
6.
7.
a.
b.
__________95___/100 = ____%