Summary Oral and Parenteral Medication AdministrationSkills & Reasoning

Primary Concept Perfusion Interrelated Concepts (In order of emphasis) • Gas Exchange • Clinical Judgment • Patient Education NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment  Management of Care 17-23%   Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12%  Psychosocial Integrity 6-12%  Physiological Integrity  Basic Care and Comfort 6-12%   Pharmacological and Parenteral Therapies 12-18%   Reduction of Risk Potential 9-15%   Physiological Adaptation 11-17%  History of Present Problem: Jerry Williams is a 62-year old obese (BMI 35.2) Caucasian male with a history of diastolic heart failure and type II diabetes. Last evening, he began having difficulty breathing with activity. He thought he might be getting a cold becausehe had a runny nose. He reports more swelling in his lower legs the past couple days. He woke up this morning with increased difficulty breathing when he woke up and his wife called 911. Paramedics report that his initial VS: HR:92 RR: 28 BP: 172/88 O2 sat: 80% on room air with scattered expiratory wheezing bilat. He was placed on oxygen by facemask and albuterol nebulizer administered with some improvement in his breathing. His RR is now 24 upon arrival to the emergency department ED). His initial labs have resulted; creatinine of 2.5 (last adm. 1.8), K+ 3.5 (last adm. 3.7) and BNP 944 (last adm. 322). Jerry is given furosemide 40 mg IV in the ED and had 800 mL urine output in the last hour. He is admitted to cardiac telemetry, and you are the nurse responsible for hiscare. What data from the present problem do you NOTICE as RELEVANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT Data: Clinical Significance: 1. obese, type II diabetes, Diastolic heart failure 2. shortness of breath with activity/ increased difficulty breathing when he woke up 3. more swelling in his lower legs 4. High RR and BP and low O2 sat 5. high creatine and BNP labs 1. shows that patient was not in the best health before these problems began 2. shows that there is something going on with his gas exchange 3. could be a problem with purfusion, possible DVT 4. proves that hes is having difficulty breathing and his heart is trying to pick up the slack 5. increase risk for kidney and heart failure What is the RELATIONSHIP of his past medical history and current medications? Why is your patient receiving thesemedications? (Which medication treats which condition? Draw lines to connect) Past Medical History (PMH): Home Medications: Hyperlipidemia Hypothyroidism Type II diabetes Diastolic heart failure Chronic kidney disease stage III Furosemide 20 mg PO every morningAtorvastatin 40 mg PO at bedtime Metoprolol 50 mg PO BID Levothyroxine 112 mcg PO daily Exenatide microspheres 2 mg subq. weekly Nursing Assessment Begins: Current VS: Most Recent in ED: P-Q-R-S-T Pain Assessment: T: 98.2 F/36.8 C (oral) T: 98.8 F/37.1 C (oral) Provoking/Palliative : P: 88 (reg) P: 92 (reg) Quality: Denies R: 24 (reg) R: 24 (reg) Region/Radiation: BP: 142/76 BP: 148/80 Severity: O2 sat: 93% 4 liters n/c O2 sat: 94% 4 liters n/c Timing: Current Assessment: GENERAL SURVEY: Pleasant, in no acute distress, calm, body relaxed, no grimacing, appears to be resting comfortably. NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink andmoist. RESPIRATORY: Breath sounds coarse crackles in bases equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort. CARDIAC: Pale/pink, warm & dry, 2+ pitting edema in feet and ankles, heart sounds regular, pulsesstrong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. Unable to assess JVD due to obesity/thick neck ABDOMEN: Abdomen round, soft, and nontender. BS + in all four quadrants GU: Voiding without difficulty, urine clear/yellow INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill 3 seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skinturgor elastic, no tenting present. What clinical data do you NOTICE that is RELEVANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: TREND: Pulse decreased BP decreased O2 sats decreased by 1% He is more calm, less work on heart Less work on heart trying to pick up slack may need O2 adjusted work on heart is decreasing, may need re-evaluated for a higher liter RELEVANT Assessment Data: Clinical Significance: TREND: Respiratory: crackles Cardiac: 2+ pitting edema Fluid is in lungs fluid in cells tissues increased buildup of fluid 1. INTERPRETING relevant clinical data, what is the primary problem? What primary health-related concept(s)does this problem represent? (Management of Care/Physiologic Adaptation) Problem: Pathophysiology of Problem in OWN Words: Primary Concept(s): Pulmonary embolism . Patient had a DVT, which was the cause for the swelling he noticed in his legs. The DVT dislodged andmoved up to lungs creating a pulmonary embolism. This is the cause of the shortness of breath and crackling lung sounds Cardiac, Perfusion, respiratory 2. What nursing priority(ies) will guide your plan of care that determines how you decide to RESPOND? (Management of Care) Nursing PRIORITY: Promote patient activity PRIORITY Nursing Interventions: Rationale: Expected Outcome: Assist patient to sit up in bed, chair, or go for short walks The movement will prevent other clots from forming. Immobilty will increase the risk of more clots and pneumonia. Sitting up will allow for easier breathing and other clots will not develop. Medical Management: Admission Medication Orders Care Provider Orders: Mechanism of Action: Expected Outcome: Administer the following homemedications: Atorvastatin 40 mg PO daily A:inhibits rate-limiting step in cholesterol biosynthesis by competitively inhibiting HMG-CoA reductase A: lower lipid levels M: Lower the risk of M:blocks response to beta-adrenergic stimulation heart attack Metoprolol 50 mg PO BID L: raise the level of Levothyroxine 112 mcg PO daily L: Synthetic T4; increases thyroid actions tyroid hormone H: decreases the New order: Heparin 5000 units subq. BID H: inhibits the conversion of prothrombin to thrombin clotting ability, and can reduce the size of a clot