1 Running head: PROCESS PAPER Process Paper: Discitis and Osteomyelitis Lori A. Risner Kent State University Stark College of Nursing 2 Running head: PROCESS PAPER Process Paper: Discitis and Osteomyelitis Introduction Seventy four year old E.H. was admitted to Altercare of Noble’s Pond on August 12, 2010. Altercare at Noble’s Pond is a senior care facility that focuses on gerontological nursing and rehabilitation needs of clients in need of assistance. Admission assessment indicated that E.H.’s chief complaint was a severe stabbing, sharp pain that was persistent and interfered with her ability to perform activities of daily living independently. The location of the pain was her lower lumbar sacral spine. After diagnostic tests were performed, E.H. was diagnosed with Discitis and Osteomyelitis of the spine. The osteomyelitis was traced back to a catheter that was inserted during her last hospitalization, which was left in place for five days. E.H. needed the assistance of the nursing staff to maintain blood levels by way of intravenous therapy and manage her chronic pain with pharmacological and non-pharmacological methods. Through use of the nursing process, a care plan was carefully written for E.H. by the skilled nursing staff which included infection control, balanced nutrition, increased mobility with regards to safety, and pain management. Client Profile Before a physical assessment was performed on E.H., I had the opportunity to look at her medical chart to obtain a past medical history. The medical chart also indicated which medications she would be receiving on my shift and which treatments needed done. This allowed me to plan my day around the care that would be provided. Before even assessing E.H., I had a perceived picture of who she was. I know nurses are not supposed to speculate about patients, Running head: PROCESS PAPER 3 but it is vital that a nurse has a thorough understanding of each patient before he or she cares for them. E.H. was admitted to Noble’s Pond on August 12, 2010. The primary reason for admission was Lumbar Disc Disorder, but she also presented with many other diagnoses which include osteomyelitis, type II diabetes, acute kidney failure, anemia, difficulty walking, anxiety, and constipation. Her primary reason for seeking medical attention was a constant sharp, stabbing pain in her lower lumbar sacral spine. Admission Medical Diagnosis Lumbar disc disorder along with Discitis was the admitting diagnoses of E.H. upon admission to the senior care facility. Definition and Pathophysiology. “Degenerative disc disease refers to a syndrome in which a compromised disc causes low back pain” (Ullrich, 2006). Lumbar disc disease usually starts with a twisting injury to the lower back (Ullrich, 2006). It can also be caused my simple wear and tear on the spine that is related to the aging process (Black & hawk, 2009). E.H. did not experience a fall prior to this admission, however she does have a past medical history of osteoarthritis and compression deformities that may have lead to the lumbar disc disorder. Osteoarthritis is defined as a type of arthritis that is caused by the breakdown and eventual loss of the cartilage in the joints (Black & Hawk, 2009). It occurs most frequently as a person ages. The normal wear and tear on the body causes the cartilage to degenerate (Black & hawk, 2009). The spine has the ability to withhold most mechanical stressors, but pain and injury may be the result if it is strained beyond its limits (Black & Hawk, 2009). Compression deformities occur as are the result of biomechanical or caustic origins (Black & Hawk, 2009). Running head: PROCESS PAPER 4 The low back pain that is associated with lumbar disc disorder is usually generated from either inflammation or abnormal motion instability (Ullrich, 2006). In the case of E.H., it resulted from inflammation. A thorough assessment of the vertebral column was completed with the end result being a diagnosis of Discitis. “Discitis, or disc space infection, is an inflammatory lesion of the intervertebral disc” (Holt, 2003). This inflammation is the result of proteins being shifted into the disc space that irritates the nerves causing the sensation of pain (Ullrich, 2006). Patients diagnosed with it to have a hard time performing activities of daily living. Severe, sharp pain was the chief complaint upon admission to the senior care facility. Signs and Symptoms. Many patients with lumbar disc disease will experience a low-grade but tolerable pain that will occasionally flare up for a few days up to a few weeks (Ullrich, 2006). Pain is usually felt in the center of the back and can radiate to the hips and down the legs (Ullrich, 2006). The characteristic findings of Discitis are extension of the spine and complete refusal to flex the spine (Holt, 2004). Patients with Discitis do not usually present with a fever and their blood work usually does not show an increase in white blood cells either (WBC). Of all lab results the one that will be affected by Discitis would be the erythrocyte sedimentation rate, which is usually increased (Holt, 2004). Primary Medical Diagnoses The primary medical diagnosis that E.H. presented with upon admission was Osteomyelitis. Definition and Pathophysiology. Osteomyelitis is defined as the inflammation and destruction of bone that is caused by a bacteria, mycobacteria, or fungi (Schmitt, 2008). It is an infrequent cause of back pain ( U r s p r u n g , K e t t n e r , & B o e s c h , 2 0 0 5 ) . V e r t e b r a l Running head: PROCESS PAPER 5 o s t e o m ye l i t i s o c c u r s f o r 2 - 4 % o f a l l o s t e m ye l t i s i s c a s e s ( U r s p r u n g e t a l . , 2 0 0 5 ) . Osteomyelitis can be spread to a born by either coming in close contact with an infected tissue or by way of a blood borne organism (Schmitt, 2008). The most common cause of osteomyelitis is Staphylococcus aureus, however Escherichia coli, Pseudomonas, Klebsiella, Salmonella, and Proteus organisms may also be the causative agent (Black & Hawk, 2009). According to Black and Hawk (2009), the most common sites for osteomyelitis to occur are the femur, tibia, sacrum, and the heels. Males are affected more commonly than women related to the fact that men experience more traumas and trauma is one of the leading causes of osteomyelitis (Black & hawk, 2009). Susceptibility to osteomyelitis is increased by many factors which include but are not limited to IV drug use, diabetes, immunocompromising disease, chronic open wounds, malnutrition, and liver failure and a history of bloodstream infections (Black & Hawk, 2009). E.H. has a past medical history of type II diabetes mellitus, thus increasing her risk for osteomyelitis. Signs and Symptoms. Patients with osteomyelitis usually experience clinical manifestations that include fever, weight loss, fatigue, localized warmth, swelling, and erythema (Schmitt, 2008). These clinical manifestations are a result of the body’s response to the invading pathogens. Signs and symptoms vary depending on the location of the infection (Black & Hawk, 2009). Clients diagnosed with osteomyelitis may not appear acutely ill with other systematic manifestations (Black & Hawk, 2009). When the infection is in the vertebrae, intense pain and mobility problems will most likely arise (Black & Hawk, 2009). E.H.’s chief complain upon admission was a severe, sharp pain in her lumbar sacral spine. With further assessment it was noted that E.H. had chronic pain that she rated a 4 or 5 out of a possible 10. The pain was slightly alleviated through the use of pain medications, however it never was rated less than a 2 out of 10. Running head: PROCESS PAPER 6 When osteomyelitis is detected in the vertebra, the health care provider should take a look at the patient’s past medical history to see if they have a history of genitourinary infections of drug abuse (Black & Hawk, 2009). This happens to be the case for E.H. Her medical chart indicated that upon admission to the hospital for an unlisted reason, a foley catheter was inserted. The catheter was left in place for 5 days and caused E.H. to develop an infection in her spine. Once a Peripherally Inserted Central Venous Catheter (PICC) was inserted and long term antibiotic therapy was initiated, E.H. was transferred to Noble’s Pond for further monitoring and rehabilitation. Diagnosis and Treatment. When a patient presents with localized bone pain, osteomyelitis is suspected and the physician will order lab work ( U r s p r u n g e t a l . , 2 0 0 5 ) . The lab work will consist of a complete blood count, erythrocyte sedimentation rate (ESR), and C-reactive protein (Black & Hawk, 2009). The lab work will be a definitive indicator that an infection is brewing. An elevated ESR is common in clients with osteomyelitis (Black & Hawk, 2009). An X-Ray of the affected bone should also be ordered on admission (Schmitt, 2008). Some physicians will also order Magnetic Resonance Imaging, as it can detect abnormal lesions within 48 hours of pathogen invasion (Black & Hawk, 2009). Another way a health care provider can diagnosis osteomyelitis is through the results of blood cultures and needle aspirations (Black & Hawk, 2009). Treatment of osteomyelitis includes parenteral antibiotics are four to eight weeks followed by oral antibiotics (Black & Hawk, 2009). The oral antibiotic therapy may last another four to eight weeks depending on the results of the blood work (Black & Hawk, 2009).In order to monitor antibiotic treatment, the health care provider will order for peaks and troughs to be drawn (Black & Hawk, 2009). In the case of E.H., it was a vancomycin trough that was ordered. Running head: PROCESS PAPER 7 “When a vancomycin dose is given, its concentration rises in the blood, peaks, and then falls.” (Lab Tests Online, 2010). The next dose of the drug is given when the first dose is beginning to lose its effectiveness. The reason we do this is so that the level of antimicrobial is always in the therapeutic range. Trough levels are collected just prior to the next ordered dose (Lab Tests Online, 2010). The result of E.H.’s trough was 21.2 mcg/ml. This does not fall in the therapeutic range for the trough draw which is 5-10mcg/mL (Lab Tests Online, 2010). If the trough level falls outside of the normal range, the patient is at risk for toxicity. Other Medical Diagnoses Aside from Discitis and Osteomyelitis, E.H. also had a past medical history of uncomplicated type II diabetes, acute renal failure, anemia, and constipation. Type II Diabetes Mellitus. Diabetes Mellitus is a chronic, progressive disease that is characterized by the body’s failure to metabolize carbohydrates, fats and proteins, which can lead to hyperglycemia (Black & Hawk, 2009). Diabetes is classified into four diverse categories: type I diabetes mellitus (insulin dependent), type II diabetes mellitus (non insulin dependent), gestational diabetes, and other specific types (Black & Hawk, 2009). E.H. has been diagnosed with type II diabetes mellitus. Her medical chart indicated that it was uncomplicated. Type II diabetes mellitus is the result of a progressive secretory defect along with insulin resistance and can be linked to obesity (Black & Hawk, 2009). In type II diabetes mellitus, a restricted beta cell reaction to hyperglycemia appears to be a major factor in its development (Black & Hawk, 2009). Along with insulin resistance, type II diabetes is also associated with resistance to biologic activity of insulin in the liver and the peripheral tissues (Black & Hawk, 2009). Running head: PROCESS PAPER 8 The clinical manifestations of type II diabetes mellitus are presented in the form of either hyperglycemia or hypoglycemia (Black & Hawk, 2009). Other signs and symptoms include increased urination (polyuria), increased thirst and fluid intake (polydipsia), increased hunger (polyphagia), weight loss, blurred vision, itching (pruritus), weakness, and dizziness (Black & Hawk, 2009). In order to diagnose type II diabetes mellitus, the health care provider will need to do a physical exam along with blood work (Black & Hawk, 2009). The diagnostic lab tests for diabetes include: fasting blood glucose (greater than 126 mg/dl indicative of DM), casual blood glucose (greater than 200 mg/dl indicative of DM) and post meal blood glucose test(Black & Hawk, 2009). The treatment for type II diabetes mellitus includes management of weight, a healthy diet, increased exercise, with the possibility of antidiabetic or hypoglycemia medications (Black & Hawk, 2009). E.H. is receiving oral Micronase help keep her blood glucose under control. She is also required to check her blood sugar every morning and before bed to see if insulin is needed. Acute Renal Failure. Acute renal failure refers to the abrupt loss of kidney function over a period of hours to days (Black & Hawk, 2009). Over this time, the glomuerular filtration rate drops which causes serum creatinine and blood urea nitrogen to increase (Black & Hawk, 2009). There are many possible causes of acute renal failure. These include hypotension and pre-renal hypovolemia (Black & Hawk, 2009). Pre-renal causes are the ones that interfere with the perfusion to the kidney (Black & Hawk, 2009). This in turn decreases the amount of fluid available to the kidney for filtration (Black & Hawk, 2009). There are two forms of acute renal failure, nonoliguric and oliguric. The pathophysiology behind renal failure is not fully understood. Running head: PROCESS PAPER 9 Clinical manifestations of acute renal failure are dependent on the phase of failure (Black & Haw, 2009). Acute renal failure effects are widespread and effect many organ systems. The clinical manifestations include: fluid and electrolyte imbalances, acidosis, increased susceptibility to infections, anemia, platelet dysfunction, gastrointestinal impediment, increased risk of pericarditis, and decreased wound healing (Black & Hawk, 2009). Medical management of acute renal failure includes maintain fluid and electrolyte balance and replacing renal function (Black & Hawk, 2009). Dialysis is frequently required for treatment of acute renal failure (Black & Hawk, 2009). The treatment for renal failure is dependent on the cause (Black & Hawk, 2009). Anemia. Anemia is a clinical condition that is the result of insufficient healthy red blood cells or decreased quantity of hemoglobin (Black & Hawk, 2009). If anemia is present, the transport of oxygen to other body tissues is hindered (Black & Hawk, 2009). In order to make up for the decreased number of red blood cells, the body attempts to make more red blood cells thus increasing the cardiac output and increasing the workload of the heart (Black & Hawk, 2009). Clinical manifestations of severe anemia include pallor, severe fatigue, malaise, lightheadedness, fever, dyspnea on exertion, and weight loss (Black & Hawk, 2009). All of these manifestations place the client at increased risk for injury. Other signs and symptoms of anemia include dry skin, brittle nails, blurred vision, tinnitus, tachycardia, palpitations, angina, hypertension, back pain, and severe bone/join pain (Black & Hawk, 2009). E.H. presented with many of these manifestations including: dyspnea on exertion, fatigue, dry skin, back pain and join/bone pain. Oxygen therapy can be used to alleviate anemia (Black & Hawk, 2009). It is used to help prevent tissue hypoxemia (Black & Hawk, 2009). Running head: PROCESS PAPER 10 Surgical History E.H.’s stated that her past surgical history only includes two items. Back in 1999, E.H. was taking a shower and she accidently fell which resulted in a left hip fracture. This led to a left total hip replacement that took place in September of 2000. The surgery went well and no major complications arose as a result aside from the persistent pain that she now endures. The second surgery E.H. underwent was in 2005. This surgery was also performed on her hip. Patient did not give details of this surgery. When all was said and done, E.H. started noticing sever pain that affected her ability to ambulate and perform activities of daily living. These surgeries have played a major role in E.H.’s life. Even though she now experience persistent pain in her hips, if she never underwent the total hip replacement in 2000 she may not be able to ambulate at all. The surgeries may have caused her pain, but they also allowed her to continue living mobile life. Assessment The assessment that was performed on E.H. on September 15, 2010 resulted in the following data. Vital signs were assessed first: T-97.6 ˚F, pulse (radial)-70, R-18, BP- 122/64, and Pain 4/5 out of a possible. E.H. described the pain as dull, but stabbing and she located it in her back and left hip. She was alert and orientated to person, place, and time. Upon assessment of her head and skin, I came to find out that her skin was pink, dry and intact. Her facial expression was smiling and her facial symmetry was symmetrical. Her tongue and mucous membranes were pink and moist. The throat appeared clear with no areas of redness or lesions. E.H. wears glasses for seeing both near and far. As a result of a stroke she experienced prior to admission, E.H. is deaf in her right ear and therefore wears a hearing aid. She also wears top dentures and sometimes wears her bottom dentures. Skin turgor was less than 3 seconds bilaterally. Hair and nails were both within normal limits. Upon assessment of E.H.’s eyes, her Running head: PROCESS PAPER 11 pupils were round, reacted to light and accommodated. Assessment of the neck revealed that her trachea was midline and no jugular vein distention was present. Respiratory assessment included lungs that were clear in all lobes to auscultation, a regular respiratory rhythm, and no presentation of a cough. E.H.’s chest was round and symmetrical. She did however complain of dyspnea on exertion and shortness of breath. Apical heart rhythm was 76 beats per minute. Assessment of the abdomen revealed a round, non-tender, non-distended abdomen with bowel sounds in all four quadrants. The date of E.H.’s last bowel movement was September 15, 2010 at 1600. E.H. can move all extremities however as a result of her stroke; her right side of her body is weaker than the left. Her extremities were warm to the touch and no edema was noted. Pedal pulses were +2 bilaterally. See Gordon’s Functional Assessment for Further details of assessment. Chart includes subjective, objective, and indirect data collected during assessment. Diagnostic Assessment Tools The assessments tools there were used in assessing E.H. were the Braden Assessment, the Fall Risk Assessment, the Geriatric Depression Scale, and ADLs. Each provided with unique data that was used in devising an appropriate care plan for E.H. Braden. The Braden Assessment tool is used in elevating a patient’s risk for developing a pressure ulcer (Black & Hawk, 2009). The criterion that is looked at includes sensory perception, moisture, nutrition, activity, friction and shear, and mobility (Black & Hawk, 2009). A score of 23 would indicate that a patient is at very low risk for developing a pressure ulcer. E.H. scored 17 out of a possible 23 on this scale. This indicates that she is at slight risk for developing a pressure ulcer. I placed her at a 3 (slightly limited) for sensory perception, 4 (rarely moist) for moisture, 3 (walks occasionally) for activity, 2 (very limited) for mobility, 3 (adequate) for nutrition, and 2 (potential problem) for friction and shear. Running head: PROCESS PAPER 12 Fall Risk. The fall risk assessment was devised in order to alert caregivers that certain clients are at high risk for falls and injuries (Black & Hawk, 2009). The results of E.H.’s fall risk assessment are as follows. Get Up & Go Test Able to rise in a single movement—No loss of balance with steps Pushes up, successful in one attempt Multiple attempts, but successful Unable to rise without assistance during test 0 - 1 - 3 3 4 - Score Greater than 5 is indicative of High fall Risk Geriatric Depression Scale. The geriatric depression scale is used to measure the amount of depression in the older adult (Black & Hawk, 2009). It entails a series of questions that the patient answers with either a yes or a no. A score that is greater than 5 is suggestive of depression (Black & Hawk, 2009). A score greater than 10 is almost always indicative of depression (Black & hawk, 2009). The results of E.H.’s geriatric depression are as follows. The results indicate that E.H. has the possibility of suffering from depression (Black & Hawk, 2009). Do you feel your life is empty? (No) Do you often get bored? (Yes) Are you in good spirits most of the time? (Yes) Are you afraid something bad is going to happen to you? (Yes) Have you dropped many of your activities and interests? (Yes) Do you feel happy most of the time? (Yes) Do you often feel helpless? (Yes) Do you prefer to stay at home, Rather than going out and doing new things? (No) Do you feel you have more problems with memory than most? (No) Do you think it is wonderful to be alive now? (Yes) Running head: PROCESS PAPER 13 Do you feel pretty worthless the way you are now? (No) Do you feel full of energy? (No) Do you feel that your situation is hopeless? (No) Do you think most people are better off than you? (Yes) Activities of Daily Living. Upon assessment of E.H.’s ADLs, it is evident that E.H. needs the assist of one to perform them successfully. She is able to toilet, feed and groom herself; however she does need assistance when it comes to dressing, physical ambulation, and bathing. She also needs reminded to take her daily medications. no no no no no no no no no 14 Running head: PROCESS PAPER Gordon’s Functional Assessment AREA OF HEALTH HEALTH/PERCEPTION HEALTH MANAGEMENT General Survey, perceived health & well-being, selfmanagement strategies, utilization of preventative health behaviors and/or services. SUBJECTIVE DATA E.H. stated that she smoked a pack of cigarettes a day in her 30s. E.H. stated that she does not use alcohol or abuse any recreational drugs. E.H. stated that she is current with her immunizations and that besides her pain, she would perceive her health as good. E.H. stated that she follows her prescribed exercise regimen during physical therapy. E.H. described her pain as a dull, stabbing pain in her back left hip. E.H. stated that her lumbar disc disorder was a OBJECTIVE DATA INDIRECT DATA INTERPRETATION *Identify source of indirect data (effective patterns or barriers/potential barriers) Vital signs were as follows T 97.6 F, P 70, BP 122/64, R 18, Pain 4/5 out of a possible 10 in the back left hip. E.H.'s past medical history include from her chart includes lumbar disc disorder, osteomyelitis, anemia, diabetes type II, acute kidney acute failure, and constipation. E.H. had just returned from physical therapy and was resting in best upon assessment. The bed was in low position and the 2 lower side rails were up. The call light was within reach in case nursing staff was needed. E.H.'s medical chart indicated that she was taking the following medications as a result of her current and past medical history. The orders are as follows: Tenormin PO 25 mg BID Norvasc PO 5mg once daily Advair Diskus 250-50 mcg/Dose Zantac PO 150mg once daily Zocor PO 40mg once daily Lasix PO 20mg once daily Lovenox SQ 40mg/0.4ml once daily Micronase PO 02.5 mg once daily Ascorbic Acid PO 500 mg once daily Aspirin PO 81mg once daily Calcium Carbonate PO 500mg TID Clonidine PO 0.1mg TID The assessment that I performed on E.H. allowed me to see that she perceives her health as valuable. She knows that she is not going to get better unless she initiates health maintenance behaviors and engages in health promotion. It seems that even though she has an extensive past medical history, she still feels good about her health. One of the biggest barriers would be her pain. Pain decreases ambition to perform activities, even if they are beneficial. If pain management is effective, E.H. should be able to effectively cope with her conditions. Her vital signs were within normal limits and her immunizations were up to date. E.H wears glasses for seeing near and far. A hearing aid is also worn in the right ear as she is deaf on that side. Dentures are worn on the top only. 15 Running head: PROCESS PAPER result of a catheter that was inserted last time she was hospitalized and left in for 5 days. Cozaar PO 100mg once daily Colace PO 100mg BID Ambien PO 10mg PRN Promethazine PO 25mg q6h PRN Vicodin PO 500mg q4h PRN Ventolin HFA INHAL 90mcg/puff 2 Puffs q6h PRN Miralax Oral 17 grams/dose PRN Treatment orders for E.H. include pressure reduction device to bed to prevent skin breakdown; Skin assessment q week; evaluation of heels while in bed; reposition q 2 h while in bed; regular diet; Bilateral top half side rails to enhance be mobility; and basic metabolic panel NUTRITIONAL/ METABOLIC Patterns of food and fluid consumption, Weight, skin turgor. (Skin, Hair, Nails; Head & Neck; Mouth, Nose, Sinus; swallowing, Ht., Wt) E.H. stated that she sometimes has swallowing disabilities as a result of her esophageal problems in the early 1990s.. E.H. stated that she wears full dentures on the top and sometimes wears her full bottom dentures also. Upon assessment, E.H.'s skin was pink, dry and intact. Facial symmetry was symmetrical. Tongue was pink and moist. Mucous membranes were pink and moist also. Throat was clear. Esophagus closes. Upper dentures were in place, no bottom dentures E.H. had an order for a regular diet in her medical chart. She had no fluid restrictions. A basic metabolic panel was ordered on 08/16/10. This metabolic panel consisted of a CBC, with diff., ESR, and CRP. E.H. had an order for repositioning every 2 hours to reduce the chance of skin breakdown. An order for weekly skin assessment was also in place for E.H. It is very evident that a balanced diet needs to maintained in order to successfully fight off her infection. The biggest barrier would be her problems swallowing. If this problem is not monitored, E.H. could be at increased risk for aspiration or may choke. He diet needs to be foods that are easily chewed and swallowed. She may also want to consider getting her bottom dentures refitted so chewing is easier. This will make her able to 16 Running head: PROCESS PAPER E.H. stated that she has a regular appetite and does not usually experience nausea, vomiting or chewing disabilities. E.H. stated that she feeds herself. ELIMINATION Patterns of excretory function & Elimination of waste; relevant labs, Medications, impacting, etc. (Abdominal - bowel and bladder) E.H. stated that she normally has 1-2 bowel movements each day now that a laxative has been ordered for her. She stated that her last BM was on September 15, 2010 at 1600. E.H. stated that she urinates five to six times a day. She states that she does not have issues with urgency, frequency, or dyuria. E.H. stated that she is continent of both her bowel and were worn during assessment. Hearing aid was in place and functioning properly in right ear. No nasal or ear drainage was present. Braden score 17/23. Skin turgor was <3seconds. Hair and nails were within normal limits. Upon assessment, E.H. had Bowel sounds in all four quadrants. Her abdomen was round, soft, and non tender. No distention was noted. chew foods that are high in protein, which is essential for healing. It is important to abide by the q2h turn schedule so skin breakdown does not occur. E.H.'s medical chart indicated that she has a history of constipation and therefore is currently taking Colace BID and Miralax 17 grams once a day PRN for relief. E.H. is also taking Lasix, which is a diuretic which increases urine output. Vicodin is order for pain management; however a side effect of narcotics is constipation. No foley has been inserted since admission to the nursing home; however E.H.'s current infection is the result of a foley catheter that was left in for 5 days for a prior hospital admission. After assessment of E.H.'s elimination patterns, it seems as though she has no significant difficulties with voiding besides occasional episodes of constipation. The laxatives make it easier for E.H. to use the bathroom. If E.H. is going to continue to take narcotics, it will be beneficial to remain on stool softeners or laxatives. One other concern would be voiding at night. This could increase the chance of an injury is she must get out of bed multiple times throughout the night. 17 Running head: PROCESS PAPER bladder, but occasionally she has accidents at night because she has to get up to urinated throughout the night. ACTIVITY/EXERCISE Patterns of exercise & daily living, self-care activities include major body systems involved. (Thoracic & Lung; Cardiac; Peripheral vascular; Musculoskeletal, vital signs) E.H. stated that she uses a walker for ambulation and sometimes depends on a wheelchair. E.H. stated that she is able to perform some activities of daily living such as dressing herself and bathing, however she does need assistance with activities such as cleaning the house, going grocery shopping, and getting to and from doctors appointments. E.H. stated that she has limited movement on her right side as a result of a stoke E.H.'s respiratory rhythm was regular with SOB with activities. Lungs were clear bilaterally. E.H. was not experiencing a cough and therefore no sputum was present. Apical pulse was 76 and regular. Chest was round and symmetrical. Upon assessment of the extremities, E.H. can move all extremities however strength in the right foot is decreased because of the stroke that was experienced. Hand grasps were strong and equal bilaterally. The left E.H. has orders to attend physical and occupational therapy five times a week for 6 weeks- 8 weeks for ADL retraining, functional mobility training, safety awareness training, balance retraining, and transfer training. E.H. has a past medical history of anemia, which interferes with activity tolerance. Lab studies indicated that E.H.'s hemoglobin was decreased to 11.1, (10.5) and hematocrit was decreased to 34.8% (33.3%). E.H. has a past medical history of difficulty walking. E.H. presented with severe sharp pain in the lower lumbar sacral spine, which limits mobility. E.H. needs assistance of 1 for some activities of daily living. It is a plus that she decided to quit smoking and that she is a non drinker. It is important to remain mobile even in times of high stress. It helps to maintain homeostasis and bodily functions. Exercise is important in decreasing the incidence of constipation. Musculoskeletal limitations are evident, but with the help of physical therapists and occupational therapists, optimal functioning can be maintained. One barrier to activity and exercise would be the past medical history of a stroke that decreased strength in the right lower extremity. 18 Running head: PROCESS PAPER that was experienced previously. She stated that she wears a brace on her right ankle for extra support. E.H. stated that she has an unsteady gait but given her circumstance, she does okay getting around. leg was stronger than the right leg. SCDs are worn at home. Activity level was up with assistance of one. Extremities were warm bilaterally. Capillary refill was <3seconds. No edema was present. Pedal pulses were +2 bilaterally. Patient stated that she experiences shortness of breath with activities and Dyspnea on exertion. E.H. stated that she is a non smoke and a non drinker. SEXUALITY/ REPRODUCTION Satisfaction with present level of Interaction with sexual partners (Breast; Testes; AbdominalGenitourinary-reproductive) E.H. stated that she has not experienced any complications related to her breasts, GI system, or reproductive tract. E.H. stated that she consistently attended her yearly No pain or tenderness in breast area. Not fully assessed No past medical history of sexually transmitted infections. No barriers related to sexuality/reproduction. This part of the assessment was not thorough or indept. 19 Running head: PROCESS PAPER pap before she hit menopause. SLEEP/REST Patterns of sleep, rest, relaxation, fatigue (Appearance, behavior) E.H. stated that on average she sleeps about 6 hours each night. She said that she does not usually sleep through the night because she has to get up and go to the bathroom throughout the night. During the assessment, E.H. appeared fatigued. She had just returned from therapy and wanted to relax. Her behavior was very calm and cooperative. E.H.'s medical chart indicated that she had an order for Ambien PO 10 mg PRN once a day before bed to help E.H. fall asleep and stay asleep It is very important to have adequate rest, especially when fighting off an infection. If proper amount of rest is not obtained, fatigue throughout the day is the result. This increases the risk for falls and injuries. If E.H. is tired she may not feel like eating or going to therapy, which will increase healing time. relaxation techniques are important to teach and reinforce throughout the day. E.H. is alert and orientated to person, Patient's chart stated that she is deaf in her right ear, thus the Pain management is a very important part of E.H.'s care plan. E.H. stated that she does not feel well rested when she wakes up in the morning because she usually wakes up 2-3 times each night. Patient stated that she enjoys reading at night because it helps her to fall asleep. COGNITIVE/ Patient rates her pain a 4/5 out of a 20 Running head: PROCESS PAPER PERCEPTUAL Patterns of thinking & ways of Perceiving environment, orientation Mentation, neuron status, glasses, Hearing aids, etc. possible 10. She describes it as dull and stabbing. She stated that her pain medication relieves it for a short period of time, but her pain is never a 0/10. The pain is located in her lower lumbar sacral spine, and radiated to her back. place, and time. Her speech is clear. Pupils are round, react to light, and accommodate. E.H. was pleasant and calm. She answered questions promptly and seemed to have no issues with confusion or impaired memory. use of a hearing aid. Uncontrolled pain impairs healing. Another barrier would be her deafness. It can be very frustrating to an older client if they are not able to hear. It is important to maintain a positive attitude. Patient seemed engaged in conversation during assessment. E.H. was very open when it came to talking about her family, although her mood changed from cheerful to No family members visited during assessment. No past medical history of violence or depression. E.H. has went through a lot and has experienced losses that I could never imagine going through. It is a very good quality that she can stay in good spirits and look on the bright side. She seems like she really adores her family and wishes she could see them more often. I think that she has a good support system and E.H. states that she wears glasses and also has a hearing aid that is used in her right ear as a result of being deaf in that ear. E.H. denies numbness and tingling. ROLE/RELATIONSHIP Patterns of engagement with others, Ability to form & maintain meaningful Relationships, assumed roles; Family communication, Patient stated that she was married, but her husband passed away in February of 2002. E.H. stated that she lives alone. E.H. stated that she had 6 children, 4 of 21 Running head: PROCESS PAPER response, Visitation, occupation, community involvement which are living. Three of them are boys and one is a girl Her oldest girl died in an automobile accident at the age of 33. Her next daughter developed a brain tumor at the age of 19 and died at the age of 45. Patient stated that most of her children live far away and do not get to come visit very often. sorrowful when talking about the loss of her children. She seemed delighted when she was talking about her grandchildren. Through all of the struggles and losses she has experienced, she still seemed hopeful and truly believes that her daughters are in a better place now. that they will help her get through this, just as they did when she experienced her losses. Patient stated that she has 10 grandchildren (5 boys and 5 girls) and 14 great grandchildren. She also mentioned that there are two more great grandchildren on the way. E.H. stated that she worked as a retail clerk a good majority of her life. SELF-PERCEPTION/ E.H. stated that she E.H. was dressed E.H. has a past medical history Positive body image promotes 22 Running head: PROCESS PAPER SELF-CONCEPT Patterns of viewing & valuing would rate her anxiety a 2 out of 10. appropriate. Personal hygiene was well maintained. Eye contact was sustained throughout conversation. Questions were readily answered without hesitation. of anxiety. longevity and increases happiness. If a person does not value themselves, chances are other people will not value them either. E.H. stated that in order to reduce stress, she enjoys reading books. It keeps her mind off of her everyday problems. Patient did not express signs or symptoms of depression. E.H. expressed normal feelings of grief when talking about touchy subjects. Patient showed no signs or symptoms of excessive stress. No history of depression. Past medical history of anxiety. When it comes to coping abilities, E.H. seems very well prepared for dealing with grief. If proper coping mechanisms are maintained, depression may be avoided. Reading is a very good way to keep the mind preoccupied. It is a way to escape the real world, even if it is just for a little while. If no coping mechanisms and stress reduction techniques were implemented, E.H. would be at higher risk for health disturbances. Self; body image & psychological state COPING/STRESS TOLERANCE Stress tolerance, behaviors, patterns of coping with stressful events & level of effectiveness, depression, anxiety. Patient stated that she has not experienced a major loss in the last year. E.H. is excited to go home, but at the same time she is nervous about performing ADLs without assistance. Patient stated that she does not feel depressed and that 23 Running head: PROCESS PAPER she feels as though her coping abilities are effective. VALUE/BELIEF Patterns of belief, values, Perception of meaning of life that guide choices or decision; includes but is not limited to religious beliefs Patient stated that she used to attend church regularly. E.H. stated that she believes in a higher power and that she believes that her daughters are up there with him watching down over her. Not fully assessed Medical record indicated that E.H. is a Prostestant. It is important to have values and beliefs, including but not limited to religious beliefs. They help people think logically through challenging situations and give them the strength they need to make it through hard times. Values help guide a person's decisions Running head: PROCESS PAPER 24 Laboratory Data E.H. had blood work drawn on upon arrival at Noble’s Pond and then had repeat blood work drawn to see if pharmacologic therapy was effective. The laboratory findings indicated that E.H. had many abnormal serum levels, which will be discussed on the chart that follows. The major concern with Osteomyelitis is white blood cell count (WBC), which is indicative of infection (Black & Hawk, 2009). E.H. had a WBC level of 4.1 mm^3 on the first drawn and 4.5 mm^3 the second draw. Both levels are below therapeutic level, which is a condition referred to as leukopenia (Black & Hawk, 2009). Leukopenia is defined as “abnormal decrease of white blood cells usually below 5000/mm^3” (Black & Hawk, 2009). The lab results also indicated that the body’s stress response was active and helping to fight off the infection. Laboratory results are as follows. All Normal ranges and interpretation were obtained from MedicalSurgical Nursing; Clinical Management for Positive Outcomes (Black & Hawk, 2009). Laboratory Value Sodium Results Time 1: 137 mEq/L Normal Range 135-145 mEq/L Within Normal Range; No hypernatremia or hyponatremia present; 95-105 mEq/L High; hyperchloremia; Associated with Anemia (decreased mass of RBCs) and acute renal failure, but of which E.H. presents with. Time 2: 136 mEq/L Chloride Time 1: 109 mEq/L Time 2: 107 mEq/L Calcium Time 1: 9.6 mg/dL Time 2: 8.9 mg/dL Interpretation 9-11 mg/dL Within Normal Range; No electrolyte imbalance Running head: PROCESS PAPER Creatinine Time 1: 1.1 mg/dL 25 0.5-1.3 mg/dL Within Normal Range 5-20 mg/dL High; Increased BUN may be increased by acute renal failure, inadequate nutrition, the infectious process, and Diabetes Mellitus, all of which E.H. presents with. 6-25 % Within Normal Range Time 2: 1.2 mg/dL BUN Time 1: 26 mg/dL Time 2: 25 mg/dL BUN/Creatinine Time 1: 24 % Time 2: 21 % Hemoglobin Time 1: 11.1 g/dL Females: 12-16 g/dL Time 2: 10.5 g/dL Males: 13.5-19 g/dL Low; Past Medical History of Anemia (decreased mass of circulating RBCs) Time 1: 34.8 % Females: 38-47% Time 2: 33.3 % Males: 40-54% MCV- Mean Corpuscular Volume Time 1: 91.1 fL 80-100 fL Within Normal Range; This measures erythrocyte size and Hcg count MCHC - Mean Corpucsular Hemoglobin Concentration Time 1: 31.9 % 31-37% Within Normal Range; Measures average hemoglobin concentration within 100 mL of packed RBCs. Neutrophil Time 1: 59.9 % 55-70 % Within Normal Range 20-40 % Within Normal Range Hematocrit Time 2: 88.6 fL Time 2: 31.5 % Time 2: 17.8 % Low; Past medical History of Anemia (decreased mass of circulating RBCs) Time 2: 55.1 % Lymphyoctye Time 1: 22.7 % Running head: PROCESS PAPER 26 Time 2: 25.9 % Monocyte Time 1: 8.9 % 2-8 % High; An increased Monocyte count is related to invading bacteria and the infectious process; body’s defense mechanisms against E.H.’s Oseteomyelitis. 0.5-1.0 % High; A result of certain types of anemias; E.H. has a Past medical history of anemia 3.5-5.0 mEq/L High; hyperkalemia as a result of acute kidney failure 22-29 mEq/L Within Normal Range 150-450 x 10^9/L Within Normal Range; No signs of thrombocytopenia or hemolytic disorders Time 2: 11.2 % Basophil Time 1: 2.2 % Time 2: 1.8 % Potassium Time 1: 5.6 mEq/L Time 2: 5.1 mEq/L Carbon Dioxide Time 1: 23 mEq/L Time 2: 22 mEq/L Platelets Time 1: 266 x 10^9/L Time 2: 257 x 10^9/L Glucose Time 1: 98 mg/dL 70-110 mg/dL Time 2: 87 mg/dL WBC Time 1: 4.1/mm^3 5,000-10,000/mm^3 Low; indicative of leukopenia (WBC < 5000mm^3); Immunosuppression of Body’s Defense mechanism r/t infection and Antibiotic therapy (Azactam) that E.H. is receiving r/t Osteomyelitis Time 2: 4.5/mm^3 RBC Time 1: 3.82 Within Normal Range; No sign of hyperglycemia or hypoglycemia Females=4.2-5.4 Low; A result of Running head: PROCESS PAPER 27 million/mm^3 million/mcL Time 2: 3.75 million/mm^3 Males=4.7-6.1 million/mm^3 E.H.’s Past medical History of Anemia; The result of Erythropoietin deficiency secondary to kidney disease Medical- Surgical Nursing; Clinical Management for Positive Outcomes (Black et. Al, 2009). Other Diagnostic Test Results 1st Step 08/12/10 Negative 2nd Step 08/25/10 Bilateral Lower Extremity Venous Duplex Scan Time 1: No echogenic Filling Within Normal limits Vancomycin Trough 21.2 mcg/ml High Chest X-Ray PICC in superior aspect of Right Atrium Within Normal limits MantouxTest MRI Lumbar Spine Computed Tomography (CT Scan) Negative Edema throughout the L4 and L5 vertebral bodies (compatible with discitis) Moderate compression deformities at the endplates of L4 Adjacent Osteomyelitis at L4-L5 No results Available Medication Information E.H.’s medication flow sheet specified that she had a medication regimen that had a vast range of drugs each with different classifications, indications, and actions. E.H is currently Running head: PROCESS PAPER 28 receiving IV Azactam. This drug is anti-infective that was prescribed to treat E.H.'s osteomyelitis (Deglin & Vallerand, 2005). Tenormin, Cozaar, Clonidine, and Norvasc have been ordered to lower E.H.'s blood pressure (Deglin & Vallerand, 2005). Advair is a corticosteroid that was prescribed to manage asthma, while Zantac was ordered to heal and prevent ulcers (Deglin & Vallerand, 2005). Zocor is used to lower LDL and cholesterol (Deglin & Vallerand, 2005). Lasix is a diuretic used in the management of hypertension and is used to diuresis excess fluids (Deglin & Vallerand, 2005). The purpose of Lovenox is to prevent thrombus formation (Deglin & Vallerand, 2005). Micronase is used to help lower blood glucose in type II diabetics (Deglin & Vallerand, 2005). Aspirin was ordered in order to decrease inflammation and manage pain (Deglin & Vallerand, 2005).The other medications are listed as "PRN" which means they are given as needed. The following charts present all medication information for all the drugs that are prescribed to E.H. All information was retrieved from Davis's Drug Guide for Nurses (Deglin & Vallerand, 2005). Drug Classification Indication Action Dosage Aztreonam (Azactam) Therapeutic Classification: anti-infectives Pharmacologic Classification: monobactams Treatment of serious gram-negative infections including: Septicemia, Skin and skin structure infections, Intra-abdominal infections, Gynecologic infections, Respiratory tract infections, & Urinary tract infections. Binds to the bacterial cell wall membrane, causing cell death. Therapeutic Effects: Bactericidal action against susceptible bacteria. IM, IV (Adults): Moderately severe infections—1–2 g q 8–12 hr; severe or life-threatening infections (including those due to Pseudomonas aeruginosa)—2 g q 6–8 hr; urinary tract infections—0.5–1 g q 8–12 hr. Renal Impairment IV (Adults): CCr 10–30 mL/min—1–2 g initially, then 50% of usual dosage at usual interval; CCr <10 mL/min–500 mg-2 g initially, then 25% of usual dosage at usual interval (⅛ of initial dose should also be given after each hemodialysis session). IM Onset Rapid Peak 60 minutes Duration 6-8 hours IV Rapid End of infusion 6-8 hours Running head: PROCESS PAPER Side Effects Assessment Drug Classification Indication Action Dosage Side Effects 29 CNS: seizures. GI: pseudomembranous colitis, altered taste, diarrhea, nausea, vomiting. Derm: rash. Local: pain at IM site, phlebitis at IV site. Misc: allergic reactions, superinfection. Assess for infection -vital signs; wound appearance, sputum, urine, and stool; Obtain a history before initiating therapy to determine previous use of and reactions to penicillins and cephalosporins. Patients allergic to these drugs may exhibit hypersensitivity reactions to aztreonam. Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results. Observe for signs and symptoms of anaphylaxis. Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of pseudomembranous colitis. May begin up to several weeks following cessation of therapy. Lab Test Considerations: May cause increase in AST, ALT, alkaline phosphatase, LDH, and serum creatinine. May cause increase prothrombin and partial thromboplastin times, and positive Coombs’ test. Tenormin (Atenolol) Therapeutic Classification: antianginals & antihypertensives Pharmacologic Classification: beta blocker Management of hypertension; Management of angina pectoris; Prevention of MI. Blocks stimulation of beta1 adrenergic receptors. Does not usually affect beta2 receptor sites. Therapeutic Effects: Decreased blood pressure and heart rate; Decreased frequency of attacks of angina pectoris; Prevention of MI. PO (Adults): Antianginal—50 mg once daily; may be increased after 1 wk to 100 mg/day (up to 200 mg/day). Antihypertensive—25–50 mg once daily; may be increased after 2 wk to 50–100 mg once daily. MI—50 mg, then 50 mg 12 hr later, then 100 mg/day as a single dose or in 2 divided doses for 6–9 days or until hospital discharge. Onset Peak Duration 1 hour 2-4 hours 24 hours CNS: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, memory loss, mental status changes, nervousness, nightmares. EENT: blurred vision, stuffy nose. Resp: bronchospasm, wheezing. CV: bradycardia, CHF, pulmonary edema, hypotension, peripheral vasoconstriction. GI: constipation, diarrhea, liver function abnormalities, nausea, vomiting. GU: erectile dysfunction, decreased libido, urinary frequency. Derm: rashes. Endo: hyperglycemia, hypoglycemia. MS: arthralgia, back pain, joint pain. Running head: PROCESS PAPER 30 Assessment Take apical pulse before administering drug. If less than 50 bpm, withhold medication and call healthcare provider. Monitor blood pressure, EKG, and pulse frequently during dosage adjustment period and occasionally throughout therapy. Monitor intake and output ratios; daily weights. Assess routinely for CHF (dyspnea, rales/crackles, weight gain, peripheral edema, jugular venous distention). Monitor frequency of prescription refills to determine adherence. Assess frequency and characteristics of angina periodically throughout therapy. Lab Test Considerations: May cause increased BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels. May cause increased ANA titers. May cause increase in blood glucose levels. Toxicity and Overdose: Monitor patients receiving beta blockers for signs of overdose which include: bradycardia, severe dizziness or fainting, severe drowsiness, dyspnea, bluish fingernails, and seizures. Notify physician immediately if these signs occur. Drug Classification Amlodipine (Norvasc) Therapeutic Classification: Antihypertensives Pharmacologic Classification: Calcium channel blockers Alone or with other agents in the management of hypertension, angina pectoris, and vasospastic angina. Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of the excitation-contraction coupling and subsequent contraction. Therapeutic Effects: Systemic vasodilation resulting in decreased blood pressure. PO (Adults): 5–10 mg once daily; PO (Geriatric Patients): Antihypertensive—Initiate therapy at 2.5 mg/day, increase as required/tolerated (up to 10 mg/day); antianginal—start therapy at 5 mg/day, increase as required/tolerated (up to 10 mg/day) Indication Action Dosage Side Effects Assessment Onset Peak Duration Unknown 6-9 hours 24 hours CNS: headache, dizziness, fatigue. CV: peripheral edema, angina, bradycardia, hypotension, palpitations. GI: gingival hyperplasia, nausea. Derm: flushing. Monitor blood pressure and pulse before therapy, during dose titration, and periodically during therapy. Monitor EKG periodically. Monitor intake and output ratios and daily weight. Assess for signs of CHF. Angina: Assess location, duration, intensity, and precipitating factors of patient’s anginal pain. Lab Test Considerations: Total serum calcium concentrations are not affected by calcium channel blockers. Running head: PROCESS PAPER Drug Classification Indication Action Dosage PO Transdermal Epidural Side Effects Assessment 31 Clonidine Therapeutic Classification: Antihypertensives Pharmacologic Classification: Adrenergics Management of mild to moderate hypertension; Epidural: Management of cancer pain unresponsive to opioids alone. Unlabelled: Management of opioid withdrawal. Stimulates alpha-adrenergic receptors in the CNS; which results in decreased sympathetic outflow inhibiting cardio-acceleration and vasoconstriction centers. Prevents pain signal transmission to the CNS by stimulating alphaadrenergic receptors in the spinal cord. Therapeutic Effects: Decreased blood pressure & Decreased pain. PO (Adults): Hypertension--100 mcg (0.1 mg) bid, increase by 100–200 mcg (0.1–0.2 mg)/day q 2–4 days. Usual maintenance dose is 200–600 mcg (0.2– 0.6 mg)/day in 2–3 divided doses (up to 2.4 mg/day).Urgent treatment—200 mcg (0.2 mg) loading dose, then 100 mcg (0.1 mg) q hr until blood pressure is controlled or 800 mcg (0.8 mg) total has been administered. Opioid withdrawal—300 mcg (0.3 mg)–1.2 mg/day, may be decrease by 50%/day for 3 days, then discontinued or decrease by 100–200 mcg (0.1–0.2 mg)/day. PO (Geriatric Patients): 100 mcg (0.1 mg) at bedtime initially, increase as needed. Transdermal (Adults): Hypertension: 100–300 mcg (0.1–0.3 mg)/24 hr applied every 7 days. Epidural (Adults): 30 mcg/hr initially; titrated according to need. Onset 30-60 minutes Peak 2-4 hours Duration 8-12 hours 2-3 days Unknown 7 days + Unknown Unknown Unknown CNS: drowsiness, depression, dizziness, nervousness, nightmares. CV: bradycardia, hypotension, palpitations. GI: dry mouth, constipation, nausea, vomiting. GU: erectile dysfunction. Derm: rash, sweating. F and E sodium retention. Metab: weight gain. Misc: withdrawal phenomenon. Monitor intake and output ratios and daily weight, and assess for edema daily, especially at beginning of therapy. Monitor blood pressure and pulse frequently during initial dose adjustment and periodically throughout therapy. Assess location, character, and intensity of pain prior to, frequently during first few days, and routinely throughout administration. Monitor for fever as potential sign of catheter infection. Monitor patient for signs and symptoms of opioid withdrawal Lab Test Considerations: May cause transient increase in blood glucose levels. May cause decrease urinary catecholamine and VMA concentrations; these may increase on abrupt withdrawal. Drug Fluticasone-Salmeterol (Advair Diskus) Running head: PROCESS PAPER Classification Indication Action Dosage Side Effects Assessment Drug Classification: Indication 32 Fluticasone: corticosteroids Salmeterol: bronchodilators, adrenergic Maintenance and prophylactic treatment of asthma; may decrease requirements for or avoid use of systemic corticosteroids and delay pulmonary damage that occurs from chronic asthma; Long term control of reversible airway obstruction due to asthma and for maintenance of asthma and prevention of bronchospasms; Prevention of exercise induced asthma Potent, locally acting anti-inflammatory and immune modifier; Produces accumulation of cyclic adenosine monophosphate at beta2 adrenergic receptors. Effect: Decrease frequency and severity of asthma attacks; Bronchodilation Salmeterol:Inhalation (Adults and children greater than 4 years): Diskus— 50mcg (one inhalation as dry powder) twice daily (approximately 12 hours apart); Inhaler 42 mcg (2 puffs) twice daily, 12 hours apart. Exercise induced brochospasm—Inhaler—42 mcg (two puffs) 30-60 minutes before exercise Fluticasone: Inhalation (Adults and children greater than 12 years) 100 mcg twice daily initially, may be increased up to 500 mcg twice daily Onset Peak Duration 10-25 minutes 3-4 hours 12 hours + CNS: headache, nervousness, CV: palpitations, tachycardia, GI: abdominal pain, diarrhea, nausea. MS: muscle cramps, soreness. Neuro: trembling. Resp: paradoxical brochospasm, cough, upper respiratory tract infection, wheezing. GI: diarrhea. MS: muscle pain. EENT: dysphonia, hoarseness, oropharyngeal fungal infections, nasal stuffiness, rhinorrhea, sinusitis. Assess lung sounds, pulse, and blood pressure before administration and periodically during therapy. Monitor pulmonary function tests before initiating therapy and periodically during therapy. Observe for paradoxical bronchospams (wheezing, dyspnea, and tightness in chest) and hypersensitivity reaction (rash, urticaria, swelling of the face, lips or eyelids). Lab test considerations: May cause increased serum glucose concentrations; occurs rarely with recommended doses and is more pronounced with frequent use of high doses. May cause decreased serum potassium concentrations, which are usually transient and dose related; rarely occurs at recommended doses and is more pronounced with frequent high doses. Toxicity and Overdose: Symptoms of overdose include persistent agitation, chest pain, or discomfort, decreased blood pressure, dizziness, hyperglycemia, hypokalemia, and vomiting Ranitidine HCL (Zantac) Therapeutic Classification: Antiulcer agents Pharmacologic Classification: Histamine H2 antagonists Short-term treatment of active duodenal ulcers and benign gastric ulcers; Maintenance therapy for duodenal and gastric ulcers after healing of active ulcers; Management of gastric hypersecretory states; Treatment of and maintenance therapy for erosive esophagitis;Treatment of gastroesophageal reflux disease; Heartburn, acid indigestion, and sour stomach. IV: Prevention and treatment of stress-induced upper GI bleeding in critically Running head: PROCESS PAPER ill patients. Inhibits the action of histamine at the H2-receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. Therapeutic Effects: Healing and prevention of ulcers; Decreased symptoms of gastroesophageal reflux; Decreased secretion of gastric acid. PO (Adults): Short-term treatment of active ulcers—150 mg twice daily or 300 mg once daily at bedtime. Duodenal ulcer prophylaxis—150 mg once daily at bedtime. GERD—150 mg twice daily. Erosive esophagitis—150 mg 4 times daily initially, then 150 mg twice daily as maintenance. IV, IM (Adults): 50 mg q 6–8 hr (not to exceed 400 mg/day). Continuous IV infusion—6.25 mg/hr. Gastric hypersecretory conditions—1 mg/kg/hr; may be increased by 0.5 mg/kg/hr (not to exceed 2.5 mg/kg/hr). Action Dosage 33 PO IM IV Side Effects Assessment Onset Peak Duration Unknown 1-3 hours 8-12 hours Unknown 15 minutes 8-12 hours Unknown 15 minutes 8-12 hours CNS: confusion, dizziness, drowsiness, hallucinations, headache. CV: arrhythmias. GI: constipation, diarrhea, nausea. GU: decreased sperm count, erectile dysfunction. Endo: gynecomastia. Hemat: agranulocytosis, aplastic anemia, neutropenia, thrombocytopenia. Local: pain at IM site. Misc: hypersensivity reactions, vasculitis. Assess patient for epigastric or abdominal pain; frank or occult blood in the stool; emesis; or gastric aspirate. Assess geriatric and debilitated patients routinely for confusion. Lab Test Considerations: CBC with differential should be monitored periodically during therapy. May cause false-negative results in skin tests using allergenic extracts. Histamine antagonists should be discontinued 24 hr before the test. May cause an increase in serum transaminases and serum creatinine. May cause a false-positive result for urine protein; test with sulfosalicylic acid. Drug Classification Indication Action Dosage Simvastatin (Zocor) Therapeutic Classification: Lipid-lowering agents Pharmacologic Classification: hmg-coa reductase inhibitors Adjunctive management of primary hypercholesterolemia and mixed dyslipidemias; Secondard prevention of myocardial infarction, coronary revascularization, stroke and cardiovascular mortality in patients with clinically evident coronary heart disease. Inhibits 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, an enzyme which is responsible for catalyzing an early step in the synthesis of cholesterol. Therapeutic Effects: Lowers total and LDL cholesterol and triglycerides. Slightly increases HDL. Slows the progression of coronary atherosclerosis with resultant decrease in CHD-related events PO (Adults): 5–80 mg once daily in the evening. Increase at 4 week intervals up to 40 mg/day. Renal Impairment PO (adults) severe renal impairment— 5mg/day initially, titrate carefully. Running head: PROCESS PAPER Side Effects Assessment 34 Onset Peak Duration Days 2-4 weeks unknown CNS: dizziness, headache, insomnia, weakness. GI: abdominal cramps, constipation, diarrhea, flatus, heartburn, altered taste, drug-induced hepatitis, dyspepsia, elevated liver enzymes, nausea, pancreatitis. GU: erectile dysfunction. Derm: rashes, pruritus. Misc: hypersensitivity reactions. Obtain a dietary history, especially with regard to fat consumption. Administer PO once a day in the evening. May be given without regard to food. Avoid grapefruit juice during therapy. Lab Test Considerations: Evaluate serum cholesterol and triglyceride levels before initiating, after 4–6 wk of therapy, and periodically thereafter. Monitor liver function tests, including AST, before, at 12 wk after initiation of therapy or after dose elevation, and then q 6 months. If AST levels increase to 3 times normal, HMG-CoA reductase inhibitor therapy should be reduced or discontinued. May also cause increase alkaline phosphatase and bilirubin levels. If patient develops muscle tenderness during therapy, monitor CK levels. If CK levels are >10 times the upper limit of normal or myopathy occurs, therapy should be discontinued. Drug Classification Indication Action Dosage PO IM IV Side Effects Furosemide (Lasix) Therapeutic Classification: diuretics Pharmacologic Classification: loop diuretics Edema due to heart failure, hepatic impairment or renal disease; Hypertension. Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule; Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium. Therapeutic Effects: Diuresis and subsequent mobilization of excess fluid; Decreased blood pressure. Edema PO (Adults): 20–80 mg/day as a single dose initially, may repeat in 6–8 hr; may increase dose by 20–40 mg q 6–8 hr until desired response. Maintenance doses may be given once or twice daily (doses up to 2.5 g/day have been used in patients with congestive heart failure or renal disease). Hypertension—40 twice daily initially; adjust further dosing based on response; Hypercalcemia—120 mg/day in 1–3 doses. IM, IV (Adults): 20–40 mg, may repeat in 1–2 hr and increase by 20 mg every 1–2 hr until response is obtained, maintenance dose may be given q 6– 12 hr; Continuous infusion-Bolus 0.1 mg/kg followed by 0.1 mg/kg/hr, double q 2 hr to a maximum of 0.4 mg/kg/hr. Hypertension PO (Adults): 40 twice daily initially Onset Peak Duration 30-60 minutes 1-2 hours 6-8 hours 10-30 minutes Unknown 4-8 hours 5 minutes 30 minutes 2 hours CNS: blurred vision, dizziness, headache, vertigo. EENT: hearing loss, tinnitus. CV: hypotension. GI: anorexia, constipation, diarrhea, dry mouth, Running head: PROCESS PAPER Assessment 35 dyspepsia, nausea, pancreatitis, vomiting. GU: excessive urination. Derm: photosensitivity, pruritis, rash. Endo: hyperglycemia, hyperuricemia. F and E dehydration, hypocalcaemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis. Hemat: aplastic anemia, agranulocytosis, hemolytic anemia, leukopenia, thrombocytopenia. MS: muscle cramps. Neuro: paresthesia. Misc: fever, increased BUN Assess fluid status. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. Notify physician or other health care professional if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs. Monitor blood pressure and pulse before and during administration. Geri: Diuretic use is associated with increased risk for falls in older adults. Assess falls risk and implement fall prevention strategies. Assess patients receiving digoxin for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Patients taking digoxin are at increased risk of digoxin toxicity because of the potassiumdepleting effect of the diuretic. Assess patient for tinnitus and hearing loss. Hearing loss is most common after rapid or high-dose IV administration in patients with decreased renal function or those taking other ototoxic drugs. Assess for allergy to sulfonamides. Lab Test Considerations: Monitor electrolytes, renal and hepatic function, serum glucose, and uric acid levels before and periodically throughout therapy. Commonly decreases serum potassium. May cause decrease serum sodium, calcium, and magnesium concentrations. May also cause increased BUN, serum glucose, creatinine, and uric acid levels. Drug Classification Indication Action Dosage Enoxaparin (Lovenox) Therapeutic Classification: Anticoagulants Pharmacologic Classification: Antithrombotics, Prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) in surgical and medical patients; Treatment of deep vein thrombosis; Prevention of ischemic complications (with aspirin) from: unstable angina Potentiates the inhibitory effect of antithrombin on factor Xa and thrombin. Therapeutic Effects: Prevention of thrombus formation. DVT Prophylaxis SC (Adults): Knee replacement surgery—30 mg q 12 hr starting 12–24 hr after surgery; Hip replacement—40 mg 12 hr before surgery then once daily; Abdominal surgery—40 mg 2 hr prior to surgery, then every 24 hr postop for 7–12 days or until ambulatory; Medical patients with acute illness—40 mg once daily. Treatment of DVT/PE SC(Adults): Outpatient—1 mg/kg every 12 hr; Inpatient—1 mg/kg every 12 hr or 1.5 mg/kg every 24 hr. Warfarin should be started within 72 hr; Enoxaparin may be continued for 5–17 days or until therapeutic anticoagulation with warfarin is achieved (INR >2 for two consecutive days). Running head: PROCESS PAPER 36 Renal Impairment Subcut (Adults CCr < 30 mL/min): DVT prophylaxis for abdominal, knee or hip surgery—30 mg once daily SC Side Effects Assessment Onset Peak Duration Unknown Unknown 12 hours CNS: dizziness, headache, insomnia. CV: edema. GI: constipation, nausea, reversible increase in liver enzymes, vomiting. GU: urinary retention. Derm: ecchymosis, pruritus, rash, urticaria. F and E hyperkalemia. Hemat: bleeding, anemia, thrombocytopenia. Local: erythema at injection site, hematoma, irritation, pain. Misc: fever. Administer deep into SC tissue. Alternate injection sites daily between right and left anterloteral and left and right anterlateral abdominal wall. Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; black, tarry stools; hematuria; fall in hematocrit or blood pressure; guaiac-positive stools); bleeding from surgical site. Assess patient for evidence of additional or increased thrombosis. Symptoms depend on area of involvement. Monitor patient for hypersensitivity reactions (chills, fever, urticaria). Report signs to health care professional. SC: Observe injection sites for hematomas, ecchymosis, or inflammation. Lab Test Considerations: Monitor CBC, platelet count, and stools for occult blood periodically during therapy. If thrombocytopenia occurs, monitor closely. If hematocrit decreases unexpectedly, assess patient for potential bleeding sites. May cause increase in AST and ALT levels. May cause hyperkalemia. Toxicity and Overdose: For overdose, protamine sulfate 1 mg for each mg of Enoxaparin should be administered by slow IV injection. Drug Classification Indication Action Dosage PO Side Effects Glyburide (Micronase) Therapeutic Classification: Antidiabetics Pharmacologic Classification: Sulfonylureas Control of blood sugar in type 2 diabetes mellitus when diet therapy fails. Requires some pancreatic function. Lowers blood sugar by stimulating the release of insulin from the pancreas and increasing the sensitivity to insulin at receptor sites; May also decrease hepatic glucose production. Therapeutic Effects: Lowering of blood sugar in diabetic patients. PO (Adults): DiaBeta :2.5–5 mg once daily initially (range 1.25–20 mg/day). Glynase PresTab (micronized)—1.5–3 mg/day initially (range 0.75–12 mg/day; doses >6 mg/day should be given as divided doses). PO (Geriatric Patients): DiaBeta : 1.25–2.5 mg/day initially; may be increased by 2.5 mg/day weekly. Onset Peak Duration 45-60 minutes 1.5-3 hours 24 hours CNS: dizziness, drowsiness, headache, weakness. GI: constipation, cramps, diarrhea, drug-induced hepatitis, dyspepsia, ↑ appetite, nausea, vomiting. Derm: photosensitivity, rashes. Endo: hypoglycemia. F and E hyponatremia. Running head: PROCESS PAPER Assessment 37 Hemat: aplastic anemia, agranulocytosis, hemolytic anemia, leukopenia, pancytopenia, thrombocytopenia. Accidental administration of oral hypoglycemic agents to non0diabetic adults and children has resulted in serious harm or death, Observe for signs and symptoms of hypoglycemic reactions (sweating, hunger, weakness, dizziness, tremor, tachycardia, and anxiety). Assess patient for allergy to sulfonamides. Lab Test Considerations: Monitor serum glucose and glycosylated hemoglobin periodically during therapy to evaluate effectiveness. Monitor CBC periodically during therapy. May cause an increase in AST, LDH, BUN, and serum creatinine. Toxicity and Overdose: Overdose is manifested by symptoms of hypoglycemia. Mild hypoglycemia may be treated with administration of oral glucose. Severe hypoglycemia should be treated with IV D50W followed by continuous IV infusion of more dilute dextrose solution at a rate sufficient to keep serum glucose at approximately 100 mg/dL. Drug Classification Indication Action Dosage PO, IM, SQ, IV Side Effects Assessment Ascorbic Acid Therapeutic Classification: Vitamins Pharmacologic Classification: Water soluble vitamins Treatment and prevention of vitamin C deficiency (scurvy) with dietary supplementation; Supplemental therapy in some GI diseases during longterm parenteral nutrition or hemodialysis. Necessary for collagen formation and tissue repair. Involved in oxidation reduction reactions; tyrosine, folic acid, iron, and carbohydrate metabolism; lipid and protein synthesis; cellular respiration; and resistance to infection. Therapeutic Effects: Replacement in deficiency states; Supplementation during increased requirements. PO (Adults): Scurvy: 500 mg/day for at least 14 days. Prevention of deficiency: 50–100 mg/day. IM (Adults): Scurvy: 100–500 mg/day for at least 14 days. Onset Peak Duration 2 days- 3 weeks Unknown Unknown CNS: drowsiness, fatigue, headache, insomnia. GI: cramps, diarrhea, heartburn, nausea, vomiting. GU: kidney stones. Derm: flushing. Hemat: deep vein thrombosis, hemolysis, sickle cell crisis. Local: pain at SC or IM sites. Often ordered as part of a multivitamin supplementation, because inadequate diet often results in multiple vitamin deficiency. Extended release capsules should be swallowed whole without crushing. Assess for signs of vitamin C deficiency (faulty bone and tooth development, gingivitis, bleeding gums, loosened teeth) before and during therapy. Running head: PROCESS PAPER 38 Lab Test Considerations: Mega doses of ascorbic acid (>10 times the RDA requirement) may cause false-negative results for occult blood in the stool. May cause decreased serum bilirubin and increased urine oxalate, urate, and cysteine levels. Drug Classification Indication Action Dosage PO Side Effects Assessment Acetylsalicylic Acid (Aspirin) Therapeutic Classification: Antipyretics & nonopioid analgesics Pharmacologic Classification: Salicylates Inflammatory disorders including Rheumatoid arthritis & Osteoarthritis; Mild to moderate pain; Fever; Prophylaxis of transient ischemic attacks and MI. Produce analgesia and reduce inflammation and fever by inhibiting the production of prostaglandins; Decreases platelet aggregation. Therapeutic Effects: Analgesia; Reduction of inflammation; Reduction of fever; Decreased incidence of transient ischemic attacks and MI. Pain/Fever PO, Rect (Adults): 325–1000 mg q 4–6 hr (not to exceed 4 g/day). Extendedrelease tablets—650 mg q 8 hr or 800 mg q 12 hr. Inflammation PO (Adults): 2.4 g/day initially; increased to maintenance dose of 3.6–5.4 g/day in divided doses. Prevention of Transient Ischemic Attacks PO (Adults): 50–325 mg once daily Prevention of Myocardial Infarction & Antiplatelet effects PO (Adults): 80–325 mg once daily; Suspected acute MI-160 mg as soon as suspected. Onset Peak Duration 5-30 minutes 1-3 hours 3-6 hours EENT: tinnitus. GI: GI bleeding, dyspepsia, epigastric distress, nausea, abdominal pain, anorexia, hepatotoxicity, vomiting. Hemat: anemia, hemolysis. Derm: rash, urticaria. Misc: allergic reactions including anaphylaxis and laryngeal edema Use lowest dose for shortest time. Administer after meals or with food or an antacid to minimize gastric distress. Patients who have asthma, allergies, and nasal polyps or who are allergic to tartrazine are at an increased risk for developing hypersensitivity reactions. Assess pain and limitation of movement; note type, location, and intensity before and at the peak after administration. Fever: Assess fever and note associated signs (diaphoresis, tachycardia, malaise, chills). Running head: PROCESS PAPER 39 Lab Test Considerations: Monitor hepatic function before antirheumatic therapy and if symptoms of hepatotoxicity occur; more likely in patients, especially children, with rheumatic fever, systemic lupus erythematosus, juvenile arthritis, or pre-existing hepatic disease. May cause increase serum AST, ALT, and alkaline phosphatase, especially when plasma concentrations exceed 25 mg/100 mL. May return to normal despite continued use or dose reduction. If severe abnormalities or active liver disease occurs, discontinue and use with caution in future. Prolongs bleeding time for 4–7 days and, in large doses, may cause prolonged prothrombin time. Monitor hematocrit periodically in prolonged high-dose therapy to assess for GI blood loss. Toxicity and Overdose: Monitor for the onset of tinnitus, headache, hyperventilation, agitation, mental confusion, lethargy, diarrhea, and sweating. If these symptoms appear, withhold medication and notify physician or other health care professional immediately. Drug Classification Indication Action Dosage Side Effects PO Assessment Calcium Carbonate Therapeutic Classification: Mineral and electrolyte replacements/supplements Treatment and prevention of hypocalcaemia; Adjunct in the prevention of postmenopausal osteoporosis; Relief of acid indigestion or heartburn; Treatment of hyperphosphatemia in end-stage renal disease. Essential for nervous, muscular, & skeletal systems; Maintain cell membrane and capillary permeability; Act as an activator in the transmission of nerve impulses and contraction of cardiac, skeletal, and smooth muscle. Essential for bone formation and blood coagulation; Therapeutic Effects: Replacement of calcium in deficiency states. Control of hyperphosphatemia in end-stage renal disease. 1 gram of calcium carbonate contains 400 mg elemental calcium. PO (Adults): Prevention of hypocalcaemia, treatment of depletion & osteoporosis:1–2 g/day in 3–4 divided doses. Antacid—0.5–1.5 g prn CNS: headache, tingling. CV: arrhythmias, bradycardia. GI: constipation, nausea, vomiting. GU: calculi, hypercalciuria. Onset Peak Duration Unknown Unknown Unknown Administer calcium carbonate 1- 1.5 hours after meals and at bedtime. Chewable tablets should be well chewed. Observe patient closely for symptoms of hypocalcemia. Notify physician or other health care professional if these occur. Protect symptomatic patients by elevating and padding side rails and keeping bed in low position. Monitor patient on digitalis glycosides for signs of toxicity. When used as an antacid, assess for heartburn, indigestion, and abdominal pain. Inspect abdomen; auscultate bowel sounds. Lab Test Considerations: Monitor serum calcium or ionized calcium, chloride, sodium, potassium, magnesium, albumin, and parathyroid hormone (PTH) concentrations before and periodically during therapy for treatment of hypocalcaemia. Toxicity and Overdose: Assess patient for nausea, vomiting, anorexia, thirst, severe constipation, paralytic ileus, and bradycardia. Contact physician or other health care professional immediately if these occur. Running head: PROCESS PAPER 40 Drug Classification Losartan (Cozaar) Therapeutic Classification: Antihypertensives Pharmacologic Classification: Angiotensin II receptor antagonists Indication Alone or with other agents in the management of hypertension; Treatment of diabetic nephropathy in patients with type 2 diabetes; Prevention of stroke in patients with hypertension and left ventricular hypertrophy. Blocks vasoconstrictor and aldosterone-producing effects of angiotensin II at receptor sites, including vascular smooth muscle and the adrenal glands. Therapeutic Effects: Lowering of blood pressure; Slowed progression of diabetic nephropathy; Decreased risk of cardiovascular death in patients with left ventricular systolic dysfunction who are post-MI; Decreased risk of stroke in patients with hypertension and left ventricular hypertrophy PO (Adults): Hypertension—50 mg once daily initially (range 25–100 mg/day as a single daily dose or 2 divided doses). Prevention of stroke in patients with hypertension and left ventricular hypertrophy: 50 mg once daily initially; hydrochlorothiazide 12.5 mg once daily should be added and/or dose of losartan increase to 100 mg once daily followed by an ↑ in hydrochlorothiazide to 25 mg once daily based on blood pressure response. Type 2 diabetic nephropathy: 50 mg once daily, may increase to 100 mg once daily depending on blood pressure response. Action: Dosage PO Side Effects Assessment Onset Peak Duration 6 hours 3-6 weeks 24 hours CNS: dizziness, anxiety, depression, fatigue, headache, insomnia, weakness. CV: hypotension, chest pain, edema, tachycardia. Derm: rashes. EENT: nasal congestion, pharyngitis, rhinitis, sinusitis. GI: abdominal pain, diarrhea, druginduced hepatitis, dyspepsia, nausea, vomiting. GU: impaired renal function. F and E hyperkalemia. MS: arthralgia, back pain, myalgia. Misc:angioedema For patients who have difficulty swallowing, the pharmacist can order a compound oral solution, stable for 4 weeks. Assess blood pressure (lying, sitting, standing) and pulse periodically during therapy. Monitor frequency of prescription refills to determine adherence. Assess patient for signs of angio-edema (dyspnea, facial swelling). Monitor daily weight and assess patient routinely for resolution of fluid overload (peripheral edema, rales or crackles, dyspnea, weight gain, jugular venous distention). Lab Test Considerations: Monitor renal function and electrolyte levels periodically. Serum potassium, BUN, and serum creatinine may be increased. May cause increase AST, ALT, and serum bilirubin. May also cause an increase in uric acid, slight decrease in hemoglobin and hematocrit, neutropenia, and thrombocytopenia. Drug Classification Promethazine (Phenergan) Therapeutic Classification: Antiemetics, antihistamines & sedative Running head: PROCESS PAPER Indication Action Dosage PO, IM Rectal IV Side Effects Assessment Drug Classification Indication Action 41 Pharmacologic Classification: Phenothiazines Treatment of various allergic conditions and motion sickness; Preoperative sedation; Treatment and prevention of nausea and vomiting; Adjunct to anesthesia and analgesia Blocks the effects of histamine; Has inhibitory effect on the chemoreceptor trigger zone in the medulla, resulting in antiemetic properties; Alters the effects of dopamine in the CNS; Produces CNS depression by indirectly decreased stimulation of the CNS reticular system. Therapeutic Effect: Relief of symptoms of histamine excess usually seen in allergic conditions; Decreased nausea & vomiting; Sedation. PO (Adults): 6.25-12.5 mg 3 times a day and 25 mg at bedtime IM, IV, Rect (Adults): 25 mg; may repeat in 2 hours Sedation: PO, Rect, IM, IV (Adults): 25-50 mg; may repeat 4-6 hours if needed Antiemetic: PO, Rect, IM, IV (Adults): 12.5 mg-25 mg every 4 hours as needed. Onset Peak Duration 20 minutes Unknown 4-12 hours 20 minutes Unknown 4-12 hours 3-5 minutes Unknown 4-12 hours CNS: confusion, disorientation, sedation, dizziness, fatigue, insomnia, nervousness. EENT: blurred vision, diplopia, tinnitus. CV: bradycardia, hypertension, hypotension, tachycardia. GI: constipation, drug-induced hepatitis, dry mouth. Derm: photosensitivity, severe tissue necrosis upon infiltration at IV site, rashes. Hemat: blood dyscrasias. Supervise ambulation closely when administering it with opioid analgesics to avoid injury. Monitor blood pressure, pulse, and respiratory rate frequently. Assess level of sedation after administration. Risk of sedation and respiratory depression are increased when administered concurrently with other drugs that cause CNS depression. Assess for delirium, acute confusion, dizziness, dry mouth, blurred vision, urinary retention, constipation, tachycardia. Assess allergy symptoms (rhinitis, conjunctivitis, hives) before and periodically throughout course of therapy. Assess patient for nausea and vomiting before and after administration If administered IV, assess for burning and pain at IV site; may cause severe tissue injury. If pain occurs, discontinue administration immediately. Labs: May cause false-positive or false-negative pregnancy test results. Evaluate CBC periodically during chronic therapy; blood dyscrasias may occur. May cause serum glucose. Hydrocodone;Acetaminophen (Vicodin) Therapeutic Classification: Allergy, Antitussive & opioid analgesics Pharmacologic Classification: opioid agonists nonopioid analgesic combination Used mainly in combination with nonopioid analgesics (acetaminophen & ibuprofen) in the management of moderate to severe pain; Antitussive Bind to opiate receptors in the CNS--> Alter the perception of and response Running head: PROCESS PAPER 42 to painful stimuli while producing generalized CNS depression; Suppresses the cough reflex via a direct central action Therapeutic Effect: Decrease in severity of moderate pain & Suppression of the cough reflex PO (Adults): 2.5-10 mg every 3-6 hours as needed; Dosage PO Side Effects Assessment Antitussive PO (Adults): 5 mg every 4-6 hours as needed Onset Peak 10-30 minutes 30-60 minutes Duration 4-6 hours CNS: confusion, dizziness, sedation, euphoria, hallucinations, headache, unusual dreams. EENT: blurred vision, diplopia, miosis. Resp: respiratory depression. CV: hypotension, bradycardia. GU: urinary retention. Misc: physical dependence, psychological dependence, tolerance. Explain the therapeutic effects of medication before administration. Assess blood pressure, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation.. Dose may need to be decreased by 25–50%. Initial drowsiness will diminish with continued use. Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk, and laxatives to minimize constipating effects. Stimulant laxatives should be administered routinely if opioid use exceeds 2–3 days, unless contraindicated. Assess type, location, and intensity of pain prior to and 1 hr (peak) following administration. Prolonged use may lead to physical and psychological dependence and tolerance. Assess cough and lung sounds during antitussive use. Labs: May cause increased plasma amylase and lipase concentrations Drug Classification Indication Action Dosage Albuterol Sulfate (Ventolin HFA) Therapeutic classification: bronchodilators; Pharmacologic Classification: adrenergics Used as a bronchodilator to control and prevent reversible airway obstruction caused by asthma or COPD. Inhaln: Used as a quick-relief agent for acute bronchospasm and for prevention of exercise-induced bronchospasm. PO: Used as a long-term control agent in patients with chronic/persistent bronchospasm. Binds to beta2-adrenergic receptors in airway smooth muscle, leading to activation of adenyl cyclase and increased levels of cyclic-3′, 5′-adenosine monophosphate (cAMP). Increases in cAMP activate kinases, which inhibit the phosphorylation of myosin and decrease intracellular calcium. Decreased intracellular calcium relaxes smooth muscle airways. Relaxation of airway smooth muscle with subsequent bronchodilation. Relatively selective for beta2 (pulmonary) receptors. Therapeutic Effects: Bronchodilation PO (Adults and Children ≥12 yr): 2–4 mg 3–4 times daily or 4–8 mg of Running head: PROCESS PAPER 43 extended-release tablets twice daily. PO (Geriatric Patients): Initial dose should not exceed 2 mg 3–4 times daily, may be increase carefully (up to 32 mg/day). Inhaln (Adults): metered-dose inhaler—2 inhalations q 4–6 hr or 2 inhalations 15 min before exercise (90 mcg/spray); some patients may respond to 1 inhalation. Adults—4–8 puffs q 20 min for up to 4 hr then q 1– 4 hr prn. Inhaln (Adults): Guidelines for acute asthma exacerbation via nebulization or IPPB—2.5–5 mg q 20 min for 3 doses then 2.5–10 mg q 1–4 hr prn; Continuous nebulization—10–15 mg/hr. PO Inhalation Side Effects Assessment Onset 15-30 minutes Peak 2-3 hours Duration 4-6 hours 5-15 minutes 60-90 minutes 3-6 hours CNS: nervousness, restlessness, tremor, headache, insomnia (Pedi: occurs more frequently in young children than adults), hyperactivity in children. CV: chest pain, palpitations, angina, arrhythmias, hypertension. GI: nausea, vomiting. Endo: hyperglycemia. F and E hypokalemia. Neuro: tremor. Assess lung sounds, pulse, and blood pressure before administration and during peak of medication. Note amount, color, and character of sputum produced. Monitor pulmonary function tests before initiating therapy and periodically during therapy. Observe for wheezing. Lab Test Considerations: May cause transient decrease in serum potassium concentrations with nebulization or higher-than-recommended doses. Drug Classification Indication Action Dosage PO Side Effects Assessment Name (Generic and Brand) Polyethylene Glycol (Miralax) Therapeutic Classification: Laxatives Pharmacologic Classification: Osmotics Treatment of occasional constipation Acts as an osmotic agent, drawing water into the lumen of the GI tract; Therapeutic Effects: evacuation of the GI tract without water or electrolyte imbalance PO Adults: 17 g in 8 ounces of water; may use up to 2 weeks Onset Peak Duration Unknown 2-4 days Unknown abdominal bloating, cramping, flatulence, nausea Assess patient for abdominal distention, presence of bowel sounds, and usual pattern of bowel function. Assess color, consistency, and amount of stool produced Docusate Sodium (Colace) Running head: PROCESS PAPER Classification Indication Action: Dosage PO Rectal 44 Therapeutic Classification: Laxatives Pharmacologic Classification: Stool softeners PO: Prevention of constipation. Rect: Used as an enema to soften fecal impaction Promotes incorporation of water into stool, resulting in softer fecal mass; may alsopromote electrolyte and water secretion into the colon. Therapeutic Effects: Softening and passage of stool PO Adults: 50-400 mg in 1-4 divided doses Rect Adults: 50-100 mg or 1 unit containing 283 mg Docusate sodium, soft soap, and glycerin Onset 24-48 hours 2-15 minues Peak Unknown Unknown Duration Unknown Unknown Side Effects Assessment EENT: throat irritation; GI: mild cramps; Derm: rashes Assess for abdominal distention, presences of bowel sounds, and usual pattern of bowel function. Assess color, consistency, and amount of stool produced. Drug Classification Indication: Action Zolpidem (Ambien) Therapeutic Classification: sedative/hypnotics Insomnia Produces CNS depression by binding to GABA receptors. Therapeutic Effects: Sedation and induction of sleep. PO, SL (Adults): Tablets, spray, or SL tablets-10 mg at bedtime; Extendedrelease tablets—12.5 mg at bedtime. PO, SL (Geriatric Patients, Debilitated Patients, or Patients with Hepatic Impairment): Tablets, spray or SL tablets-5 mg at bedtime initially; Extended-release tablets—6.25 mg at bedtime. Dosage PO Side Effects Assessment Onset Peak Duration Rapid 30 minutes- 2 hours 6-8 hours CNS: abnormal thinking, daytime drowsiness, dizziness, amnesia, behavior changes, hallucinations, sleep-driving. GI: diarrhea, nausea, vomiting, hypersensitivity reactions, physical dependence, psychological dependence, tolerance. Assess mental status, sleep patterns, and potential for abuse prior to administration. Prolonged use greater than 7–10 days may lead to physical and psychological dependence. Limit amount of drug available to the patient. Assess alertness at time of peak effect. Notify health care professional if desired sedation does not occur. Running head: PROCESS PAPER 45 Medications Azactam (aztreonam) :2 gram IV TID (0600, 1400, 2200) Tenormin 25 mg tablet PO BID Norvasc 5 mg tablet PO once daily Advair Diskus 250-50 mcg Inhalation BID Zantac 150 mg tablet PO once daily Zocor 40 mg tablet PO once daily Lasix 20 mg PO once daily Lovenox 40 mg/0.4 mL SCs once daily Micronase 2.5 mg tablet PO once daily Ascorbic Acid 500 mg tablet PO once daily Aspirin 81 mg tablet PO once daily Calcium 500 + D 500 mg tablet PO TID Clonidine 0.1 mg tablet PO TID Cozaar 100 mg PO once daily Colace 100 mg capsule PO BID Ambien 10 mg tablet PO once daily PRN Promethazine 25 mg tablet PO q6h PRN Vicodin 5 mg tablet PO q4h PRN Ventolin HFA 90 mcg Inhalation q 6 h as PRN Miralax 17 gram/dose PO once daily PRN IV Sites/Fluids/Rate PICC Past Medical /Surgical History Osteomyelitis Hx. Of Type II Diabetes mellitus (uncomplicated) Hx . ofAcute Kidney Failure Hx. ofAnemia Difficulty Walking Hx. Of Constipation Hx. Of Anxiety Past Surgical Hx: 2000: Left total hip replacement r/t fall in 1999 2005: Surgery on Right Hip Lab Values/Diagnostic Test Results N30040 Concept Map Student Name: Lori Risner Client Initials: E.H. Date: 11-19-10 Age:74 Gender:F Room:409 Bed 1 Admit Date:8-12-10 Activity: Up w/1 assist 136 mEq/ L 107 mEq /L CODE Status: Full Na+ Cl- Allergies: NKA & NKDA Braden Score: 17/23 Admitting Diagnoses/Chief Complaint Diet _Regular, LCS____ Activity _Up with Assistance__Braden Score __________ Severe Sharp Pain in Lower Lumbar Sacral Spine secondary to Lumbar Disc Disorder 8.9 mg/dL Ca+ K+ Creat. 5.1 mEq/ L 1.2 mg/dL 10.5 g/dL Assessment 4.5/mm^ 3 257 33.3% Vital signs: T-97.6 ˚F, P-70, R-18, BP- 122/64 87 mg/ dL PLT WBC HCT Pain 4/5 out of a possible 10 --> Pain Sharp & stabbing Pt stated the pain was located it in her back and left hip. A&Ox3; Speech Clear; Skin: pink, dry and intact. Facial expression: Smiling; Facial symmetry: symmetrical; Tongue & mucous membranes: Pink and Moist. Throat: Clear with no areas of redness or lesions. Pt. stated she was not experiencing a cold Hemoglobin: Low Hematocrit: Low WBC: Low Pt. wears glasses. Pt. is deaf in her right ear--> wears hearing aid. Top dentures in place Pt. stated she does not usually wear her bottom dentures because they don't fit right Skin turgor < 3 seconds bilaterally. Hair & Nails: WNLs. PERRLA Trachea was midline & no jugular vein distention; Lungs: clear in all lobes; Regular respiratory rhythm; No cough; Chest round & symmetrical. Pt. complains of DOE and SOB. Apical heart rhythm: 76 bpm Abdomen: round, non-tender, non-distended; Bowel sounds in all four quadrants; Last BM: September 15, 2010 at 1600. Pt. moves all extremities; Right side of body is weaker than the left; Extremities: warm to the touch and no edema was noted. Pedal pulses: +2 bilaterally. Treatments Pressure reduction device to bed to prevent skin breakdown q shift Skin assessment q wk Elevate heels while in bed q shift Encourage to turn and reposition q2h while in bed Regular Diet Bilateral top half side rails to enhance bed mobility q shift Basic metabolic panel( CBC with diff, ESR, and CRP once a day on Monday at 10:00 PM Running head: PROCESS PAPER 46 Care Plan The following plan of care was created for E.H. to promote patient comfort, reduce the risk of injury, reinforce infection control mechanisms and encourage health promotion behaviors by way of appropriate nursing interventions and adequate patient teaching. The focus of E.H.'s care plan is pain management and increased mobility. The care plan includes three nursing diagnoses, goals (short and long term), interventions with rationales, and an evaluation of each goal. It is very important to set realistic goals that patients can work towards and achieve. If the patients think that their goals are unreachable, they will not work as hard to attain them. Primary Nursing Diagnosis Chronic pain R/T musculoskeletal disorder as evidence by lumbar disc disorder, history of diabetes mellitus, total left hip replacement in 2000, constant sever pain 5/10, and osteomyelitis. Goals Short Term Goal: The patient will experience relief of pain through pain management techniques and pharmacological measures every shift and as needed (Black & Hawk, 2009) NOC Comfort Level, Pain: Disruptive Effects, Pain Control Interventions with Rationale Long Term Goal: The patient will relate improvement of pain and increased daily activities AEB decreased assistance with ADLs, a pain rating of < 2/10 with pain management mechanisms, longer physical therapy sessions with less breaks, and vital signs that are within normal limits by time of discharge from nursing home (CarpenitoMoyet, 2010, p. 146). NOC Comfort Level, Pain: Disruptive Effects, Pain Control, Depression Control 1.) Determine the effects of chronic pain on the patient's life by assessing the patient's physical well being (fatigue, strength, appetite, sleep, function, constipation, and nausea) and Running head: PROCESS PAPER Evaluation of Goals 47 psychological well being (hopefulness, sense of purpose, fear, and enjoyment) during each assessment and as needed. Rationale: Pain is an intense experience for the client. Pain associated with osteomyelitis can get so severe that neither analgesics nor bed rest are palliative (Ursprung, 2005, p. 715). Ferrell (1995) validated that pain affects quality of life and assessment of specific effects is essential (Carpenito-Moyet, 2010, p. 146). NIC: Pain Management & Coping 2.) Provide pain relief and prescribed analgesics (hydrocodone-acetaminophen 5500mg PO q 4 h PRN) as ordered and as needed. Assess client's response to the medication; Return in 30 minutes to assess effectiveness Rationale: Combinations of analgesics may be more effective than those given singularly (Black & Hawk, 2009, p. 371). NIC: Pain Management & Medication Management 3.) Provide patient with information regarding medications, dosage, and possible side effects prior to administering medication and as needed. Rationale: A plan of pain management should be developed with the patient and patient's family (Black & Hawk, 2009, p. 372). NIC: Medication Management 4.) Promote optimal mobility by planning daily activities when the pain is at the lowest level. Anticipate pain and pre-medicate the patient prior to painful experiences. Rationale: The preventative approach may reduce the total 24 hour dose compared with the PRN approach (Carpenito-Moyet, 2010, p. 146). NIC: Pain Management, Medication Management, Exercise Promotion Short Term: During my shift, E.H. reported her pain to be a 4/5 out of a possible 10 before medication administration and then it was reduced to a 2 out of a possible 10 thirty minutes after medication administration. The Running head: PROCESS PAPER 48 pain was constant and had very few relieving factors. E.H. understood the action, therapeutic effects, and possible side effects of analgesics she was receiving. Long Term: The long term goal will be monitored throughout E.H.'s stay and reevaluated at discharge. Her vital signs were within normal limits. E.H. completed physical therapy with break periods. ADLs are currently performed with assist of one. Upon discharge, ADLs should be performed with miminal assistance. Nursing Diagnosis #2 Goals Interventions with Rationale Impaired physical mobility R/T musculoskeletal impairment and joint stiffness secondary to inflammation of the disc space as evidence by diagnoses of lumbar disc disorder, discitis, and osteomyelitis; and a past medical history of anemia and chronic pain. (CarpenitoMoyet, 2010, p.391). Short Term Goal: The patient will report increased strength and endurance of limbs every shift. NOC: Joint Movements & Mobility Long Term Goal: The patient will be able to participate in physical therapy and occupation therapy 5 times a week for the next 6-8 weeks to increased physical mobility. NOC: Ambulation, Mobility & Joint Movements 1.) Consult with physical therapy for evaluation and development of a mobility plan; E.H. is to attend P.T. 5 times a week for functional mobility training for 8 weeks. Rationale: Physical therapists are professional experts on mobility (Carpenito-Moyet, 2010, p.394). NIC: Exercise Therapy & Exercise Promotion; Strength Training 2.) Teach the patient how to ambulate with adaptive equipment; When using a walker, use arm strength to support weakness in lower limbs. Rationale: Ambulatory aids must be used Running head: PROCESS PAPER Evaluation of Goals Nursing Diagnosis #3 49 correctly and safely to ensure effectiveness and prevent injury (Carpenito-Moyet, 2010, p.398). NIC: Ambulation & Fall Prevention 3.) Perform passive and active range of motion exercises daily and as tolerated; Medicate for pain especially before an activity such as ROM. Rationale: Active ROM increases muscle mass, tone, and strength and improves cardiac and respiratory functioning. Passive ROM improves joint mobility and circulation (Carpenito-Moyet, 2010, p.395). NIC: Joint Mobility & Strength Training 4.) Increase time out of bed by 15 minute increments daily or as tolerated. Rationale: Researchers have shown that early mobilization has better outcomes than bed rest after an injury, medical procedure, or a treatment of a medical treatment (CarpenitoMoyet, 2010, p.397). NIC: Exercise Promotion; Strength Training Short Term: By the end of my shift E.H. reported that after each physical therapy session, she feels better a little less tense. She stated that she really thinks she benefits from attending PT and OT, even if she does experience SOB and DOE afterwards. She stated that her pain interferes with her therapy, but she tries to work through it to finish each session. E.H. ambulates as much as tolerated each day. During shift however, E.H. remained in bed the majority of the time. I reinforced the importance of early ambulation. Long Term: E.H. reports the importance of attending physical therapy and occupational therapy. She has attended each session since she was admitted and plans on attending the rest in order to promote health and wellness for discharge. Risk for Infection R/T compromised host defense mechanisms secondary to hematologic disorder (anemia), acute renal failure, osteoarthritis, insufficient leukocytes, and impaired mobility as evidence by current Running head: PROCESS PAPER Goals Interventions with Rationale 50 osteomyelitis infection and antibiotic therapy. Short Term Goal: Patient will report risk factors associated with infection and precautions needed to evade it every shift. These factors include but are not limited to meticulous hand washing technique, being able to describe the transmission of infection and describing the influence of nutrition on prevention of an infection (Carpenito-Moyet, 2010, p. 336). NOC: Immune Status Long Term Goal: By discharge, patient will have a WBC count that is in the therapeutic range of 5,000-10,000 mm^3 and will not report any clinical manifestations of infection. NOC: Infection Status 1.) Wash hands before and after all contact with patient and/or specimens collected. Rationale: Meticulous hand washing and alcohol based rubs are the most important means to prevent the spread of infection (Carpenito-Moyet, 2010, p. 336), (Black & Hawk, 2009, p. 332). NIC: Infection control & Health Education 2.) Teach patient the causes, risks, and communicability of infections; Have patient and family demonstrate use of equipment or treatment procedure before discharge. Rationale: Proper use of equipment and treatment procedures are needed to prevent infection and injury (Carpenito-Moyet, 2010, p.338) A diet high in protein, moderate carbohydrates, and a low fat diet will bring the patient into a state of positive nitrogen balance (Ursprung et al., 2005, p. 718). NIC: Health Education 3.) Administer prescribed antimicrobial therapy (Azactam 1 gram IV TID) within 15 minutes of scheduled dose. Rationale: Antibiotics administered at proper intervals ensure maintenance of therapeutic levels, which minimizes length of nursing home stay (Carpenito-Moyet, 2010, p.338) Studies have indicated that 23% to 38% of clients receive antibiotics, half of which are administered inappropriately (Black & Hawk, Running head: PROCESS PAPER Evaluation of Goals 51 2009, p. 330). Once the organism has been identified, proper antiobiotic therapy can commence. An antibiotic is chosen based on a culture and sensitivity (Ursprung et al., 2005, p718). NIC: Infection Control 4.) Maintain aseptic technique for all invasive devices (PICC), changing sites, dressings, tubing, and solutions per policy schedule at all times. Rationale: Invasive lines provide a site for organism entry. Interventions focus on prevention and identification of early signs of infection (Carpenito-Moyet, 2010, p.337). NIC: Infection Control Short Term: E.H. was able to demonstrate proper hand washing during shift. She was also able to describe the infectious process and could determine risks that impede health. E.H. understood how her infection began and how her antibiotics work to rid the body of the pathogens. Long Term: At the end of my shift, E.H.'s WBC count was not in therapeutic range according to her medical chart. Antibiotic therapy was initiated to rid the body of the invaders. In order for her WBC count to rise to therapeutic range (5,000-10,000mm^3), E.H.'s defense mechanisms need to sustain control. E.H. did not report any signs or symptoms of infection besides pain in her lumbar sacral spine. Conclusion E.H. was a very pleasant patient. She was not overly demanding or rude. Overall, I would say this clinical experience was very beneficial. I had the opportunity to devise a plan of care that was unique to E.H. If she sticks to her plan of care and continues to work towards her long term goals, E.H. should be able to overcome this obstacle that has been placed in front of her. Her biggest barriers will be mobility and pain management once she is released. It is important that Running head: PROCESS PAPER 52 she sticks to her medication regimen and perform activities that promote health and decrease the chance of acquiring another infection. Meticulous hand washing, proper nutrition, and increased exercise are all part of this plan of care. Running head: PROCESS PAPER 53 References Black, J.M., Hawk, J.H. (2009). Medical-surgical nursing: Clinical management for positive outcomes. (8th ed). St. Louis, MO: Saunders, an imprint of Elsevier Inc. Carpenito-Moyet, L. J. (2010). Nursing Diagnosis: Application to Clinical Practice. Philadelphia, PA: Lippincott Williams and Wilkins. Deglin, J.H., & Vallerand, A.H. (2005). Davis’s drug guide for nurses (9th ed.). Philadelphia: F.A. Davis Company Publishers. Holt , J.Y. (2003, February 02). Discitis: disc space infection . Retrieved from http://www.spineuniverse.com/conditions/spinal disorders/discitis -disc-space-infection-0 Ullrich, P.F. (2006, November 06). Lumbar degenerative disc disease . Retrieved from http://www.spinehealth.com/conditions/degenerative -disc-disease/lumbardegenerative-disc-disease Ursprung, W.M., Kettner, N.W., & Boesch, R. (2005). Vertebral o s t e o m ye l i t i s : a c a s e r e p o r t o f a p a t i e n t p r e s e n t i n g w i t h a c u t e l o w back pain. Journal of Manipulative and Physiological Therapeutics , 28, 713-718.