Running Head: NURSING PROCESS PAPER

NPR Document 31

Running head: NURSING PROCESS PAPER

Nursing Process Recording

Kimberly E. Fuller

KentStateUniversity

11 October 2005

Kent State University N30040

Medical Information

Student Name: Kimberly Fuller Date of clinical: September 20, 2005

Pt. Initials / Room Number / Age / Gender / Admission
MP / 252 / 77 / Female / 2/15/2005
Primary Medical Diagnosis: Stroke (CVA)
Definition, S/Sx, Treatment, Citation(s): A CVA is the interruption of blood flow in one or more of the blood vessels that supply the brain. Stroke is the leading cause long-term disability and the third highes cause of death in the United States (Elmore & Miller, 2005). Tissues become ischemic, leading to hypoxia or anoxia with destruction or necrosis of the neurons, glia, and vasculature (Sommers & Johnson, 2002). There are two types of strokes, embolism (ischemic) and hemorrhagic. Early signs of an impending ischemic stroke are transient hemiparesis, hemiosensory loss, and loss of speech. A hemorrhagic stroke occurs very rapidly, with symptoms developing in minutes to hours. Symptoms of hemorrhagic strokes include occipital or nuchal headaches, vertigo or syncope, epistaxis, retinal hemorrhages, parethesias, and transient paralysis. Also, symptoms must persist longer than 24 hours to be diagnostic of a stroke (Minton, 2005). “If certain conditions are met, IV-t-PA can be administered within three hours of a stroke to reduce chances of death and disability” (Elmore & Miller, 2005, p.58). Medical management of a CVA includes support of vital functions and ongoing surveillance to identify early neurologic changes as the patient’s condition evolves. Treatment consists of maintaining life, reducing ICP, preventing complications, and limiting the extension of the CVA. For patients that cannot maintain their own airway and circulation independently, ventilation, intubation, and oxygen may be required. If the CVA is hemorrhagic, surgery may be needed to stop the bleeding or remove the hematoma. Also, physical therapy is very important and should begin as soon as the patient’s condition stabilizes. One should use passive range of motion exercise to prevent the development of contractures on the affected side. Lastly, strengthening the unaffected side is important because it helps to compensate for the losses on the affected side (2002).
Secondary Medical Diagnosis: Schizophrenia

Definition, S/Sx, Treatment, Citation(s): “Schizophrenia is a mental disorder characterized by disturbed thought processes, altered perception, and labile affect” (Margolis, 2001, p.375). There are five types of schizophrenia. Paranoid schizophrenia is characterized by the presence of delusional thinking and hallucinations. The paranoid schizophrenic is fairly organized in speech and behavior and can possibly show some range in affect. Disorganized schizophrenia is characterized by disorganized speech and behavior and flat, or inappropriate, affect. Disorganized schizophrenics can also have delusions and hallucinations. Residual schizophrenia is characterized by alterations in range of affect and thinking patterns. Undifferentiated schizophrenia is characterized by the presence of two or more of the following symptoms: hallucinations, delusions, flat affect, and disorganized speech or behavior. Lastly, catatonic schizophrenia is characterized by strange motor activity. Catatonic schizophrenics can be mute or show incoherent speech (Shoemaker, 2005). A complete health history, physical, and psychiatric examination are very important in the treatment of schizophrenia. It is important that the individual be kept safe from others and safe from self. Medications include lithium salts and antipsychotics. Medications are started out at low doses and are gradually bought up (2001). Lastly, psychotherapy is very important in the treatment of schizophrenia because of the negative manifestation and severe social impairments (2005).
Surgery & Date of Surgery: Client has no record of surgeries in hard chart or ECS.
Explanation of surgery, citation(s):

KENTSTATEUNIVERSITY

COLLEGE OF NURSING

DRUG INFORMATION

Date: 9/20/2005 Patient’s Intials:MP

Patient Diagnosis: StrokeAllergies: Prolixin, Codeine

Drug / Indications for Use / Side Effects / Nursing Responsibilities / Your Assessments on Patient
Generic: diltiazem
Trade: Cardizem, Cardizem LA, CartiaXT, Dilacor XR, Diltia XT, Nu-Diltiaz, Tiamate, Tiazac
Dose: 30mg tab
Frequency/Route: tid via enteral tube
Pharmacotherapeutic: calcium channel blockers
Clinical: antianginals, antiarrhythmics (class IV), antihypertensives / General Use: Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. Thereby resulting in systemic vasodialation (decreased BP), coronary vasodialation, and suppression of arrhythmias.
Reason for giving this drug to this client: Management of clients HTN. / Serious side effects include arrhythmias, CHF, and Stevens-Johnson Syndrome. Another side effect, less serious though, is peripheral edema. / BP and pulse should be monitored periodically during therapy. The nurse should assess for signs of CHF such as, peripheral edema, dyspnea, weight gain, jugular venous distention, and rales/crackles. Also, the nurse should monitor ECG continuously during administration and report any signs of bradycardia and prolonged hypotension immediately. This could be a sign of an arrhythmia.
Drug-Drug interactions with NSAID’s. / HR-93, BP-122/72
Client absent of any edema or arrhythmias.
Generic: lactulose
Trade: Cephulac, Cholac, Constulose, Duphalac, Enulose, Evalose, Heptalac, Kritalose, Lactulose PSE, Portalac
Dose: 30mL
Frequency/Route: tiw via enteral tube
Pharmacotherapeutic: osmotics
Clinical: laxatives / General Use: Increases the water content and softens the stool and lowers the pH of the colon. Consequently, relief of constipation and decreased blood ammonia levels are achieved.
Reason for giving this drug to this client: Managements of clients constipation. / Side effects include belching, cramps, distention, flatulence, diarrhea, and hyperglycemia in diabetic patients. / Bowel assessment should be performed. The nurse should also assess color, consistency, and amount of stool produced. Lastly, the nurse should monitor glucose levels and serum electrolytes with chronic use. / BS x 4. Abdomen soft and non-distended. Client had one large watery/non- formed bowel movement during shift.
Na-142, Cl-104, K-4.2, Ca-8.7, glucose-153
Generic: acetaminophen
Trade: Tylenol
Dose: 650mg
Frequency/Route: tid via enteral tube
Pharmacotherapeutic:
Clinical: antipyretics, non-opioid analgesics. / General Use: Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. Consequently, this drug achieves analgesia and antipyresis.
Reason for giving this drug to this client: Management of clients pain. / Severe side effects include hepatic failure and hepatoxicity. Other side effects include renal failure, rash, urticaria. / Assess type, location, and intensity prior to and 30-60minutes following administration. If given for fever note signs of diaphoresis, tachycardia, and malaise. Lastly, hepatic, hematologic, and renal function should be assessed.
Drug-Drug interactions with NSAID’s. / Client exhibited no signs and symptoms of pain while on shift.
BUN-18, Creatinine-0.6, Hgb-12.9, RBC-4.01, Hct-38.4
Generic: oxycodone
Trade: Endocodone, M-Oxy, Oxycontin, OxyFAST, OxyIR, Percolone, Roxicodone SR
Dose: 5mg
Frequency/Route: q.d. via enteral tube
Pharmacotherapeutic: opioid agonists, opioid agonists/nonopiod analgesic combinations
Clinical: opioid analgesic / General Use: Binds to opiate receptors in the CNS and alters the perception of and response to painful stimuli, while producing generalized CNS depression resulting in decreased pain.
Reason for giving this drug to this client: Management of clients pain. / A serious side effect is respiratory depression. Other side effects include confusion, sedation, and constipation. / The nurse should perform a pain assessment. The nurse should also perform a bowel assessment and monitor BP, pulse, and RR. The nurse may also want to watch plasma amylase and lipase levels.
Drug-drug interactions with sedatives and hypnotics. / BP-122/72, HR-93. RR-18.
BS x 4. Abdomen soft and non-distended.
Client appeared comfortable and absent of pain.
Generic: risperidone
Trade: Risperdal, Risperdal M-TAB
Dose: 1.5mg
Frequency/Route: b.i.d. via enteral tube
Pharmacotherapeutic:
Clinical: antipsychotic / General Use: May act by antagonizing dopamaine and serotonin in the CNS. Consequently, this drug results in decreased symptoms of psychosis.
Reason for giving this drug to this client: Management of clients schizophrenia. / A serious side effect is neuroleptic malignant syndrome. Other side effects include aggressive behavior, dizziness, extrapyramidal reactions, headache, increased dreams, increased sleep duration, insomnia, sedation, pharyngitis, rhinitis, visual disturbances, cough, constipation, diarrhea, dry mouth, nausea, decreased libido, dysmenorrheal/menorrhagia, itching/skin rash, and weight gain. / The nurse should monitor the patients mental status and assess for mood changes. Also, the nurse should monitor for onset of extrapyramidal side effects, tardive diskinesia, and development of neoroleptic malignant syndrome. Lastly, the nurse should know that this drug can cause increased serum prolactin, AST, and ALT. Risperidone can also cause anemia, thrombocytopenia, leukocytosis, and leucopenia.
Drug-Drug interactions with NSAID’s and antacids. / Client confused and appears to be oriented to person.
Client had a non-productive cough while on shift.
RBC-4.01
Generic: quetiapine
Trade: Seroquel
Dose: 150mg
Frequency/Route: q.d. at 8pm/hs via enteral tube
Pharmacotherapeutic:
Clinical: antipsychotic / General Use: Probably acts by serving as an antagonist of dopamine and serotonin thereby decreasing manifestation of psychoses.
Reason for giving this drug to this client: Management of client’s schizophrenia symptoms. / Two serious side effects are neuroleptic malignant syndrome and seizures. Other side effects include dizziness and weight gain. / The nurse should monitor patient’s mental status and monitor for mood changes. Also, the nurse should monitor for onset of extrapyramidal side effects, tardive diskinesia, and development of neoroleptic malignant syndrome. Seroquel can also cause anemia, thrombocytopenia, leukocytosis, and leucopenia.
Drug-Drug interactions with opioid analgesics ad sedatives/hypnotics. / Client confused and appears to be oriented to person.
Client absent of any of the common side effects.
RBC-4.01
Generic: moxifloaxcin
Trade: Avelox
Dose: 400mg
Frequency/Route: q.d. at 8pm/hs via enteral tube
Pharmacotherapeutic:
Clinical: anti-infective / General Use: Ingibits bacterial DNA synthesis by inhibiting DNA gyrase thereby producing death of susceptible bacteria (Deglin & Vallerand, 2005).
Reason for giving this drug to this client: Management of client’s pneumonia. / Severe side effects include seizures, arrhythmias, pseudomembranous colitis, anaphylaxis, and Stevens-Johnson Syndrome. Other side effects include dizziness, drowsiness, headache, insomnia, abdominal pain, diarrhea, and nausea (Deglin & Vallerand, 2005). / The nurse should assess the patient for signs and symptoms of anaphylaxis and infection. The nurse should also be aware that this drug can cause hyperglycemia, hyperlipidemia, increased WBC count, increased serum calcium, chloride, albumin, and globulin. Decreases in glucose, Hgb, RBC’s, neutophils, eosinophils, and basophils can occur (Deglin & Vallerand, 2005). / Breath sounds diminished and crackles heard upper/lower bilaterally.
Client absent of potential side effects.
Na-142, Ca-8.7, WBC-5.2, glucose-153, RBC-4.01, Hgb-12.9
Generic: metoclopramide
Trade: Clopra, Octamide, Octamide-PFS, Reclomide, Reglan
Dose: 10mg (10ml)
Frequency/Route: q.i.d. via enteral tube
Pharmacotherapeutic:
Clinical: antiemetics / General Use: Blocks dopamine receptors in chemoreceptor trigger zone of CNS and stimulates motility of upper GI tract and accelerates gastric emptying. Consequently, this drug produces decreased N/V and symptoms of gastric stasis (Deglin & Vallerand, 2005).
Reason for giving this drug to this client: Management of client’s N/V. / Symptoms include drowsiness, extrapyramidal reactions, and restlessness (Deglin & Vallerand, 2005). / The nurse should assess the patient for N/V, abdominal distention, bowel sounds before and after, extrapyramidal side effects, tardive dyskinesia, and for signs of depression. Also, the nurse should know that this drug could alter hepatic function test results.
Drug-Drug interactions with CNS depressants, opioid analgesics, and sedative/hypnotics (Deglin & Vallerand, 2005). / BS x 4 and abdomen non-distended.
N/V absent during shift.
Generic: ipatropium
Trade: Atrovent
Dose: 1UD-0.02% inh. sol.
Frequency/Route: q.i.d via aerosol PRN
Pharmacotherapeutic: enzyme inhibitors
Clinical: antineoplastics / General Use: Inhibits cholinergic receptors bronchial smooth muscle, resulting in decreased concentrations of cGMP. Consequently, this drug produces bronchodialation without any systemic anticholinergic effects (Deglin & Vallerand, 2005).
Reason for giving this drug to this client: Management of client’s SOB when it occurs / Side effects include dizziness, headache, nervousness, blurred vision, sore throat, bronchospasm, cough, hypotension, palpitations, GI irritation, and nausea (Deglin & Vallerand, 2005). / The nurse should assess for allergies to atropine and belladonna alkaloids.
Assess respiratory status before and after administration (Deglin & Vallerand, 2005). / Breath sounds diminished and crackles heard upper/lower bilaterally.
HR-93, RR-18, O2-86%
Generic: albuterol
Trade: AccuNeb, Airet, Proventil, Proventil HFA, salbutamol, Ventodisk, Ventolin, Ventolin HFA, Volmax, VoSpira ER
Dose: 1UD-0.083% inh. sol.
Frequency/Route: q.i.d. via aerosol PRN
Pharmacotherapeutic: adrenergic
Clinical: bronchodialators / General Use: Binds to beta2-adrenergic receptors in the smooth muscle of the airway, leading to activation of adenyl cyclase and increased levels of cAMP. Therefore subsequent relaxation of airway smooth muscle with subsequent bronchodialation is achieved (Deglin & Vallerand, 2005).
Reason for giving this drug to this client: Management of client’s SOB when it occurs. / Side effects include nervousness, restlessness, tremor, chest pain, and palpitations (Deglin & Vallerand, 2005). / Assess lung sounds, pulse, and BP before and after administration. The nurse should also periodically monitor pulmonary function tests and observe for wheezing. Lastly, the nurse should be aware that this drug could cause a decrease in serum potassium (Deglin & Vallerand, 2005). / Breath sounds diminished and crackles heard upper/lower bilaterally prior to administration. O2 saturation 86% prior to administration.
Breath sounds still diminished upper/lower bilaterally, but crackles were not present after administration. O2 saturation up to 92% after administration.
HR-93, RR-18 (remained the same before and after administration
Client absent of potential side effects.
Generic: sennosides
Trade: Black-Draught, Ex-Lax, Ex-Lax Chocolated, Fletchers’ Castoria, Maximum Relief Ex-Lax, Sena-Gen, Senexon, Senokot, SenokotXTRA.
Dose: 2tsps (10ml)
Frequency/Route: q.d. via enteral tube
Pharmacotherapeutic: stimulant laxatives
Clinical: laxatives / General Use: Active components of sennosides alter water and electrolyte transport in the large intestine, resulting in accumulation of water and increased peristalsis, thereby producing a laxative action (Deglin & Vallerand, 2005).
Reason for giving this drug to this client: Management of client’s chronic constipation. / Common symptoms include cramping and diarrhea (Deglin & Vallerand, 2005). / Nurse should perform a bowel assessment and assess the color, consistency, and amount of stool (Deglin & Vallerand, 2005). / BS x 4. Abdomen soft and non-distended. Client had one large watery/non- formed bowel movement during shift.
Generic: acetaminophen
Trade: Tylenol
Dose: 650mg
Frequency/Route: q6h via enteral tube PRN
Pharmacotherapeutic:
Clinical: antipyretics, non-opioid analgesics. / General Use: Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. Consequently, this drug achieves analgesia and antipyresis (Deglin & Vallerand, 2005).
Reason for giving this drug to this client: Management of clients pain. / Severe side effects include hepatic failure and hepatoxicity. Other side effects include renal failure, rash, urticaria (Deglin & Vallerand, 2005). / Assess type, location, and intensity prior to and 30-60minutes following administration. If given for fever note signs of diaphoresis, tachycardia, and malaise. Lastly, hepatic, hematologic, and renal function should be assessed (Deglin & Vallerand, 2005). / Client exhibited no signs and symptoms of pain while on shift.
BUN-18, Creatinine-0.6, Hgb-12.9, RBC-4.01, Hct-38.4
Generic: oxycodone
Trade: Endocodone, M-Oxy, Oxycontin, OxyFAST, OxyIR, Percolone, Roxicodone SR
Dose: 5mg
Frequency/Route: q3h via enteral tube PRN
Pharmacotherapeutic: opioid agonists, opioid agonists/nonopiod analgesic combinations
Clinical: opioid analgesic / General Use: Binds to opiate receptors in the CNS and alters the perception of and response to painful stimuli, while producing generalized CNS depression resulting in decreased pain (Deglin & Vallerand, 2005).
Reason for giving this drug to this client: Management of client’s breakthrough pain. / A serious side effect is respiratory depression. Other side effects include confusion, sedation, and constipation (Deglin & Vallerand, 2005). / The nurse should perform a pain assessment. The nurse should also perform a bowel assessment and monitor BP, pulse, and RR. The nurse may also want to watch plasma amylase and lipase levels (Deglin & Vallerand, 2005). / BP-122/72, HR-93. RR-18.
BS x 4. Abdomen soft and non-distended.
Client appeared comfortable and absent of pain.

Diagnostic Tests:Results of significant diagnostic tests should be recorded under appropriate functional health pattern.

Laboratory Analysis:

Test Date / Test Name / NormalRange / Client Results / Interpretation of Abnormal Results For Your Client
9/16/2005 / Sodium / 136-145 / 142 / WNL
9/16/2005 / Chloride / 98-107 / 104 / WNL
9/16/2005 / Glucose / 70-105 / 153 / This test is a measure of the amount of glucose in the blood. A high amount of glucose in the blood would be indicative of Diabetes Mellitus. This result would be consistent with my client’s diagnosis of TypeII Diabetes Mellitus (Fischbach, 2004).
9/16/2005 / Creatinine / 0.6-1.3 / 0.6 / WNL
9/16/2005 / Electrolyte Balance / 4-18 / 12 / WNL
9/16/2005 / Potassium / 3.5-5.1 / 4.2 / WNL
9/16/2005 / CO2 / 22-29 / 30 / An elevated CO2 is characteristic of respiratory alkalosis. This result would be consistent with the poor inspiration of my client (Fischbach, 2004).
9/16/2005 / BUN / 7-18 / 18 / WNL
9/16/2005 / Calcium / 8.4-10.2 / 8.7 / WNL
8/18/2005 / WBC / 4.8-10.8 / 5.2 / WNL
8/18/2005 / HgB / 12-16 / 12.9 / WNL
8/18/2005 / MCV / 80-100 / 95.9 / WNL
8/18/2005 / MCHC / 31-37 / 33.5 / WNL
8/18/2005 / RDW / 11.5-14.5% / 13.5% / WNL
8/18/2005 / RBC / 4.0-5.5 / 4.01 / WNL
8/18/2005 / Hct / 36-46 / 38.4 / WNL
8/18/2005 / MCH / 26-34 / 32.1 / WNL
8/18/2005 / Platelets / 130-400 / 187 / WNL

STUDENT NAME: Kimberly FullerDATE:

DATABASE