Nursing Care Plan
Steven C Scanlon, S00533997, 1450 - Spring 2013
General Information: Patients initials:
Date of Care: 03/05/13 - 03/06/13
Admission Date: 03/03/13
Patient
Chart
Family Member
Health Care Team
Other:
Source of Data:
Sex: Male
Marital Status: Single
Advanced Directive: DNRCC
Religion:
Age: 45
Patient’s Description of Problem/Needs
(Pts own words):
Reason for Admission
Primary Medical Diagnosis: SOB, Cough, Leukocytosis:
SOB: Inability to respirate effortlessly at 12-20 breathes/
min. Leukocytosis: WBC count above the normal range.
Secondary Medical Diagnosis: Multiple Sclerosis, Cyst removal from Rt Leg
“I was having a hard time breathing. I cant
cough up the stuff keeps dripping into my
lungs, I can’t cough with enough force to
get it out”
Surgical Procedures and Dates: Pt has an implanted Baclofen Pump in his RUQ. This pump gets assessed and refilled with medication every
6 months. This is the Pts second such pump. The older model was larger and more bulky and less comfortable
for the Pt. The current pump is aprox 10cm X 10cm X 2cm in size.
3 Nursing Diagnoses
1. - Impaired Gas exchange
2. - Impaired physical Mobility
3. - Impaired Skin integrity
3 Assessment Priorities
1. - Monitor respiratory and perfusion status
2. - Take measures to reduce pressure ulcer risks, treat current pressure ulcers
3. - Keep family and Pt informed on the plan of care, develop relationshipbased care for all involved.
Pt is a 45 YO male who presented to the ED with severe SOB and a weak cough. Baseline vitals are as follows: T98.5, P137, R22,
SPO2 95% on 4LPM NC, BP103/66, Pain 0/10. EKG shows a rate of 140 with a Lt anterior fistular block with artifact, Negative ST
elevations or depressions are present. Initial X-Ray was negative, initial blood tests showed an elevated WBC count with 75%
neutrophils indicating infection of some kind. UA was negative as well as Rapid Flu tests A & B however the Pt was started on
Tamaflu prophylactically in case he was positive for a flu strain not detectable by standard tests. negative Strep. CT was also negative.
Pt has no known drug allergies. Pt denies CP, N/V, and occasionally produces yellow sputum with cough. Pt was admitted to the
floor for SOB, Cough & Leukocytosis.
Pt has a Hx of an aggressive Multiple Sclerosis at age 32 and has deteriorated rapidly. Pt is incapable of standing and is confined
to a bed or chair. Pt has limited mobility in the upper extremities with dominance on the Lt side. Pt has a Hx of a cyst removal form the
Rt leg. Pt is a remote smoker from before contracting MS, and denies drinking. Pt is UTD on Flu, Pneumonia & Tetanus vaccinations. Pt
was adopted as an infant, and currently lives with his mother who is his primary care giver. Pt also employs a home health care
nurse who accompanies him when he travels or when his mother needs a break from care giving. On 03/04/13 at aprox 0030 the
Pts SPO2 dropped to the low 80s and the Pt was put on a nonrebreather 15LPM. Pt was administered a one time dose of Lasix
40mg IV for course crackles found bilaterally and a foley cath was placed. Pt stayed on the NRB for aprox 18 hrs and then was
weened down to 3LPM NC and SPO2 remains at 97%.
Upon physical exam (03/05/13) , Pt is A&OX4, Cap refill <2 Sec but Pt seems pale, T98.5, P114 and strong, R22 and shallow,
BP95/60. Neuro exam finds weak hand grips with slightly stronger grip on the Lt side, pulses present and sensation in tact. Lower
extremities present with slight contracture due to MS, MSPs present in both lower extremities which are also weak. Pupils are
PERRLA, No facial droop noted, Apical pulse is strong and regular, S1 & S2 sounds heard with no S3, S4 or Murmurs detected. Rales
detected in bilaterally in the lower lobes with louder adventitious rales detected on the Rt lateral. Bowel sounds present in all 4
quadrants. URQ shows a 10cm X 10cm X 1.5cm protrusion consistent with the Pts Baclafin Pump which administers the drug at a
set rate to help with muscle contracture due to MS. Pt has a foley cath and is incontinent of stool and is currently experiencing
diarrhea most likely to IV antibiotics currently being administered. Three Stage I wounds were found. The first on the Lt heal 2cm
X 1cm, the second on the Lt foot on the mediolateral 1cm X 1cm, and the last one is just over the coccyx 2.5cm X 1cm. Pt sts his
mother is very good at prevention of wounds, however the Pt recently vacationed on a cruise ship in Alaska with his home healthcare
nurse and was unable to bring his air mattress with him which was a causal factor in the current wounds that he has. No Profile
sign noted. Mucus membranes are dry most likely due to lack of humidified O2 during administration over the last 24 hours.
Pt has been ordered repeat chest X-Rays, A swallow evaluation, Q6 breathing treatments + 2 PRN, Pulse Ox monitoring, PT consultation,
Pulmonary consultation & routine blood draws. Ativan Q6 PRN.
Nursing Care Plan
Labs
Norms
CBC
RBC:
Hgb:
Hct:
WBC:
Differential:
Neutrophils:
Eosinophils:
Basophils:
Lymphocytes:
Monocytes:
Platelets:
4.5
14.1
41.6
19
Manual
59
0
0
4
6
159
Chemistry
Na:
K:
Cl:
CO2:
BUN:
Glucose:
Creatinine:
T Protein:
Albumin:
Mg:
Ph:
140
3.7
103
28
10
94
.8
ABGs
4.5-6.0
13-17.3
39-50
4.0-11.0
41.5-75.5%
0-3%
0-2%
24-44%
1-8%
150-400
Norms
Steven C Scanlon, S00533997, 1450 - Spring 2013
Tests / Orders
Rational
03/05/13: Negative
Indicates Infection
CT
Impaired Lyph Tissue / Infection
Rational
Other Rapid Flu A & B: Negative
Strep Test: Negative
50-136
Norms
pH:
pO2:
pCO2:
HCO3:
Urinalysis
Norms
Rational
PT:
PTT:
INR:
IV antibiotics administered
Rational
Physical therapy consult ordered
O2 Therapy ordered
Turn schedule ordered
Norms
Rational
9.3-11.4
Culture & Sensitivity
Swallow Eval showed no aspiration
EKG: Rate 140, Lt Anterior Fiscular Block
with Artifact, Negative ST Elevation and
Negative Depression
0.89-1.10
Anaerobic negative
Aerobic negative
UA: Negative
Daily Blood draws ordered
Specific Gravity:
pH:
Protein:
Acetone:
Pregnancy:
Coagulation
03/03/13: Chest with contrast:
Negative
136-145
3.5-5.1
98-107
21-32
7-18
74-106
0.6-1.3
6.4-8.2
3.4-5.0
7.37-7.44
75-95
36-44%
22-30
X-Ray 03/03/13: Negative
Rational
Nursing Care Plan
Med List
Steven C Scanlon, S00533997, 1450 - Spring 2013
Decadron/dexamethasone - Long-Acting Glucocotoroid/Corticosteroid - Used to treat Pts SOB
- 4mg IV BID
Heparin - anticoagulant - To prevent DVT in a Pt that has limited mobility
- 5000 Units SQ BID
Baclofen/Gablofen - Skeletal Muscle Relaxer/Antispasmotic - Pt has MS
- 20mg BID Via implanted pump & 40mg PO with Dinner
Neurontin/gabapentin - anti-epileptic medication/anticonvulsant - Used to help Pt with involuntary Muscle contracture due to MS
- 600mg PO QHS
Lasix/furosemide - Loop diuretic, Pt has pulmonary sounds which may indicate fluid in the lungs
- 40mg IV One time dose
Ampyra/dalfampridine - Potassium channel blocker - Muscle contracture associated with MS
- 10mg PO BID
Tamiflu/oseltamivir - Antiviral - Pt is taking this med prophylactically for possible influenza not detectable by standard tests
- 75mg PO BID
Duoneb/ipratropium bromide and albuterol sulfate - Antibronchospasmotic - Pt has SOB
- 3ml Nebulized Q6 + 2 PRN
Ambien/zolpidem - Sedative/hypnotic - Pt has trouble falling asleep
- 5mg PO HS
Ativan/lorazepam - Benzodiazepine - Pt has anxiety due to fear of death and further loss of muscular control/ability
- 1mg Q6 PRN
Cetacaine/butamben / tetracaine / benzocaine - Analgesic - Pt has a sore throat
- 2 Sprays PRN
Rocephin/ceftriaxone - Antibiotic - Used in this Pt to fight and prevent infection
- 1gm in osmotic dextrose IV Piggyback
Zofran/ondansetron - Antiemetic - Pt has occasional bouts of nausea
- 4mg IV Q6 PRN
Nursing Care Plan
Steven C Scanlon, S00533997, 1450 - Spring 2013
Assessments
Objective:
- Please see Head to toe for VS, Pt is A&OX4, Cap refill <2 Sec, Pt is pale, Weak hand grips with slightly stronger grip on Lt side,
pulses present, sensation in tact. Lower extremities slightly contracted, MSPs present, Pupils are PERRLA, No facial droop, Apical
pulse is strong and regular, S1 & S2 sounds heard with no S3, S4 or Murmurs detected. Rales detected in bilaterally in the lower
lobes with louder adventitious rales detected on the Rt lateral. Bowel sounds present in all 4 quadrants. 10cm X 10cm X 1.5cm
protrusion in Abd RUQ consistent with the Pts Baclafin Pump Pt has a foley cath and is incontinent of stool and is currently
experiencing diarrhea, IV 20g RFA Three Stage I wounds were found. The first on the Lt heal 2cm X 1cm, the second on the Lt
foot on the mediolateral 1cm X 1cm, and the last one is just over the coccyx 2.5cm X 1cm, Mucus membranes are dry. Pt is
breathing shallowly but perfusing.
Subjective:
- Pt sts his mother is very good at prevention of wounds. Pt sts anxiety for fear of death due to respiratory failure. Pt sts “I was
having a hard time breathing. I cant cough up the stuff keeps dripping into my lungs, I can’t cough with enough force to get it out”
Pt sts “my legs always get contracted”
1. - Impaired Gas exchange
Analysis
Nursing Diagnosis (1)
2. - Impaired physical Mobility
3. - Impaired Skin integrity
- Impaired Gas Exchange as evidenced by low pulse ox related to inadequate respiratory rate & depth and MS exacerbation
Goals
Short Term (2)
1 - Pt will be weened off of high flow O2 as evidenced by Decreasing liter flow and moving from a NRB to a NC within the
next 24 hours
2 - Pt will expand lungs and expel secretions as evidenced by forceful coughing once per hour until the end of this shift
Long Term (1)
- Pt will Maintain clear lung fields and remain free of signs of respiratory distress as evidenced by Improved rate and depth
of breathing pattern with SPO2 levels at greater than or equal to 95% on room air by discharge.
Interventions with Rationale (10)
- Monitor respiratory rate, depth, and ease of respiration. Watch for use of accessory muscles and nasal flaring. Normal respiratory
rate is 14 to 16 breaths/min in the adult (Bickley & Szilagyi, 2009). EBN: A study demonstrated that when the respiratory rate
exceeds 30 breaths/min, along with other physiological measures, a significant cardiovascular or respiratory alteration exists
(Considine, 2005; Hagle, 2008).
• Bickley LS, Szilagyi P: Guide to physical examination, ed 10, Philadelphia, 2009, Lippincott Williams & Wilkins.
• Considine J: The role of nurses in preventing adverse events related to respiratory dysfunction: literature review, J Adv Nurs 49(6):624-633, 2005.
- Auscultate breath sounds every 1 to 2 hours. The presence of crackles and wheezes may alert the nurse to airway obstruction,
which may lead to or exacerbate existing hypoxia. In severe exacerbations of chronic obstructive pulmonary disease (COPD), lung
sounds may be diminished or distant with air trapping
• Bickley LS, Szilagyi P: Guide to physical examination, ed 10, Philadelphia, 2009, Lippincott Williams & Wilkins.
- Monitor the client's behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme
lethargy. Changes in behavior and mental status can be early signs of impaired gas exchange. In the late stages the client becomes
lethargic and somnolent.
• Clark AP, Giuliano K, Chen HM: Pulse oximetry revisited: “but his O(2) sat was normal!”, Clin Nurse Spec 20(6):268-272, 2006.
- Observe for cyanosis of the skin; especially note color of the tongue and oral mucous membranes. Central cyanosis of the tongue
and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in the extremities may be due to
activation of the central nervous system or exposure to cold and may or may not be serious
• Bickley LS, Szilagyi P: Guide to physical examination, ed 10, Philadelphia, 2009, Lippincott Williams & Wilkins.
- Monitor the effects of sedation and analgesics on the client's respiratory pattern; use judiciously. Both analgesics and medications
that cause sedation can depress respiration at times. However, these medications can be very helpful for decreasing the
sympathetic nervous system discharge that accompanies hypoxia.
• Simmons P, Simmons M: Informed nursing practice: the administration of oxygen to patients with COPD, Medsurg Nurs 13(2):82-85, 2004.
• Wong M, Elliott M: The use of medical orders in acute care oxygen therapy, Br J Nurs 18(8):462-464, 2009.
Nursing Care Plan
Steven C Scanlon, S00533997, 1450 - Spring 2013
Interventions with Rationale (continued)
- Position clients in semi-Fowler's position, with an upright posture at 45 degrees if possible. EB: Research done on clients on a ventilator
demonstrated that being in a 45-degree upright position increased oxygenation and ventilation (Speelberg & Van Beers, 2003).
Research on healthy subjects demonstrated that sitting upright resulted in higher tidal volumes and minute ventilation versus sitting
in a slumped posture (Landers et al, 2003).
• Speelberg B, Van Beers F: Artificial ventilation in the semi-recumbent position improves oxygenation and gas exchange, Chest 124(4):S203, 2003.
• Landers M, Barker G, Wallentine S et al: A comparison of tidal volume breathing frequency, and minute ventilation between two sitting postures in healthy
adults, Physiother Theory Pract 19(2):109-119, 2003.
- Administer humidified oxygen through an appropriate device (e.g., nasal cannula or Venturi mask per the physician's order); aim
for an oxygen (O2) saturation level of 90% or above. Watch for onset of hypoventilation as evidenced by increased somnolence.
There is a fine line between ideal or excessive oxygen therapy; increasing somnolence is caused by retention of carbon dioxide
(CO2) leading to CO2 narcosis
• Simmons P, Simmons M: Informed nursing practice: the administration of oxygen to patients with COPD, Medsurg Nurs 13(2):82-85, 2004.
• Wong M, Elliott M: The use of medical orders in acute care oxygen therapy, Br J Nurs 18(8):462-464, 2009.
- Turn the client every 2 hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return
to baseline promptly, turn the client back into the supine position and evaluate oxygen status. If the client does not tolerate
turning, consider use of a kinetic bed that rotates the client from side to side in a turn of at least 40 degrees. EBN: Use of the
kinetic bed was shown to decrease development of atelectasis and ventilator associated pneumonia in critically ill clients
• Ahrens T, Kollef M, Stewart J et al: Effect of kinetic therapy on pulmonary complications, Am J Crit Care 13(5):376, 2004.
- Help the client deep breathe and perform controlled coughing. Have the client inhale deeply, hold the breath for several seconds,
and cough two or three times with the mouth open while tightening the upper abdominal muscles as tolerated. Controlled
coughing uses the diaphragmatic muscles, which makes the cough more forceful and effective.
• Simmons P, Simmons M: Informed nursing practice: the administration of oxygen to patients with COPD, Medsurg Nurs 13(2):82-85, 2004.
• Wong M, Elliott M: The use of medical orders in acute care oxygen therapy, Br J Nurs 18(8):462-464, 2009.
- Work with the client to determine what strategies are most helpful during times of dyspnea. Educate and empower the client
to self manage the disease associated with impaired gas exchange. EBN and EB: A study found that use of oxygen, self-use of
medication, and getting some fresh air were most helpful in dealing with dyspnea (Thomas, 2009). Evidence-based reviews
have found that self-management offers COPD clients effective options for managing the illness, leading to more positive
outcomes (Kaptein et al, 2008).
• Thomas L: Effective dyspnea management strategies identified by elders with end-stage chronic obstructive pulmonary disease, Appl Nurs Res 22(2):79-85, 2009.
• Kaptein AA, Scharloo M, Fischer MJ et al: 50 years of psychological research on patients with COPD—road to ruin or highway to heaven? Respir Med 103:3-11, 2008.
Evaluations with Supporting Observations
- Pt was weened off of high flow O2 (15LPM NRB) within 18 hrs of initial application down to 3LPM NC Humidified and is
maintaining an O2 saturation of 97%
- Pt demonstrated forceful coughing with each nursing rounding trip. Pt however was not able to produce any sputum.
- Pt & family express desire to achieve a return to baseline respiratory status with clear lungs and no O2 use in the home.
Pt is receiving Q6 Duoneb treatments and Pt states they are working and he is able to breath more easily, respiratory
depth is increasing and respiratory rate is down to 18. Pt is moving in a direction that aims at the long term goal.
Nursing Care Plan
Vital Signs
o
T: 98.5 f
P: 114, Strong Regular
BP: 95/60
Resp: 22, Shallow
SPO2: 95% 15LPM NRB
Pain: 0/10
Steven C Scanlon, S00533997, 1450 - Spring 2013
Monitoring/Access
Head to Toe Assessment
Cardiac Monitor: Yes No
Bed Alarm: Yes No
SPO2 Monitor: Yes No
20
RFA
IV Access: Yes No Gage_____
Location____________________
Central Line: Yes No Gage_____ Location____________________
Neuro
LOC:
Awake
Lethargic
Obtunded
Coma | Comments: Pt had not slept well & had just received meds
Orientation:
Person Place Time Situation | Comments:
Speech:
Clear Slurred Nonverbal | Comments:
Conversation:
Appropriate Confused Nonverbal | Comments:
Face:
Symmetrical Droop to ____ side | Comments:
3
Pupils: Right_____
Reactive Nonreactive Fixed Dilated Pinpoint
3
Pupils: Left _____
Reactive Nonreactive Fixed Dilated Pinpoint
Musculoskeletal
Grading: Right Arm_____ Left Arm_____ Right Leg_____ Left Leg_____ | Comments:
Mobility:
Bedrest Gait Steady Gait Unsteady No movement to _____ side | Comments: Pt has MS, Has limited mobility
Cardiovascular
of lower extremities, can not ambulate
JVD:
No Yes | Carodid:
No Yes | Bruit Thrill | Calf size: Left_____ | Right_____
Pulses:
Radial Brachial Dorsalis Pedal | Comments:
Heart:
S1 S2 S3 S4 Regular Irregular Murmur | Comments:
Edema:
Yes No Location____________________ Homan’s Sign:
Pos Neg | Comments:
Skin Color:
Appropriate Pallor Ruddy Rubor Cyanosis Jaundice | Comments: Bruising bilat upper extremities
consistent with IVs and blood draws.
Turgor:
Poor Fair Brisk | Comments:
Sclera:
White Red Jaundice Other____________________ | Comments:
AV Fistula:
NA Bruit Thrill Location____________________ | Comments:
Respiratory
Pattern:
Regular Irregular | Comments: Shallow but non-labored may be due to MS
Depth:
Deep Moderate Shallow | Comments:
Accessory Muscles:
Yes No | Comments:
95
15LPM
SPO2: ______%
Room Air _______Liter
Flow Cannula Simple Mask Non-Rebreather Other_____________________
Lungs: RIGHT UPPER:
Clear Crackles Ronchi Wheezes Diminished Friction Rub
RIGHT LOWER:
Clear Crackles Ronchi Wheezes Diminished Friction Rub
LEFT UPPER:
Clear Crackles Ronchi Wheezes Diminished Friction Rub
LEFT LOWER:
Clear Crackles Ronchi Wheezes Diminished Friction Rub
Cough:
None Dry Moist Non-Productive Moist Productive | Comments:
20 / Gravity
Chest Tube:
No Yes Settings____________________
Drainage____________________ | Comments:
Abdomen
Shape:
Flat Sunken Round Distended Ascites | Comments: Pt is lacking adequate adipose and musculature due to atrophy
Bowel Sounds:
RLQ RUQ LUQ
LLQ | Comments:
Pain:
No Yes With Palpation Without Palpation | Comments:
Vascular:
No Yes Bruit Thrill | Comments:
Palpation:
Soft Firm Rebound Tenderness | Comments:
NG Tube:
No Yes Nare
Nare#_____
Clamped Suction Drainage | Comments:
Feeding Tube:
No Yes PEG
Small Bore Nare#_____ | Comments:
Tube Feed:
No Yes____________________
Residual | Comments:
Ostomy:
No Yes Location___________________
Stoma___________________ Drainage___________________
02/27am FMS Tube | Comments:
Stool:
None Seen Yes Last BM_______
16g
Amber
Clear
Urine:
None Seen Yes Color___________________
Turbidity____________________
Foley____________________
Suprapubic BRP Anuric: Dialysis Access___________________ | Comments:
Nursing Care Plan
Steven C Scanlon, S00533997, 1450 - Spring 2013
Head to Toe Assessment
Drains/Access
JP:
Drainage: Amount:
JP:
Drainage: Amount:
HVAC:
Drainage: Amount:
HVAC
Drainage: Amount:
Wound Vac:
Drainage:
Implanted
med
pump
in
RUQ
Abd,
10cm X 10cm X 1.5cm
Other:
Color:
Color:
Color:
Color:
Settings:
Integumentary
12
Braden Scale:
Strategies:
Air Mattress
Specialty Bed
Barrier Cream
Pt
is
able
to
make
small
position
changes
but
requires
assistance
for
major
changes
in position
Other:
No Skin Breakdown Macerated:
Excotiated:
Ecchymosis:
Steri Strips:
#:
Description:
Steri Strips:
#:
Description:
Staples:
#:
Description:
Staples:
#:
Description:
Sutures:
#:
Description:
Sutures:
#:
Description:
Dressing:
#:
Description:
Dressing:
#:
Description:
Dressing:
#:
Description:
Stage 1: Rt Foot, Heel
Stage 1: Rt Ft, Mediolateral
Stage 1: Coccyx Midline
Stage 2:
Stage 3:
Stage 3:
Stage 4:
Stage 4:
Eschar:
Eschar:
DTI:
DTI:
Measurement:
Measurement:
Measurement:
Measurement:
Measurement:
Measurement:
Measurement:
Measurement:
Measurement:
Measurement:
Measurement:
Measurement:
2cm X 1cm
1cm X 1cm
2.5cm X 1cm
Turn Schedule
Tx: Red-pink non-blanchable, no secretions, some minor abrasions
Tx: Red-pink non-blanchable, no secretions
Tx: Red-pink non-blanchable, no secretions, some minor abrasions
Tx:
Tx:
Tx:
Tx:
Tx:
Tx:
Tx:
Tx:
Tx:
Equipment/Interventions
TED Hose
SCD’s
C-Collar
Seizure Precautions Isolation:
Ortho: Rt Elbow pad to prevent breakdown. Legs elevated & padded with pillows, turn schedule every 2 hours
Print Name: Steven C Scanlon
Signature:
Date: 03/14/13
Nursing Care Plan
Drug Cards
Steven C Scanlon, S00533997, 1450 - Spring 2013
Drug Name (Generic & Trade) - Decadron/dexamethasone
Classification - Long-Acting Glucocotoroid/Corticosteroid/Antiemetic
Drug Actions - Inhibits accumulation of inflammatory cells at inflammation sites, suppresses the inflammatory response
Clinical Indications - Acute exacerbations of chronic allergic disorders, inflammatory conditions, Nausea
Dosage and administration - PO, IV, IM 0.75-9mg/day in divided doses
Nursing interventions - Question hypersensitivity to corticosteroids, B/P
Side effects/toxicity - Muscle wasting, CHF, Cough, Dry Mouth, Throat Irritation, HTN
Contraindications - Active untreated infections, systemic fungal infections, cerebral malaria
Antidote - None noted
Aging/developmental considerations - Pregnancy category C (D if first trimester), Elderly may be more
susceptible to hypertension
Drug use in this patient - Pt is SOB
Patient Teaching - Do not stop taking drug without consulting your physician, Avoid alcohol, limit caffeine
Drug Name (Generic & Trade) - Heparin/Hepalean
Classification - Anticoagulant
Drug Actions - Interferes with blood coagulation by blocking conversion of prothrombin to thrombin to thrombin and
fibrinogen to fibrin. Prevents further extension of existing thrombi or new clot formation. No effect on existing clots
Clinical Indications - Prophylaxis, treatment of thrombolitic disorders.
Dosage and administration - IV 60-70 units/kg Max 5000 Units, SQ 5000 Units
Nursing interventions - Check dose with co-worker, Determine PTT before administration
Side effects/toxicity - Bleeding complications, Puritus, Burning by vasospastic reaction
Contraindications - Intercranial hemorrhage, severe hypotension, severe thrombocytopenia, uncontrolled bleeding
Antidote - Protamine Sulfate
Aging/developmental considerations - Pregnancy category C, Elderly more susceptible to hemorrhage
Drug use in this patient - Pt is susceptible for DVT due to lack of mobility
Patient Teaching - Use a soft toothbrush and electric razor to prevent bleeding, report signs of dark or red urine
Nursing Care Plan
Drug Cards
Steven C Scanlon, S00533997, 1450 - Spring 2013
Drug Name (Generic & Trade) - Lasix/furosemide
Classification - Loop diuretic
Drug Actions - Enhances excretion of sodium, chloride, potassium by direct action at ascending limb of loop of Henle.
Produces diaeresis, lowers B/P.
Clinical Indications - Treatment of edema associated with CHF, chronic renal failure (including nephrotic syndrome),
hepatic cirrhosis, acute pulmonary edema. Treatment of hypertension, either alone or in combination with other antihypertensives.
Dosage and administration - PO: 20–80 mg/dose; may increase by 20–40 mg/dose q6–8h. May titrate up to 600 mg/
day in severe edematous states, IV, IM: 20–40 mg/dose; may increase by 20 mg/dose q1–2h. Maximum single dose: 160–200 mg
Nursing interventions - Assess eyes of Pt
Side effects/toxicity - profound water loss/electrolyte depletion, resulting in hypokalemia, hyponatremia, dehydration.
Sudden volume depletion may result in increased risk of thrombosis, circulatory collapse, sudden death, Increased urinary frequency/
volume, Nausea, dyspepsia, abdominal cramps, diarrhea or constipation, electrolyte disturbances
Contraindications - Anuria, Pregnancy. Cautions: Hepatic cirrhosis or coma, severe electrolyte depletion, prediabetes, diabetes
Antidote - None noted
Aging/developmental considerations - Elderly: May be more sensitive to hypotensive, electrolyte effects
Drug use in this patient - Acute SOB with course crackles in all lung fields
Patient Teaching - Drink fluids often with drug use. Expect increased frequency, volume of urination.
Drug Name (Generic & Trade) - Baclofen/Gablofen
Classification - Skeletal Muscle Relaxant/ Antispasmotic
Drug Actions - Inhibits transmission of reflexes at spinal cord level, relieves muscle spasticity
Clinical Indications - Treatment of cerebral spasticity, reversible spasticity associated with MS, Spinal cord lesions
Dosage and administration - PO: Initial 5mg TID Therapeutic range 40-80mg/day. Intrathecal Dose (Implanted pump
dose): 50-100mcg/day over 24 hrs
Nursing interventions - Check for immobility, stiffness, swelling
Side effects/toxicity - Abrupt discontinuation may produce hallucinations, seizures. Drowsiness, nausea, HA, constipation
Contraindications - None Known
Antidote - None noted
Aging/developmental considerations - Pregnancy Category B, Elderly: increased risk for CNS toxicity
Drug use in this patient - Pt has MS
Patient Teaching - Avoid tasks that require motor skills
Nursing Care Plan
Drug Cards
Steven C Scanlon, S00533997, 1450 - Spring 2013
Drug Name (Generic & Trade) - Ampyra/dalfampridine
Classification - Potassium channel blocker/Multiple Sclerosis agent
Drug Actions - Increases conduction of action potentials in demyelinated axons, inhibiting potassium channels
Clinical Indications - Indicated to improve ambulation in Pts with MS
Dosage and administration - PO 10mg BID
Nursing interventions - Creatinine clearance, BUN, CBC
Side effects/toxicity - UTI, Insomnia, Dizziness, HA, Nausea, Back Pain
Contraindications - Hx of seizures, Renal Impairment
Antidote - None noted
Aging/developmental considerations - Pregnancy Category C, Elderly: Age related renal impairment may
require dose adjustment
Drug use in this patient - Pt has MS
Patient Teaching - Avoid activities that require fine motor skills. Report sleeplessness
Drug Name (Generic & Trade) - Tamiflu/oseltamivir
Classification - Antiviral agent
Drug Actions - Selective inhibitor of influenza virus neuraminidase, enzyme required for viral reproduction, (influenza A & B)
Clinical Indications - Influenza A or B
Dosage and administration - PO: 75mg BID for 5 Days
Nursing interventions - Obtain baseline laboratory tests as indicated
Side effects/toxicity - Colitis, pneumonia, tympanic membrane disorder, fever, N/V/D, Abd Pain
Contraindications - None Known
Antidote - None noted
Aging/developmental considerations - Pregnancy Category C. Elderly: No age-related precautions noted
Drug use in this patient - Prophylaxis for undetectable strains of influenza
Patient Teaching - Not a substitute for a flu vaccination
Nursing Care Plan
Drug Cards
Steven C Scanlon, S00533997, 1450 - Spring 2013
Drug Name (Generic & Trade) - Zofran/ondansetron
Classification - Selective serotonin and receptor antagonist. Anti-nausea, antiemetic
Drug Actions - Blocks serotonin, both peripherally on vagal nerve terminals and centrally in chemoreceptor trigger zone.
Clinical Indications - Nausea/Vomiting
Dosage and administration - 4-8mg IV/IM/SL every 4 hrs PRN
Nursing interventions - Assess for dehydration
Side effects/toxicity - HTN, Acute renal failure, respiratory depression, coma, Anxiety, dizziness, HA, fatigue constipation
Contraindications - Use of apomorphine
Antidote - None noted
Aging/developmental considerations - Pregnancy Category C, Elderly: No age-related cautions noted
Drug use in this patient - Pt has Nausea
Patient Teaching - Notify physician id peripheral edema or SOB
Drug Name (Generic & Trade) - Ambien/zolpidem
Classification - Nonbenzodiazepine/Sedative-hypnotic
Drug Actions - Enhances action of inhibitory neurotransmitter gamma-aminobutyric acid (GABA), Induces sleep with fewer
nightly awakenings, improves sleep quality.
Clinical Indications - Short-term treatment of insomnia (with difficulty of sleep onset)
Dosage and administration - PO, SPRAY, SUBLINGUAL (Edluar, Zolpimist): ADULTS: 10 mg immediately before bedtime
Nursing interventions - Assess B/P, pulse, respirations, mental status, sleep patterns.
Side effects/toxicity - Severe ataxia (clumsiness, unsteadiness), bradycardia, diplopia, severe drowsiness, nausea, vomiting,
difficulty breathing, unconsciousness. HA
Contraindications - None known. Cautions: Renal/hepatic impairment, pts with depression, history of drug dependence,
sleep apnea, COPD, respiratory disease, myasthenia gravis.
Antidote - None noted
Aging/developmental considerations - Pregnancy category C. Elderly: More likely to experience falls or confusion
Drug use in this patient - Pt has difficulty falling asleep
Patient Teaching - Do not abruptly discontinue medication after long-term use.
Avoid alcohol and tasks that require alertness, motor skills
Nursing Care Plan
Drug Cards
Steven C Scanlon, S00533997, 1450 - Spring 2013
Drug Name (Generic & Trade) - Ativan/lorazepam
Classification - Benzodiazepine/Antianxiety, sedative-hypnotic, antiemetic, skeletal muscle relaxant, amnesiac,
anticonvulsant, antitremor
Drug Actions - Enhances action of inhibitory neurotransmitter gamma-aminobutyric acid (GABA) in CNS, affecting memory,
motor, sensory, cognitive function. Produces anxiolytic, anticonvulsant, sedative, muscle relaxant, antiemetic effects.
Clinical Indications - Management of anxiety disorders, short-term relief of symptoms of anxiety, anxiety associated with
depressive symptoms. Treatment of nausea, vomiting.
Dosage and administration - PO: 1–10 mg/day in 2–3 divided doses. IV: 0.02–0.06 mg/kg q2–6h.
IV INFUSION: 0.01–0.1 mg/kg/h
Nursing interventions - Asses type, severity, frequency of cough, increase fluid intake
Side effects/toxicity - Drowsiness, confusion, diminished reflexes, coma
Contraindications - Acute narrow-angle glaucoma, preexisting CNS depression, severe hypotension, severe uncontrolled
pain, IV administration in pts with sleep apnea, severe respiratory depression (except during mechanical ventilation).
Antidote - Flumazenil
Aging/developmental considerations - Pregnancy category D. Elderly: Use small initial doses with gradual
increases to avoid ataxia, excessive sedation, or paradoxical CNS restlessness, excitement.
Drug use in this patient - Pt has anxiety due to fear of death & further loss of muscular control/ability
Patient Teaching - Avoid tasks that require alertness, motor skills
Drug Name (Generic & Trade) - Cetacaine/butamben/tetracaine/benzocaine
Classification - Topical Analgesic
Drug Actions - Suppress pain by blocking impulses along axons
Clinical Indications - Pain relief of topical or mucosal areas
Dosage and administration - 2 sprays PRN
Nursing interventions - Assess administration area for open wounds
Side effects/toxicity - None noted
Contraindications - Open wounds
Antidote - None noted
Aging/developmental considerations - Pregnancy category C, otherwise no age related precautions noted
Drug use in this patient - Pt has sore throat
Patient Teaching - Be cautious when drinking hot fluids
Nursing Care Plan
Drug Cards
Steven C Scanlon, S00533997, 1450 - Spring 2013
Drug Name (Generic & Trade) - Neurontin/gabapentin
Classification - Gamma-aminobutyric acid analogue. Anticonvulsant, antineuralgic
Drug Actions - May increase synthesis or accumulation of gamma-aminobutyric acid (GABA) by binding to as-yet-undefined
receptor sites in brain tissue. Therapeutic Effect: Reduces seizure activity, neuropathic pain.
Clinical Indications - Adjunct in treatment of partial seizures, Treatment of moderate to severe primary restless legs syndrome
Dosage and administration - PO: Initially, 300 mg 3 times a day. May titrate dosage. Range: 900–1,800 mg/day in 3
divided doses. Maximum: 3,600 mg/day.
Nursing interventions - Assess location, intensity of neuralgia/neuropathic pain
Side effects/toxicity - Slurred speech, drowsiness, lethargy, diarrhea. Fatigue, drowsiness, dizziness, ataxia
Contraindications - Non Known. Cautions: Renal impairment.
Antidote - None noted
Aging/developmental considerations - Pregnancy Category C. Elderly: Age-related renal impairment may
require dosage adjustment.
Drug use in this patient - Used to help Pt w/ involuntary muscle contracture due to MS
Patient Teaching - Avoid tasks that require alertness, motor skills until response to drug is established. Avoid alcohol.
Drug Name (Generic & Trade) - Rocephin/ceftriaxone
Classification - Antibiotic
Drug Actions - Binds to bacterial cell membranes, inhibits its cell wall synthesis, bactericidal
Clinical Indications - Susceptible infections due to gram-negatve aerobic organisms, some gram-positive organisms including
respiratory tract, GU tract, Skin, Bone, Intra-abdominal, billiary tract infections, septicemia, meningitis, perioperative prophylaxis, acute
bacterial otitis media
Dosage and administration - 1-2g IM/IV q12-24hrs
Nursing interventions - Question allergy Hx, in particularly cephalosporins & penicillins
Side effects/toxicity - Antibiotic-associated colitis, Other superinfections, Thrush, Diarrhea, Abd cramping, vaginal candidiasis
Contraindications - Hypersensitivity to PCN, Cephalosporins
Antidote - None noted
Aging/developmental considerations - Pregnancy category B, Age-related renal impairment
Drug use in this patient - Pt has elevated WBCs
Patient Teaching - Continue antibiotic therapy for full length of treatment
Nursing Care Plan
Drug Cards
Steven C Scanlon, S00533997, 1450 - Spring 2013
Drug Name (Generic & Trade) - Ipratropium bromide/Atrovent
Classification - Anticholinergic/Bronchodiolator
Drug Actions - Blocks action of acetylcholine at parasympathetic sites in bronchial smooth muscle. Causes bronchodilation,
inhibits nasal secretions.
Clinical Indications - Maintenance treatment of bronchospasm due to COPD, bronchitis, emphysema, asthma.
Not to be used for immediate bronchospasm relief.
Dosage and administration - May be administered with or without dilution in 0.9% NaCl. Stable for 1 hr when
mixed with albuterol. Give over 5–15 min.
Nursing interventions - Offer emotional support (high incidence of anxiety due to difficulty in breathing,
sympathomimetic response to drug).
Side effects/toxicity - Worsening of angle-closure glaucoma, acute eye pain, hypotension occur rarely.
Cough, dry mouth, headache, nausea
Contraindications - History of hypersensitivity to atropine. Cautions: Narrow-angle glaucoma, prostatic hypertrophy.
Antidote - None noted
Aging/developmental considerations - Pregnancy category B. Elderly: No age-related precautions noted.
Drug use in this patient - Pt has SOB
Patient Teaching - increase fluid intake (decreases lung secretion viscosity).
Duoneb
Drug Name (Generic & Trade) - Albuterol / Pro Air
Classification - Sympathomimetic, Adrenergicagonist, bronchodilator
Drug Actions - Stimulates beta2-adrenergic receptors on lungs, relaxing bronchial smooth muscle relieving bronchospasm
and reducing airway resistance
Clinical Indications - Relief of bronchospasm due to reversible obstructive airway disease, prevention of bronchospasm
Dosage and administration - PO: 2-8mg 1-4 times/day PRN, MDI: 1-2 puffs Q4-6h (Max 12/day) PRN,
NEBULIZER: 1.25-5mg Q4-8h PRN - Usual dosage is 2.5mg in 3ml NS in nebulizer at 6-10 LPM over 5-10min
Nursing interventions - Assess mung sounds, B/P, SPO2, Provide emotional support for anxiety
Side effects/toxicity - Palpitations Tachycardia, CP, increased B/P, HA, Anxiety, Nausea, Dizziness, Insomnia, Dry Mouth
Contraindications - Hypersensitivity to sypathomimetics, CAUTIONS: Htn, Cardiovascular disease, DM, CHF, Glaucoma
Antidote - None noted
Aging/developmental considerations - Crosses placental barrier, May inhibit uterine contractions,
Age related sensitivity may increase side effects or toxicity
Drug use in this patient - Pt is an asthmatic