Running Head: INTERDISCIPLINARY CARE Patient Care Elsie King Chamberlain University NR 341 Complex Adult Health March 2018 Running Head: INTERDISCIPLINARY CARE 2 Background Information Mrs. J.E. is a 62-year-old African American female. She has a significant other with two children. She was admitted on 03/10/2018 at the emergency room. She is a full code. No allergy to medications. She smokes a pack of cigarettes daily, she drinks about four to five glasses of wine daily and she does combination of heroin and pain killers medications. The main reason why the patient was admitted was due to shortness of breath and opiate overdose. Past medical history for Mrs. J.E. are asthma, hypertension, urinary incontinence, UTI and diabetes mellitus Type II. Patient had knee replacement on the right knee about five years ago, had a cyst removal on the right breast, but the biopsy came back benign. The patient present diagnosis is bilateral pulmonary infiltrate suspect opiate overdose. According to Lilley L, (2017)., Act as agonists–drugs that stimulate receptors in the body. They are central nervous system depressants, risk for respiratory depression and dependency associated with opiate use. opiates and opioids do create a slowing of your respiration, your breathing, and if it slows too much it creates severe respiratory depression. Significant assessment findings during the day of care includes vital signs which include blood pressure is 98/58mm hg on the right arm laying supine, oral temperature 98.9F, respiratory 8 breaths per minute, weight of 146 pounds, radial pulse recorded is 40 beats per minute pulse and oximetry recording of 88% on room air. Focused assessments include odor of alcohol on breath, odor of smoke on clothing. Intoxicated behavior during examination. Patient had Slurred speech, inflamed nasal mucosa, Gingival ulceration notice, skin color warm to touch, laceration and bruises all over the abdomen, legs and arms. Patient was alert and oriented to person. Running Head: INTERDISCIPLINARY CARE 3 PERRLA was present, pupils were not equal, react to light and accommodative. Breathing was labored, evidence of shortness of breath indicated, shallow reparations, dyspnea indicated. Wheezing indicated with auscultations, Respiratory depression indicated. Laboratory and Diagnostic Tests The significant laboratory values performed are as follow. Test Result Reference Range pH 7.20/7.39 7.35 -7.45 Pco2 60/37 35-45 Po2 50/135 80-100 Bicarbonate 18/22 22-26 Sodium 145 Potassium 3.2 Urea Nitrogen 29 Creatinine 1.2 RBC Count 3.9 135-145 3.5-5.0 10-20 0.7-1.5 4.7-6.1 WBC count 9.5 5-11 Hemoglobin 12.0 12-16 Hematocrit 37 40-48 Running Head: INTERDISCIPLINARY CARE Platelet Count 120 Urinalysis Opiate positive 4 150,000-400,000 The diagnostic test or procedure performed EKG, Chest X-ray. EKG showed sinus bradycardia, prolonged PR and QTc intervals. Chest X-ray showed a hazy infiltrate lower lobe. The treatment that was done which was not successful because she did not respond naloxone, due to that, intubation was done and between two to three hours after the arrival in the emergency room, she was transferred to ICU. Medication According Vallerand, A. H., (2015). These are the lists and summary of relevant, significant medication, and the information’s given. Drug Name Classification Therapeutic Use Adverse Effect Nursing Implication Metformin Trade: Fortamet, Glumetza, Glucophage, Riomet Antidiabetic Maintenance of blood glucose Abdominal bloating, diarrhea, nausea, vomiting, unpleasant metallic taste. Hydrochlorothiazide Trade: Microzide, Oretic, Urozide Antihypertensives, diuretics Lowering of blood pressure in hypertensive patients and diuretic with mobilization of edema. Hypokalemia, dizziness, drowsiness, lethargy, weakness, When combined with oral sulfonylureas, observe for signs and symptoms of hypoglycemic reactions. Monitor renal function before initiating at least annually during therapy. Monitor BP, intake, output, and daily weight and assess feet for edema daily. Monitor BP before and periodically during therapy. Assess patient for Running Head: INTERDISCIPLINARY CARE 5 allergy to sulfonamides. Enoxaparin Trade: Levonox Anticoagulant Prevention of venous thrombosis, DVT. Prophylaxis. Dizziness, insomnia, edema, alopecia, anemia. Oxybutynin Trade: Ditropan XL, Oxytrol, Gelnique. Urinary tract antispasmodics Increased bladder capacity. Delayed desire to void Dizziness, drowsiness, constipation, dry mouth, nausea, urinary retention Albuterol Trade: Accuneb, airomir, Proventil HFA, Ventolin HFA Bronchodilators Bronchodilation Nervousness, restlessness, tremor, chest pain, palpitation. Salicylates Trade: Aspirin Antipyretics Analgesia. Reduction of inflammation. Reduction of fever. Dyspepsia, epigastric distress, nausea, abdominal pain, anorexia, vomiting, hepatotoxicity. Morphine Trade: Astramorph PF, Avinza, Duramorph Opiod Analgesics Decrease in severity of pain Confusion, sedation, constipation, hypotension Assess for signs of bleeding and hemorrhage, assess for evidence of additional or increased thrombosis. Monitor voiding pattern and intake and output ratios and assess abdomen for bladder distention prior to and periodically during therapy. Assess lung sounds, pulse, and blood pressure before administration and during peak of administration. Monitor pulmonary function test before initiating therapy and periodically during therapy. Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome or toxic epidermal necrolysis. Assess pain and limitation of movement; note type, location and intensity before and the peak after administration. Prolonged use may lead to physical and physiological dependence and tolerance. Assess bowl function routinely. Running Head: INTERDISCIPLINARY CARE 6 The dosage and route of administration are Metformin 500mg twice a day orally, Hydrochlorothiazide 25mg daily orally, Enoxaparin 40mg subcutaneously, Oxybutynin 5mg three times daily. Albuterol 2mg orally twice daily, Salicylates 81mg orally and Morphine 2mg, IV push every 4 hours PRN. Nursing Diagnosis Ineffective airway clearance related to sedating or paralytic effects of drugs evidence by non-responsiveness and using Narcan to revive the patient. The nursing outcome for the patient will be, patient will improve a patent airway, and keeping the patient calm and comfortable. Patient will maintain a patent airway at the end of the shift. A long-term care will be patient will demonstrate an effective coughing and clear breath sounds by the end of the day. The nursing interventions will be monitoring of blood gas values and pulse saturation levels. Normal ABGs values of PO2 are 80-100mm Hg and a PCO2 of 35-45mm Hg. An oxygen saturation of less than 90% indicates problems with oxygenation. Hypoxemia can result from ventilation perfusion. Ineffective health maintenance related to inability to make deliberate and thoughtful judgement evidence by drug overdose. The nursing outcome for the patient will be improving health promoting behavior and health seeking behavior. The nursing interventions will be referring the patient to community agencies for appropriate follow up care. It is known that social support has been related to decrease mortality rate. Making sure that a follow up appointment is schedule before her discharge, by discussing with the patient to make sure that the appointment is kept. Risk for suicide related to substance abuse evidence by Statements of helplessness, despair.Nursing outcome will be patient will remain safe while in the hospital, with the aid of Running Head: INTERDISCIPLINARY CARE 7 nursing intervention and support. The nurse intervention will be encouraging the client to speak freely about feeling and help plan alternative ways of handling disappointment, anger and frustration. The rationale will be giving the client the power to learn ways of dealing with strong emotions and gaining a sense of control. Interventions- Routine Nursing Management Due to the patient condition, the nursing management will be staying with an unresponsive patient and not be distracted by anything other than performing resuscitation. Vital signs were taken such as heart rate, blood pressure, oxygen saturation and temperature were carefully monitored. Naloxone the antidote was used to reverse the opiate effects.12- lead ECG test was done to initiate continuous ECG monitoring. Maintaining a patent airway was the priority. The patient was position in high fowler position. Mechanical ventilation was using to move air in and out of the lungs. Indwelling catheter was placed instantly. Monitoring for any changes or improvement. IV access was established immediately and initiated fluid placement. Obtaining information about the type of substance abuse, the route it was used, when taken, the amount taken or any combination of substance abuse. Drug levels or comprehensive toxicity screen was obtained. Obtained health history and any allergies from the patient. Monitor level of consciousness and oxygen saturation. The patient was monitored closely because naloxone has a shorter duration of action and been aware that the patient may have had mixed drug ingestion that does not respond to opioid antagonists. Safety precaution was constantly use by the health providers, constantly asking the patient and checking the name band for the name and date of birth before any treatment was done, hand Running Head: INTERDISCIPLINARY CARE 8 hygiene was done. Patient was monitored continuously for neurologic status, including level of consciousness, monitoring respiratory function and cardiovascular function was very critical to make sure that the patient was stable. Collaborative Management – Interdisciplinary Care The interdisciplinary team members that came together to take care of Mrs. J. E. were respiratory therapist, nurse, emergency medical doctor, ECG technician, Lab/diagnostic tests personnel, assistive personnel. The respiratory therapist administers respiratory care treatment involve managing life support mechanical system. The respiratory therapist analyzed blood sample of Mrs. J.E. to determine levels of oxygen and other gases. Assessed lungs capacity to determined impairment. Managing artificial airways and ventilators. Consulted with the physicians and members of medical team to recommend a change in therapy. The next interdisciplinary care will be nurse, the nurse provides hand on care to the patient, by monitoring and observing patient conditions, communicating with the doctors and maintaining records. The nurse also administers medications, managing intravenous lines. The nurses also relied on to give directions and supervisions to nurse aides. The nurse is always the first person and the last health care provider a patient will see. They provide emotional support to patient and patient’s family members. The emergency medical doctors are responsible for several series by assessing the condition of the patient and providing treatment. The emergency medical doctors order tests such as CT Scan, MRI and chest X-ray and providing medication. They help to stabilize a critical patient. Running Head: INTERDISCIPLINARY CARE 9 The ECG technician attaches electrodes to the patient and constantly monitoring the patient cardiac activities. Records the activities of the heart and print out the data recorded for further treatment of the patient. The Lab/diagnostic tests personnel roles collect specimens from patient and properly labels them for testing. Basically, the technicians perform tests and procedures that physician orders. Assistive personnel assist the nurse in taking vital signs, they are supervised, and delegations are given to them by the nurse. Therapeutic Modalities Therapeutic modalities provide a non-surgical medication free treatment for a wide range of condition. Therapeutic Modalities helps to provide pain relief physically and emotionally. Helps to provide better quality of life and functioning. One of the therapeutic modalities care that was used for Mrs. J.E. was psychosocial assessment, which involve sitting by the patient bedside, taking to the patient, which in turns relaxes and calm the patient. As you gain the trust of your patient. The nurse provides a lot of therapeutic modalities care by just taking time to communicate, engaging the patient with treatment, explaining treatment for the patient understanding. Demonstrating respect and non-judgmental. Promote equality and attempt to promote independence where it is possible. Just by actively listening and been attentive to patient provides a therapeutic modality care. The nurse does a continuous assessment on the patient, which is a form of therapeutic modality care, by touching the patient, getting the attention of the patient and just been there for the patient or answer some question. Running Head: INTERDISCIPLINARY CARE 10 Nursing Role Reflection My clinical day was quiet at first at the emergency room until Mrs. J.E came to the ER by the ambulance. I was assigned to follow the Patient nurse by the charge nurse. I remembered going to the patient room assisting with ECG placement, taking vital signs like blood pressure, respiration, heart rate. Respiratory therapist came, lab technician and emergency doctor arrived. One nurse was getting the patient history, while another nurse was establishing IV line. All hands were on deck, helping the patient to maintain patency. I was told to step out for a few minutes because the room was crowded. I waited by the door for about 15-20 minutes just in case they will need me to get something for them. I remembered having an anxiety and at the same time excited to experience an overdose case. The doctor told me to come in after a while, the doctor ordered for mechanical ventilation which was done on the patient, labs were taken, indwelling catheter was placed. The patient kept trying to pull out the indwelling Foley catheter, she was not aware of what she was doing. The emergency doctor ordered for a restraint. It was beautiful to see how everyone came together to save a life. The patient was finally stable and was transferred to ICU. In conclusion watching the nurses taking care of the patient, makes me know that I made the right choice. I learned a lot from my instructor and the nurse I was place that I was placed with. She was calm and moving quickly and making sure things were done appropriately. Running Head: INTERDISCIPLINARY CARE References Carpenito, L. J. (2017). Nursing diagnosis: Application to clinical practice. Philadelphia, PA: Wolters Kluwer. For All Your Nursing Needs. (n.d.). Retrieved March 30, 2018, from https://nurseslabs.com/ Lewis, S. L., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed.). Elsevier Mosby. Lilley, L. L., Collins, S. R., & Snyder, J. S. (2017). Pharmacology and the nursing process. St. ALouis, MO: Elsevier. 11 Running Head: INTERDISCIPLINARY CARE 12 Vallerand, A. H., (2015). Davis's Drug Guide for Nurses (14th ed.). Philadelphia, PA: F.A Davis Company. Running Head: INTERDISCIPLINARY CARE 13 Running Head: INTERDISCIPLINARY CARE . 14 Running Head: INTERDISCIPLINARY CARE 15