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Running head: PROCESS PAPER
Process Paper: Discitis and Osteomyelitis
Lori A. Risner
Kent State University Stark College of Nursing
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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,
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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).
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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
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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.
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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.
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“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).
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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.
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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).
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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
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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.
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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)
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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
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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.
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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
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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.
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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
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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
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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
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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.