NR 341 RUA - Interdisciplinary Rounds Assignment., Assignments of Nursing

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NR 341

INTERDISCIPLINARY

ROUNDS

ASSIGNMENT

BACKGROUND INFORMATION

PATIENT AGE: 53 HEIGHT AND WEIGHT: 61 KG AND 160 CM DEMOGRAPHICS: (ALCOHOL, TOBACCO, JOB, SPOUSE, CHILDREN) 1 PACK OF CIGARETTES DAILY; UNEMPLOYED; SINGLE AND 1 DAUGHTER ALLERGIES: CODEINE, LIDOCAINE, AMOXICILLIN, SULADIAZONE, VANCOMYCIN, ASPIRIN, SULFA DRUGS, SHELLFISH, PERCOCET, NOVOCAIN, DARVOCET N, MARCAINE, HCL WITH EPINEPHRINE, EXCEDRIN, BETADINE, ADVIL, LEVAQUIN, VERSED, LORTAB 7.5/500, ADHESIVE BANDAGE, CONTRAST DYE, LATEX, NEXIUM, IODINE CONTAINING COMPOUNDS, IODINE, AVINZA CODE STATUS : FULL CODE

SUMMARY OF PATIENTS

HOSPITALIZATION

• (^) WHAT WERE THE EVENTS LEADING TO THE PATIENT’S ADMISSION? PATIENT HAD A PERMACATH THAT MALFUNCTION THAT WAS UNABLE TO BE USED FOR DIALYSIS WAS THE PATIENT AT THE DIALYSIS CENTER TO GET DIALYSIS WHEN IT WAS DISCOVERED?
• (^) WHAT HAPPENED TO THE PATIENT AFTER ADMISSION? PATIENT RECEIVED TPA TO RESOLVE TO RESOLVE MALFUNCTION OF PERMACATH TO BE ABLE TO CONTINUE HEMODIALYSIS IS THIS ALL THAT HAPPENED?

ASSESSMENT FINDINGS

Cardiovascula r System Assessment Respiratory System Assessment Temperature 36.8*C Respiratory rate 18 Heart Rate 86 Respiratory rhythm Even and symmetrical Heart Rhythm Sinus rhythm Effort Unlabored B/P 172/83 Pulse Oximetry 100 Pain (rating, location, quality) 10/10, aching, back and abdomen Oxygen Room Air Capillary Refill < 3 seconds ETT/ Tracheostomy n/a Heart Sounds s1, s2 noted Ventilator Settings n/a Murmur n/a Breath Sounds Clear bilaterally IABP n/a Cough None present Pacemaker Settings n/a Secretions n/a

Integument System Assessment Musculoskelet al System Assessment Integrity Healed incision on right foot. Scar from AV fistula R arm No skin breakdown noted Mobility/ Strength (RUE/RLE/LUE/ LLE) LLE weakness What about the RUE, RLE, LUE? Turgor No tenting noted Assistive Devices Motorized Wheelchair Incisions/ Dressings Transparent dressing over permacath Risk for Fall High Lesions/Wounds (Location/ Description) No lesions or wounds noted. Immobilization Devices n/a Edema (Location/Amount) No edma present Braden Scale 16 What is risk? (High, low, mod)

IV ACCESS/MONITORING

DEVICES

IV/Central Line Access Location and IV Fluids Other Monitoring Devices Location and Data from Device Peripheral IV 24g L forarm CVP Monitor n/a Triple Lumen Catheter n/a PA pressure monitor n/a PICC Line n/a ICP monitor n/a Other (Describe) n/a Arterial line n/a Other (Describe) n/a Restraints n/a

LABS

CBC Result Rationale for Abnormals WBC 5.0 million cells/ul

WNL

RBC 4.23 million cells/ucL Anemia and previous bleeding in patient HGB 11.3 g/dL Nutritional deficiencies and previous internal bleeding. HCT 35.9 % Previous internal bleeding and decreased RBC count and decreased Hgb. Platelets 186 k/mcL WNL Neutrophils 50 cells/mm Vitamin deficiency Lymphocytes 50 cells/mm Vitamin deficiency Monocytes n/a Eosinophils n/a

LABS

Metabolic Panel Result Rationale for Abnormals Glucose 389 Patient consumed foods high in sugar against medical advice Was patient a diabetic? BUN 22 WNL Creatinine 3.57 Pt consuming high sodium diet and recurrent illness What does your patient have that would cause this level to be elevated? GFR 14 Patient has ESRF Sodium 137 WNL Potassium 4.2 WNL Chloride 98 WNL CO2 24 WNL

DIAGNOSTIC TESTS

Test Results Rationale for Abnormals Chest X-ray

N/A N/A

CT scan N/A N/A MRI N/A N/A EKG N/A N/A Ultrasou nd

N/A N/A

Endosco py

N/A N/A

MEDICATIONS

Trade/Generic Name Humalog/ Insulin Lispro Therapeutic Use Control hyperglycemia Rationale for use for this patient Patient has hx of DM and hyperglycemia Mechanism of Action Facilitates cellular uptake of glucose in muscle and other tissues, except the brain 2 major Adverse Effects Hypoglycemia Blurred vision 2 Patient Teaching Points Take this medication 15

MEDICATIONS

Trade/Generic Name Acetaminophen -oxycodone/ Percocet Therapeutic Use Relieve severe pain Rationale for Use for this patient Patient had a pain of 9 out of 10 scale Mechanism of Action Oxycodone is a full opioid agonist with relative selectivity for the mu-opioid receptor, although it can interact with other opioid receptors at higher doses. The precise mechanism of the analgesic properties of acetaminophen is not established but is thought to involve central actions.

NURSING DIAGNOSES

Nursing Diagnosis # Acute pain r/t constipation AEB patient stating “I haven’t had a bowel movement in a few days and when you press on my stomach it hurts,” patient verbalized pain 9/10 on a 10 pain scale 3 Outcomes (What are the desired goals for this diagnosis? Make them specific).

1. Patient will have bowel movement by end of shift
2. Patient will have decreased pain of 3 out of 10 by end of shift
3. Patient will display improvement in mood by end of shift 3 Nursing Interventions (What nursing interventions will help achieve the desired goals?)
4. Nurse will educate patient on eating foods high in fiber to promote bowel movement and increase fluid intake
5. Nurse will administer pain medication to help alleviate pain

NURSING DIAGNOSES

Nursing Diagnosis # Risk for unstable blood glucose r/t lack of adherence of diabetes management 3 Outcomes (What are the desired goals for this diagnosis? Make them specific).

1. Patient will have a blood glucose reading of less than 150 by next glucose check
2. Patient will verbalize the importance of keeping blood glucose within normal range by end of shift
3. Patient will verbalize understanding of proper food choices to keep blood glucose within normal range by end of shift 3 Nursing Interventions (What nursing interventions will help achieve the desired goals?)
4. Assess patient’s current knowledge and understanding about prescribed diet
5. Teach patient how to perform home glucose monitoring
6. Assess blood glucose level before meals and at bedtime 3 Collaborative Interventions (What will interdisciplinary team members do that will help achieve the desired
7. Dietician will educate patient on correct diet to maintain adequate blood glucose levels and proper nutrition

SBAR (USE THIS SLIDE FOR YOUR PRESENTATION TO THE CLASS) Patient Initials Situation 62 y.o female A7Ox4 admitted on 4/30/18 for RLE perm cath malfunction in R thigh Was the patient in the dialysis clinic when the malfunction was found? Has the patient received dialysis since the malfunction? What was done to fix the problem? Background Hx: ESRF, DM, HTN, visual impairment in both eyes, L toe amputation RA, Full code, High fall risk, Renal Diet (but non- compliant) Tele: sinus rhythm @ what rate? Dialaysis MWF Uses electrical wheelchair BG at 0612 of 389 Patient to receive 1 unit of packed RBCs Has the RBCs been ordered? Why haven’t these been administered? Patient had lumbar puntcher 5/7/18 to assess spinal infection What are the details that caused this to be done?