The University of Texas Medical Branch School of Nursing - Research Paper Example

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: Seizures (2000) Prior surgical history/dates: None 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 98.4, P 98, R 18, BP 119/76, The patient was in the unit for only one day for observation and hence vital signs of a single day are mentioned here How do the patient’s vital signs affect your nursing care? Vital signs are important parameters that guide the clinicians about the condition of the patient and response to treatment. SKIN/NAILS/HAIR The patient is a Hispanic female. Her skin overtone is light brownish, consistent with her ethnicity. The skin appears pink, warm, dry, well hydrated and perfused. There is no evidence of edema or rash. There is a lacerated wound about 0.5cm length in the left lower lip. Hair and nails are not neatly groomed. Hair is brownish with several locks of gray hair. Nails are not trimmed. Overall appearance is shappy. 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. Accomodation appears normal. The patient is able to follow the pen movements through the six cardinal positions of gaze. The patient does not wear glasses and near sight and distant vision appear normal. Vision, night vision, color vision, perception of depth of both eyes appear normal. The patient has running nose. Hearing appears normal on both the sides. Ear canals have plenty of wax. There is no evidence of otitis media. MOUTH & THROAT Oral mucosa appears pale and moist. The lips are dry with cracks. There is a lacerated wound over lower lip, about 0.5cm long. Wound is gaping. The tongue appears moist and is freely mobile. It does not deviate. All teeth remain intact. FACE/HEAD/NECK The shape of the head is normocephalic and atraumatic. The patient has discoloration of white spots on face. There is laceration on the right half of the face:1cm length. The staples are intact. Neck is supple. There is no JV distention or bruit. RESPIRATORY The saturations of the patient are above 96 percent. Auscultation of the chest is unremarkable.. CARDIOVASCULAR/PERIPHERAL VASCULAR Heart rate is about 98 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 S2 are heard. There is no evidence of murmur. The patient was given blood, but more details regarding the source and quantity is unknown. GASTROINTESTIVAL/NUTRITION 120lbs. The patient is eating hospital food. She has not eaten food properly for several days prior to admission. Abdominal soft, nontender and nondistended. Bowel sounds are present in all 4 quadrants. Last bowel movement was last night. GU Input- 1,260 Output- 400 Total balance- 860 MUSCULOSKELETAL Extremities- no clubbing, cyanosis, or edema Rest-Unremarkable NEUROLOGICAL History of seizures. Recovered. No evidence of gross deficits. 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 non cooperative in providing information. However, she is polite. She appears depressed because of her injury and financial status. Tobacco, Alcohol &/or Drug use No history of smoking/alcohol intake/drug abuse GENERAL IMPRESSION Patient is a cooperative person, but is depressed because of financial problems . Has a 10 year old son in which she stated that she tells him to eat as much as he can at school because she has no money for food. Her chart stated that she was non compliant w medication but when I questioned her it was because she cannot afford it and when at ben taub 7 months prior they did not help her or showed her how to apply for the gold card assistance that is through the county She appeared in no apparent distress This is what the physician states about her I thought it might help: This pt is a 30 year old female who presents to the hospital w.laceration to the back, status post fall w/ seizure. The pt is a poor historian and is unclear from history whether she fell first and then had laceration or fell then had seizure. According to patients family patient fell and hit her head in the back on the ground. She has had previous seizures in the past. OTHER SIGNIFICANT INFORMATION CLIENT/FAMILY TEACHING Educational Need Method of Teaching Client/family Response to Teaching Causes and mechanism of seizures I explained to the patient as to why seizures occur. I told her that sudden alteration in the activity of the brain leads to seizures. They occur suddenly. “I'm really concerned because it happens suddenly and I won't even have an idea of it until I reach the hospital” Importance of medication in seizure disorder I explained the patient about the importance of taking medications regularly in seizure disorder. I told her that since seizures happen suddenly and can cause bodily injury, the best way is to prevent their occurrence by taking medications regularly and having a regular follow up with physician. “My main problem is financial.” Importance of nutrition in maintaining health I explained to the patient the importance of taking a balanced nutrition in maintaining good health. I told her to take food rich in nutrition like cereals, pulses, bread, vegetables and fruits. “I don't think that much about my nutrition because, I need to feed my son too.” Food assistance I advised the patient to seek help for regular meals. Local catholic church is one of the options I gave “Thank you. I will try..” Blood transfusion I advised the patient about the benefits and side effects of blood transfusion “OK” Refer to ben taub for further assistance of medication and health needs I went ahead and filled out the application because patient does not know how to read or write Patient was glad that I did that. What are the discharge planning needs of this client? The patient must be educated about the need to adhere to medication prescription. Financial and nutritional needs of the patient needs to be met. The wounds must heal. 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 revision of medication for seizures. Patient need to follow the nutritional advice. Lab and Other Diagnostic Tests Date/Time Pertinent Lab & Diagnostic Tests Patient Results Normal Values or Findings 10/16 8:00 AM WBC RBC Hemoglobin Hematocrit Platelet 5.8 3.57L 8.8L 27.1L 24.8H 3.7-10.4 4.70-6.10 14.0-18.0 42-54 133-450 Rationale for ordering tests Why were the lab tests and diagnostic tests ordered? Complete blood picture was done to look into any possibility of infection and status of hemoglobin (blood transfusion done) What do these lab values and test results tell you about this patient? The hemoglobin is coherent with the injury, pallor appearance and nutritional status. Platelet count is very low .warranting platelet count monitoring and transfusion How do these lab values and test results affect your nursing care? Since WBC counts are normal, it can be said that the patient does not have any acute infection. Low hemoglobin warrants administration of hematinics, vitamins and nutritional advice. Platelet count warrants platelet count monitoring and transfusion Clinical Plan of Care Patient Data Medical Diagnosis: Post-seizure state, anemia secondary to acute blood loss, thrombocytopenia Comorbidities or Risk Factors: Seizure disorder, poor nutrition status, drug non-compliance Reason Seeking Health Care: Seizures and fall Psychosocial Factors Affecting Care: No proper employment. Poor financial status. Has only a son who is too young to take care of her. Not much help from friends and relatives Cultural Factors Affecting Care: Patient is a second generation immigrated Hispanic male. She is poor and cannot afford proper food and medicine. Spiritual Factors Affecting Care: Patient is a Catholic and attends to Church regularly. She believes in Jesus. 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. Risk of injury related to seizure activity 2. Ineffective coping due to psychosocial and economic consequences of epilepsy 3. Lacerated wounds over face and lips due to seizure activity related fall PLAN OF CARE FROM CAREMAP #1 Nursing Diagnosis: Risk of injury related to seizure activity Data to support: Subjective: “I get scared..I do not know when I will get fits and when I will fall and get hurt” Objective: Patient is admitted following seizure activity. During seizures, she fell down and wounded herself. The objective data supports the patient’s complaint of injury during seizure activity. Patient Goals: How will you know they are met? The patient suffers from recurrent seizures because of drug non-compliance. The patient will be advised about drug compliance. The patient will be provided a chart with the drugs she need to take. She will be advised to tick against the drug after taking it. The chart will provide information whether the patient has taken the drug. 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. Promoting safe environment in hospital and advising the same at home 1. The effects of injury can be minimised by keeping the surrounding clean and safe 1. Action appropriate. Patient says “Last time I feel over a dining table with sharp edges.” 2. Placing bed in low position 2. many patients have seizure activity during sleep and can fall off the bed. 2. Action appropriate. Patient's bed was placed low and she felt more comfortable and secure. 3. Patient should not be restrained during seizures 3. This can worsen injury caused to the patient. 3. Action appropriate. Evaluation of Goals: State whether each goal met or not State status of each goal or plan (ongoing, revised, discontinued) Provide revisions as needed Patient will adhere to medication regimen. Goal met. The patient was provided with medication chart and each medicine was described as to how to be consumed and at what time. Ongoing goal: The patient will be monitored for medication intake, behaviour and personal care #2 Nursing Diagnosis: Data to support Patient goals Ineffective coping due to psychosocial and economic consequences of epilepsy. The patient is poor financially and the nutrition status is poor. Personal hygiene and care appear negligent. Patient laments that this disease is a burden for her young son. Patient will be referred to a suitable source of help for constant financial, medical and food support 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. Consult with social worker for various community resources like counselors, support groups and vocational rehabilitation (Nettina, 2006) 1. It is important to support the patient socially, economically and financially for overall improvement and prevention of recurrent seizures 1. Action appropriate. A local social worker adopted the patient. 2. Teach various stress reduction techniques 2. These techniques decrease stress 2. Action appropriate. Patient said “I feel much better after applying these techniques 3. Answer questions regarding the disease and prognosis 3. It is important for the patient to know about the disease and the need for regular medication and follow up (Smeltzer et al, 2008) 3. Action appropriate. Patient said “Thank you. I now know how important it is to take care of myself.” #3 Nursing Diagnosis: Data to support Patient goals Lacerated wounds over face and lips due to seizure-related fall Lacerated wounds of 0.5cm length over the lower lip and 1 cm length over right half of the face are seen. Both the wounds appear fresh and gaping. Appropriate wound dressing and care will be done to facilitate healing 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. Clean the wound thoroughly with normal saline and apply wet wound dressing 1. Wound debris and slough needs to be removed to prevent external infection and facilitate formation of granulation tissue (Kunimoto, 2001). 1. Action appropriate. The wound appeared clean after cleaning with normal saline. Patient was relieved after the dressing 2. Teach the patient to keep the wound moist and clean even after going home 2. A clean and moist environment is essential to prevent maceration of wound and facilitate healing (Kunimoto, 2001). 2. Action appropriate. Patient said “Thank you for teaching me how to take care of the wound. I was worried as to what I wound do atfer going home” 3. Encourage patient to take good food and balanced nutrition. 3. Good nutrients and protein are essential for adequate wound healing 3. Action appropriate. Patient said “I know. But I have difficulty in getting proper diet” REFERENCES References used (APA format). Include all textbooks, journals used, including drug reference. Kunimoto, B.T. (2001). Discussion of a Literature-Guided Approach. Ostomy/Wound Management, 47(5), 38–53. 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 Ceftriaxone 1 gram IV q 24 hours 9 am Every 24 hours Antibiotics 3rd generation cephalosporin A) extended spectrum of activity against gram positive and gram negative bacteria Check for allergic reaction Allergy to the drug Penicillin allergy Allergy to any cephalosporin’s stomach pain, nausea, vomiting; headache; skin rash or itching; white patches or sores inside your mouth or on your lips Acetaminophen oral Every 4 hours Every 4 hours Nonsteroidal anti-inflammatory drug inhibition of prostaglandin synthesis varying levels of analgesic, anti-inflammatory, antipyretic and antiplatelet actions Risk of toxicity Do not administer in liver failure Stomach bleeding eczema Atropine 0.5mg IV PRN Anticholinergic agent Missing Atropine increases firing of the sinoatrial node (SA) and conduction through the atrioventricular node (AV) of the heart, opposes the actions of thevagus nerve, blocks acetyl choline sites, and decreases bronchial secretions. Risk of supraventricular tachycardia Tachycardia, ventricular arrhythmia Ventricular fibrillation, supraventricular or ventricular tachycardia, dizziness, nausea, blurred vision, loss of balance, dilated pupils, photophobia, dry mouth and potentially extreme confusion, and excitation. Lorazepam (Ativan) 1mg IV Every 15 minutes Every 15 minutes Benzodiazepine-fast acting interacts at benzodiazepine binding sites, which are located on GABAA receptors in the CNS. Risk of respiratory failure Hypersensitivity Severe respiratory failure Acute intoxication Atxia Acute narrow angle glaucoma Sleep apnea Myasthenia gravia Ataxia, Sedation, Hypotension, Ataxia, Anterograde amnesia, Confusion, hand-over effects. Paradoxical effects: increased hostility, aggression, angry outbursts, and psychomotor agitation. Suicidality: sometimes unmask suicidal ideation in depressed patients References MIMS Online. (2010). Drug Information. Retrieved on 15th October, 2010 from www.mims.com Read More