Critical Care paper

Medications
(see attached) / Student NameTaysha Demetro
Client Initials_W.R._
Date_1-31-13__
Age_72_Gender_Male_ Room#_ICCU-122_ Admit Date_1-29-13_ CODE Status_Full__ Allergies_NKDA__ Diet_NPO-then clear liquids. Activity_Bedrest_
Braden Score__19/23__ Weight- __90.7 kg__
Glasgow coma scale __15/15__ / State lab values and identify trends.

1-31-13 EGD- revealed 2 ulcers that were cauterized. Doctor ordered H&H, Carafate 1 gram by mouth twice a day, and patient’s diet advanced to clear liquids.
Labs 1-31-13
Na 147 H (135-145)
K 3.5 N
Cl 112H (95-105)
Co2 25N
Glucose 106N
BUN 34H (5-20)
Creat 1.10N
Ca 7.7L (9-11)
Po4 2.4L
Alb 2.6L
Mg 1.5N
WBC 12.3 H
Hgb 8.9L
Hct 24.6L
Plate 99L
Detailed explanation is located below.
IV Sites/Fluids/Rate
IVs-
~R AC #18 HL clean, dry, dressing intact, WNL
~L hand #20 D5 ½ NS @125 ml/hr
Monitoring: Invasive/Non-Invasive State specific monitoring device and specific values with each device
~5 lead EKG
~blood sugars / Chief Complaint: GI Bleed/ Coffee Brown Emesis
Admitting Diagnosis (es): GI Bleed, Hyperglycemia, Renal failure, UTI
Past Medical/Surgical History
Relevant to this admission
  • Chronic Hypertension
  • DM
  • CABG
  • CAD
  • Past history of smoking (quit 20 years ago)
  • Occasional ETOH

ECG Interpretation
(see attached) / 1.Describe the patient’s condition, including signs/symptoms that led to thisadmission.
1. W.R. is a 72-year-old male admitted to ACH on 1-29-13. His son brought him into the ER for loose stool with maroon colored blood. He was not taking his insulin as directed for the past 3 days and was described as “generally weak” due to a decrease in his PO intake. While he was in the ER, he had coffee brown emesis and was lethargic. He has a strong family history of Coronary Artery Disease. He has a history of Chronic Hypertension, Diabetes Militias, CABG, and a past history of smoking and occasional use of alcohol. He was diagnosed with a GI Bleed, Hyperglycemia, Renal failure, and labs drawn on 1-31-13, he was diagnosed with a UTI. He was put on an Insulin drip 2 units/hr and a NG was placed for nausea and vomiting, but the patient pulled it out. Pt. stated, “I did not like it” for reason for removal. He was admitted to the ICCU on 1-30-13.
2. GI Bleed- Gastrointestinal hemorrhage is characterized by acute, massive bleeding. Regardless of the cause, the results are hypovolemic shock, initiation of shock response, and development of multiple organ dysfunction syndrome if left untreated. The most common cause of death in cases of gastrointestinal hemorrhage is exacerbation of the underlying disease, not intractable hypovolemic shock (Urden, Stacey, & Lough, 2010).
Hyperglycemia- (high blood glucose) happens when the body has too little insulin or when the body can't use insulin properly. Insulin levels are inadequate to meet the body’s needs. Glucose cannot be utilized by the cells and it accumulates in the bloodstream.The excess sugar begins to spill over into the urine. As the sugar is excreted it takes excessive amounts of water with itresulting in serious dehydration.Ketones and acids are produced as cellular glucose depletioncontinues. Ketoacidosis is a serious complication that can result in coma anddeath (Urden, Stacey, & Lough, 2010).
Renal failure- the interaction of tubular and vascular events result in ARF. The primary cause of ATN is ischemia. Ischemia for more than two hours results in severe and irreversible damage to the kidney tubules. Significant reduction GFR is a result of ischemia, activation of the RAsystem, and tubular obstruction by cellular debris. As nephrotoxins damage the tubular cells and these cells are lost through necrosis, the tubules become more permeable. This results in filtrate absorption and a reduction in the nephrons ability to eliminate waste.
UTI- urinary tract infections occur due to invading bacteria. The organism triggers an inflammatory response in the lining of the urinary tract. This irritation leads to pain, frequent voiding, and other clinical manifestations (Black & Hawks, 2009).
3. Head-to-toe assessment performed on 1-31-13 at 0750
Vital signs: T- 98.6 F, HR 96 regular, BP 148/70, R 12, 02- 99% RA, Pain 0/10.
The client was A&O x 3. He was alert and oriented to person, time, and place.
PERRLA WNL. Calm, pleasant, and speech clear.
Diet- NPO for EGD, then advance to clear liquids (no orange or red liquids)
Activity - Bedrest
Braden Score- 19/23
Weight- 90.7 kg
Glasgow coma scale- 15/15
R AC #18 HL clean, dry, dressing intact
L hand #20 D5 ½ NS @125 ml/hr
  • HOB elevated 30 degrees
  • Turn an reposition every 2 hours (self)
  • Blood sugars AC/HS
  • NPO to clear liquid diet (no red or orange liquids)
  • Bedrest
  • Foley
  • R AC #18 HL clean, dry, dressing intact
  • L hand #20 D5 ½ NS @125 ml/hr
  • Daily weights
  • 5 lead EKG
  • Strict I&O every shift
  • Vital signs every 1 hour
  • Assessments every 4 hours
  • EGD
  • SCD’s
  • Cough and deep breathing
Lung sounds were clear, anterior and posterior, even.
Heart rate was normal, 96 bpm and regular.
Abdomen was soft, round, non-tender to palpation, bowel sounds present in all four quadrants, hypoactive.
His pedal pulses are +1 bilaterally, radial pulses +2, capillary refill <3 seconds WNL, skin turgor <2 seconds.
His skin is warm, dry, and intact. Color WNL, no edema.
Intake- 0ml
Output- Foley 200+ ml/hr clear, yellow urine
Bowel movement- 0
W.R. HOB is elevated 30 degrees. His blood sugar at 1206 was 145. Sliding scale starts at 111-150, 2 units were given sq. He is on Daily weights, 5 lead EKG on continuous monitoring, strict I&O every shift, vital signs every 1 hour, assessments every 4 hours with temperature.
  1. LABS- 1-31-13
Na 147 H (135-145)
~W.R.'s sodium levels are high. Normal sodium levels are 135-145 mEq/L. His levels are 147 high. (Cavanaugh, 2009). These levels are elevated possibly because he is dehydrated due to frequent nausea and vomiting (Deglin & Vallerand, 2010).
Cl 112 H (95-105)
~W.R.’s chloride levels may be increased because he has lab results that indicate anemia.
Anemia is the lowering of red blood cells. His Hgb and Hct are low. This can cause his chloride to increase. The levels may also be high because on admission he had not been drinking or eating, which can cause dehydration. Dehydration can cause an increase in chloride levels. This can also be caused by his DM (Deglin & Vallerand, 2010).
BUN 34 H (5-20)
~W.R.'s BUN levels are high. Normal BUN levels are 5-20 mg/dL. His levels are 34 high. (Cavanaugh, 2009). These levels are elevated possibly due to having CAD, dehydration, drug reactions, and his recent blood lost (Deglin & Vallerand, 2010).
Ca 7.7 L (9-11)
~W.R.'s calcium levels are low. Normal levels are 9-11 mg/dL. His levels are 7.5 low. (Cavanaugh, 2009). His low calcium levels could be low due to dehydration, frequent nausea and vomiting, blood lost, CAD, his age of 72, and DM (Deglin & Vallerand, 2010).
Po4 2.4L (2.5-4.5 mg/dL)
~W.R.'s phosphorus levels are low. Normal levels are 2.5-4.5 mg/dL. His levels are 2.4 low. (Cavanaugh, 2009). His low levels are due his DM (Deglin & Vallerand, 2010).
Alb 2.6L (3.5-5 g/dL)
~W.R.'s albumin levels are low. Normal levels are 3.5-5 g/dL. His levels are 2.6 low. (Cavanaugh, 2009). His low levels are due his history of CAD, could be low due to dehydration, frequent nausea and vomiting, and DM (Deglin & Vallerand, 2010).
WBC 12.3 H (5,000-10,000/mm3)
~W.R.'s white blood count levels are high. Normal levels are 5,000-10,000/mm3. His WBC level is 12.3 high. W.R. has an UTI and is taking Ampicillin/ Sulbactam (Unasyn) 3 grams IVPB q 6h/ 30 minutesto fight the infection (Cavanaugh, 2009).
Hgb 8.9 L (13-18)
Hct 24.6 L (42-50%)
Plate 99 L (150,000-450,000)
~W.R.'s hemoglobin levels are low. Normal levels are 13-18 m/dL in males. His hemoglobin is 8.9 low.
~W.R.'s hematocrit levels are low. Normal levels are 42-50% in males. His hemotacrit is 24.6 low.
~W.R.’s platelet count levels are low. Normal levels are 150,000-450,000/mm3
(Cavanaugh, 2009). These levels could all be low due to his recent blood lost and/or medications. He has not been given any blood (Deglin & Vallerand, 2010).
(Cavanaugh, 2009).
(Deglin & Vallerand, 2010).
MEDS-
~W.R. is taking Magnesium sulfate IVPB. This medication is an electrolyte replacement and will help to increase his magnesium level. His magnesium level is 1.5, which is the low minimum.
~W.R. is taking Ampicillin/ Sulbactam (Unasyn) 3 grams IVPB q 6h/ 30 minutes. This medication is an anti-infective and will help to treat his UTI.
~W.R. is taking pantoprazole (Protonix) 40mg=10ml IV push q 12h, It is a proton pum inhibitor and will help to heal my patient’s ulcers and decrease acid secretion
~W.R. is taking Insulin Glargine (Lantus) 40 units sq at bedtime. This medication will help control my patient’s blood sugar.
~W.R. is taking Insulin Lispro (Humalog) 3 times a day sq b4 meals. This medication will help control my patient’s blood sugar.
~W.R. is taking sucrafate (Carafate) 1g tablet PO b4 breakfast and at bedtime. This medication is an antiulcer agent/ GI protectant and this medication will help coat the lining therefore decreasing his pain and help to heal his ulcers.
(Deglin & Vallerand, 2010).
The patient is ordered sequential compression devices (SCDs). SCDs will prevent deep vein thrombosis from occurring in the legs of W.R. The SCDs work by using passive leg muscle contraction to promote venous return (Black & Hawks, 2009). W.R. has a 5 lead EKG on continuous monitoring system to monitor his cardiac status. EKG helps health care providers to select what other diagnostic test to select for the patient (Urden et al., 2010).
W.R. HOB is elevated 30 degrees. He is on Daily weights, 5 lead EKG on continuous monitoring, strict I&O every shift, vital signs every 1 hour, assessments every 4 hours with temperature. These interventions are essential to the patient’s well-being post op.
Past Medical/Surgical History
Relevant to this admission / Treatments/ Medical and Nursing Interventions
  • HOB elevated 30 degrees
  • Turn an reposition every 2 hours (self)
  • Blood sugars AC/HS
  • NPO to clear liquid diet (no red or orange liquids)
  • Bedrest
  • Foley
  • R AC #18 HL clean, dry, dressing intact
  • L hand #20 D5 ½ NS @125 ml/hr
  • Daily weights
  • 5 lead EKG
  • Strict I&O every shift
  • Vital signs every 1 hour
  • Assessments every 4 hours
  • EGD
  • SCD’s
  • Cough and deep breathing

Primary Nursing Diagnosis with Relational Statement
Imbalanced Nutrition: less than body requirements related to lack of exogenous nutrients and increased metabolic demand (Urden et al., 2010). / Short Term Goal Relevant to Nursing Diagnosis
~W.R. will ingest daily nutritional requirements in accordance with his activity level and metabolic needs by the end of my shift.
~W.R. ate 40 % of his clear liquid diet. Napped early afternoon and spend most of the afternoon talking and visiting family / 6 Nursing Diagnosis with Relational Statement
1. Risk for Infection related to invasion lines (Carpenito-Moyet, 2010).
2. Impaired Physical Mobility related to external devices secondary to intravenous tubing (Carpenito-Moyet, 2010).
3. Risk for Injury related to effects of medication on mobility secondary to fatigue (Urden et al., 2010).
4. Anxiety related to biologic, psychologic, or social integrity (Urden et al., 2010).
5. Knowledge Deficit related to lack of previous exposure to information on carotid artery disease, DM, and Renal failure (Urden et al., 2010).
6. Ineffective health maintenance related to unhealthy habits (Carpenito-Moyet, 2010).
Definition (State definition and source)
Intake of nutrients insufficient to meet metabolic needs (Urden et al., 2010). / Outcome Criteria (Must be specific and measurable)
~Pt. exhibit weight maintained or weight gain by end of shift.
*Outcome met. Pt did not complain of nausea, and showed no signs of vomiting during my shift. Daily weights are done early morning next shift.
~Albumin level is greater than 3.5g/dL by end of shift.
*Outcome unmet/unable to evaluate outcome. Labs are done at 1800. My shift ended at 1530.
~Daily caloric intake equals estimated nutritional requirements by end of shift.
*Outcome met. Patient attempted to eat his meal at lunch time with 40% completion. Pt. did not complain of any nausea or vomiting, no emesis noted.
~Increase endurance is evident by end of shift.
*Outcome met. Patient napped early in the afternoon and was alert and visiting with the family most of the afternoon.
AEB: Defining characteristics specifically exhibited by your patient that support primary nursing diagnosis.
  • Chronic hypertension
  • Generalized weakness
  • Unsteady gait
  • Albumin level 2.6L (3.5-5 g/dL)
  • Bedrest
  • Fatigue (pt laid and took little naps during my shift)
  • Ate 40% of clear liquid diet
  • Pt. states, “I have no taste for food”
  • Wgt on 1-30-13 91.5kg
  • Wgt on 1-31-13 90.7kg
  • Pt had nausea and vomiting
  • Coffee brown emesis
  • Rectal bleeding

Identify nursing interventions that you implemented with this patient.
Evaluate patient progress towards achieving outcome criteria as a result of nursing interventions.
~Encourage patient to rest before meals. Fatigue can set in and reduce a patient’s desire and ability to eat (Black & Hawks, 2009). W.R. was tired most of the morning so I encourage him to nap. He ate 40% of his clear liquid diet and spent the afternoon visiting his family.
~Encourage patient to maintain good oral hygiene. Poor oral hygiene can lead to a bad odor and taste, which can diminish appetite (Black & Hawks, 2009). Patient stated, “I will brush before bed tonight.”
~Encourage patient to eat most caloric food first. This will ensure more calories early on. Patient ate the soup broth and apple juice first, then the hot tea.
~Weight daily. This keeps an eye on the patient’s weight lost/gain status. Patient’s weight wason 1-30-13 was 91.5kg. On 1-31-13 patient weight was 90.7kg.
~Confirm with patient that food was tolerated. This ensures patient is meeting the nutritional intake that he needs. After lunch, I confirmed with the patient that his lunch was kept down. He did not experience and nausea or vomiting.
~Offer the patient frequent, small meals instead of few, large ones. This helps with maintaining calories. The patient ate 40% of his lunch but saved the Italian ice for later.
What I Would Do Differently
I would have done ROM exercises with him, because was on bedrest during my shift. I also would have encouraged him to eat a little bit more of his lunch or ordered something else. I should have asked more about his past medical history to understand this case better and I should have had more patient education with him, for example, encouraged more couch and deep breathing through out my shift. I asked my patient is he wanted to give himself a bath or if he would like me to do it, he declined. I should have insisted more on it. He wanted to wait and to do it at home. I also should have insisted more and oral and mouth care.
Secondary Nursing Diagnosis with Relational Statement
Risk for Impaired Skin Integrity related to impaired mobility (Carpenito-Moyet, 2010). / Short Term Goal Relevant to Nursing Diagnosis
~W.R. will demonstrate skin integrity free of pressure ulcers by end of my shift.
*Evaluation of Short Term Goal- W.R. demonstrated skin integrity free of pressure ulcers by end of my shift.
Definition (State definition and source)
The state in which an individual experiences or is at risk for altered epidermis and /or dermis (Carpenito-Moyet, 2010). / Outcome Criteria (Must be specific and measurable)
~Daily caloric intake equals estimated nutritional requirements by end of shift.
*Outcome met. Patient attempted to eat his meal at lunch time with 40% completion. Pt. did not complain of any nausea or vomiting, no emesis noted.
~Turn patient every 2 hours or as needed.
*Outcome met. Patient self turned.
~Apply barrier to skin during once a shift or as needed.
*Outcomes met. After PT came in I looked over W.R.’s skin and applied a barrier cream to his lower back after my assessment. His skin was free from pressure ulcers.
~Have pt. maintain diet throughout shift.
*Outcome met. W.R. ate 40% of his lunch. He had more energy after he napped so he could visit with his family after lunch.
AEB: Defining characteristics specifically exhibited by your patient that support primary nursing diagnosis.
  • Chronic hypertension
  • Renal failure
  • Generalized weakness
  • Bedrest
  • SCD’s
  • DM
  • 75 years old
  • skin is dry
  • Unsteady gait
  • Fatigue (pt laid and took little naps during my shift)
  • Ate 40% of clear liquid diet
  • Pt. states, “I have no taste for food”
  • Wgt on 1-30-13 91.5kg
  • Wgt on 1-31-13 90.7kg
  • Pt had nausea and vomiting
  • Coffee brown emesis
  • Rectal bleeding

Identify nursing interventions that you implemented with this patient.
Evaluate patient progress towards achieving outcome criteria as a result of nursing interventions.
~Inspect the patient’s skin daily.Checking skin daily will help prevent sores from getting worst. Patient’s skin was free from any pressure ulcers.
~Suspend heels off bed surface daily.Friction is the physiologic wearing away of tissue. If the skin is rubbed, the epidermis can be damaged. Patient’s heels were free from any pressure ulcers.
~Increase frequency of turning schedule if any reddened areas that appear do not disappear with 1 hour after turning as needed.Tissue can be damaged as a result of hypoxia. Patient turned self.
~Ascertain that daily intake of vitamins and minerals are maintained through diet or supplements daily.Adequate nutrition is vital for healing wounds and preventing infection. Patient went from NPO to a clear liquid diet and ate 40% of his lunch.
~Encourage range of motion exercises to increase blood flow to all areas daily.Increase blood flow will help decrease the chance of bedsores and abrasions. Patient was on bedrest.
~Apply barrier to skin everyday. This protects the skin from pressure ulcers.

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.

ORDER
Drug Name (generic & trade)
Dosage
Frequency
Route
Show dosage calculations
*Include all IV continuous medications* / DRUG CLASSIFICATION/THERAPEUTIC USES
1) Identify pharmacologic/therapeutic classification
2) Describe mechanism of action for the drug and the END RESULT of that action
3) Describe how your patient will benefit from this drug