cpe4 week 4

Clinical/Practicum Medication Profile Worksheet Student Name: Dave Jay S. ManriquezPatient Initials: A.A.; Age: 77 years old; Sex: MalePatient Diagnosis: August 19, 2016 – Acute Renal Failure (Kidney Mass)/ Bilateral Hydronephrosis August 19, 2016 – Right and Left Nephrostomy Insertion Medical History: Hypertension, Diabetes Mellitus Type 2, High Cholesterol, Mass in Kidney causing hydronephrosisDate: August 22, 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

Premixed:1. Ampicillin

Anti-infectives Patient has open wound from the insertion of right and left nephrostomy tube. To prevent infection.

1 g in 0.9% NaCl via IV

500 mg q 6 hrs via IV

Seizures, diarrhea, rash

None Assess patient for infection (v/s, wound appearance, urine, WBC) throughout the therapy.

Scheduled:2. Bicalutamide(Handle With Gloves)

Antineoplastic Patient is likely to be diagnose with prostate carcinoma. Prostate specific antigen is high.

50 mg (1 tab) PO daily

50 mg PO once daily

Weakness, constipation, diarrhea, nausea

None Assess patient for adverse GI effects.

3. Heparin Anticoagulants Patient just have a surgery. Prevention of thrombus formation.

5,000 units (0.5 ml) SC q 12 hours

5,000 Units once daily SC

Bleeding, anemia

None Assess for signs of bleeding and hemorrhage such as bleeding gums and nose.

4. Atorvastatin Lipid lowering agent

Patient has a history of high cholesterol. Lowers LDL cholesterol and triglycerides.

10 mg (1 tab) PO daily

10-20 mg once daily PO

Abdominal cramps, constipation, diarrhea, flatus, heart burn, rashes

None Monitor liver function test esp. AST and ALT.

5. Insulin Regular (Humulin)

Antidiabetics Patient has Diabetes Mellitus Type 2.

Sliding Scale q 4 hours

Per sliding scale

Hypoglycemia None Assess patient periodically for symptoms of hypoglycema such as anxiety and restlessness.

PRN:6. Acetaminophen

Non-opioid/ Antipyretic

Patient has a recent surgery. To help in breakthrough pain.

325-650 mg (1-2 tab) PO q 4-6 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.

7. Hydromorphone Opioid Patient undergone recent surgery and presence of abdominal wounds.

1-4 mg PO q 4 hrs 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.

8. Lactulose Syrup Laxatives Patient just have a surgery. To prevent constipation.

10 to 40 g (15 to 60 ml) PO daily

15-60 ml/day PO

Belching, cramps, distension, flatulence

None Assess pt for abdominal distention, bowel sounds, normal bowel function.

9. Microlax Enema Laxatives Patient just have a surgery. To prevent

5 ml PO daily 5 ml PO daily Belching, cramps, distension,

None Assess pt for abdominal distention,

constipation. flatulence bowel sounds, normal bowel function.

10. PEG 3350 Powder

Laxatives Patient just have a surgery. To prevent constipation.

17 g (1 packet) PO daily

17 g (1 packet) PO daily



11. Sennosides Laxatives Patient just have a surgery. To prevent constipation.

8.6 – 17.2 mg (1-2 tab) PO hs

12-50 mg 1-2 times daily



12. Ondansetron Antiemetic To prevent nausea if patient going to take opioid analgesics.

4-8 mg (2-4 ml) IV

8 mg not to exceed per day

Headache, dizziness, constipation, diarrhea

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

13. Bisacodyl Laxatives Patient just have a surgery. To prevent constipation.

10 mg (1 supp) PO daily

10 mg/day single dose supp

Abdominal cramps, nausea


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

25-50 mg (0.5-1 ml) IV q 4h PRN

25-50 mg (0.5-1 ml) IV q 4h PRN

Headache, dizziness, constipation, diarrhea

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

LAB VALUES WORKSHEET

Patient Initials: A.A. Age: 77 years old Sex: Male Date: August 22, 2016Diagnosis: August 19, 2016 – Acute Renal Failure (Kidney Mass)/ Bilateral Hydronephrosis August 19, 2016 – Right and Left Nephrostomy Insertion

Medical History: Hypertension, Diabetes Mellitus Type 2, High Cholesterol, Mass in Kidney causing hydronephrosisStudent: 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

(0.40-0.50) No (0.28) Low Patient just undergo a recent major surgery to create a urinary diversion, an insertion of right and left nephrostomy, blood loss during the surgery. Left nephrostomy draining blood.

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

2. Red Blood Cells

(4.20-5.80 x10 12/L)

No (3.19) Low Patient just undergo a recent major surgery to create a urinary diversion, an insertion of right and left nephrostomy, blood loss during the surgery. Left nephrostomy draining blood.

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) No (91) Low Patient just undergo a recent major surgery to create a urinary diversion, an insertion of right and left nephrostomy, blood loss during the

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

surgery. Left nephrostomy draining blood.

may need blood transfusion.

4. Red Cell Distribution Width

(11-15%) No (15.1) 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.

5. Urea (2.5-8.0 mmol/L) No (1.5) Low Patient has renal mass on his kidney. Impaired kidney function. Elevated waste product.

Treat underlying cause. Creation of a urinary diversion to eliminate waste product.

6. Creatinine (60-100 mmol/L) No (33) High Patient has renal mass on his kidney. Impaired kidney function. Elevated waste product.

Treat underlying cause. Creation of a urinary diversion to eliminate waste product.

7. Est GFR (>59 ml/min) Yes (10) Low Patient has renal mass on his kidney. Impaired kidney function.

Treat underlying cause. Creation of a urinary diversion.

8. Bicarbonate (22-31 mmol/L) No (20) Low Patient has renal mass on his kidney. Impaired kidney function. Body excrete bicarbonate as natural physiologic reaction for any kidney disease.

Treat underlying cause. Creation of a urinary diversion. Like nephrostomy insertion.

Lytes:9. Calcium

(2.18-2.58 mmol/L)

No (2.14) Low Patient is in advance age. Decrease intake of calcium rich food.

Treat cause. Provide food rich in calcium.

Calcium supplements.

10. Phosphorus (0.80-1.60 mmol/L)

No (2.49) High Patient has a kidney problem. As calcium is low, phosphate goes up as natural physiologic reaction of the body when having a kidney disease.

Treat underlying cause of the kidney disease.

ROOM # 1009 - bed 4 Diagnosis: August 19, 2016 – Acute renal failure (kidney mass)/

MEDICATIONS

Name: A.A.Age: 77 years oldCode: Full codeAllergies: NoneV/S: BP: 129/61 Temp: 36.6 Pulse: 102 , keep monitoring PR RR: 18 O2 Sat: 97% RAActivity: Activity as toleratedDiet: renal diet, fruit lax 30 ml PO BIDFoley/Output: D/C at 0815 of 8/22Drains: Left Nephrostomy – draining scant amount of sero-sanguinous drainage; right nephrostomy draining amber urine.IV: 8/22 NS @ 75 ml/hr ½ NS @ 75 ml/hr replacement8/23 change to D5 ½ NS @ 84 ml/hrO2: O2 @ 2 lpm if having shortness of breathLBM: Have a large liquid stool 8/23

Other:Pain: Stated pain at surgical site, rated 8/10. Pain is tolerable. Refuse pain medication.Nephrostomy: Right and Left nephrostomy dressing clean and dry. Right nephrostomy draining amber urine; left nephrostomy draining sero-sanguinous scant amount.

bilateral nephrostomyAugust 19, 2016 – Right and Left Nephrostomy Insertion

Medical History: Hypertension, Diabtes Mellitus Type 2, High Cholesterol, Mass in kidney causing hydronephrosis

Date of Admission:August 19, 2016

Premix: 12. Bisacodyl1. Ampicillin 13. OndansetronScheduled: 14. Dimenhydrinate2. Bicalutamide3. Heparin4. Atorvastatin5. Insulin Regular (Humulin)PRN:6. Acetaminophen7. Hydromorphone8. Lactulose Syrup9. Microlax Enema10. PEG 3350 Powder11. Sennosides

Assessment Focus Assessment Findings1. Chest Assessment2. Vital Signs3. Abdominal Assessment4. Genitourinary Assessment5. Peripheral Vascular Assessment6. Pain Assessment7. Nephrostomy Assessment8. IV assessment

8/23 Awake, alert, coherent, oriented x3 @ 0830. Wheeze heard at times on auscultation. No shortness of breath. O2 no longer use as of the moment, SPO2 97% RA. No longer tachycardic, PR @ 92 bpm. At 0830 CBG 11.9 per sliding scale no insulin given. Abdomen flat and soft to touch, + passing of flatus, LBM 8/23/16 of large solid stool. Left and Right Nephrostomy dressing clean and dry. Left nephrostomy draining scant amount of sero-sanguinous drainage, right nephrostomy draining amber urine with sufficient amount @ 0830 drain 410 ml. Random bladder scanner done @ 0840 showing 69 ml. At 0900 urine sample taken on Right and Left NT for C/S. Sample placed on fridge. At 1020 change IV of 1L D5 ½ NS @ 84 ml/hr. Sent to O.R. for bone scan. Stated pain at surgical site rated 8/10. Pain is tolerable as stated. Refuse for any pain medication.

CARE PLAN

Client Initials: A.A. Student Name: Dave Jay S. Manriquez

Problem/Strength Goal Intervention Rationale EvaluationNursing Diagnosis Associated with Right and Left Nephrostomy insertion; and Renal Mass:1. Acute pain related to tissue injury secondary to surgical intervention (as evidenced by restlessness, anxiety, and report of pain at the surgical site rated 8/10)- Right and Left wound due to Nephrostomy insertion.- PRN Hydromorphone and Acetaminophen 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 stated 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. Ambulation activities

Expected outcome for the patient:a. After nursing intervention, the patient pain will be relieved and controlled.b. Patient verbalize no longer in pain and will be able to ambulate early and do daily activities.

Nursing Diagnosis Associated with Right and Left Nephrostomy insertion; and Renal Mass:1. Impaired urinary elimination related to acute renal failure due to a kidney mass causing bilateral hydronephrosis as evidenced by decrease in urinary output and pain in urination.- The need for nephrostomy insertion through surgery, to have a urinary diversion.

The overall goal for the patient:Short Term:After 2-3 hours of nursing interventions, the patient will verbalize understanding of condition.

Long Term:After 1-2 days of nursing interventions, the patient will participate in measures

6. Medicate before an activity to increase participation, but evaluate the hazard of sedation.

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

1. Establish rapport.

2. Monitor and record vital signs.

3. Assess pt's general condition

4. Review for laboratory test for changes in renal function.

will be enhanced if pain is controlled or tolerable. Assessing level of sedation should precede the activity to ensure necessary safety precautions are put in place.7. Research shows that 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.

1. To get the cooperation of the patient and significant others.

2. To obtain baseline data.

3. To know what problem and interventions should be prioritize.

4. To assess for contributing or causative factors.

5. Enhance commitments

Expected outcome for the patient:Short Term:The patient shall have demonstrated participation in his recommended treatment program.

Long Term:The patient shall have demonstrated behavior/lifestyle changes to prevent complications.

to correct/compensate for defects. 5. Establish realistic activity goal

with patient.

6. Determine patient pattern of elimination.

7. Investigate pain, noting location.

to promoting optimal outcomes.

6. To assess degree of interference.

7. To investigate extent of interference.

MIND MAP

24 Hour Patient Care Flowsheet

PAIN – Stated pain at surgical site rated 8/10. Mentioned pain is tolerable. Refuse for any pain medication.

NEUROLOGICAL – Awake, alert, coherent, oriented x3.

RESPIRATORY – Wheezing at times on auscultation, + SOBOE, SPO2 96% at 02 2 lpm, no use of accessory muscles

CARDIOVASCULAR – Color is appropriate with ethnicity, warm to touch, capillary refill less than 3 seconds, and pulses are strong to touch peripherally. At 0830 tachycardic @ 103 bpm, asymptomatic, continue monitoring of BP @ 1200 98 bpm.

GASTROINTESTINAL – Passages of gas, and bowel sound heard during auscultation at the 4 quadrant. Abdomen flat and soft to touch, LBM 8/21/16 of large solid stool.

GENITOURINARY – Left and Right Nephrostomy dressing clean and dry. Left Nephrostomy draining scant amount of sero-sanguinous drainage; Right Nephrostomy draining amber urine @ 0900 drain 550 ml.

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

MUSCULOSKELETAL – Activity as tolerated with 1 person assist when out of bed and going to washroom.

PSYCHOSOCIAL – Communicates appropriately with health care staff/ personnel.

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

DRESSING/ INCISIONS – Right and left nephrostomy, dressing clean and dry.

DARINAGE TUBES – At 0815 Foley D/C by the RN 8/22/16. Left Nephrostomy draining scant amount of sero-sanguinous drainage; Right Nephrostomy draining amber urine.

OTHERCBG TID ac meals + HS per sliding scale.Monitor ins/out, nephrostomy tubes and foley catheter for replacement q 4 hours; Monitor urine output q4h and replace ½ loses with ½ NS.O2 at 2 lpm if tachycardicKeep PIV 2 lines all the time, poor accessCytotoxic Precaution, wear protective equipment’s when dealing with body fluidsRandom bladder scanner done @ 0840 showing 69 ml. At 0900 urine sample taken on right and left nephrostomy for C/S. sample placed on fridge.At 1020 change IV of 1L D5 ½ NS @84 ml/hr. Sent to O.R. for bone scan. Nuclear medicine result likely to be diagnose with prostate cancer metastasize to lungs + nodes, bone mets? Prostate specific antigen – 8331 (<4.50)

Patient safety to be observed at all times.

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.

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 CBG count of the patient, document and inform primary nurse of the result.

0845 – 0905 – Do some focus assessment on the patient. Drain Right Nephrostomy as it is half full.

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 on the red binder.

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.

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. Acute renal failure – is the abrupt loss of kidney function, resulting in the retention of urea and other nitrogenous waste products and in the dysregulation of extracellular volume and electrolytes.

2. Diabetes Mellitus Type 2 – is a long term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent urination, and unexplained weight loss.3. Cytotoxic Precaution – are the ways that your healthcare team protects themselves from cytotoxic medications or body wastes. Although the risk of harm may be very low, it is important to be careful.4. Nephrostomy – is an artificial opening created between the kidney and the skin which allows for the urinary diversion directly from the upper part of the urinary system (renal pelvis).5. Bicalutamide – is a synthetic non-steroidal antiandrogen (NSAA) that is used primarily in the treatment of prostate cancer. It is also used in the treatment of hirsutism and other androgen-dependent conditions and as a component of hormone replacement therapy for transgender women.

Admitting Diagnosis:August 19, 2016 – Acute renal failure (kidney mass)/ bilateral nephrostomyAugust 19, 2016 – Right and Left Nephrostomy Insertion

Medical History: Hypertension, Diabetes Mellitus Type 2, High Cholesterol, Mass in kidney causing hydronephrosis

Premix and Schedule Medications:1. Ampicillin (Anti-infectives) – To prevent infection. Patient has an open wound from the nephrostomy insertion.2. Bicalutamide (Antineoplastic) – To decrease the spread of prostate carcinoma.3. Heparin (Anticoagulants) – Prevention of thrombus formation. 4. Atorvastatin (Lipid lowering agent) –To slow progression of coronary atherosclerosis. Lowers total LDL and triglycerides; while increasing HDL.5. Insulin Reg (Humulin) () – To control hyperglycemia as he is diabetic.

PRN Medications:1. Acetaminophen (Non-opioid) – To be administer for breakthrough pain.2. Hydromorphone (Opioid) – Recently have a surgery for nephrostomy insertion, has an open wound.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.5. Lactulose Syrup (Laxatives) – To prevent constipation esp. patient just have a recent surgery and often in bed.6. Microlax Enema (Laxatives) – To prevent constipation esp. patient just have a recent surgery and often in bed.

7. PEG 3350 Powder (Laxatives) – To prevent constipation esp. patient just have a recent surgery and often in bed.8. Sennosides (Laxatives) – To prevent constipation esp. patient just have a recent surgery and often in bed.9. Bisacodyl (Laxatives) – To prevent constipation esp. patient just have a recent surgery and often in bed.

Abnormal Labs:CBCD1. Low HGB, RBC, and HCT - Patient just undergo a recent major surgery to create a urinary diversion, an insertion of right and left nephrostomy, blood loss during the surgery. Left nephrostomy draining blood.2. High RDW – Due to advance age may have Vitamin B12 or folic acid deficiency. May also cause from an internal bleeding.

LYTES, Urea and Crea1. High Urea, and Creatinine – Patient has renal mass on his kidney. Impaired kidney function. Elevated waste product.2. Low Est GFR and Bicarbonate – Patient has renal mass on his kidney. Impaired kidney function.3. Low Calcium – Patient is in advance age. Decrease intake of calcium rich food.4. High Phosphorus - Patient has a kidney problem. As calcium is low, phosphate goes up as natural physiologic reaction of the body when having a kidney disease.

Focus Assessments:1. Chest Assessment – To check for adventitious breathing sound. Shortness of breath and use of accessory muscles in breathing.3. Abdominal Assessment – To check for abdominal distention and presence of bowel sounds. + passing of flatus and LBM.4. Peripheral Vascular Assessment – To check any signs of DVT especially patient is always on the bed and undergone a urinary diversion surgery.5. Pain Assessment – To check patient perception of pain and his tolerance.6. Nephrostomy Assessment – To check if the site is dry and clean and draining completely to a bag attach to it.7. IV line Assessment – To check if IV is infusing properly. The site is clean and dry.8. Genitourinary Assessment – To check if can void independently with no pain, and to check the amount voided.

Health Teachings:1. Encourage deep breathing and coughing. To slightly elevate the head of the bed to promote ventilation.2. To ambulate as much as possible within the day to prevent DVT and stimulate movement to prevent paralytic ileus.3. Encourage to report any pain, abnormalities, and sign and symptoms of infection.4. Inform to report to health care professionals if noticing any signs of bleeding.5. Encourage to increase fluid intake.

Now What:Patient is POD3. He is still recovering from surgery. He can already walk around but still need assistance in going to bathroom considering also his age. He loss blood during surgery and also his left nephrostomy is draining bloods that is why his Hgb, Hct, and RBC are low. He is in Cytotoxic

Precaution because he is taking cytotoxic drugs to slow down the spread of carcinoma. His nuclear medicine report show he is likely to be diagnose with of Prostate Cancer that already metastasize to his lungs and nodes. As to the bone it still remain a question mark that is why in 8/23/16 he went for a bone scan to determine if the cancer have already metastasize to the bone. His prostate specific antigen is high 8331 (<4.50). Continuous monitoring to be done on this patient particularly on his voiding and respiration.

cpe4 week 4

Health & Medicine