cpe4 week 5

Clinical/Practicum Medication Profile Worksheet Student Name: Dave Jay S. ManriquezPatient Initials: R.M.; Age: 86 years old; Sex: MalePatient Diagnosis: CholecystitisChief Complaints: Abdominal Pain in Right Lower Quadrant.Date: August 28, 2016

Medication (generic and trade

names)

Class and action

Reason my patient is

receiving this

Patient’s dose, route,

and frequency

Standard dose, routes,

and frequency

Common side effects

Is my patient experiencing

any side effects?

Priority Nursing Considerations

Premix:1. Magnesium

Antiulcer/ Supplements, Antacids

Patient is not taking any solid food due to cholecystitis. He can take only ice chips. Also help in maintaining a normal heart beat and regulates sugar.

5 g IV q 8 hrs x 2 doses

5 g IV q 8 hrs x 2 doses

Constipation, diarrhea

None Assess for heartburn and indigestion as well as location, duration, character, and precipitating factors of gastric pain.

2. Piperacillin/ Tazobactam

Anti-infectives Patient has cholecystitis to prevent infection.

3.375 g in D5W 50 ml to be infuse in 30 mins q 6 hrs

3.375 g every 6 hours IV

Diarrhea, rashes, pain, phlebitis

None Assess for infection (vital signs throughout the therapy.

Scheduled:3. Heparin

Anticoagulants Patient has a possible internal bleeding or perforation might happen due to obstructed duct.

5,000 units (0.5 ml) inj SC q 12hrs

5,000 units (0.5 ml) inj SC q 12hrs

Bleeding, anemia

None Assess for signs of bleeding and hemorrhage. Like bleeding gums, nosebleed, and decrease BP.

4. Metropolol Antianginals/ Antihyperten-sive

Patient has medical history of hypertension.

50 mg PO BID 25-100 mg/day PO

Fatigue, weakness, erectile dysfunction

None Monitor BP, ECG, and pulse frequently during therapy.

5. Amlodipine Antihyperten-sive, Calcium channel blockers


10 mg PO daily

5-10 mg once daily PO

Dizziness, fatigue, peripheral edema, hypotension, nausea, flushing

None Monitor BP and pulse before and during administration.

6. Ramipril Antihyperten-sive, ACE inhibitor


10 mg PO daily

10 mg PO daily

Cough, hypotension, taste disturbance

None Monitor BP and pulse before and during administration

7. Amitriptyline Tricyclic antidepres-sants

To control anxiety, insomnia, aggression, and depression.

20 mg PO HS 50-100 mg at bedtime PO

Lethargy, sedation, blurred vision, dry eyes, dry mouth, arrhythmias, hypotension, constipation

None Monitor for mood changes during therapy.

8. Magnesium Glucohept

Antiulcer/ Supplements, Antacids

Patient is not taking any solid food due to cholecystitis. He can take only ice chips. Also help in maintaining a

300 mg PO daily

300 mg PO daily

Constipation, diarrhea

None Assess for heartburn and indigestion as well as location, duration, character, and precipitating

normal heart beat and regulates sugar.

factors of gastric pain.

9. Pantoprazole Antiulcer/ Proton-pump inhibitors

Patient is not eating solid food, only ice chips allowed, to prevent stomach ulcer.

40 mg PO daily

40 mg PO daily

Headache, diarrhea, abdominal pain, hypomagnesemia

None Assess for epigastric or abdominal pain.

10. Insulin Regular (Humulin)

Antidiabetics Patient is diabetic.

Sliding scale q 4 hrs before meals

Sliding scale q 4 hrs before meals

Hypoglycemia, anaphylaxis

None Assess for symptoms of hypoglycemia such as anxiety, restlessness, tingling in hands and feet.

PRN:11.Acetaminophen

Non-opioid/ Antipyretic

Patient has abdominal pain from cholecystitis. For breakthrough pain.

650 mg (2 tab) PO q 4 hrs PRN

325-650 mg q 6 hours PO

Agitation, anxiety, headache, fatigue, insomnia, hepatotoxicity

None Assess type, location, and intensity of pain prior to and 30-60 mins following administration.

12.Hydromorphone Opioid Patient has abdominal pain from cholecystitis.

1-4 mg (1 to 4 ml) PO q 4hrs PRN

4-8 mg q 3-4 hrs PO

Confusion, sedation, hypotension, constipation, urinary retention, dry mouth

None Assess type, location, and intensity of pain. Assess BP, pulse, and respiration during administration.

13. Ondansetron Antiemetic To prevent 0.5 – 2 ml (1- 4 mg INJ via Headache, None Assess patient

nausea if patient going to take opioid analgesics.

4 mg) 50 ml IV fluid infuse over 15 mins

IV dizziness, constipation, diarrhea

for nausea and vomiting, abd. distention and bowel sounds.

14.Dimenhydrinate Antiemetic To prevent nausea if patient going to take opioid analgesics.

25-50 mg (0.5-1 tab) PO q 6 hrs.

25-50 mg (0.5-1 tab) PO q 6 hrs.

Headache, dizziness, constipation, diarrhea

None Assess patient for nausea and vomiting, abd. distention and bowel sounds.

LAB VALUES WORKSHEET

Patient Initials: R.M. Age: 86 years old Sex: Male Diagnosis: Cholecystitis Date: August 28, 2016Chief Complaint: Abdominal Pain in Right Lower Quadrant.Student: Dave Jay S. Manriquez

Lab Test Normal Values for Patient of

similar age/sex

Critical Values Patient Results High or Low N (Normal)

Reason(s) for high or low specific to this particular patient

Medical/nursing implications (ie

potential complications and

treatments)CBCD1. Hematocrit

(0.40-.50) No (0.34) Low Patient has cholecystitis, possible internal bleeding happening due to an obstructed duct.

Treat underlying cause. Routine blood testing. May require intravenous iron.

2. Red Blood Cells

(4.20-5.80 g/L) No (4.01) Low Patient has cholecystitis, possible internal bleeding happening due to an obstructed duct.

Treat underlying cause of anemia. Routine blood testing. May require intravenous iron. For severe cases may need blood transfusion.

3. Hemoglobin (135-170 g/L) Yes (112) Low Patient has cholecystitis, possible internal bleeding happening due to an obstructed duct.

Treat underlying cause of anemia. Routine blood testing. May require intravenous iron. For severe cases may need blood transfusion.

4. White Blood Cells

(4.0-11.0 x 10 g/L)

Yes (18.4) High Patient has inflamed gallbladder (cholecystitis). Indicate infection might be happening .

Treat underlying cause or give antibiotics to prevent infection.

5. Red Cell Distribution Width

(11-15%) No (15.4) High Due to advance age may have Vitamin B12 or folic acid deficiency. May also cause from an internal bleeding.

Treat underlying cause. May require vitamin B12 and iron supplements.

6. Neutrophil (2.0-8.0 X 10 g/L)

Yes (14.8) High Patient has inflamed gallbladder (cholecystitis). Indicate infection might be happening .


7. Monocyte (0.2-1.0 x 10 g/L) No (1.3) High Patient has inflamed gallbladder (cholecystitis). Indicate infection might be happening .


Lytes10. Potassium

(3.6-4.7 mmol/L) No (3.5) Low Patient in advance age may have a decrease consumption of food rich in potassium. Patient is not allowed to eat solid food only ice chips allowed.

Need IV potassium added to a solution or K-Dur.Monitor heart rhythms.

11. Alkaline Phosphate

(30-105 u/L) Yes (401) High Due to acute cholecystitis and common bile duct stones (choledocholithiasis), or blockage in the

Treat underlying cause. A surgical operation such as cholecystectomy might be needed after ERCP results

duct. found out there is gallstones causing the gallbladder to be inflamed.

12. ALT (15-55) Yes (104) High Due to acute cholecystitis and common bile duct stones (choledocholithiasis), or blockage in the duct.

Treat underlying cause. A surgical operation such as cholecystectomy might be needed after ERCP results found out there is gallstones causing the gallbladder to be inflamed.

13. AST (15-45) Yes (57) High Due to acute cholecystitis and common bile duct stones (choledocholithiasis), or blockage in the duct.


14. Total Bilirubin

(<20 umol/L) Yes (26) High Due to acute cholecystitis and common bile duct stones (choledocholithiasis), or blockage in the duct.


15. Conjugated Bilirubin

(<6 umol.L) Yes (22) High Due to acute cholecystitis and common bile duct stones (choledocholithiasis), or blockage in the duct.


16. Lactase Dehydrogenase

(<50 u/L) Yes (757) High Indicate tissue damage or injury from infections such as cholecystitis.

Treat underlying cause. A surgical operation such as cholecystectomy might be needed.

ROOM # 1006 - bed 4 Diagnosis: CholecystitisRelevant History: Advance

MEDICATIONS

Name: R.M.Age: 86 years oldCode: Full codeAllergies: NoneV/S: BP: 153/69 Temp: 36.7 Pulse: 93 RR: 18 O2 Sat: 89% RAActivity: BedrestDiet: ice chips only; sip water with meds okayFoley/Output: Voiding through urinal; 1 person assistDrains: NoneIV: D5 ½ NS + 20 KCl @ 100 ml/hrO2: 2 lpm LBM: Have no bowel movement since admission.

Other:Pain: RLQ pain when palpated. PRN pain meds given.Abdomen: Abdomen distended and soft to touchGastro: Passing gas, BSx4, No bowel movement since admissionCBG: Every 4 hours, per sliding scaleCommunication: Through picture card, still cognitive but speech is affected by ALS.

Amyotrophic Lateral Sclerosis, Atrial Fibrillation, Diabetes, Smoker, Hypertension

Date of Admission:August 28, 2016

Reason for referral: Complaints of abdominal pain in the right lower quadrant

Premix: PRN:1. Magnesium 11. Acetaminophen2. Piperacillin/Tazobactam 12. HydromorphoneScheduled: 13. Ondansetron3. Heparin 14. Dimenhydrinate4. Metropolol5. Amlodipine6. Ramipril7. Amitriptyline8. Magnesium Glucohept9. Pantoprazole10. Insulin Regular (Humulin)

Assessment Focus Assessment Findings1. Chest Assessment2. Vital Signs3. Abdominal Assessment4. Genitourinary Assessment5. Peripheral Vascular Assessment6. Pain Assessment7. IV Assessment

Awake, alert, communicates through picture card @0800. VSSA, chest clear to bases. SPO2 89% @ 0715 place on O2 3 lpm by RN, reassessed 94% from 3 lpm decrease to 2 lpm. Elevated head of the bed. Right lower quadrant pain when palpated. Abdomen distended but soft to touch. No bowel movement since admission, + passing of gas, ice chips can be given. Voiding per urinal, assisted with voiding drain 20 ml @ 1230. CBG taken 10.4 @ 0800, no insulin given per sliding scale. Mostly bedrest. Morning care done.

CARE PLAN

Client Initials: D.P. Student Name: Dave Jay S. Manriquez

Problem/Strength Goal Intervention Rationale EvaluationNursing Diagnosis Associated with Cholecystitis:1. Acute pain related to inflammatory process of the cholecystitis (as evidenced by restlessness, anxiety, and pain in the right lower quadrant when palpated)- Facial grimacing and nodding of head when RLQ of the abdomen palpated.- Pain meds are given to control pain.

The overall goal for the patient:a. Understand the use of nonpharmacological treatments in addition to pain medication to keep pain in controlled level.b. Patient feeling of pain will be 0/10 after pain medication is given or use.c. Patient will have a controlled pain throughout the shift.

1. Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain.

2. Consider cultural influence on pain response.

3. Reduce or eliminate factors that precipitate or increase pain experience.

4. Teach the use of nonpharmacological techniques such as relaxation and distraction.

5. Provide optimal pain relief with prescribed analgesics.Each client has a right to expect maximum pain relief.

1. Pain is a subjective experience and must be described by the client in order to plan effective treatment.

2. Each person experiences and expresses pain in an individual manner using a variety of sociocultural adaptation techniques.3. Factors that may be precipitating or augmenting pain should be reduced or eliminated to enhance the overall pain management program.4. The use of non-invasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications.5. Optimal pain relief using analgesics includes determining the preferred route, drug, dosage, and frequency for each individual.6. Research shows that

Expected outcome for the patient:a. After nursing intervention, the patient pain will be relieved and controlled.b. Patient will no longer in pain and will feel at ease.

Nursing Diagnosis Associated with Cholecystitis:2. Risk for infection related to development of inflammatory process or worsening Cholecystitis.

The overall goal for the patient:a. To remain afebrile, comfortable, and no experiences of pain.

6. Evaluate the effectiveness of the pain control measures used through ongoing assessment.

7. Administer pain medications as prescribed and indicated.

1. Assess vital signs including temperature every 4 hours and as needed. Report any abnormal findings to the healthcare provider.2. Assess mental status and level of consciousness every 4-6 hours.

3. Report and note any abnormal laboratory values (i.e. elevated WBC count) to the healthcare provider..

the most common reason for unrelieved pain is failure to routinely assess pain and pain relief. Many clients silently tolerate pain if not specifically asked about it.7. Analgesics are helpful in relieving pain and helping in the recovery process.

1. Fever is often one of the first signs of infection.

2. Mental status changes, confusion, or any deterioration from baseline can signify infection.3. Certain abnormal laboratory results could be an indicator of infection.

Expected outcome for the patient:a. By discharge the patient will remain free signs and symptoms of infection.

MIND MAP

24 Hour Patient Care Flowsheet

PAIN – Pain in the right lower quadrant when palpated.

NEUROLOGICAL – Cognitive, communicates through a picture card.

RESPIRATORY – Chest clear to bases. SPO2 89% @ 0715 place on O2 3 lpm by RN, at 0800 reassessed 94% decrease to 2 lpm.

CARDIOVASCULAR – Color is appropriate with ethnicity, warm to touch, capillary refill less than 3 seconds, and pulses are strong to touch peripherally.

GASTROINTESTINAL – Passages of gas, and bowel sound heard during auscultation at the 4 quadrant. No bowel movement since admission, allowed for ice chips.

GENITOURINARY – Voiding per urinal; 1 person assists.

INTEGUMENTARY (SKIN) – Has a good skin turgor. No sign of skin ulcers and rashes.

MUSCULOSKELETAL – Bedrest. No strength on the lower extremity due to ALS.

PSYCHOSOCIAL – Not applicable

SAFETY – Call bell within reach; side rails in appropriate position; bed in lowest position; patient safety and equipment check complete.

DRESSING/ INCISIONS – Not applicable

DARINAGE TUBES – Not applicable

OTHERPatient safety to be observed at all times.CBG every 4 hours per sliding scale.To O.R. for Endoscopic Retrograde Cholangio-Pancreatograhy.

Plan of Care for H.S.

0630 – Take a look on the patient chart and get pertinent information to be used in assessing the patient. Check information on night shift report.

0700 – Introduce self to the primary nurse of the patient and see personally and greet the patient.

0730 – Attend the morning shift report in the nursing lounge.

0740 – Take the vital signs of the patient.

0745 – 0845 – Provide morning care and assistant to the patient. Take Capillary Blood Glucose.

0845 – 0905 – Do some focus assessment on the patient.

0905 – 0910 – Write down vital signs in the patient chart.

0910 – 0930 – Write down information on the 24 hours flow sheet.

0930 – 0945 – First Break

0945 – 1005 – Write down focus charting.

1005 – 1200 – Buddy up with the assign primary nurse of the patient. Knowing things he is up to for his other patient assignments on that day.

1200 – Take second set of vital signs of the patient.

1205 – 2010 - Write down vital signs in the patient chart.

2010 – 2020 – Check back on the assign patient. Take Capillary Blood Glucose.

2030 – 1300 – Take Lunch Break

1300 – 1430 – Buddy up again with the primary nurse. Do seek and find resources within the facility. Attend student post conference in the lounge.Definition of Terms:

1. Amyotrophic lateral sclerosis – is a progressive neurodegenerative disease that affected nerve cells in the brain and the spinal cord. ”No muscle nourishment”.2. Atrial Fibrillation – is an irregular and often very fast heart rate. May cause symptoms as heart palpitation, fatigue, and shortness of breath.3. Magnesium IV and Magnesium glucoheptonate – to prevent low magnesium level esp in older adults having GI issue where magnesium are not absorb instead excreted by the body. It helps maintain normal nerve and muscle function, healthy immune system, make the heart beat steady, help bones remain strong, regulates blood glucose. Magnesium is also use as antiulcer/antacids. The patient is not eating solid food since admission, he is only allowed for ice chips, to prevent stomach ulcer because magnesium help decrease acid production.4. Cholecystitis – Inflammation of the gallbladder. Treatment of cholecystitis depends on the severity of the condition and the presence or absence of complications. Uncomplicated cases can often be treated on an outpatient basis; complicated cases may necessitate a surgical approach. In patients who are unstable, percutaneous transhepatic cholecystostomy drainage may be appropriate. Antibiotics may be given to manage infection. Definitive therapy involves cholecystectomy or placement of a drainage device; therefore, consultation with a surgeon is warranted. Consultation with a gastroenterologist for consideration of endoscopic retrograde cholangiopancreatography (ERCP) may also be appropriate if concern exists of choledocholithiasis. Patients admitted for cholecystitis should receive nothing by mouth because of expectant surgery. However, in uncomplicated cholecystitis, a liquid or low-fat diet may be appropriate until the time of surgery.

Admitting Diagnosis:August 28, 2016 – Cholecystitis. Admitted for complaints of abdominal pain in right lower quadrant.

History: Has a history of advance amyotrophic lateral sclerosis, atrial fibrillation, smoker for 35 years (30 cigarettes a day), has hypertension.

Schedule Medications:Premix Meds:1. Magnesium IV (Antiulcer/Antacids) - Patient is not allowed to eat food, only ice chips is allowed. To prevent stomach ulcer.2. Piperacillin/Tazobactam (Anti-infectives) – To prevent infection since patient has cholecystitis.Per Orem, Subcutaneous:3. Amlodipine (Antihypertensive) – Has hypertension. Amlodipine is a calcium channel blocker that inhibits the transport of calcium into myocardial and vascular smooth muscle, resulting in inhibition of contraction. As a result it cause systemic vasodilation that decrease BP and coronary vasodilation that decrease frequency and severity of attacks of angina.4. Metropolol (Antihypertesive) – Has hypertension. Metropolol is a beta blocker, blocks stimulation of beta 1 causing decrease BP and heart rate.5. Ramipril (Antihypertensive) – Has hypertension. Ramipril is a ACE inhibitor, lowers BP by preventing the conversion of angiotensin 1 to angiotensin 2.6. Heparin (Anticoagulants) – Patient has cholecystitis, possible internal bleeding happening or perforation due to obstructed duct.

http://emedicine.medscape.com/article/175667-overview

7. Amitriptyline (Antidepressants) – To control anxiety, insomnia, aggression, and depression.8. Magnesium Glucoheptonate (Antacid) – Patient is not allowed to eat food, only ice chips is allowed. To prevent stomach ulcer.9. Pantoprazole (Antiulcer/Proton pump inhibitor) – Patient is not eating solid food, only ice chips allowed, to prevent stomach ulcer.10. Insulin Regular (Humulin) (Antidiabetic) – Patient is diabetic.

PRN Medications:1. Acetaminophen (Non-opioid) – To be administer for breakthrough pain.2. Hydromorphone (Opioid) – Has abdominal pain due to cholecystitis.3. Dimenhydrinate (Antiemetic) – To prevent nausea and vomiting, when patient is taking an opioid.4. Ondansetron (Antiemetic) - To prevent nausea and vomiting, when patient is taking an opioid.

Abnormal Labs:CBCD1. Low HGB, RBC, and HCT – Possible internal bleeding due to cholecystitis, obstructed duct might have cause perforation.2. High RDW – Due to advance age may have Vitamin B12 or folic acid deficiency. May also cause from an internal bleeding.3. High WBC, Neutrophil, and Monocyte – Indicate infection might be from cholecystitis.LYTES and Enzymes1. Low Potassium – Due to decrease potassium intake. Need IV potassium added to a solution or K-Dur.2. High Alkaline phosphate, Alanine transaminase, Aspartate transaminase, Total Bilirubin, Conjugated Bilirubin – Due to acute cholecystitis and common bile duct stones (choledocholithiasis) or blockage in the duct.3. High Lactase Dehydrogenase – indicate tissue damage or injury from infections such as cholecystitis.

Focus Assessments:1. Chest Assessment – To check for adventitious breathing sound. To check for shortness of breath. SPO2 89% @ 0715 O2 3 lpm, reassessed 94% O2 decrease to 2 lpm.2. Abdominal Assessment – To check for abdominal distention, presence of bowel sounds, and abdominal pain. RLQ pain when palated.3. Peripheral Vascular Assessment – To check any signs of DVT especially patient is on bedrest due to his condition, ALS.4. Pain Assessment – To check patient perception of pain and his tolerance.5. IV Assessment – to check for IV complication6. Vital Signs – Every 4 hours, patient has heart rhythm problem and ALS affecting his breathing due to muscle degeneration.

Health Teachings:1. Encourage to inform staff if having shortness of breath so that SPO2 will be taken and oxygen might be given and also staff can raise the head of the bed, or position patient comfortably in bed not slouching.2. Encourage to push the call bell if need assistance.3. Encourage to report any pain, abnormalities, and sign and symptoms of infection.

Now What:The patient was admitted for abdominal pain in the right lower quadrant and they found out in emergency that he has Cholecystitis an inflammation in the bladder. It is the first day of the patient in the unit when I met him as one of my assigned patient. He is dyspneic and sometimes tachycardic. Vital sign monitoring is very important for this patient. If there is a significant findings with v/s, it should be followed up after an hour maybe after giving an oxygen, raising the head of the bed, and positioning comfortably in bed. Every significant findings need to be reported to the primary nurse of the patient. As off 8/29/16 he is scheduled for ERCP (endoscopic retrograde cholangio-pancreatography), this will enables physician to examine the bile duct, pancreatic duct, and gallbladder using an endoscope inserted to the GI system. From the result, they can tell if the patient need some surgical procedure or not. Antibiotic is given to manage infection. As off the moment continuous monitoring need to be observe especially the patient is already in advance age. He is still cognitive but can no longer speak and walk because he has a degenerative disease called ALS. His BP and pulse needs to be monitored closely because he has atrial fibrillation.

cpe4 week 5

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