GERO NPR 1
Taysha Demetro
Kent State University
Gero NPR
Gero NPR
Patient’s Background
Resident “R.P.” is a 63-year-old Caucasian woman. She is divorced, with two living children, and her mother visits her daily and is active with her care. R.P. has a durable power of attorney and her mother is her legal guardian. She does not have a living will and her code status is full code. She has Medicaid insurance. Her highest level of education is a GED, and she has worked as a cashier previously.
Patient’s Profile
R.P. was taken to the emergency room on 4-19-11, for increased temperature and change in status. Her vital signs were temperature 102.4F, pulse- 129, respiratory rate 22, BP 126/80, pulse ox 91%, Rhonchi left and right upper lobes, apical pulse 72 R, cap refill <3 sec., pedal pulses +3. After being discharged from the hospital, she was sent to C.H.C.C. On May 18, 2011, I performed a head-to-toe assessment on R.P.
Patient’s Medical History
R.P.’sadmitting diagnosis is end stage Huntington’s chorea. Her past medical and health history include seizure disorder, anemia, arthritis, respiratory failure, GERD, peripheral vascular disease, insulin-dependent diabetes mellitus,hypo-malnutrition, spasm of muscle, dysphagia, dementia, expressive aphasia, COPD, pneumonia, urinary tract infection, sepsis, VRE in her urine, and C-diff. Past surgical history include tracheotomy, peg tube, and supra pubic catheter.
Huntington’s chorea/disease is an autosomal-dominant degenerative neurologic disease (Black & Hawks, 2009). It causes intellectual decline, emotional disturbances, and abnormal movements. Symptoms of the disease usually present in the 30s and 40s and lead to disability and death within 15 to 20 years. The most common cause of death is usually from an infection, most commonly pneumonia, and fall related injuries (Black & Hawks, 2009).
There is a 50% chance of Huntington’s chorea being passed to offspring (Black & Hawks, 2009). R.P.’s father had it, as well as his mother. R.P.’s children could have Huntington’s chorea, and there is a simple blood test that can be performed.
R.P.’s chart indicated that she has been living with Huntington’s disease for 30 years now. Huntington’s disease involves the degeneration of the striatum in the basal ganglia and loss of neurons with an increased number of glial cells, leading to an increase in dopamine and norepinephrine levels (Black & Hawks, 2009). These increased levels cause excessive movements, emotional disturbances, mental deterioration, depression, psychosis, and severe mood swings. There is no pharmacologic treatment for Huntington’s chorea, justsupportive care (Black & Hawks, 2009).
Chronic obstructive lung disease (COPD) occurs from an increase in airway resistance,becauseof bronchial mucosal edema or smooth muscle contraction, leading to a decreased driving force to empty the lungs (Black & Hawks, 2009). The pathophysiology of COPD is acombination of chronic obstructive bronchitis, asthma, and emphysema, mainly caused from cigarette smoking, as well as a history of respiratory tract infections, air pollution, and heredity. Irritants, especially those found in cigarette smoke, cause mucus production and coughing that lead to inflammation, the destruction of cilia, and damage to the alveolar walls (Black & Hawks, 2009).
Functional Health Pattern Data Base
AREA OF HEALTH / SUBJECTIVE DATA / OBJECTIVE DATA / INDIRECT DATA*Identify source of indirect data / INTERPRETATION
(effective patterns or barriers/potential barriers)
HEALTH/PERCEPTION/ HEALTH MANAGEMENT
General Survey, perceived health
& well-being, self-management
strategies, utilization of
preventative health behaviors
and/or services. / Nonverbal due to health status / 5/18/11 0720 Head-to-toe assessment
Alert, no distress noted, unable to establish orientation due to nonverbal status.
T-98.8 F axillary, RR-34, pulse ox- 97% RA, BP-118/80 RA, heart rate- 88R, eyes- Left pupil- PERRLA, Right pupil-is round, is not equal, reactive to light and accommodation, lungs- Rhonchi anterior and posterior, bowel sounds- bs x4 firm to palpation, supra pubic cath intact, 0cc urine in foley, skin turgor < 3 sec., pedal pulses +1 bilateral, skin- warm and clammy, trach- midline and intact, spontaneously open eyes when spoken to, feeding tube- intact / Huntington’s chorea, seizure disorder, anemia, tracheotomy, peg tube, arthritis, respiratory failure, GERD, peripheral vascular disease, insulin-dependent diabetes mellitus, hypo-malnutrition, spasm of muscle, dysphagia, dementia, expressive aphasia, COPD, pneumonia, urinary tract infection, sepsis, and VRE in her urine.
Allergies- metal, tape paper, NKFA,
Height-66” weight-160 lb
BMI- 25.8
(Chart)
Plavix, Tylenol (MAR) / Nonverbal status is a barrier.
NUTRITIONAL/
METABOLIC
Patterns of food and fluid consumption,
Weight, skin turgor.
(Skin, Hair, Nails; Head & Neck;
Mouth, Nose, Sinus; swallowing, Ht., Wt) / Nonverbal due to health status / skin turgor < 3 sec., pedal pulses +1 bilateral, skin- warm and clammy, trach- midline and intact, feeding tube- intact,
1130 blood sugar 138 / Height-66” weight-160 lb
BMI- 25.8
(Chart)
Blood sugar taken before meals.
0700 blood sugar 140(chart)
tracheotomy, peg tube, insulin-dependent diabetes mellitus, hypo-malnutrition, dysphagia- NPO
Feeding tube- diabeta source 55 ml/hr.
1584 total calories, 80 gm total protein, 1082 free water, 2842 free water and flush
Oral- no teeth
Apply lip cream prn for dry, chapped lips.
nonalcoholic
(chart)
Albuterol, Artifi tears, Tylenol, Novolin R (MAR)
Carbon dioxide 31 High, glucose 131 High (labs) / Nonverbal status is a barrier.
ELIMINATION
Patterns of excretory function &
Elimination of waste; relevant labs,
Medications, impacting, etc.
(Abdominal - bowel and bladder) / Nonverbal due to health status / bowel sounds- bs x4 firm to palpation, supra pubic cath intact,
0700 0cc urine in foley.
1600 190cc amber urine in foley.
Braden Score- 9/23
Tongue and mucous membranes dry without lesions.
R.P. has 2 loose stools.
Changed and protective cream applied prn. / Bowel and bladder 3 day assessment (chart)
Medicated with Immodium 2 mg cap via peg tube
Pepcid,
Tobramycin
Zyvox,
Amikacin,
Vancomycin
(MAR)
Albumin 2.9 Low, urine culture heavy GNB (labs)
ACTIVITY/EXERCISE
Patterns of exercise & daily living,
self-care activities include major body systems involved.
(Thoracic & Lung; Cardiac;
Peripheral vascular; Musculoskeletal,
vital signs) / Nonverbal due to health status / T-98.8 F axillary, RR-34, pulse ox- 97% RA, BP-118/80 RA, heart rate- 88R, lungs- Rhonchi anterior and posterior, skin turgor < 3 sec., capillary refill <3 sec., pedal pulses +1 bilateral, skin- warm and clammy.
Non-ambulatory / R.P. needs help with all ADL. (chart)
nonsmoker
Rotate every 2 hours (R-L-B)
(chart)
Lovenox, Plavix (MAR) / Nonverbal status is a barrier. Also due to end stage Huntington’s disease it is effecting her activity level.
SEXUALITY/ REPRODUCTION
Satisfaction with present level of
Interaction with sexual partners
(Breast; Testes; Abdominal-
Genitourinary-reproductive) / Nonverbal due to health status / supra pubic cath intact, 0cc urine in foley,
Buttocks area is redden due to diarrhea. Cream applied prn. / R.P. has 2 children and her marital status is divorced (chart) / Nonverbal status is a barrier.
SLEEP/REST
Patterns of sleep, rest, relaxation,
fatigue
(Appearance, behavior) / Nonverbal due to health status / After respiratory came in and changed R.P.’s trach, R.P. had increased anxiety and agitation. Nurse gave her Ativan 1 mg tab via peg tube. / Restlessness (chart)
Ativan (MAR) / Her diseases and her nonverbal status causes her anxiety.
COGNITIVE/ PERCEPTUAL
Patterns of thinking & ways of
Perceiving environment, orientation
Mentation, neuron status, glasses,
Hearing aids, etc. / Nonverbal due to health status / Alert, no distress noted, unable to establish orientation due to nonverbal status.
No glasses, no hearing aid
eyes- Left pupil- PERRLA, Right pupil-is round, is not equal, reactive to light and accommodation, spontaneously open eyes when spoken to.
dysphagia, expressive aphasia / Memory and concentration impaired, psychomotor activity was reduced, aphasia, agnosia, confused, disoriented, depressed
(chart)
Sometimes able to understand others (chart)
Keppra-
*R.P. is taking it to decrease her seizures. (MAR) / Nonverbal status is a barrier. The progression of Huntington’s disease is taking over her cognitive and perceptual processes.
ROLE/RELATIONSHIP
Patterns of engagement with others,
Ability to form & maintain meaningful
Relationships, assumed roles;
Family communication, response,
Visitation, occupation, community
involvement / Nonverbal due to health status / R.P.’s mother never visited during my shift, so I assumed that she would be in later. STNA and R.N. were very friendly and talked to R.P. / R.P. has two children. (Chart) / Nonverbal status is a barrier and potential barrier when seeing family as well as C.H.C.C. staff.
SELF-PERCEPTION/ SELF-CONCEPT
Patterns of viewing & valuing
Self; body image & psychological
State / Nonverbal due to health status / R.P. needs help with all ADL. / Needs help with all ADL. (chart)
Needs assistance: moving to bed and chair, turning in bed, nail and hair care, bathing (bath, shower, bed bath), toileting, dressing
(Chart)
Ativan-
*R.P is taking it to decrease her anxiety.
(MAR) / Nonverbal status is a barrier and the C.H.C.C. staff does not know what R.P. is thinking.
COPING/STRESS TOLERANCE
Stress tolerance, behaviors, patterns
of coping with stressful events &
level of effectiveness, depression, anxiety. / Nonverbal due to health status / Spontaneously open eyes when spoken to.
Alert, no distress noted, unable to establish orientation due to nonverbal status when first assessed in morning assessment.
After respiratory came in and changed R.P.’s trach, she had increased anxiety and agitation. Nurse gave her Ativan 1 mg tab via peg tube.
The Ativan was effective, because when I checked on her, she was resting peacefully. / aphasia, agnosia, confused, disoriented, depressed
(chart) / Nonverbal status is a barrier and the C.H.C.C. staff does not know what R.P. is thinking. Nonverbal status is causing anxiety and depression.
VALUE/BELIEF
Patterns of belief, values,
Perception of meaning of life that guide choices or decision; includes
but is not limited to religious beliefs. / Nonverbal due to health status / Religion: Catholic
CODE Status- Full Code
(Chart) / Nonverbal status is a barrier.
Lab Interpretation and Other Diagnostic Tests
Lab Test / Result / NormalRange / InterpretationUrine culture / Preliminary
#1 heavy GNB / > 100,000 CFU/ml / Pending- results had not come in even when I went to look the next week. R.P has a history of VRE in her urine, and this time she could have e. coli (gram negative bacteria) in it due to the nature of the human body.
glucose / 131 H / 70-110 mg/dl / Has a history of IDDM, diabeta source 55ml/hr
Carbon dioxide / 31 H / 22-29mmol/L / Co2 levels are too high, because gas exchange is ineffective d/t medical history-Huntington’s chorea, seizure disorder, respiratory failure, COPD, pneumonia, and her trach.
Albumin / 2.9 L / 3.5-5.0 gm/dl / Low albumin levels may be caused by renal dysfunction (Cavanaugh, 2003).
*Lab values were obtained from patient’s chart and were the most current, dated 5/18/2011.
**Sources for interpretation are RN Labs (Cavanaugh, 2003) and Med-Surg Nursing by Black and Hawks (2009).
R.P. NPR Medication Sheet
Drug Name(generic/trade name) / Drug Action/
Purpose / Dose / Major side
Effects / Nursing Considerations
Levetiracetam sol (Keppra)-
*R.P. is taking it to decrease her seizures. / Anticonvulsants- to decrease incidence and severity of seizures.
Action-
Appears to inhibit burst firing affecting normal neuronal excitability and may selectively prevent hypersynchronization of epileptiform burst firing and propagation of seizure activity. / IV and oral
100mg/ml / Suicidal thoughts, dizziness, weakness / May cause dizziness and somnolence. Caution patient to avoid driving or activities requiring alertness until response of medication is known. Do not resume driving until physician gives clearance based on control of seizure disorder.
Assess location, duration, and characteristics of seizure activity. May cause decrease in RBC and WBC and abnormal liver function tests. Assess patient for CNS adverse effects throughout therapy. These adverse effects are categorized as somnolence and fatigue, coordination difficulties, and behavioral abnormalities and usually occur during the first 4 weeks of therapy.
Lorazepam (Ativan)-
*R.P is taking it to decrease her anxiety. / Analgesic adjuncts, antianxiety agents, sedative/hypnotics/ Benzodiazepines
-Depresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter
-Therapeutic: Sedation. Decreased anxiety. Decreased seizures. / -Administered orally, IM, SL, and IV.
1mg tablet
Antidote-
Administer Flumazenil (do not use with patients with seizures disorder. May induce seizures) / dizziness, drowsiness, lethargy, respiratory depression, APNEA, CARDIAC ARREST, bradycardia, hypotension / -asses geriatric patients carefully for CNS reactions as they are more sensitive to these effects.
- Assess fall risks.
-ANXIETY: assess degree and manifestations of anxiety and mental status (orientation, mood, behavior) prior to and periodically throughout therapy
-Advise patient that lorazepam is usually prescribed for short-term use and does not cure underlying problem
-Advise patient to taper lorazepam by 0.05 mg q 3 days to decrease withdrawal symptoms; abrupt withdrawal may cause tremors, nausea, vomiting, and abdominal and muscle cramps
Vancocin- Vancomycin- oral- anti infectives
*R.P. is taking it to treat c-diff. / Drug use for-PO: Treatment of staphylococcal enterocolitis or pseudomembranous colitis due to Clostridium difficile
Action of drug on the body- Bactericidal action against susceptible organisms- active against gram positive pathogens / oral and IV
oral 250 mg / ototoxicity, hypotension, nausea, vomiting, nephrotoxicity, rashes, eosinophilia, leucopenia, phlebitis, back and neck pain, HYPERSENSITIVITY REACTIONS INCLUDING ANAPHYLAXIS , chills, fever, "red man" syndrome (with rapid infusion), superinfection. / -Assess patient for infection at beginning of and throughout therapy
-Monitor intake and output ratios and daily weight. Cloudy or pink urine may be a sign of nephrotoxicity
-Assess patient for signs of superinfection
- Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction
-Assess bowel status.
-Monitor albumin, CBC, and renal function periodically during therapy
-May cause increased BUN levels
Amikacin-anti-infectives
*R.P. is taking it to treat an infection. / Action-Bactericidial action against susceptible bacteria / IM, IV
-500mg in 100 NS / S/E- vertigo, ototxicity, pephrotoxicity, apnea / -Keep pt. hydrated
-assess for infection
-observe eighth cranial nerve
-monitor I&O, daily weights, -assess for signs of super infection.
-Monitor renal function by urinalysis, specific gravity, BUN, creatinine, and CCr.
Albuterol- Proventil HFA/ Accuneb/ Proair HFA
*R.P. is taking it for brochospasms. / Classification of drug- Brochodilator/ adrenergic—binds to beta 2 adrenergic receptors in airway smooth muscle
Action- Relaxes airway smooth muscle, bronchodilation / PO, Inhallation
Neb 0.5% / Side effects- h/a, insomnia, hyperactivity, chest pain, palpitation, incr BP, angina, n, v, incr blood sugar, hypokalemia, tremors / Shake well and allow 1 min between inhalations of aerosol medication.
-Assess lung sounds, pulse, and bp
- potassium levels may decrease
Artifi tears-
*R.P. is taking it to keep her eyes moist. / beta blocker / Ophthalmic medication-
1 drop q 4 hours. / Blurred vision, stinging, eye discomfort, lidedema, photophobia
Famotidine- pepcid—
*R.P. is taking it to treat GERD. / antiulcer—histamine h2 antagonists
-Decreased secretion of gastric acid, symptoms of gastroesophageal reflux, healing and prevention o ulcers / PO
20 mg tablet / s/e confusion, arrhythmias, agranulocytosis aplstic anemia / -administer with meals or at bedtime,
-assess for epigastric or abdominal pain, confussion, monitor cbc, black tarry stool,
Enoxaparin (Lovenox)-anticoagulants
*R.P. is taking it for immobility. / -Prevention of thrombus formation.
Action- Potentiates the inhibitory effect of antithrombin on factor Xa and thrombin. / Subcutaneous injection / Edema, hyperkalemia, bleeding, anemia, thrombocytopenia, urinary retention / -Assess for signs of bleeding.
-Observe injection sites for hematomas, ecchymosis, or inflammation.
-Monitor for CBC, platelet count, and stools of occult blood
-May cause increase in AST and ALT levels. May cause hyperkalemia.
--Protamine sulfate 1mg for each mg of enoxaparin, should be administered by slow IV injection.
Plavix- clopidogrel- antiplatelet agents
*R.P. is taking it for PVD and for immobility. / antiplatelet agents
-Reduction of atherosclerotic events (MI, stroke, vascular death) in patients at risk for such events including recent MI, acute coronary syndrome (unstable angina/non–Q-wave MI), stroke, or peripheral vascular disease.
-Inhibits platelet aggregation by irreversibly inhibiting the binding of ATP to platelet receptors. / PO
75 mg tab / -Incidence of adverse reactions similar to that of aspirin
GI BLEEDING, abdominal pain, diarrhea, thrombocytopenic / -Monitor bleeding time during therapy. Prolonged bleeding time, which is time- and dose-dependent, is expected.
-Monitor CBC with differential and platelet count periodically
Loperamide (imodium)-
*R.P. is taking it to treat diarrhea / antidirrheals
Therapy of acute diarrhea, chronic diarrhea associated with inflammatory bowel disease, and decreases the volume of ileostomy drainage.
Action-Inhibits peristalsis and prolongs transit time by a direct effect on nerves in the intestinal muscle wall. / PO
2 mg cap / dizziness, allergic reactions, abdominal pain, distention, and discomfort. / -Assess the frequency and consistency of stools, bowel sounds, fluid and electrolyte balance, and dehydration.
-Caution patient to avoid using alcohol and other CNS depressants.
-Instruct the patient to notify a healthcare professional if diarrhea persists or if fever, abdominal pain, or distention occurs.
Tobramycin-
*R.P. is taking it to treat an infection. / anti-infectives IM, nebulizer solution
Action-Inhibits protein synthesis in bacteria at level of 30S ribosome—bactericial action / IM, IV, neb uilzer solution
40 mg/ml / ototxicity, nephrotoxity / -Keep pt. hydrated, assess for infection, observe eighth cranial nerve, monitor I&O, daily weights, assess for signs of super infection.
-Monitor renal function by urinalysis, specific gravity, BUN, creatinine, and CCr.
Zyvox- linezoid
*R.P. ia taking it for an infection. / anti-infectives PO, IV
bactericidal action against streptococci, bacteriostatic action against enterococci and staphylococci / PO
600 mg tablet / S/E- ha, psudomembranous colitis, diarrhea, n, v, / PO with/without food, invert oral solution to mix do not shake,
-Assess for infection, obtain specimens for C&S, vision changes,
-monitor bowel function, monitor cbc, platelet count
Acetaminophen- Tylenol
*R.P. is taking it for pain and fever. / Antipyretic/ non-opioid analgesic
Action- decreases pain and fever / PO, Rectal
PO 325 mg tablet / Side effects- hepatotoxicity, renal failure, rash, urticaria / Po- administer with a full glass of water, watch for overdose, assess pain and fever.
Antidote- acetylcysteine
Novolin R-
*R.P. is taking it for diabetes mellitus. / Antidiabetic-
-Control of hyperglycemia in diabetic pts. Lowers blood glucose by -stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. / Sq,IV
SQ-
onset, 30-60 min,
peak 2-4 hr, duration 5-7 hr
v-100 sliding scale / S/e hypoglycemia, swelling / -administer regular insulin within 15-30 min before a meal,
-Watch for signs of hypoglycemia and hyperglycemia, -monitor body weight, blood glucose q 6 hr
(Deglin & Vallerand, 2008).