Medications
(see attached) / Student Name-Taysha Demetro
Client Initials- J.O.
Date- 4-5-12
Age- 78Gender- Female Room# SCU-10 Admit Date- 3-7-12CODE Status- Full Allergies- Prednisone Diet- CVS soft-low cholesterol, NAS, no cardiac stimulants, advance as tolerated
Activity- up ad lib with assistance
Braden Score- 22/23 Weight- 63.3 kg
Glasgow coma scale-15/15 / State lab values and identify trends
Labs-3-10-12
K 3.2 L (3.5-5)
Cl 113 H (95-105)
BUN 63H (5-20)
Creatinine 1.68H (0.5-1.3)
Glucose 152H (70-110)
Ca 7.5L (9-11)
Hemoglobin 11.2L (12-15)
Detailed explanation is located below.
IV Sites/Fluids/Rate
IVs-
~RIJ MAC II-HL dry, dressing intact, WNL
~Left chest tube suction, water seal at 200cc.
  • Monitoring: Invasive/Non-Invasive State specific monitoring device and specific values with each device
  • SCDs
  • Bilateral knee high TED hose
  • HOB elevated 30 degrees
  • Blood sugars AC/HS
  • RIJ MAC II-HL dry, dressing intact
  • Daily weights
  • 5 lead EKG
  • I&O every shift
  • Continuous Pulse Ox
  • Vital signs every 1 hour
  • Assessments every 3 hour
  • Aquacel dressing to all surgical wounds
  • Cardene IV drip
/ Chief Complaint: Carotid bruit
Admitting Diagnosis(es): Surgery-CABG x2, Coronary Artery Disease (family history is strongly positive for CAD), AI
Past Medical/Surgical History- Relevant to this admission
  • Chronic Hypertension
  • Cataracts
  • Sinus headaches
  • Cerebrovascular disease
  • Tonsillectomy
  • C-section
  • CAD (family history is strongly positive for CAD)
  • Nonsmoker
  • Nondrinker

ECG Interpretation
(see attached) / 1.Describe the patient’s condition, including signs/symptoms that led to thisadmission.
1. J.O. is a 78-year-old female admitted to MMC on 3-7-12, for a scheduled elective coronary artery bypass. She presented with a carotid bruit and workup demonstrated severe internal carotid artery stenosis of her left carotid artery measuring 75-80%. She was asymptomatic. She has a strong family history of coronary artery disease. She has a history of hypertension and cerebrovascular disease.
2.Briefly describe the pathophysiology related to the patient’s diagnosis and current medical/surgical condition.
2. The carotid arteries are a common site for atherosclerotic plaque development. This leads to carotid artery disease (Urden, Stacey, & Lough, 2010). Blood supply to the brain is cut off and could lead to a stroke, which could lead to brain damage. Uncontrolled hypertension, smoking, diabetes with uncontrolled blood glucose, and hyperlipidemia are all modifiable risk factors of carotid artery disease (Urden et al., 2010).
A carotid bruit is a systolic sound heard over the carotid artery area during auscultation (Black & Hawks, 2009). It may occur as the result of carotid artery stenosis—patients are often asymptomatic. Stenosis, if present, must be evaluated by ultrasound or imaging. J.O. was asymptomatic, but she has a strong family history of coronary artery disease and was scheduled for an elective CABG.
3.Describe the patient’s head to toe assessment findings and explain how they relateto the pathophysiology. Include the vital signs.
3. Head-to-toe assessment performed on 3-12-12 at 1610
Vital signs: T- 98.1 F, HR 66 regular, BP 153/72, R 22, 02- 91% on 5L 02 NC continuous, Pain 0/10.
The client was A&O x 3. She was alert and oriented to person, time, and place. PERRLA WNL.
Diet- CVS soft-low cholesterol, NAS, no cardiac stimulants, advance as tolerated.
Activity - up ad lib with assistance, unsteady gait
Braden Score- 22/23
Weight- 63.3 kg
Glasgow coma scale- 15/15
RIJ MAC II-HL dry, dressing intact, WNL
She has left chest tube suction, water seal at 200cc.
Lung sounds were clear, anterior and posterior. SOB
Heart rate was normal, 66 bpm and regular.
Abdomen was soft, non-tender to palpation, bowel sounds present in all four quadrants, and last bowel movement was on that morning, on 3-12-12.
Her pedal pulses are +1 bilaterally, radial pulses +2, capillary refill <3 seconds WNL, skin turgor <2 seconds.
Her skin is warm, dry, and intact. Extremities are cooler to touch. She has mild generalized +1 edema.
Intake- 300 cc liquid
Output- Void- 200cc clear, yellow urine
Bowel movement- small form
J.O. is wearing SCDs, bilateral knee high TED hose, and her HOB is elevated 30 degrees.
Her blood sugar at 0700 was 116. Sliding scale starts at 150, no coverage needed. At 1200, was 151, no coverage needed.
She is on Daily weights, 5 lead EKG on continuous monitoring, I&O every shift, vital signs every 1 hour, assessments every 3 hours, and continuous pulse ox.
J.O.’s doctor ordered every 15 minutes blood pressure and pulse monitoring.
Assessment in the am: 830- 194/81; 0930- 190/79; 0950- 163/73; 1145- 190/76, pulse 66; 1215- 202/90, 66, started Cardene gtt at 30cc/hr.
My shift: 1330- 154/67; 1345-160/71, pulse 69; 1400- 145/94; 1415- 154/65; 1445- 163/74, 69; 1500- 151/70, 66; 1515- 147/65, 65; 1530- 156/68, 66; 1600- 153/72, 66; 1630- 158/72, 64. Wgt- 63.3 kg.
J.O.'s blood pressure is elevated. She was ordered numerous medications STAT to help lower her blood pressure. She was also ordered blood pressure and pulse monitoring every 15 minutes.
4.Integrate the current laboratory, diagnostic test results, hemodynamic parameters medications, medical and nursing interventions, and other treatments into thepathophysiology and explain how it is affecting this patient’s outcome/currentcondition.
LABS-
~J.O.'s potassium levels are low. Normal levels are 3.5-5mEq/L. Her levels are 3.2 low. This is due to her Coronary Artery Disease (Cavanaugh, 2009). Pt. is taking Potassium chloride 10% 40 mEq PO PRN to help increase her levels (Deglin & Vallerand, 2010).
~J.O.'s chloride levels are high. Normal levels are 95-105 mEq/L. Her levels are 113 high (Cavanaugh, 2009). This is a result of having CAD and medication, like Potassium chloride, could elevate her chloride levels (Deglin & Vallerand, 2010).
~J.O.'s BUN and Creatinine levels are high. Normal BUN levels are 5-20 mg/dL. Her levels are 63 high. Normal Creatinine levels are 0.5-1.3 md/Ll. Her levels are 1.68 high (Cavanaugh, 2009). These levels are elevated possibly due to having CAD, dehydration, drug reactions, and her recent surgery (Deglin & Vallerand, 2010).
~J.O.'s glucose is elevated. Normal levels are 70-110 mg/dL. Her levels are 152 high (Cavanaugh, 2009). This level could be elevated due to her CAD, stress, her recent surgery, and medications (Deglin & Vallerand, 2010).
~J.O.'s calcium levels are low. Normal levels are 9-11 mg/dL. Her levels are 7.5 low. (Cavanaugh, 2009). Her low calcium levels could be due to frequent blood administration, CAD, her age of 78, and being post-menopausal (Deglin & Vallerand, 2010).
~J.O.'s hemoglobin levels are low. Normal levels are 12-15 m/dL in females. Her hemoglobin is 11.2 low (Cavanaugh, 2009). This could be low due to blood lost from her recent surgery and/or medications. She was given blood post op (Deglin & Vallerand, 2010).
(Cavanaugh, 2009).
(Deglin & Vallerand, 2010).
MEDS-
~J.O. is taking Norvasc, an Antihypertensive. It is a calcium channel blocker, and it causes systemic vasodilation, resulting in decreased blood pressure. This medication will help to decrease afterload, which will decrease the patient’s blood pressure due to her CAD and hypertension. It will also decrease contractility and heart rate.
~J.O. is taking Atenolol, an antianginal/antihypertensive. It is a beta blocker and decreases blood pressure and heart rate. It will decrease afterload, contractility and heart rate due to her CAD and hypertension.
~J.O. is taking Nitroglycerin, an antianginal/nitrate. This medication will increase coronary blood flow by dilating coronary arteries. It produces vasodilation and decreases left ventricular end-diastolic pressure and left ventricular end-diastolic volume (preload). This medication will help to decrease the patient’s blood pressure and afterload.
~J.O. is on a Cardene IV drip. It is an antianginal/antihypertensive. It is a calcium channel blocker, which produces systemic vasodilation, resulting in decreased blood pressure. This medication will help to decrease the patient’s blood pressure due to hypertension.
~J.O. is on a Catepres patch, an antihypertensive. It stimulates vasoconstriction and decreases blood pressure and pain, because the patient has hypertension.
~J.O. is taking BuSpar. It is an antianxiety, and it increases norepinephrine in the brain to relieve her anxiety, because she has hypertension and a high respiratory rate.
(Deglin & Vallerand, 2010).
The patient is ordered sequential compression devices (SCDs). SCDs will prevent deep vein thrombosis from occurring in the legs of J.O. The SCDs work by using passive leg muscle contraction to promote venous return (Black & Hawks, 2009). J.O. has a 5 lead EKG on continuous monitoring system to monitor her cardiac status. EKG helps health care providers to select what other diagnostic test to select for the patient (Urden et al., 2010).
J.O. is wearing bilateral knee high TED hose, and her HOB is elevated 30 degrees. She is on Daily weights, 5 lead EKG on continuous monitoring, I&O every shift, vital signs every 1 hour, assessments every 3 hours, and continuous pulse ox. These interventions are essential to the patient’s well-being post op.
Past Medical/Surgical History
Relevant to this admission
  • Chronic Hypertension
  • Cataracts
  • Sinus headaches
  • Cerebrovascular disease
  • Tonsillectomy
  • C-section
  • CAD (family history is strongly positive for CAD)
  • Nonsmoker
  • Nondrinker
/ Treatments/ Medical and Nursing Interventions
  • SCDs
  • Bilateral knee high TED hose
  • HOB elevated 30 degrees
  • Blood sugars AC/HS
  • 2 units PRBC post op
  • 2 PLT post op
  • 10 Cryo post op
  • RIJ MAC II-HL dry, dressing intact
  • Daily weights
  • 5 lead EKG
  • I&O every shift
  • Continuous Pulse Ox
  • Vital signs every 1 hour
  • Assessments every 3 hour
  • up ad lib with assistance
  • Aquacel dressing to all surgical wounds

Primary Nursing Diagnosis with Relational Statement
Ineffective Cerebral Tissue Perfusion related to vascular obstruction (Urden et al., 2010). / Short Term Goal Relevant to Nursing Diagnosis
J.O. will have improved cerebral tissue perfusion, as evidenced by a decrease in blood pressure, no headache, no decrease in LOC, and a stable Glasgow coma scale by end of my shift. / 6 Nursing Diagnosis with Relational Statement
1. Risk for Infection related to invasion lines (Carpenito-Moyet, 2010).
2. Risk for Impaired Tissue Integrity related to impaired mobility (Carpenito-Moyet, 2010).
3. Impaired Physical Mobility related to external devices secondary to intravenous tubing (Carpenito-Moyet, 2010).
4. Risk for Injury related to effects of medication on mobility secondary to fatigue (Urden et al., 2010).
5. Acute Pain related to transmission and perception of cutaneous, muscular, or ischemic impulses (Urden et al., 2010).
6. Anxiety related to biologic, psychologic, or social integrity (Urden et al., 2010).
7. Knowledge Deficit related to lack of previous exposure to information on carotid artery disease (Urden et al., 2010).
Definition (State definition and source)
Ineffective Cerebral Tissue Perfusion: Decrease in oxygen, resulting in the failure to nourish tissues at the capillary level (Urden et al., 2010). / Outcome Criteria (Must be specific and measurable)
~ Patient’s Glasgow coma scale will maintain at 15/15 during shift.
*Outcome met. Patient Glasgow come scale maintained at 15/15 during my shift.
~ Patient will continue to not report a headache with a pain scale of 0/10 during shift.
*Outcome met. Patient reported no headache and a pain scale of 0/10 during whole shift.
~ Patient will maintain LOC during shift by being alert and orientated to self and place.
*Outcome met. Patient stayed alert and orientated to self and place. Patient knew where she was at, the year, and the reason why she was in the hospital.
~ Patient will continue to show signs of a decreasing blood pressure by end of shift.
*Outcome met. Patient’s blood pressure was lowering at a steady pace.
AEB: Defining characteristics specifically exhibited by your patient that support primary nursing diagnosis
  • AEB: Chronic hypertension
  • Generalized weakness
  • Unsteady gait
  • Bilateral pedal pulses +1
  • up ad lib with assistance
  • SCD
  • Continuous pulse ox
  • bilateral knee high TED hose
  • 5 lead EKG on continuous monitoring
  • Ordered every 15 minutes blood pressure and pulse monitoring. Assessment in the am 830- 194/81; 0930- 190/79; 0950- 163/73; 1145- 190/76, pulse 66; 1215- 202/90, 66. My shift: 1330- 154/67; 1345-160/71, pulse 69; 1400- 145/94; 1415- 154/65; 1445- 163/74, 69; 1500- 151/70, 66; 1515- 147/65, 65; 1530- 156/68, 66; 1600- 153/72, 66; 1630- 158/72, 64.
  • RR 22
  • Extremities are cooler to touch.
  • Ordered numerous medications STAT to help lower her blood pressure (Norvasc, Atenolol, Nitroglycerin, Catepres patch, Cardene IV drip).

Identify nursing interventions that you implemented with this patient.
Evaluate patient progress towards achieving outcome criteria as a result of nursing interventions.
~Maintain and monitor Cardene IV drip during shift. It produces systemic vasodilation, resulting in decreased blood pressure. This medication will help to decrease the patient’s blood pressure due to hypertension.
*Decreasing her blood pressure will help with tissue perfusion to vital organs and peripheral tissue (Deglin & Vallerand, 2010).
~Administer Heparin, 5,000 units SC every 12 hours. This medication will prevent thrombus formation (Deglin & Vallerand, 2010).
*Patient was given one dose of HeparinSC during my shift and did not show any signs of new thrombi formed.
~Neurological assessment to be done every three hours during shift, since stable. This will catch neurological changes that can be caused by a decrease in cerebral tissue perfusion.
*Patient did not have a negative change in LOC, change in motor or sensory function, pupillary changes, respiratory difficulty, development of visual perceptual defects, or aphasia, while on shift (Black & Hawks, 2009).
~An assist of at least one other person is needed to help J.O. ambulate during shift.
*This will reduce the chance of falls and injury (Black & Hawks, 2009).
~Patient will wear SCDs and Ted hose while up in chair during shift.
*Patient wore SCDs and Ted hose while in chair during shift. This will help to decrease clots formation (Black & Hawks, 2009).
~Administer and monitor 02 status during shift.
*Patient was on 5L of 02 NC during shift, and her 02 levels never fell below 91% during shift. This will ensure adequate oxygen to peripheral tissues and organs (Black & Hawks, 2009).
What I Would Do Differently
I should have looked at the labs more than once during my shift and taken her temperature more than once, because she is at risk for infection. I would have done ROM exercises with her, because she ambulated once to the bathroom during my shift. I would have 2 assistants, because her blood pressure was still elevated. I also would have encouraged her to eat a little bit more of her lunch or ordered something else, because the rice and peas were not cooked to her liking. I should have also asked if she had any anxiety early on with my care. I waited a couple of hours when it seemed as though she was anxious, and then, I treated her.

References

Black, J.M., & Hawks, J.H. (2009). Medical-Surgical nursing: Clinical management for positive outcomes(8th ed.). Philadelphia, PA: W.B. Saunders Co.

Carpenito-Moyet, L.J. (2010).Nursing diagnosis: Application to clinical practice(13th ed.). Philadelphia, PA: Lippincott.

Cavanaugh, B.M. (2003). RN Labs -Nurse’s manual of laboratory and diagnostic tests(4th ed.). Philadelphia, PA: F. A. Davis Company.

Deglin, J.H., & Vallerand, A.H. (2008). Davis’s drug guide for nurses(12th ed.). Philadelphia, PA: F.A. Davis Company Publishers.

Urden, L.D., Stacey, K.M., & Lough, M.E. (2010).Critical care nursing: Diagnosis and management(6th ed.). St. Louis, MO: Mosby.