Nursing Practice in Singapore - Research Paper Example

Nursing Practice in Singapore THE UNIVERSITY OF TEXAS MEDICAL BRANCH SCHOOL OF NURSING Adult 1 CLINICAL WORKSHEET AND NURSING CARE PLAN Student Name: Clinical Instructor: Prior medical history/dates: Chronic renal disease (2010), Heart disease-Myocardial Infarction (1972), Diabetes Mellitus type-2 (1970) Prior surgical history/dates: Heart Surgery-Left ventricular artery bypass (1997), Spinal surgery for L4-L5 slip disc (1988), Back surgery (1968), Appendicectomy (1966) PHYSICAL ASSESSMENT With emphasis on areas directly related to the pathology (For Day 2, indicate only changes from Day 1) VITAL SIGNS: (Record T,P, R, BP, and pain rating) Day-1: T 97.3, P 70, R 24, BP 92/47, PAIN 0/10 Day 2: T 98.3, P 75, R 22, BP 168/68, PAIN 0/10 Day-3: Day 2: T 98.3, P 78, R 20, BP 140/90, PAIN 0/10 How do the patient’s vital signs affect your nursing care? Vital signs reflect response to nursing and medical care. The patient’s BP will be checked before administering his BP medication, following which the BP will also be checked an hour following the administration of BP medication. Patient’s vital signs will be checked q 4 hours. Pain medication will be administered only if there is any pain and response to the medication will be checked after an hour of administration of the drugs. The main concern in this patient is blood pressure. SKIN/NAILS/HAIR The patient is a Hispanic male. His skin overtone is moderate brown, which is consistent with his ethnicity. The skin appears warm, dry, well hydrated and perfused. There is mild pitting edema in both the lower limbs. Skin over the lower pat of the lower limbs where edema is present appears dry with few petechiae. Hair and nails are not neatly groomed. The patient has brownish hair with a few specks of grey hair interspersed in the fore-lock. There is evidence of baldness over the forehead region. The patient has mustache and beard, which have brownish hair with many grey hair interspersed. On the whole, the hair appears as if not much care has been taken. EYES/EARS/NOSE The size of the pupils are equal on both he sides. They constrict to light equally on both the sides. There is no evidence of extraocular muscle dysfunction. The patient is able to follow the pen movements through the six cardinal positions of gaze. The patient wears glasses. The power of the glasses are -1.5 on both the sides. Vision, night vision, color vision, perception of depth of both eyes appear normal with glasses worn. There is no evidence of nasal drainage or nasal block. The patient has deviated nasal septum towards the right with hypertrophied left inferior turbinator. Hearing appears normal on both the sides. There is no evidence of otitis media. MOUTH & THROAT Oral mucosa appears pale and moist with twp small ulcers over the buccal mucosa. The lips are dry with cracks. The tongue appears moist and is freely mobile. It does not deviate. All teeth remain intact, except upper 2nd molar and front upper middle incisor. There is also evidence of poor dental hygiene. The upper second molar has dental caries and there is also evidence of dental erosion over the lower incisors. FACE/HEAD/NECK The shape of the head is normocephalic. There is normal ROM for the neck. There is no evidence of JVD. Thyroid is not palpable. Few cervical lymph nodes are palpaple, but are less than 2 cm in diameter. RESPIRATORY The respiratory movements are even and slightly labored and shallow . The respiratory rate is about 24 per minute (elevated). Lungs have a few crepitations and occasional rhonchi in the lower lobes Pulse oximeter shows 92% room air and 99% with one liter per minute of oxygen through mask. There is equal chest expansion. CARDIOVASCULAR/PERIPHERAL VASCULAR Heart rate is about 70 per minute. It is regular and in sinus rhythm. Pulse rate, rhythm and volume appear normal. The pulse is non-collapsing. All peripheral pulses are present and equal. S1 and Se are heard. There is no evidence of murmur. GASTROINTESTIVAL/NUTRITION 2 gm Na, 2 gm K, on decrease potassium diet. Bowel sounds are present in all 4 quadrants. Last bowel movement was last night. GU Input 280. Output 900. MUSCULOSKELETAL Steady gait with mild hunch back. Moves independently and needs no help for day-to-day activities. All limbs are bilaterally even with equal movement and strength. NEUROLOGICAL Patient is awake, active and alert. Patient is oriented to time place and person. Glascow Coma Scale is 15/15. Speech is clear and understandable without any slurring. He answers questions appropriately. Appropriate/inappropriate verbal/non-verbal behavior: The patient is friendly and cooperative, but appears sad because of the chronic nature of his disease. He feels that it is because of immigration and acculturation that his health has deteriorated. Only if he had heeded his parents advice, would he have not been in this shape. Tobacco, Alcohol &/or Drug use Patient is a known alcoholic since the age of 25 years. For the past 3 years, he consumes about 27 beers a week. He is a chronic smoker. He used to smoke about 1 pack cigarettes a day until his cardiac surgery. Now he smokes occasionally. He does not indulge in drug activities. GENERAL IMPRESSION Patient is a cooperative person, but is depressed because of his chronic illness. He enjoys movies. He is independent and is aware of his body needs and limitations. He however is unable to control the urge to consume alcohol. He does have back ache now and then, but is not worried about that. He enjoys body massage. He does care about how he looks. Infact, he jokes that he is a “shabby guy” OTHER SIGNIFICANT INFORMATION Patient was a clerk in a private office until a couple of years ago, when he sought voluntary retirement because of his illness. The patient lives with his wife. He has four sons, all of who are married and live separately. He does not have much financial help, except for some from his sons. He feels that racial discrimination and acculturation are two factors which ruined his life. Patient went to Milby HS but did not graduate. He could not graduate for financial reasons and other commitments. CLIENT/FAMILY TEACHING Educational Need Method of Teaching Client/family Response to Teaching Nutrition Education I explained to the patient about the diet he must be taking. The prescribed diet for him is diabetic diet with low salt and low potassium food in view of hypertension and chronic renal failure. I provided the information in the form of a chart after consulting his daily food timings and interests. I made a tailor-made diet chart for him. “This now appears easy and interesting to follow. You have included some of my favorite foods.” Dialysis education I explained the patient about the need for regular dialysis and the benefits and complications associated with it. “I know...it is a difficult thing” Smoking awareness I explained to the patient the hazards of smoking and the drastic improvement he would see once he is off it. “I am anyway dying, let me enjoy it atleast once in a while.” Medication administration I gave the patient written literature about the medicines he must be taking regularly. In the sheet, the dosage, timing and frequency were also included. I also explained to his wife about the medications. “Thank you. The medication information is clear.” What are the discharge planning needs of this client? Appropriate diabetic and chronic renal diet, continue medications for heart disease, adjust medications for hypertension, stop smoking and consume alcohol in moderation. He needs to undergo dialysis regularly. What are the long term health care needs based on the disease process, the physical assessment, the client’s understanding and the psychosocial factors? The patient will need to have routine health check ups and dialysis. Care of dialysis tubes is essential. Patient will need counseling from a psychologist/psychiatrist for depression and sad mood. Patient need to follow the nutritional advice. Lab and Other Diagnostic Tests Date/Time Pertinent Lab & Diagnostic Tests Patient Results Normal Values or Findings 10/02/10 8:00 AM Fasting Blood glucose 210H 70-110 10/02/10 8;00 AM BUN Creatinine WBC RBC Hemoglobin Hematocrit Platelet 54 H 2.44 H 6.9, 10.4 3.62, 3.62 10.8, 10.7 32.2, 32.3 2.45 135, 150 10-26 0.5-1.2 Rationale for ordering tests Why were the lab tests and diagnostic tests ordered? Blood glucose test was done to ascertain the patient’s glucose level (normal, hypoglycemia, hyperglycemia, DKA). Creatinine-BUN lab test was done to ascertain how well the kidneys are functioning. Complete blood picture was done to evaluate for hemoglobin levels because of his paleness and look for any infections. What do these lab values and test results tell you about this patient? The patient’s blood glucose level is marginally high, indicating that the patient is currently is in a state of hyperglycemia due to uncontrolled diabetes. It also indicates that the patient is not adhering to the norms of nutrition related to diabetes. Creatinine-BUN is high, indicating that the patient’s kidneys are not functioning properly. The hemoglobin levels are low because of chronic renal failure, in which erythropoietin deficiency occurs. Also, pallor is related to chronic disease and improper dietary management. How do these lab values and test results affect your nursing care? The patient's blood glucose levels and hemoglobin will be monitored closely. His input/output also will be monitored to assess his kidney function and ascertain his needs for fluids and electrolytes. Clinical Plan of Care Patient Data Medical Diagnosis: Dyspnea, CHF, Pneumonia, COPD, Chronic Kidney Disease Comorbidities or Risk Factors: Diabetes mellitus, hypertension, ischemic heart disease, alcoholism, smoking, unhealthy lifestyle behaviours, obesity and depression. Reason Seeking Health Care: Shortness of breath and swelling in the lower limbs. Psychosocial Factors Affecting Care: Retired (Voluntary). Patient lives with wife only. Wife also has health related problems: arthritis, obesity and diabetes. Cultural Factors Affecting Care: Patient is a second generation immigrated Hispanic male. He has unhealthy lifestyle behaviours. He is sedentary and does not heed medical advice properly. Spiritual Factors Affecting Care: Patient is a Catholic and attends to Church regularly. He believes in Jesus. He strongly believes that regular attending to religious meetings will heal him better than the medications prescribed to him. Prioritized Nursing Diagnoses Statements (List the client/families problems – real or potential - with related to statement and as evidence by data to support as needed) 1. Shortness of breath due to impaired gas exchange secondary to fluid overload 2. Ineffective glucose control due to diabetes and improper diet and medication management. PLAN OF CARE FROM CAREMAP #1 Nursing Diagnosis: Shortness of breath Data to support: Subjective: “I am unable to breath properly and feel as if suffocated” Objective: Takes shallow and frequent breaths. He is requiring minimal oxygen support. Lower lobes of the lungs have evidence of fluid accumulation. Some rhonchi are also heard because of chronic lung disease. The lower limbs have edema which is suggestive of fluid overload. Thus the main problem in this patient is fluid overload secondary to chronic renal disease and improper fluid and diet management. The objective data supports the patient’s complaint of shortness of breath Patient Goals: How will you know they are met? The patient will be on room air by tomorrow. Excess fluid will be removed through dialysis and fluid management. The respiratory rate of the patient will come down to less than 18 per minute. The patient's saturations will be above 96 percent in room air. The patient will look comfortable and better. Patient will be able to inform that he has undergone dialysis and the experience he felt during and after dialysis Nursing Interventions Specific to your patient? Rationale with reference and citations for each Nursing Implementation & Patient Response to Intervention State whether appropriate or not. 1. Assess respiratory rate every four hours. 1. Respiratory rate increases whenever there is fluid accumulation in the lungs because of poor ventilation-perfusion gradient. As the fluid overload decreases, perfusion and ventilation increase and the respiratory rate drops to normal (Nettina, 2006) 1. Action appropriate. Patient says “I am finding it difficult to breathe and feel ill” Respiratory rate is 24 per minute. 2. Administer oxygen through mask and monitor saturations through continuous oximetry. Dialyse the patient under strict and close monitoring 2. In chronic renal failure, dialysis is essential for removal of excess fluid. 2. Action appropriate. Dialysis was done and following dialysis the patient stated “I am feeling better and don't feel suffocated any more.” The patient however complained of “weakness and tiredness” following dialysis. 3. Reassess the respiratory rate and vital signs every 2 hours after dialysis. 3. Following dialysis, it is important to monitor the patient regularly in view of complications associated with dialysis and also to ascertain response to dialysis with respect to fluid overload. 3. Action appropriate. Patient informed that he was feeling much better after dialysis in terms of breathing and swelling in the lower limbs. 4. Patient education regarding the possible side effects of dialysis 4. There are many side effects to consider and anticipate during dialysis (Nettina, 2006)) 4. Action appropriate. The patient was provided with literature about the side effects of dialysis. He was also provided oral instruction about side effects of dialysis. The patient was able to identify side effects of dialysis like weakness and pain in lower limbs. 5. Patient education regarding reduction of fluid overload 5. Fluid reduction involves dietary measures, medications and dialysis 5. Action appropriate. The patient was provided with literature regarding methods to decrease fluid overload and warning signs of fluid overload which warrant dialysis. Evaluation of Goals: State whether each goal met or not State status of each goal or plan (ongoing, revised, discontinued) Provide revisions as needed The patient will be on room air by tomorrow. Excess fluid will be removed through dialysis and fluid management. Goal met. Within 6 hours after admission, dialysis was completed and fluid overload removed. This improved gas exchange in the lungs and brought down the shortness of breath and respiratory distress. Peripheral edema also decreased. Respiratory rate came down to normal and the patient was able to maintain saturations even in room air. Ongoing goal: The fluid status will be monitored throughout the shift patient will be educated about dietary measures of fluid restriction and the need to undergo dialysis regularly. #2 Nursing Diagnosis: Ineffective glucose control due to diabetes mellitus-type-2 and poor management of diet and nutrition. Nursing Interventions Specific to your patient? Rationale with reference and citations for each Nursing Implementation & Patient Response to Intervention State whether appropriate or not. 1. Assessment of the blood glucose level q AC of the patient. 1. To decrease the risk of development of either hypoglycemia and hyperglycemia and thus to carefully monitor blood glucose levels. (Smeltzer et al, 2008) 1. Action appropriate. Patient blood glucose was abnormally high at 210mg/dl. 2. Administration of sliding scale insulin PRN with meals as prescribed. 2. The main goal of initiating insulin therapy is to to normalize blood glucose levels without hypoglycemia and to maintain blood glucose levels at a stable level without significant fluctuations. (Smeltzer et al, 2008) 2. Action appropriate. Insulin therapy can cause sudden drop in blood glucose levels and cause hypoglycemia. Hypoglycemia is dangerous and worse than hyperglycemia. 3. Reassessment of blood glucose level 1one hour after administration of insulin. 3. Risk for hypoglycemia after insulin therapy is highest at one hour after administration of insulin (Smeltzer et al, 2008) 3. Action appropriate. At one hour, the blood glucose level reverted to 96mg/dl. 4. Educating the patient about strategies to manage glucose levels in blood. 4. Self-management of blood glucose levels is the most appropriate method of diabetes management (Nettina, 2006). 4. Action appropriate. The patient was provided appropriate literature for self-assessment and management of diabetes. Monitoring of blood sugar levels at home was taught to the patient and his wife. REFERENCES References used (APA format). Include all textbooks, journals used, including drug reference. Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2008) Brunner & Suddarth’s textbook of medical-surgical nursing (11th ed.). New York: Lippincott Williams & Wilkins. Nettina, S. (2006). Lippincott manual of Nursing Practice. Singapore: Lippincott Medications Name of Med (Generic & Brand) Dose Route Frequency Admin. Times Time last PRN dose given Drug Classification Safe Dose Range (for this child) A) Action of Medication B) Reason for use with this client Nursing Implications What needs to be checked or validated before and/or after administration? Things such as labs, vs, with food, etc. Contraindications Significant Major Side Effects Drug Antidote Major side effects: bullet format, significant ones, own words, brief Amlodipine (amlodipine besylate) (Norvasc) 10 MG PO bedtime 21:00:00 Antihypertensive (A calcium channel blocker) A) causes systemic and coronary vasodilation by inhibition of calcium transportation into myocardial and vascular smooth muscle cells B) Decrease BP Grapes or grape fruit juice must not be consumed while on amlodipine There are no major contraindications for this drug, except for hypersensitivity and low blood pressure Headache Peripheral edema Bradycardia Hypotension Flushing Gingival hyperplasia Dizziness Nausea Hydralazine (apresoline) 10 mg PO TID 9 am; 5 pm; 1 am antihypertensive; vasodilator Decreases blood pressure by causing direct vasodilatation of arteries The drug must be with held when systolic pressures drop to below 110 Hg -hypersensitivity -intolerance to tartrazine Tachycardia Peripheral neuropathy Nausea and diarrhoea Retention of sodium Peripheral neuropathy Orthostatic hypotension Doxazosin (Cardura) 4mg PO bedtime 21:00:00 Antihypertensive Alpha-blocker Withod when systolic pressures are less than 110mmHg Hypersensitivity Headache tiredness swelling of the hands, feet, ankles, or lower legs shortness of breath weight gain muscle or joint pain or weakness abnormal vision runny nose decreased sexual ability NovoLog (Insulin Aspart) 20 or 10 Units SC 3 times a day with meals 9 am; 1 pm; 5 pm antidiabetic; hormone; pancreatic A) Causes stimulation of glucose uptake and also causes inhibition of lipolysis and proteolysis . It also enhances protein synthesis. B) Control blood glucose level Sliding scale insulin. Check blood glucose level before administering. hypoglycemia allergy or hypersensitivity to insulin aspart Hypoglycemia Anaphylaxis Lipodystrophy Clonidine (Catapres) 0.2mg PO 3 times daily 9am, 5pm, 1am Antihypertensive Alphablocker Do not withdraw suddenly because of rebound hypertension Allergy Caution in chronic renal failure fast or pounding heartbeats; a very slow heart rate (fewer than 60 beats per minute); feeling short of breath, even with mild exertion; swelling, rapid weight gain; confusion, hallucinations; fever, pale skin; urinating less than usual or not at all; or feeling like you might pass out. Cefepime (maxipime) 1 gram IV q 8 hours 9 am, 5pm, 1am Antibiotics 4th generation cephalosporine A) extended spectrum of activity against gram positive and gram negative bacteria Adjust to kidney function Allergy to the drug Penicillin allergy Allergy to any cephalosporins Dosage adjustment to kidney failure pain, swelling, or skin rash where the injection was given; stomach pain, nausea, vomiting; headache; skin rash or itching; white patches or sores inside your mouth or on your lips; Esomeprazole (Nexium) 40mg PO 2 times daily 9 am, 9pm Proton pump inhibitor A) Reduces gastric acid secretion through inhibition of H+/K+-ATPase in gastric parietal cells. B) Prevents formation of gastric acid. Interact with drugs that depend on CYP enzymes for metabolism such as diazepam and warfarin hypersensitivity Headache, diarrhea, nausea, gas, decreased appetite constipation, dry mouth, abdominal pain. Tiotropium bromide (Spiriva) 18mcg INH daily 9 am long-acting, 24 hour anticholinergic bronchodilator antimuscarinic or anticholinergicagent . B) bronchodilatory effect A) patients with acute angle glaucoma B) hypersensitivity dry mouth and/or throat irritation Aspirin 325mg PO daily 9 am after breakfast Antiplatelet A) antiplatelet effect by inhibiting the production of thromboxane . Hypersensitivity Severe hepatic impairment Asthma or other bronchospastic disorders. Gastrointestinal ulcers stomach bleeding tinnitus Ciprofloxacin 400mg/200ml IVPB Every 8 hours 9am, 5pm, 1am Antibiotic of the fluoroquinolone drug class A) Broad spectrum that is active against both gram-positive and gram negative bacteria. B)It functions by inhibiting DNA gyrase, a type-2 topoisomerase, Use with caution in depression Dosage adjustment for renal disease status Coadministration may dangerously increase coumarin activity; INR should be monitored closely. Hypersensitivity restlessness nausea vomiting rash headache diarrhoea abdominal pain Ipratropium (Atrovent) 2.5ml INH Every 4 hours Every four hours through nebulisation Anticholinergic drug blocks muscarinic cholinergic receptors, without specificity for subtypes, resulting in a decrease in the formation of cyclic guanosine monophosphate (cGMP) dry mouth sedation Isosorbide mononitrate (Imdur) 60mg PO Every morning 09:00:00 Anti-anginal drug acts by dilating the blood vessels Use with caution along with calcium channel antagonists and beta-blockers Use with caution in hypoension Headache Tiredness sleep disturbances (6%) gastrointestinal disturbances vomiting, diarrhoea heartburn vertigo headache Simvastatin 40mg PO bedtime 21:00:00 Lipid-lowering drug act by inhibiting 3-hydroxy-3-methylglutaryl coenzymeA Do not eat grape fruit when on this medication abdominal pain diarrhea indigestion general feeling of weakness References MIMS Online. (2010). Drug Information. Retrieved on 15th October, 2010 from www.mims.com Read More