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Nursing Assignment


Joy Lee

on 4 December 2017

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Transcript of Nursing Assignment

Date of Admission: 10/15/2012 (3E-379)
Pt. Initials: SIB
Gender/Age: Female 60 y/o (DOB: 12/07/1951)
Ht: 65 in.; Wt: 194.06 lbs
Erikson’s Developmental Stage: Generativity vs. Stagnation (Middle Adulthood 40-65y/o)
Sociocultural Orientation: American- Caucasian, widow
Language: English; literate
Available resources: stable family support system

Current Health State: Patient has been admitted into the
hospital with Syncope, Exacerbation of COPD, and
Diabetes Type II after passing out numerous times prior to admission.

Allergies: Erythromycin, Penicillins, Sulfa Antibiotics, Tape
Patient Demographics:
Pt. with a history of COPD came in complaining of passing out four times over the past few days (not to the floor directly). When she came to the hospital she felt like she was going to pass out, she is coughing, and has a high POC. The physician diagnoses Pt. with Syncope, exacerbation of COPD, and Diabetes Mellitus Type II. Pt is admitted to the med-surg floor on 3-East.
Patient Situation and concern:
Syncope is a brief or transient loss of consciousness that can be cause by numerous reasons such as low blood pressure, low serum glucose level, but most commonly caused my decreased perfusion to the brain.

COPD Exacerbation is the increase of severity of symptoms of COPD.

Diabetes Mellitus Type II is having high blood glucose level in the blood that can be treated with insulin. It is a metabolic disease of the endocrine system where the body has lost receptor sensitivity to insulin.
Pathophysiology of Diagnoses:
Past Medical Dx: Diabetes Mellitus Type II (08/10/2012), Breast Cancer (Mastectomy 05/07/2012), Tumor in head (2011), Syncope (2010-2011), UTI (201)

Social: is a widow in a single family home; is on a 1800 Calorie Diet (regular diet at home); no use of substances currently; quit smoking in 1993

ADL’s/IADL’s: No difficulty before admission to hospital; Level 03 Fall Risk after admission

Immunizations: Up to date; Flu (2012), Pneumococcal (2012)

Screenings: Mammogram (2010-2012)

Family Hx: Father – Coronary Artery Disease, Cerebrovascular Accident, HTN; Mother – Coronary Artery Disease, HTN, Diabetes, Stomach and Breast Cancer; Brother – Bladder Cancer; Sister – Breast Cancer

Allergies: Erythromycin, Penicillins, Sulfa Antibiotics, Tape

Skin: normal and healthy hx
HEENT: no problems; healthy; does not wear glasses
Cardio/Peripheral Vascular: HTN, Cholesterol, SOB, Dizziness, Syncope, Cardiomyopathy (Heart Cath several yrs.ago)
Hematology: hx of cancer
Respiratory: Cough, 02 use, wheezing, asthma, COPD
Hepatic/accessory GI: Gallbladder disease (surgery cholecystectomy)
Renal: Incontinence
Endocrine: Diabetes Mellitus Type II (neuropathy)
Muscoskeletal: Arthritis, Degenerative Disk Disease
Neuro: Tumor in Head (radiation 2011), neuropathy
Psychiatric: Depression, Anxiety
Infectious disease: no hx of severe infectious disease
Reproductive: Breast Cancer (R. Mastectomy 2012)
Medical Dx and Hx:
Review of Systems:

Humalog (Insulin Lispro Human) 100 Unit/ml Inj.
Dose: look at Humalog protocol Subcutaneous (SC)
Protocol: Administer within 15 minutes of receiving meal or snack
Dose – by weigh based sliding scale protocol
If POC <70 Call the physician before next Lantus or any long-acting insulin
If POC 70-149 Normal value - No treatment for all weights
If POC 150-174 3 Units Subcutaneous (SC) for pt. wt. 70-89 KG
If POC 175-199 4 Units SC for pt. wt. 70-89 KG
If POC 200-249 5 Units SC for pt. wt. 70-89 KG
If POC 250-274 6 Units SC for pt. wt. 70-89 KG
If POC 275-299 8 Units SC for pt. wt. 70-89 KG
If POC 300-34910 Units SC for pt. wt. 70-89 KG
If POC 350-374 11 Units SC for pt. wt. 70-89 KG
If POC >400 Call the physician
Frequency: INS4 (0730, 1130, 1630, 2100)
Pharmacological Class: Antidiabetic, Insulins
Side effects: Hypoglycemia (sxs: tachycardia, confusion, sweating), lipohypertrophy, weight gain (pp.683)

Glucophage (metformin Hcl)
Dose: 500 mg <1 Tab> PO
Frequency: BIDM
Pharmacological Class: Antidiabetic, Biguanides
Side effects: GI related (Nausea, vomiting, abdominal discomfort, metallic taste, diarrhea, and anorexia), headache, dizziness, fatigue (pp. 689)

Lantus (Insulin Glargine ) 100 Unit/ml Inj.
Dose: 10 Units <0.1 ml> SC
Frequency: HS
Pharmacological Class: Antidiabetic, Insulins
Side effects: hypoglycemia (sxs. Diabetic Ketoacidosis), lipohypertrophy (pp. 681)
Duoneb (albuterol Ipratropium) Inhalation Solution 3ml
Dose: 3 ml <1 vial> Inhalation (INH)
Frequency: QID –RT
Pharmacological Class: Beta2 Adrenergic, Bronchodilator
Side effects: burning of mucosa, rebound congestion, reflex bradycardia (pp.133)

Ditropan (oxybutynin chloride) 5 mg tab
Dose: 5 mg <1 Tab> PO
Frequency: TID
Pharmacological Class: Antispasmodic Agents, Antimuscarinic/Anticholinergic effects (Incontinence)
Side effects: dry mouth, constipation, urinary retention, increased heart rate (pp. 144)
Pepcid (famotidine) 20 mg Tab
Dose: 20 mg <1 Tab> PO
Frequency: BID
Pharmacological Class: Histamine H2 Antagonist, Antiulcer
Side effects: Headache, Nausea, dry mouth (pp. 612)
Protonix (Pantoprazole) 40 mg Tab
Dose: 40 mg <1 Tab> PO
Frequency: BID
Pharmacological Class: Proton Pump Inhibitors
Side effects: headache, diarrhea, nausea, rash, dizziness (pp.611)
Zofran (ondasetron) 4 mg/2 ml vial
Dose: 4 mg <2 ml> IVP
Frequency: Q6HRS PRN
Pharmacological Class: Anti-emetic, 5-HT3 Antagonist
Side effects: headache, drowsiness, fatigue, constipation, diarrhea (pp. 630)
Diovan (valsartan) 160 mg Tab
Dose: 320 mg <2 Tabs> PO
Frequency: QDAY
Pharmacological Class: Angiotensin II Receptor Blocker/ ACE Inhibitor
Side effects: headache, dizziness, orthostatic hypotension, rash (pp. 311)
Requip (ropinirole hydrochloride) 2 mg Tab
Dose: 3 mg <1.5 Tab> PO
Frequency: At bedtime (HS)
Pharmacological Class: Antiparkinson Agents, Dopamine Receptor Agonist
Side effects: nausea, constipation, headache, orthostatic hypotension, nasal congestion (pp. 258)
Sinequan (doxepin Hcl) 50 mg Tab
Dose: 50 mg <1 Cap> PO
Frequency: HS
Pharmacological Class: Antidepressant, Tricyclic
Side effects: Drowsiness, sedation, dizziness, orthostatic hypotension, dry mouth, constipation (pp. 186)
Tenormin (atenolol) 50 mg Tab
Dose: 50 mg <1 Tab> PO
Frequency: BID
Pharmacological Class: Beta1 Adrenergic Antagonists, Antihypertensive
Side effects: orthostatic hypotension, dizziness, drowsiness, reflex tachycardia (pp. 137)
Flush Normal Saline 3 ml Sodium Chloride 0.9% 3 ml
Dose: 3 min/min IVF
Frequency: Q8H
Pharmacological Class: Fluid Electrolyte Replacement Agents
Side effects: fluid overload, cellular edema (pp. 433)
Prednisone 20 mg Tab
Dose: 40 mg <2 Tabs> PO
Frequency: QDAY
Pharmacological Class: Anti-Inflammatory Agent, Glucocorticoid
Side effects: hyperglycemia, mood changes, cataracts, PUD, electrolyte imbalance (pp. 470)
Rocephin 1 gm in dextrose 5% 50 mil P13 (ceftriaxone sodium)
Dose: 100 ml/hr IV
Frequency: Q24HRS
Pharmacological Class: Cephalosporin 3rd gen, Antibiotics
Side effects: Diarrhea, abdominal cramping, nausea, fatigue (pp. 487)
Percocet 10/325 mg (oxycodone/APAP) 10/325 mg Tab
Dose: 1 Tab PO
Frequency: Q6HRS PRN
Pharmacological Class: Opiate Agonist, Analgesics
Side effects: sedation, nausea, constipation, dizziness (pp. 222)
Zanax (alprozolam) 1 mg Tab
Dose: I mg <1 Tab> PO
Frequency: BID
Pharmacological Class: Anxiolytic, Benzodiazepine
Side effects: drowsiness, sedation, lethargy, ataxia (pp. 157)
Temperature: 98.1 Degrees F PO
Respirations: 20 Breaths/min
Blood Pressure: 110/65 Automatic
O2 Sat.: 95%
Heart Rate: 81 BPM
Pain: 0/10
POC: 274H (0730)
Temperature: 97.1 Degrees F PO
Blood Pressure: 137/89 Automatic
O2 Sat.: 94%
Heart Rate: 87 BPM
Pain: 0/10
Vital Signs:
Lab Values:
CBC/Blood type
WBC 15.01 K/ul
RBC 4.50 M/ul
Hgb12.9 g/dL
Hct39.1 g/dL
PTL248 K/ul

Pt. has a high WBC. This is abnormal and should be monitored for more increase or decrease. Elevated WBC may mean that there is an infection, inflammation, allergy, systemic injury, tissue injury, or leukemia.
Glucose: 287 mg/dL (1140 on 10/17)
Pt. has an abnormally high glucose level in the serum blood. The normal range is 65 to 110. Monitor POC and intervene if increases over 400 mg/dL. Assess for hypoglycemia after insulin and Antidiabetic agents are administered (especially during peak levels).
Lab Values:

Urine Culture (10/17)
Results: Gram negative Bacilli >100,000 CFu/mL – ID and MIC to follow
Interpretation: Pt. may have an infection or an UTI.

Chest X-Ray (10/15)
Results: Mild cardiomegaly; patchy bibasilar atelectasis worse on the L. than R.; Small L. Pleural effusion
Interpretation: Pt. has Atelectasis and Pleural effusion from exacerbation of COPD.

Echocardiogram (10/15)
Results: Apical wall of Left Ventricle motion is abnormal; Right ventricle, mitral valve, tricuspid valve, aortic valve, and pericardium are normal
Diagnostic Tests:

General: Room is clean and clear of fall risk. Pt. has not had bath yet. Nasal cannula set at 2L, with IV on the left arm.

Safety: Patient is a Level 3 Fall Risk; Bed is locked and bed exit alarm is set.

Neuro/Musculoskeletal: Patient is alert and oriented, seated on the bed eating breakfast. She Is oriented to person, place, and time. Cognitivity is good.

Respiratory: Breathing is slightly labored and pt. is short of breath. Pt. states she has a little bit of a cough, but not a productive cough. Rate and rhythm difficult to assess due to pt. difficulty breathing deep during anterior lungs auscultation; However, lung sounds are diminished. Pt. is on 2 liters of oxygen through nasal cannula. A&P:L ratio is 1:2.

Cardiovascular/Peripheral: Heart sounds are clear and normal; they are steady and regular. Pt. is not experiencing any chest pain. Pt. has no edema. Carotid pulse is steady and rhythmic; radial and Pedal pulses are bilaterally palpable and are steady and normal.

GI/GU: Pt. is on a 1800 calorie diet. On inspection, abdomen is normal and symmetrical. Pt. has no abdominal pain.
Last bowel movement on 10/14; Bowel sounds are normoactive in all four quadrants during auscultation. Urine color is amber and pt. is having no pain during urination. According to diagnostic tests, doctor states she has a UTI.

Skin: Color is good and normal. Skin turgor is normal. No lumps or masses. No bruises or wounds on inspection, but scarring on right chest from mastectomy and skin discoloration on the legs from flea bites. Pt. has no edema. Cap refill of fingers and toes is 1-3 seconds.

Watch for tangled tubing and cords in the room to decrease risks of fall.
Encourage pt. to ask for assistance if needing to use the bathroom or for personal hygiene.
Monitor for and assess for dizziness and confusion that may be caused from hypoglycemia or
Be cautious of medication and tape allergies.
Physical Assessment
Ineffective Airway Clearance r/t exacerbation of COPD and hx of smoking a.e.b wheezing and rhonchi lung sounds on admission, coughing and on 2L Oxygen
Nursing Dx #1:
Patient will maintain a patent airway at all times a.e.b. 02 saturation of 90 to 100% by the end of the clinical shift at 1400 on 10/18
Short-term Goal:
Student nurse will monitor pt. respiratory patterns, including rate depth, and effort by inspection and auscultation – Monitor breathing (more specific, access for tolerance of activity)
monitor breathing to assess for tolerance of activity
Student nurse will monitor pt. ABG’s values and pulse oxygen saturation levels by assessing
Because COPD can increase acidosis, monitor lab values for changes
Student nurse will administer oxygen for the pt. by nasal cannula according to physician’s order when Pt. is experiencing SOB
treat discomfort and Shortness of Breath
Educate client to position for more comfortable breathing by raising the head of the bed up to 30 degrees angle
teach non-pharmacological therapy for comfort
Administer Duoneb (albuterol Ipratropium) as ordered by the physician at specified time
pharmacological therapy for short of breath or difficulty breathing
Educate Pt. how to deep breathe by inspiring a deep breath and then holding breath for 3 seconds
to decreases mucous and increase lung capacity
Patient will demonstrate how to have a patent airway by discharge from the unit
Long-term Goal:
Educate Pt. how to incentive spirometer
for pneumonia prevention
teach non-pharmacological therapy for comfort
Turn and position patient Q2HRS using the following schedule: 0600 – supine, 0800 – right side, 1000 – left side, 1200 –supine, 1400 – right side, 1600 – left side, 1800- supine, 2000 – right side, 2200 - left side, 2400 – supine
Prevent intolerance to activity
Intolerance r/t diagnosis of Type II Diabetes and long hospitalized stay a. e. b generalized weakness, oxygen demand during activity, and overweight
Nursing Dx #2:
Patient will ambulate to chair without SOB and maintain oxygen Sat of 90 to 100% once by the end of the clinical day at 1400 on 10/18
Short-term Goal:
Patient will increase activity by ambulating in the hallways Q6HRS by discharge from the unit.
Long-term Goal:
Student nurse will assist Pt. to ambulate to the bathroom as needed
increase activity
Student nurse will educate Pt. to ambulate in the hallway on the floor twice daily on the scheduled time at 1000 and 1600
Assist Pt. with toileting if needed
Consult Physical Therapist and refer Pt. activity status
Student nurse will encourage Pt. to sit on chair for 15 minutes daily at 1400 if Pt. is awake
educate pt. how to increase activity
Student nurse will monitor pt. respiratory patterns, including rate depth, and effort by inspection and auscultation – Monitor breathing (more specific, access for tolerance of activity)
monitor breathing to assess for tolerance of activity
long-term supportive therapy
Increase range of motion by standing and sitting
prevention of Pt. risk of falls
monitor breathing to assess for tolerance of activity
Goal Evaluation:
The goal was met. The Pt. maintained a patent airway and kept a O2 Sat. level above 90%, by the ned of the clinical shift.

Revised goal:
For this particular patient on this clinical day, I would not need to revise the goal because I was met.
Goal Evaluation:
The goals were met. That patient was able to ambulate to the bathroom and to the chair with stable respirations and oxygen sat of 90 and above by the end of the clinical shift 1400 on 10/18

Revised Goal:
The goal was met, however to increase activity for the patient the goal can be revised.
Patient will increase activity a.e.b. ambulating to the hallway by discharge
This diagnosis was chosen according to the patients data of wheezing and rhonchi lung sounds, coughing, and labored and difficulty breathing. This si a bigger priority than Nursing Dx #2 because it addresses the airway and importance to keeping pt. physiological needs.
The second diagnosis was chosen due to the Pt. oxygen demand during activing and because of the long hospitalized stay. It is secondary to the first nursing dx because it is not the first priority and care that needs to be carried out. Yet it is still important, thus it is the second dx.
By Joy Lee
Clinical Instructor: Professor Osborn

(Ackley & Ladwig, 2011)
(Ackley & Ladwig, 2011)
(pp. 271, Ignatavicius & Workman, 2010)
(pp. 1813, Ignatavicius & Workman, 2010)
Side Effects: (Adams, Holland & Urban, 2010)
Side Effects: (Adams, Holland & Urban, 2010)
Side Effects: (Adams, Holland & Urban, 2010)
Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook an evidence-based guide to planning care. (9th ed.). St. Louis,Missouri: Mosby Elsevier.

Adams, M. P., Holland, L. N., & Urban, C. Q. (2010).Pharmacology for nurses, a pathophysiologic approach. (3 ed.). Upper Saddle River, NJ: Prentice Hall.

Ignatavicius, D. D., & Workman, M. L. (2010). Medical-surgical nursing, patient-centered collaborative care. (6th ed., Vol. 1). St.Louis, Missouri: W B Saunders Co.
Due Date: Nov 19, 2012
Nursing Dx
Short-term Goal:
Goal Evaluation
Full transcript