Nursing Care Plan

Course: NUR 1210L
Instructor:
Dates of Care: 12, 13, 19 & 20 Sept 96
Date Submitted: 11/15/96
Student Names: Anthony Bernardi, SN/SPJC
HOLISTIC NURSING CARE PLAN
STUDENT Anthony Bernardi
GRADE
DATE November 15, 1996
Client’s Clinical Picture (5)
(Initial Cephacaudal assessment)
Textbook Description of Diagnosis (5)
Summary of Client’s Progress (5)
Completion of Holistic NCP Tool (30)
NURSING DIAGNOSIS (15)
GOALS (10)
INTERVENTIONS (10)
RATIONALES (5)
EVALUATIONS (10)
REFERENCES (5)
TABLE OF CONTENTS
SUBJECT PAGE #
Cover Page 1
Grading Point Scale 2
Table of Contents 3
Summary Page 4
Client’s Clinical Picture (Cephacaudal Assessment) 5
Medical Diagnosis 6
Textbook Description of Disease 6-12
Treatments and Procedures 13
Summary of Caregiver Progress Notes 14
Diagnostic Values Out Of Normal Range Clinical Implications 16
Radiology 17
Medications 18-52
Holistic Nursing Care Plan Form 53-62
List of Nursing Diagnosis 65
Five Nursing Diagnoses 66-70
References 71
CLIENT CLINICAL PICTURE:
Please see attached Cephacaudal Assessment (Pages 5)
MEDICAL DIAGNOSIS: Current diagnosis:Necrotizing pneumonia,
cachexia secondary to malnutrition / infection, hypothroidism, NIDDM, empyema RUI,
Aspergilloma, RUI, and depression. HX: HTN, atrial fibrillation, COPD, asthma
TEXTBOOK DESCRIPTION OF DIAGNOSIS:
See attached Disease Process Description (pages 6-12-)
SUMMARY OF CAREGIVER PROGRESS NOTES:
See attached Caregiver Progress Notes (page 14-15)
CLIENT CLINICAL PICTURE
Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for “ atypical chest pain and hemoptysis”. V/S BP 114/51, P 84, R 24, T 97.4. He seems alert and oriented x 3 and cheerful. Bowel sounds present x 4. Pt. has a red area on his coccyx. Silvadene treatments have been started. Pt. Has a fungal lung infection with a pleural suction drainage tube inserted in his chest . Pt is extremely thin with poor skin turgor with a diagnosis of cachexia ( wasting) secondary to malnutrition and infection. Patient is no known allergies to drugs but is allergic to aerosol sprays disinfectants and dust.. Advanced directives on chart. Code status DNR. Primary physician Dr. R, Thoracic surgeon Dr. L. Psychology Dr.W. There is PT, OT Dietary and Infectious Disease consults when necessary. He lives with his wife who he has been married to for 56 years. His son and his daughter come to visit him. He does not smoke. He wears dentures but did not bring them. He dose not use a hearing aid but he does have a hearing deficit.

Pt. is able to do all his ADL’s with limited assistance. He wants to get better and leave the HSP. Pt. Stated’ 90 days is to long to be here”. Pt. States that he is concerned about caring for his tube site when he goes home and does not feel that his wife can do this for him.

Diet: Pureed Hi protein, low fat, anti-dumping with Calorie count (all meals) and drink supplements between meals. TPN @ 79cc/hr 12hr around the clock through PICC line
MEDICAL DIAGNOSIS: Empyema, Hemoptysis, Necrotizing pneumonia, Aspergillosis (Aspergillus fumigatus) cachexia secondary to malnutrition/infection, hypothyroidism, Diabetes Type II melitius , and depression.

PATHOPHYSIOLOGY
HEMOPTYSIS: Expectoration of blood arising from the oral cavity, larynx, trachea, bronchi or lungs (Tabor’s, 17th ed. 1989 p.879)
CACHEXIA SECONDARY TO MALNUTRITION/INFECTION : The state of ill health, malnutrition, and wasting It may occur in any chronic diseases, certain malignancies and advanced pulmonary tuberculosis. (Tabor’s, 17th ed. 1989 p.287)
NECROTIZING PNEUMONIA: Aspiration pneumonia. Aspiration pneumonia is frequently called necrotizing pneumonia because of the pathologic changes in the lungs. It usually follows aspiration of material in the mouth into the trachea and subsequently the lungs. The aspirated material. Either food, water, or vomitus, is the triggering mechanism for the pathology of this type of pneumonia. If the aspirated material is an inert substance (e.g. barium or nonacid stomach contents), the initial manifestation is usually caused by obstruction of airways. When the aspirated materials contain gastric acid, there is chemical injury to the lung parenchyma with infection as a secondary event usually 48 to 72 hours later. The infecting organism is usually one of the normal oropharyngeal flora. The clinical manifestations proceed as those of a classic pneunococcal or streptococcal pneumonia. Fungi may also be a cause of pneumonia. These infections are not transmitted from person to person, and the patient does not have to be placed in isolation. The clinical manifestations are similar to those of bacterial pneumonia. Skin and serology tests are available to assist in identifying the infecting organism. However, identification of the organism In a sputum specimen or in other body fluids is the best diagnostic indicator. (Lewis, S.M. & Collier, p. 643-644)
ASPERGILLOSIS INFECTIONS : There are several forms of Aspergillosis infections. All are caused by one or more of the many different Aspergillus fungus species; only a few of these organisms are capable of producing disease in humans. These species are spread through the air and can be found almost any place in the world. Because these spores are inhaled, they usually affect the lungs or other airway passages such as the bronchial tubes, nose and sinuses. The fungi can be invasive, affecting any tissue, mucous membrane or vital organ of the body.

Allergic Bronchopulmonary Aspergillosis (ABPA) is an immune disorder that occurs in people with asthma or chronic obstructive pulmonary disease (COPD) infected with Aspergillosis fungi. It causes an excess of certain white blood cells (eosinophils), an infiltration of the lungs, and impaction of the bronchial tubes with eosinophils and Aspergillus organisms. Symptoms of this disease may consist of fever, shortness of breath (dyspnea), chest pain, wheezing, a cough with sputum (with or without blood) or a generalized feeling of ill-health (malaise). This form of Aspergillosis is not usually invasive, but it can lead to a chronic dilation of the bronchial tubes (bronchiectasis).

Pulmonary Mycetoma, also known as Aspergilloma or fungus ball, is a form of Aspergillosis that often occurs as a result of the Aspergillus fungus growing together (colonization) in a cavity of the lungs. These cavities are usually caused by other pulmonary diseases such as tuberculosis, sarcoidosis, histoplasmosis or coccioidomycosis. The fungus ball can be seen on x-rays. This form of Aspergillosis is characterized by a chronic cough, weight loss, a generalized feeling of ill-health (malaise) and the spitting up of blood (hemoptysis).

Fulminative or Invasive Aspergillosis is another form of this disorder that can cause distribution of the Aspergillus fungus to other parts of the body. This disease can progress from a localized infection to a widespread erosion and ulceration of the bronchial system and an inflammation of the vascular system (vasculitis). Vasculitis is a narrowing of the inside of a blood vessel that can obstruct the flow of blood to the tissues. This lack of blood can cause damage to the tissues (necrosis), and a possible formation of blood clots (thrombosis). Invasive Aspergillosis is usually first confined to the lungs but it can spread through the blood to other organs especially the liver, brain, kidneys, skin, gastrointestinal tract and other sites. This can be a very serious disease which can have a slow or rapid course. It is seen in those whose immune system has been weakened by other illnesses, especially people with cancer (e.g., Leukemia, Hodgkin's Disease), kidney transplant patients or those undergoing certain drug therapies.

Occasionally, Aspergillosis can cause Infective Endocarditis which is an infection of the inner lining of the heart muscle (endocardium). A type of infective endocarditis, prosthetic valvular endocarditis (PVE), may develop in patients who have previously had artificial (prosthetic) heart valve replacement. This infection may occur as a result of contamination of the operating room area by the Aspergillus spores. Drug addicts are also more susceptible to this form of Aspergillosis.

Mycetoma, also known as Madura Foot, is a chronic infection produced by Aspergillosis as well as several other fungi. It is a progressive fungal disease that is characterized by lesions of the foot, face, trunk, hand or leg. These lesions can cause swelling, hardening, pus formation, sinus drainage and abscesses that can lead to bone destruction and deformities. It is more commonly seen in tropical climates.

Aspergillosis is a group of infectious diseases that are caused by the inhalation of the Aspergillus fungus. The spores that cause these infections can be found in decaying vegetable matter, grains, grass, leaves, soil, wet paint, air conditioning systems, on refrigerator walls and in construction and fireproofing materials. It is not known why most people resist infection from this common fungus, and why others are more susceptible to infection. A weakened immune system, or an abnormal immune response to the fungus, may cause the fungus to proliferate and become a threat to one's health.

Aspergillosis is a rare disorder that affects males and females in equal numbers. It is seen more often in those people who have chronic respiratory problems or whose immune system has been weakened by other serious illnesses or drug therapy.

DEPRESSION: Depression is the most common functional disorder. Signs of depression include sadness, low energy, diminished memory and concentration, sleeping disturbances, appetite disturbance, with withdrawal, irritability, alcohol abuse, expressed feelings of helplessness and hopelessness, apathy, impaired attention span, and expression of suicidal wishes. Depression is often treatable and reversible through use of antidepressant medications and counseling. (Brunner/ Suddarth, 1988)
HYPERTENSION: Hypertension can be defined arbitrarily as persistent levels of blood pressure in which the systolic pressure is above 140 mm Hg and the diastolic pressure is above 90 mm Hg. In the elderly population, hypertension is defined as systolic pressure above 160 mm Hg and diastolic pressure above 90 mm Hg. Hypertension is a major cause of heart failure, stroke, and kidney failure. It is called the “silent killer” because the person who has it is often symptom free. Gerontological Considerations: Changes in the peripheral vascular system are responsible for the changes in blood pressure that occur with age. As the age related process of atherosclerosis evolves, the ability of the vessels to distend and recoil is reduced. Consequently, the aorta and large arteries are less able to accommodate the ejected stroke volume, and a decrease in cardiac output and increase in peripheral resistance result. Systolic blood pressure increases as a result of the increased peripheral resistance, and pulse pressure widens subsequent to the diastolic fall that accompanies reduced distensibility of the aorta. The risk factors for high blood pressure that are present in the population in general continue into old age. These are approximately the same for elderly men and women. (Brunner/ Suddarth, 1988)
CHRONIC OBSTRUCTIVE PULMONARY DISEASE : Chronic obstructive pulmonary disease (COPD) is the most common cause of death and disability due to lung disease in the United States. COPD is a broad classification that includes a group of conditions associated with chronic obstruction of air flow entering or leaving the lungs. Airway obstruction is diffuse airway narrowing, causing increased resistance to air bronchiectasis, emphysema, and asthma. Basically, the person with COPD has (1) excessive secretion of mucus within the airways not due to specific causes (bronchitis or bronchiectasis), (2) an increase in the size of the air spaces distal to the terminal bronchioles with loss of alveolar walls and elastic recoil of the lungs (emphysema), and (3) narrowing of the bronchial airways that varies in severity (asthma). As a result there is a subsequent derangement of airway dynamics for example, loss of elasticity and obstruction of air flow. There is often an overlap of these conditions. (Brunner/ Suddarth, 1988 )
ASTHMA : Asthma is an intermittent, reversible, obstructive airway disease characterized by increased responsiveness of the trachea and bronchi to various stimuli. This results in narrowing of the airways, causing dyspnea This narrowing of the airway changes in degree, either spontaneously or because of therapy. Asthma differs from other obstructive lung diseases in that it is a reversible process, and patients may exhibit no symptoms for a prolonged period of time. Asthma is a reversible diffuse airway obstruction. The obstruction is caused by one or more of three developments: (1) contraction of muscles surrounding the bronchi, which narrows the airway (2) swelling of membranes that line the bronchi and (3) filling of the bronchi with thick mucus. In addition, there is bronchial muscle enlargement, mucous gland enlargement, thick, tenacious sputum, and hyperinflation or air trapping in the alveoli but most of what is known involves the immunologic system and the autonomic nervous system. (Brunner/ Suddarth, 1988
ATRIAL FIBRILLATION: Atrial fibrillation (disorganized and uncoordinated twitching of atrial musculature) is usually associated with atherosclerotic heart disease, rheumatic heart disease, CHF, thyrotoxicosis, or pulmonale, or congenital heart disease. Atrial fibrillation is characterized by the following- lowing: Rate: An atrial rate of 350 to 600 beats per minute ventricular response usually 120 to 200 beats per minute. P waves: No discernible P waves: irregular undulation, termed fibrillary or “f” waves, is seen; PR interval cannot be measured. QRS complex: Usually normal. Conduction: Usually normal through the ventricles. Characterized by an irregular ventricular response, because the AV node is incapable of responding to the rapid atrial rate. Impulses that are transmitted cause the ventricles to respond irregularly. Rhythm: Irregular and usually rapid, unless controlled. Irregularity of rhythm is due to concealed conduction within the AV node. A rapid ventricular response reduces the time for ventricular filling and hence the stroke volume. The atrial kick, which is 25 to 30% of the cardiac output, is also lost. Congestive heart failure frequently follows. There is usually a pulse deficit, the numerical difference between apical and radial pulse rates. Treatment is directed toward eliminating the cause, decreasing the atrial irritability, and decreasing the rate of the ventricular response. In patients with chronic atrial fibrillation, anticoagulant therapy may be used to prevent thromboemboli from forming in the atria. Drugs of choice to treat atrial fibrillation are similar to those used in the treatment of paroxysmal atrial tachycardia, digitalis preparation is used to slow the heart rate, and an antidysrhythmic such as quinidine is used to correct the dysrhythmia. (Brunner, & Suddarth 1988).
TYPE II DIABETES MELLITUS: In diabetes, insulin is not secreted in proportion to blood glucose levels because of several possible factors: deficiency in the production of insulin by the beta cells, insensitivity of the insulin secretory mechanism of the beta cells, delayed or insufficient release of insulin, or excessive inactivation by chemical inhibitors or “binders” in the circulation. In some non-insulin dependent persons with diabetes, however, insulin secretion is increased, resulting in higher , circulating insulin levels. Although excess insulin is present, it is not utilized because of an inadequate number of insulin receptors present on cells. This mechanism has been
observed in obese patients. With weight loss, the number of insulin receptors on the cells increases, thereby allowing glucose to enter the cell. This may result in return of a normal glucose tolerance. (Burner/ Suddarth, 1988 )
HYPOTHYROIDISM : Hypothyroidism is a condition in which there is a slow progression of thyroid hypofunction, followed by symptoms indicating thyroid failure. More than 95% of patients with hypothyroidism have primary dysfunction of the thyroid gland itself. When the thyroid dysfunction is due to failure of the pituitary gland, it is known as secondary hypothyroidism; when failure of the hypothalamus is the underlying cause, the term tertiary hypothyroidism is used. When thyroid deficiency is present at birth, the condition is known as cretinism. In such instances, the mother may also suffer from thyroid deficiency. (Brunner/ Suddarth, 1988)
TREATMENTS AND PROCEDURES
Patients activity orders are as tolerated with wheel chair transport. Pt needs partial assist with ADLs. He is continent of B & B with assistance
Needs to be turned in bed Q 2 hr, elevate heels in bed . Pt has a special mattress.
Encourage I.S. Q 1 hr w/a. IV flush q shift peripheral line. PICC line flush.

Chest tube to water seal to 20cm, with cont. suction 55-60 wall green. DO NOT DISCONTINUE SUCTION.

Chest tube dressing change no deviations from present form.
Accurate I&O’s . VS. Q shift and prn. with lung sounds assessment. Skin assessment q 2 hr with wound assessment at the same time(abrasion on the back ) and finger ulceration. FSGs q 6 hr with Sliding scale coverage. Weight every week on Monday.
SUMMARY OF CARE GIVER NOTES:
All times are approximate
07:30 Received report on G.B. from night shift.

08:00 Spoke with G.B. before breakfast was delivered. Vital signs taken and noted. Insured patency of chest drainage tubes and amount of fluid from last shift. Noted time and initialed on collecting container.

09:00 09:00 medications given and noted
09:30 Assisted G.B. with ADL’s. Pt stated that he wasn’t very hungry. Pt. Ate only 25% of solid food. Noted intake of 250ml. Urine output after breakfast 225ml. Pt. Performed own bed bath and oral care. Lotion applied to Pt. Pt. Helped into bedside commode. Curtains drawn for privacy.

10:30 Dressing change on tube insertion site as ordered. Skin assessment done and lung sounds checked. Check position of G.B. He had re-positioned himself for comfort
10:45 X-Ray of G.B. performed in room. G.B. dressed and assisted into wheel chair.

11:00 Reported pt status to Team Leader.

11:00 Documented morning activities in appropriate charts, i.e. Nsg Notes, treatment book and V/S charts.

11:15 Returned to room to interview G.B. . Pt was cheerful but stated that he was feeling tired and wanted to be helped back into bed.

11:45 Noted I & O
12:00 G. B. In bed resting comfortably. Reported pt status to team leader and report off floor to post-conference.
DIAGNOSTIC VALUES OUT OF NORMAL RANGE CLINICAL IMPLICATIONS
BUN 32H 10-26 A. Increased BUN levels (azotemia) 1. The most common cause of increased BUN level is inadequate excretion due to kidney disease or urinary obstruction, frequently- : occurring in cases of prostate enlargement. (A) An increased BUN of 50 to 150 mg / 100 ml indicates serious impairment of renal function. (Fishbach p. 312)
Creatinine .5H 0.7-1.4 A disorder of kidney function reduces excretion of creatinine, resulting in increased levels of blood creatinine. The test is used to diagnose impaired renal function. It is a more specific and sensitive indicator of kidney disease than BUN, although in chronic renal disease, BUN correlates more accurately with symptoms of uremia than does the blood creatinine.( (Fishbach p. 312)
WBC 10.4H 5-10 A. Leukocytosis (white blood cell count above l0000 / gl) 1. Leukocytosis is usually due to an increase of only one type of White cell and is given the name of the type of cell that shows white cell and is given the name of the type of cell that shows the main increase. .In increase in circulating leukocytes is rarely due to a proportional increase in leukocytes of all types. When it occurs it is usually to hemoconcentration. Leukocytosis occurs in acute infections in which the degree of increase of white cells depends on, 1. The severity of the infection, 2. The patient’s resistance, 3. The patient’s age.(Fishbach p. 25.)
RBC 2.96L 4.2-5.6 Decreased RBC Values . Anemia, a condition in which there is a reduction in the number of circulating RBCs, in the amount of hemoglobin, and/or in the volume of packed cell(hematocrit).(Fishbach p. 41)
HGB 10.L 13.1-17.2 Anemia
HCT 29.3L 39-50 decreased hematocrit values are an indicator of anemia. In hematocrit of 30 or less means the patient is moderately to severely anemic.
ALBUMIN 3.1l 3.9-5 decreased albumin levels severe hypoalbuminemia is often associated with edema and decreased transport function such as hypocalcemia. Decreased albumin levels are caused by many different conditions i.e. Nephrosis (Fishbach p. 363)
LY# 1.2L 1.8-2.6 Anemia
MCH 34H 26-34 An increase of the MCH is associated with macrocytic anemia.
MCV 99.2H 87 -103 Note VA values differ from Fishbach. F the MCV is greater than 103 mm3, the red cell 5 are macrocy tic.
PLT 433H 150-350 Abnormally increased numbers of platelets (thrombocythemial thrombocytosis) occur in iron-deficiency and posthemorrhagic anemia acute infections and many other diseases. In 50% of those patients who exhibit an unexpected increase in plate- lets, a malignancy will be found. This malignancy is usually disseminated, advanced, or inoperable.
MPV 6.3L 8 -10L This test is done in the investigation of various hematologic disorders such as thrombocytopenic purpura, and study of alcoholics under treatment.
Na+ 135 135-148 Hyponatremia usually reflects a relative excess of body water rather than a low total body sodium.
K 4.6 2.7-4.5 Hyperphosphatemia (increased phosphorus levels) The most common causes of elevated blood phosphate levels are in association with kidney dysfunction and uremia. This is because phosphate is so closely regulated by the kidneys. Renal insufficiency and severe nephritis (accompanied by elevated- : BUN and creatine)
Albumin 3.1 3.8-5.0 albumin is a protein that is formed in the liver and that helps to maintain normal distribution of water in the body (colloidal osmotic pressure). It also helps in the transport of blood constituents such as ions, pigments, bilirubin, hormones, fatty acids, enzymes, and certain drugs. Decreased albumin levelsDecreased albumin levels are caused by many different conditions- inadequate iron intake, Severe liver diseases Malabsorption, Starvation, excessive administration of IV glucose in water
RADIOLOGY
F/Y empyema status no change since 9/3/96. F/U - bilateral sever pulmonary emphysema & interstitial fibrosis. CBC shows high levels of WBC’s and bends indicative of ongoing infection. Chemistry shows elevated liver enzymes. UA and C&S are negative. Blood cultures are also negative. Sputum C&S and Gram Stain show WBC* 25, Eph.*10 and presence of Alpha streptococcus & neisseria.

LABS AND X-RAYS: CXR done on 9/3 shows normal heart size, no change in the status of pulmonary fibrosis, emphysema but there is new fluid in R major fissure. Echo done 7/22 reveals L ventricular systolic dysfunction and ejection fraction of 31%. ECG done 7/29 shows Arterial Fibrillation. CT-scan of chest is ordered.
MEDICATIONS
ALBUTEROL
Albuterol, Proventil, Proventil Repetabs, Salbutamol, Ventolin, Ventolin Rotacaps, Volmax
Func. class.: Adrenergic b2 agonist
Action: Causes bronchodilation by action on b2 (pulmonary) receptors by increasing levels of cAMP, which relaxes smooth muscle; produces bronchodilation, CNS, cardiac stimulation, as well as increased diuresis and gastric acid secretion; longer acting than isoproterenol
Uses: Prevention of exercise-induced asthma, bronchospasm, production of premature labor
Dosage and routes:
To prevent exercise-induced asthma
• Adult: INH 2 puffs 15 min before exercising, NEB/LPPB 5 mg tid-qid
Bronchospasm
• Adult: INH 1-2 puffs q4-6h PO 2-4 mg tid-qid, not to exceed 8 mg
Prevention of premature labor
Available forms: Aerosol 90 mg/actuation; tabs 2, 4 mg; syr 2 mg/5 ml, cont rel 4, 8 mg
Side effects/adverse reactions:
CNS: Tremors, anxiety, insomnia, headache, dizziness, stimulation, restlessness, hallucinations, flushing, irritability
EENT: Dry nose, irritation of nose and throat
CV: Palpitations, tachycardia, hypertension, angina, hypotension, dysrhythmias
GI: Heartburn, nausea, vomiting
MS: Muscle cramps
Contraindications: Hypersensitivity to sympathomimetics, tachydysrhythmias, severe cardiac disease
Precautions: Lactation, pregnancy , cardiac disorders, hyperthyroidism, diabetes mellitus, hypertension, prostatic hypertrophy, narrow-angle glaucoma, seizures, exercise-induced bronchospasm (aerosol) in children *12 years
Pharmacokinetics:
Well absorbed PO, extensively metabolized in the liver, excreted in urine, crosses placenta, breast milk, blood-brain barrier
PO: Onset hr, peak 2 hr, duration 4-6 hr, half-life 2 hr
PO-ER: Onset hour; peak 2-3 hr; duration 12 hr
INH: Onset 5-15 min, peak 1-1 hr, duration 4-6 hr, half-life 4 hr
Interactions/incompatibilities:
• Increased action of aerosol bronchodilators
• Increased action of albuterol: tricyclic antidepressants, MAOIs, other adrenergics
• May inhibit action of albuterol: other b-blockers
NURSING CONSIDERATIONS
Assess:
• Respiratory function: vital capacity, forced expiratory volume, ABGs, lung sounds, heart rate and rhythm (baseline)
• That patient has not received theophylline therapy before giving dose
• Client’s ability to self-medicate
• For evidence of allergic reactions
Administer:
• After shaking, exhale, place mouthpiece in mouth, inhale slowly, hold breath, remove, exhale slowly
• Gum, sips of water for dry mouth
• PO with meals to decrease gastric irritation
• Syrup to children (no alcohol, sugar)
Perform/provide:
• Storage in light-resistant container, do not expose to temperatures over 86 F (30 C)
Evaluate:
• Therapeutic response: absence of dyspnea, wheezing after 1 hr, improved airway exchange, improved ABGs
Teach patient/family:
• Not to use OTC medications; extra stimulation may occur
• Use of inhaler; review package insert with patient
• To avoid getting aerosol in eyes; blurring may result
• To wash inhaler in warm water qd and dry
• To avoid smoking, smoke-filled rooms, persons with respiratory infections
• That paradoxical bronchospasm may occur and to stop drug immediately
• To limit caffeine products such as chocolate, coffee, tea, and colas
Treatment of overdose: Administer a b2-adrenergic blocker
PANCRELIPASE
Creon Capsules,
Func. class.: Digestant
Chem. class.: Pancreatic enzyme-bovine/porcine
Action: Pancreatic enzyme needed for proper pancreatic functioning
Uses: Exocrine pancreatic secretion insufficiency, cystic fibrosis (digestive aid), steatorrhea, pancreatic enzyme deficiency
Dosage and routes:
• Adult and child: PO 1-3 caps/tabs ac or with meals, or 1 caps/tab with snack or 1-2 pdr pkt ac
Available forms: Tab 8000, 11,000, 30,000 U; caps 8000, 30,000 U; enteric coated caps 4000, 5000, 20,000, 25,000 U; powd 16,800 U
Side effects/adverse reactions:
GI: Anorexia, nausea, vomiting, diarrhea
GU: Hyperuricuria, hyperuricemia
Contraindications: Allergy to pork, chronic pancreatic disease
Precautions: Pregnancy
Interactions/incompatibilities:
• Decreased absorption: cimetidine, antacids, oral iron
NURSING CONSIDERATIONS
Assess:
• I&O ratio; watch for increasing urinary output
• Fecal fat, nitrogen, pro-time during treatment
• For polyuria, polydipsia, polyphagia (may indicate diabetes mellitus)
Administer:
• After antacid or cimetidine; decreased pH inactivates drug
• Powder mixed in prepared fruit for infants, children
• Whole, not crushed or chewed (enteric coated)
• Low-fat diet to decrease GI symptoms
• Powder mixed with pureed fruit; take tabs with or before food
Perform/provide:
• Storage in tight container at room temperature
Evaluate:
• FOR ALLERGY TO PORK
DIGOXIN
Digoxin, Lanoxicaps, Lanoxin
Func. class.: Antidysrhythmic, cardiac glycoside
Chem. class.: Digitalis preparation
Action: Inhibits the sodium-potassium ATPase, which makes more calcium available for contractile proteins, resulting in increased cardiac output
Uses: CHF, atrial fibrillation, atrial flutter, atrial tachycardia, rapid digitalization in these disorders
Dosage and routes:
• Adult: IV 0.5 mg given over *5 min, then PO 0.125-0.5 mg qd in divided doses q4-6hr as needed
• Elderly: PO 0.125 mg qd maintenance
• Child *2 yr: PO 0.02-0.04 mg/kg divided q8h over 24 hr; maintenance 0.006-0.012 mg/kg qd in divided doses q12hr; IV loading dose 0.015-0.035 mg/kg over *5 min
• Child 1 mo-2 yr: IV 0.03-0.05 mg/kg in divided doses over *5 min q48h; change to PO as soon as possible; PO 0.035-0.060 mg/kg divided in 3 doses over 24 hr; maintenance 0.01-0.02 mg/kg in divided doses q12h
• Neonates: IV loading dose 0.02-0.03 mg/kg over *5 min in divided doses q4-8h; change to PO as soon as possible; PO loading dose 0.035 mg/kg divided q8h over 24h; maintenance 0.01 mg/kg in divided doses q12hr
• Premature infants: IV 0.015-0.025 mg/kg divided in 3 doses over 24 hr, given over *5 min; maintenance 0.003-0.009 mg/kg in divided doses q12h
Available forms: Caps 50, 100, 200 mg; elix 50 mg/ml; tabs 125, 250, 500 mg; inj 100, 250 mg/ml
Side effects/adverse reactions:
CNS: Headache, drowsiness, apathy, confusion, disorientation, fatigue, depression, hallucinations
CV: Dysrhythmias, hypotension, bradycardia, AV block
EENT: Blurred vision, yellow-green halos, photophobia, diplopia
GI: Nausea, vomiting, anorexia, abdominal pain, diarrhea
Contraindications: Hypersensitivity to digitalis, ventricular fibrillation, ventricular tachycardia, carotid sinus syndrome, 2nd or 3rd degree heart block
Precautions: Renal disease, acute MI, AV block, severe respiratory disease, hypothyroidism, elderly, pregnancy , sinus nodal disease, lactation, hypokalemia
Pharmacokinetics:
PO: Onset -2 hr, peak 6-8 hrs, duration 3-4 days
IV: Onset 5-30 min, peak 1-5 hr, duration variable, half-life 1.5 days excreted in urine
Interactions/incompatibilities:
• Hypokalemia: diuretics, amphotericin B, carbenicillin, ticarcillin, corticosteroids, piperacillin
• Decreased digoxin level: thyroid agents
• Increased blood levels: propantheline bromide, spironolactone quinidine, verapamil, aminoglycosides PO, amiodarone, anticholinergics, quinine
• Increased bradycardia: b-adrenergic blockers, antidysrythmics
• Toxicity: adrenergics, amphotericin, corticosteroids, diuretics, glucose, insulin, reserpine, succinylcholine, quinidine, thioamines
• Incompatible with acids, alkalies, Ca salts
Lab test interferences:
Increase: CPK
NURSING CONSIDERATIONS
Assess:
• Apical pulse for 1 min before giving drug; if pulse *60 in adult or *90 in an infant, take again in 1 hr; if *60 in adult, call physician; note rate, rhythm, character
• Electrolytes: K, Na, Cl, Mg, Ca; renal function studies: BUN, creatinine; blood studies: ALT, AST, bilirubin, Hct, Hgb before initiating treatment and periodically thereafter
• I&O ratio, daily weights; monitor turgor, lung sounds, edema
• Monitor drug levels (therapeutic level 0.5-2 ng/ml)
• Cardiac status: apical pulse, character, rate, rhythm
Administer:
• PO with or without food; may crush tabs
• K supplements if ordered for K levels *3, or foods high in K: bananas, orange juice
• IV undiluted or 1 ml of drug/4 ml sterile H2O, D5, or NS; give over *5 min through Y-tube or 3-way stopcock; during digitalization close monitoring is necessary
Perform/provide:
• Storage protected from light
Evaluate:
Therapeutic response: decreased weight, edema, pulse, respiration, rales; increased urine output; serum digoxin level (0.5-2 ng/ml)
Teach patient/family:
• Not to stop drug abruptly; teach all aspects of drug, to take exactly as ordered
• To avoid OTC medications, since many adverse drug interactions may occur; do not take antacid at same time
• To notify physician of any loss of appetite, lower stomach pain, diarrhea, weakness, drowsiness, headache, blurred or yellow vision, rash, depression, toxicity
• Toxic symptoms of this drug and when to notify physician
• To maintain a sodium-restricted diet as ordered
• To report shortness of breath, difficulty breathing, weight gain, edema, persistent cough
Treatment of overdose: Discontinue drug; administer K; monitor ECG, administer an adrenergic blocking agent, digoxin immune FAB
FOSINOPRIL
Monopril
Func. class.: Antihypertensive
Chem. class.: Angiotension-converting enzyme (ACE) inhibitor
Action: Selectively suppresses renin-angiotensin-aldosterone system; inhibits ACE; prevents conversion of angiotensin I to angiotensin II; results in dilation of arterial, venous vessels
Uses: Hypertension, alone or in combination with thiazide diuretics
Dosage and routes:
• Adult: PO 10 mg qd initially, then 20-40 mg/day divided bid or qd
Available forms: Tabs 10, 20 mg
Side effects/adverse reactions:
CV: Hypotension, chest pain, palpitations, angina, orthostatic hypotension
GU: Proteinuria, Increased BUN, creatinine, decreased libido
HEMA: Decreased Hct, Hgb, eosinophilia, leukopenia, neutropenia
INTEG: Angioedema, rash, flushing, sweating, photosensitivity, pruritus
RESP: Cough, sinusitis, dyspnea, bronchospasm
META: Hyperkalemia
GI: Nausea, constipation, vomiting, diarrhea
CNS: Insomnia, paresthesia, headache, dizziness, fatigue, memory disturbance, tremor, mood change
MS: Arthralgia, myalgia
Contraindications: Hypersensitivity to ACE inhibitors, pregnancy (D), lactation, children
Precautions: Impaired liver function, hypovolemia, blood dyscrasias, CHF, COPD, asthma, elderly
Pharmacokinetics:
PO: Peak 3 hr; serum protein binding 97%; half-life 12 hr; metabolized by liver (metabolites excreted in urine, feces)
Interactions/incompatibilities:
• Increased hypotension: diuretics, other antihypertensives, ganglionic blockers, adrenergic blockers
• Increased toxicity: vasodilators, hydralazine, prazosin, K-sparing diuretics, sympathomimetics
• Decreased absorption: antacids
• Decreased antihypertensive effect: indomethacin
• Increased serum levels of: digoxin, lithium
• Increased hypersensitivity: allopurinol
Lab test interferences:
False positive: Urine acetone
NURSING CONSIDERATIONS
Assess:
• Blood studies: neutrophils, decreased platelets
• B/P, orthostatic hypotension, syncope
• Renal studies: protein, BUN, creatinine; watch for increased levels that may indicate nephrotic syndrome
• Baselines in renal, liver function tests before therapy begins
• K levels, although hyperkalemia rarely occurs
• Dipstick of urine for protein qd in first morning specimen; if protein is increased, a 24-hr urinary protein should be collected
• Edema in feet, legs daily
• Allergic reactions: rash, fever, pruritus, urticaria; drug should be discontinued if antihistamines fail to help
• Renal symptoms: polyuria, oliguria, frequency, dysuria
Administer:
• IV infusion of 0.9% NaCl (as ordered) to expand fluid volume if severe hypotension occurs
Perform/provide:
• Storage in tight container at 86 F (30 C) or less
• Supine or Trendelenburg position for severe hypotension
Evaluate:
• Therapeutic response: decrease in B/P
Teach patient/family:
• Not to discontinue drug abruptly
• Not to use OTC products (cough, cold, allergy) unless directed by physician; do not use salt substitutes containing potassium without consulting physician
• Importance of complying with dosage schedule, even if feeling better
• To rise slowly to sitting or standing position to minimize orthostatic hypotension
• To notify physician of mouth sores, sore throat, fever, swelling of hands or feet, irregular heart beat, chest pain
• To report excessive perspiration, dehydration, vomiting, diarrhea; may lead to fall in B/P
• That drug may cause dizziness, fainting, light-headedness during 1st few days of therapy
• That drug may cause skin rash or impaired perspiration
• How to take B/P; normal readings for age group Treatment of overdose: 0.9% NaCl IV INF, hemodialysis
FLUOCINONIDE
Flucinolone, Fluocinolone Acetonide, Fluonid, Flurosyn, Synalar, Synalar-HP, Synemol, Fluocinonide, Lidemol, Lidex, Lidex-E, Vasoderm, Vasoderm E
Func. class.: Topical corticosteroid
Chem. class.: Synthetic fluorinated agent, group II potency
Action: Possesses antipruritic, antiinflammatory actions
Uses: Psoriasis, eczema, contact dermatitis, pruritus
Dosage and routes:
• Adult and child: Apply to affected area tid-qid
Available forms: Oint 0.05%; cream 0.05%; sol 0.05%; gel 0.05%
Side effects/adverse reactions:
INTEG: Burning, dryness, itching, irritation, acne, folliculitis, hypertrichosis, perioral dermatitis, hypopigmentation, atrophy, striae, miliaria, allergic contact dermatitis, secondary infection
Contraindications: Hypersensitivity to corticosteroids, fungal infections
Precautions: Pregnancy (C), lactation, viral infections, bacterial infections
NURSING CONSIDERATIONS
Assess:
• Temperature: if fever develops, drug should be discontinued
Administer:
• Only to affected areas; do not get in eyes
• Medication, then cover with occlusive dressing (only if prescribed), seal to normal skin, change q12h; use occlusive dressings with extreme caution
• Only to dermatoses; do not use on weeping, denuded, or infected area
Perform/provide:
• Cleansing before application of drug
• Treatment for a few days after area has cleared
• Storage at room temperature
Evaluate:
• Therapeutic response: absence of severe itching, patches on skin, flaking
Teach patient/family:
• To avoid sunlight on affected area; burns may occur
INSULIN,
Beef NPH Iletin II, Humulin N, Iletin NPH, Insulatard NPH, NPH Iletin I, Pork NPH Iletin II, Novolin N, NPH Insulin, NPH Purified Pork
Func. class.: Antidiabetic
Chem. class.: Exogenous unmodified insulin
Action: Decreases blood sugar; indirectly increases blood pyruvate, lactate; decreases phosphate, potassium
Uses: Ketoacidosis, type I (IDDM), type II (NIDDM) diabetes mellitus, hyperkalemia
Dosage and routes:
• Adult: SC dosage individualized by blood, urine glucose, usual dose 7-26 U; may increase by 2-10 U/day if needed
Available forms: SC 100 U/ml
Side effects/adverse reactions:
CNS: Headache, lethargy, tremors, weakness, fatigue, delirium, sweating
CV: Tachycardia, palpitations
EENT: Blurred vision, dry mouth
GI: Hunger, nausea
META: Hypoglycemia
INTEG: Flushing, rash, urticaria, warmth, lipodystrophy, lipohypertrophy
SYST: Anaphylaxis
Contraindications: Hypersensitivity to protamine
Precautions: Pregnancy (B)
Interactions/incompatibilities:
• Increased hypoglycemia: salicylate, alcohol, b-blockers, anabolic steroids, fenfluramine, phenylbutazone, sulfinpyrazone, guanethidine, oral hypoglycemics, MAOIs, tetracycline
• Decreased hypoglycemia: thiazides, thyroid hormones, oral contraceptives, corticosteroids, estrogens, dobutamine, epinephrine
Pharmacokinetics:
SC: Onset 1-2 hr, peak 4-12 hr, duration 18-24 hr
Metabolized by liver, muscle, kidneys; excreted in urine
Lab test interferences:
Increase: VMA
Decrease: K, Ca
Interference: Liver function studies, thyroid function studies
NURSING CONSIDERATIONS
Assess:
• Fasting blood glucose, 2 hr PP (80-150 mg/dl normal fasting level) (70-130 mg/dl-normal 2 hr level)
• Urine ketones during illness; insulin requirements may increase during stress, illness
• Hypoglycemic reaction that can occur during peak time
Administer:
• After warming to room temperature by rotating in palms to prevent injecting cold insulin
• Increased doses if tolerance occurs
• Human insulin to those allergic to beef or pork
Perform/provide:
• Storage at room temperature for *1 mo, keep away from heat and sunlight, refrigerate all other supply, do not use if discolored; do not freeze
• Rotation of injection sites within one area: abdomen, upper back, thighs, upper arm, buttocks; keep record of sites
Evaluate:
• Therapeutic response: decrease in polyuria, polydipsia, polyphagia, clear sensorium, absence of dizziness, stable gait
Teach patient/family:
• That blurred vision occurs; not to change corrective lens until vision is stabilized 1-2 mo
• To keep insulin, equipment available at all times
• That drug does not cure diabetes but controls symptoms
• To carry Medic Alert ID as diabetic
• Hypoglycemia reaction: headache, tremors, fatigue, weakness
• Dosage, route, mixing instructions, if any diet restrictions, disease process
• To carry candy or lump sugar to treat hypoglycemia; have glucagon emergency kit available
• Symptoms of ketoacidosis: nausea, thirst, polyuria, dry mouth, decreased B/P, dry, flushed skin, acetone breath, drowsiness, Kussmaul respirations
• That a plan is necessary for diet, exercise; all food on diet should be eaten; exercise routine should not vary
• To avoid OTC drugs unless directed by physician
Treatment of overdose: Glucose 25g IV, via dextrose 50% solution, 50 ml or 1 mg glucagon
ITRACONAZOLE
Sporanox
Func. class.: Antifungal
Chem. class.: Triazole derivative
Action: Alters cell membranes and inhibits several fungal enzymes
Uses: Systemic candidiasis, chronic mucocandidiasis, oral thrush, candiduria, coccidioidomycosis, histoplasmosis, chromomycosis, paracoccidioidomycosis, blastomycosis (pulmonary and extrapulmonary)
Dosage and routes:
• Adult: PO 200 mg qd with food; may increase to 400 mg qd if needed; divide doses over 200 mg in two doses
Available forms: Caps 100 mg
Side effects/adverse reactions:
GU: Gynecomastia, impotence, decreased libido
INTEG: Pruritus, fever, rash,
CNS: Headache, dizziness, insomnia, somnolence, depression
GI: Nausea, vomiting, anorexia, diarrhea, cramps, abdominal pain, flatulence, GI bleeding, hepatotoxicity
MISC: Edema, fatigue, malaise, hypertension, hypokalemia, tinnitus
Contraindications: Hypersensitivity, lactation, fungal meningitis, coadministration with terfenadine
Precautions: Hepatic disease, achlorhydria or hypochlorhydine (drug-induced), children, pregnancy (C)
Pharmacokinetics:
PO: Peak 3-5 hr, half-life 60 hr; metabolized in liver; excreted in bile, feces; requires acid pH for absorption; distributed poorly to CSF; highly protein bound
Interactions/incompatibilities:
• Do not use with terfenadine: may result in rare instance of life-threatening dysrhythmias and death
• Hepatotoxicity: other hepatotoxic drugs
• Itraconazole increases levels of cyclosporine
• Decreased action of itraconazole: antacids, H2-receptor antagonists, isoniazid, rifampin
• Increased anticoagulant effect: coumarin anticoagulants
• Severe hypoglycemia: oral hypoglycemics
• Concomitant administration with phenytoin may result in decreased levels of itraconazole; effects of phenytoin may be increased
NURSING CONSIDERATIONS
Assess:
• I&O ratio
• Liver studies (ALT, AST, bilirubin) if on long-term therapy
• For allergic reaction: rash, photosensitivity, urticaria, dermatitis
• For hepatotoxicity: nausea, vomiting, jaundice, clay-colored stools, fatigue
Administer:
• In the presence of acid products only; do not use alkaline products or antacids within 2 hr of drug; may give coffee, tea, acidic fruit juices
• With food to decrease GI symptoms
• With hydrochloric acid if achlorhydria is present
Perform/provide:
• Storage in tight container at room temperature
Evaluate:
• Therapeutic response: decreased fever, malaise, rash, negative C&S for infecting organism
Teach patient/family:
• That long-term therapy may be needed to clear infection (1 wk-6 mo depending on infection)
• To avoid hazardous activities if dizziness occurs
• To take 2 hr ac administration of other drugs that increase gastric pH (antacids, H2-blockers, anticholinergics)
• Importance of compliance with drug regimen
• To notify physician if GI symptoms, signs of liver dysfunction (fatigue, nausea, anorexia, vomiting, dark urine, pale stools)
ISOSORBIDE
Ismotic
Func. class.: Miscellaneous ophthalmic agent
Action: Increases osmotic gradient between plasma and ocular fluids, which decreases intraocular pressure
Uses: Reduces intraocular pressure from glaucoma and cataract surgery
Dosage and routes:
• Adult: PO 1.5 g/kg, then increase to 1-3 g/kg bid-qid
Available forms: Sol 45%
Side effects/adverse reactions:
CNS: Headache, light-headedness, irritability, lethargy, syncope, confusion, dizziness, vertigo, disorientation
GI: Nausea, vomiting, anorexia, diarrhea, cramps, thirst
INTEG: Rash
META: Hypernatremia, hyperosmolarity
Contraindications: Hypersensitivity, anuria, severe renal disease, pulmonary edema, hemorrhagic glaucoma, dehydration
Precautions: Pregnancy , patients on Na-restricted diet
NURSING CONSIDERATIONS
Assess:
• I&O; report decrease in urinary output
• Electrolytes during treatment
Administer:
• After pouring over ice (oral)
Evaluate:
• Therapeutic response: decreased intraocular pressure
LEVOTHYROXINE SODIUM
Func. class.: Thyroid hormone
Chem. class.: Levoisomer of thyroxine
Action: Increases metabolic rates, increases cardiac output, O2 consumption, body temperature, blood volume, growth, development at cellular level
Uses: Hypothyroidism, myxedema coma, thyroid hormone replacement, cretinism, thyrotoxicosis
Dosage and routes:
Severe hypothyroidism
• Adult: PO 0.025-0.1 mg qd, increased by 0.05-0.1 mg q1-4 wk until desired response, maintenance dose 0.1-0.4 mg qd
• Child: PO 0.01-0.05 qd, may increase 0.025-0.05 mg q1-4 wk until desired response
Mild hypothyroidism
• Initial 50 mg qd; increase by 25-50 mg at interval of 2-4 wk
Cretinism
• Child: IV 0.025-0.05 mg qd, may increase by 0.05-0.1 mg PO q2-3wk
Myxedema coma
• Adult: IV 0.2-0.5 mg, may increase by 0.1-0.3 mg after 24 hr; place on oral medication as soon as possible
Available forms: Inj IV 200, 500 mg/vial; tabs 0.025, 0.05, 0.075, 0.088 mg, 0.1, 0.112 mg, 0.125, 0.15, 0.175, 0.2, 0.3 mg
Side effects/adverse reactions:
CNS: Anxiety, insomnia, tremors, headache, thyroid storm
CV: Tachycardia, palpitations, angina, dysrhythmias, hypertension, cardiac arrest
GI: Nausea, diarrhea, increased or decreased appetite, cramps
MISC: Menstrual irregularities, weight loss, sweating, heat intolerance, fever
Contraindications: Adrenal insufficiency, myocardial infarction, thyrotoxicosis
Precautions: Elderly, angina pectoris, hypertension, ischemia, cardiac disease, pregnancy (A), lactation
Pharmacokinetics:
IV/PO: Peak 12-48 hr, half-life 6-7 days; distributed throughout body tissues
Interactions/incompatibilities:
• Decreased absorption of levothyroxine: cholestyramine
• Increased effects of: anticoagulants, sympathomimetics, tricyclic antidepressants
• Decreased effects of: digitalis drugs, insulin, hypoglycemics
• Decreased effects of levothyroxine: estrogens
• Considered to be incompatible in syringe with all other drugs
Lab test interferences:
Increase: CPK, LDH, AST, PBI, blood glucose
Decrease: TSH, 131I uptake test, uric acid, triglycerides
NURSING CONSIDERATIONS
Assess:
• B/P, pulse before each dose
• I&O ratio
• Weight qd in same clothing, using same scale, at same time of day
• Height, growth rate if given to a child
• T3, T4, FTIs, which are decreased; radioimmunoassay of TSH, which is increased; radio uptake, which is increased if patient is on too low a dose of medication
• Pro-time may require decreased anticoagulant, check for bleeding, bruising
• Increased nervousness, excitability, irritability, which may indicate too high dose of medication, usually after 1-3 wk of treatment
• Cardiac status: angina, palpitation, chest pain, change in VS
Administer:
• IV after diluting with provided diluent 0.5 mg/5 ml; shake; give through Y-tube or 3-way stopcock; give 0.1 mg or less over 1 min; do not add to IV inf; 0.1 mg = 1 ml
• In AM if possible as a single dose to decrease sleeplessness
• At same time each day to maintain drug level
• Only for hormone imbalances; not to be used for obesity, male infertility, menstrual conditions, lethargy
• Lowest dose that relieves symptoms; lower dose to the elderly and in cardiac diseases
Perform/provide:
• Storage in tight, light-resistant container; sol should be discarded if not used immediately
• Removal of medication 4 wk before RAIU test
Evaluate:
• Therapeutic response: absence of depression; increased weight loss, diuresis, pulse, appetite; absence of constipation, peripheral edema, cold intolerance, pale, cool dry skin, brittle nails, alopecia, coarse hair, menorrhagia, night blindness, paresthesias, syncope, stupor, coma, rosy cheeks
Teach patient/family:
• That hair loss will occur in child, is temporary
• To report excitability, irritability, anxiety, which indicate overdose
• Not to switch brands unless approved by physician
• That drug may be discontinued after birth, thyroid panel evaluated after 1-2 mo
• That hypothyroid child will show almost immediate behavior/personality change
• That drug is not to be taken to reduce weight
• To avoid OTC preparations with iodine; read labels
• To avoid iodine food, iodized salt, soybeans, tofu, turnips, some seafood, some bread
MAGNESIUM SALTS
Concentrated Phillip’s Milk of Magnesia, Milk of Magnesia, Phillip’s Milk of Magnesia
Func. class.: Laxative, saline
Action: Increases osmotic pressure, draws fluid into colon neutralizes HCl
Uses: Constipation, bowel preparation before surgery or examination
Dosage and routes:
• Adult: PO 30-60 ml hs (Milk of Magnesia), 300 mg
• Adult and child *6 yr: PO 15 g in 8 oz H2O (magnesium sulfate); PO 10-20 ml (concentrated Milk of Magnesia); PO 5-10 oz hs (magnesium citrate)
• Child 2-6 yr: 5-15 ml (Milk of Magnesia)
Available forms: Oral sol, susp 77.5 mg/g; tabs 300, 600 mg
Side effects/adverse reactions:
CNS: Muscle weakness, flushing, sweating, confusion, sedation, depressed reflexes, flaccid, paralysis, hypothermia
GI: Nausea, vomiting, anorexia, cramps
CV: Hypotension, heart block, circulatory collapse
META: Electrolyte, fluid imbalances
Contraindications: Hypersensitivity, renal diseases, abdominal pain, nausea/vomiting, obstruction, acute surgical abdomen, rectal bleeding
Precautions: Pregnancy (B)
Pharmacokinetics:
PO: Peak 1-2 hr; excreted in feces
Interactions/incompatibilities:
• Increased CNS depression: CNS depressants, barbiturates, narcotics, anesthetics
NURSING CONSIDERATIONS
Assess:
• I&O ratio; check for decrease in urinary output
• Cause of constipation; identify whether fluids, bulk, or exercise is missing from life-style
• Cramping, rectal bleeding, nausea, vomiting; if these symptoms occur, drug should be discontinued
• Mg toxicity: thirst, confusion, decrease in reflexes
Administer:
• With 8 oz H2O
Evaluate:
• Therapeutic response: decreased constipation
Teach patient/family:
• Not to use laxatives for long-term therapy; bowel tone will be lost
• Chilling helps the taste of magnesium citrate
• Shake suspension well
• Do not give at hs as a laxative; may interfere with sleep
• Give citrus fruit after administering to counteract unpleasant taste
PIPERACILLIN SODIUM
Pipracil
Func. class.: Broad-spectrum antibiotic
Chem. class.: Extended-spectrum penicillin
Action: Interferes with cell wall replication of susceptible organisms; osmotically unstable cell wall swells and bursts from osmotic pressure
Uses: Respiratory, skin, urinary tract, bone infections; gonorrhea; pneumonia; effective for gram-positive cocci (S. aureus, S. pyogenes, S. viridans, S. faecalis, S. bovis, S. pneumoniae), gram-negative cocci (N. gonorrhoeae, N. meningitidis), gram-positive bacilli, C. perfringens, C. tetani, gram-negative bacilli (Bacteroides, F. nucleatum, E. coli, Klebsiella, P. mirabilis, M. morganii, P. vulgaris, P. rehgesii, Enterobacter, Citrobacter, P. aeruginosa, Serratia, Acinetobacter, Peptococcus, Peptostreptococcus, Eubacterium)
Dosage and routes:
Systemic infections
• Adult and child *12 yr: IM/IV 100-300 mg/kg/day in divided doses q4-6h
Prophylaxis of surgical infections
• Adult: IV 2g -1 hr before procedure; may be repeated during surgery or after surgery
Available forms: Inj IM, IV 2, 3, 4, 40 g; IV INF 2, 3, 4 g
Side effects/adverse reactions:
HEMA: Anemia, increased bleeding time, bone marrow depression
GI: Nausea, vomiting, diarrhea, increased AST, ALT, abdominal pain, glossitis, colitis
GU: Oliguria, proteinuria, hematuria, vaginitis, moniliasis, glomerulonephritis
CNS: Lethargy, hallucinations, anxiety, depression, twitching, coma, convulsions
META: Hypokalemia, hypernatremia
Contraindications: Hypersensitivity to penicillins; neonates
Precautions: Pregnancy (B); hypersensitivity to cephalosporins; CHF
Pharmacokinetics:
IM: Peak 30-50 min
IV: Peak 20-30 min
Half-life 0.7-1.33 hr; excreted in urine, bile, breast milk; crosses placenta
Interactions/incompatibilities:
• Decreased antimicrobial effect of piperacillin: tetracyclines, erythromycins, aminoglycosides IV
• Increased piperacillin concentrations: aspirin, probenecid
• Incompatible in sol with aminoglycosides, amphotericin B, chloramphenicol, lincomycin, polymyxin B, promethazine, tetracycline, Vit B with C
Lab test interferences:
False positive: Urine glucose, urine protein, Coombs’ test
NURSING CONSIDERATIONS
Assess:
• I&O ratio; report hematuria, oliguria, since penicillin in high doses is nephrotoxic
• Any patient with compromised renal system, since drug is excreted slowly in poor renal system function; toxicity may occur rapidly
• Liver studies: AST, ALT
• Blood studies: WBC, RBC, H&H, bleeding time
• Renal studies: urinalysis, protein, blood
• C&S before drug therapy; drug may be taken as soon as culture is taken
• Bowel pattern before and during treatment
• Skin eruptions after administration of penicillin to 1 wk after discontinuing drug
• Respiratory status: rate, character, wheezing, tightness in chest
• Allergies before initiation of treatment, reaction of each medication; highlight allergies on chart, Kardex
Administer:
• IV after diluting 1 g or less/5 ml or more sterile H2O or 0.9% NaCl; shake; give dose over 3-5 min; may further dilute to 50-100 ml with D5W, 0.9% NS, and give over hr; discontinue primary IV
• Drug after C&S has been completed
Perform/provide:
• Adrenalin, suction, tracheostomy set, endotracheal intubation equipment on unit
• Adequate intake of fluids (2 L) during diarrhea episodes
• Scratch test to assess allergy after securing order from physician; usually done when penicillin is only drug of choice
• Storage at room temperature, reconstituted solution for 24 hr or 7 days refrigerated
Evaluate:
• Therapeutic response: absence of fever, purulent drainage, redness, inflammation
Teach patient/family:
• That culture may be taken after completed course of medication
• To report sore throat, fever, fatigue; (may indicate superimposed infection)
• To wear or carry Medic Alert ID if allergic to penicillins
• To notify nurse of diarrhea
Treatment of overdose: Withdraw drug, maintain airway, administer epinephrine, aminophylline, O2, IV corticosteroids for anaphylaxis
SILVER SULFADIAZINE (topical)
Silvadene, SSD, SSD AF
Func. class.: Local antiinfective
Chem. class.: Sulfonamide
Action: Interferes with bacterial cell wall synthesis, broad-spectrum
Uses: Burns (2nd, 3rd degree); prevention of wound sepsis
Dosage and routes:
• Adult and child: TOP apply 1/16 in to affected area qd-bid
Available forms: Cream 10 mg/g
Side effects/adverse reactions:
INTEG: Rash, urticaria, stinging, burning, itching, pain, skin necrosis, erythema
HEMA: Reversible leukopenia
Contraindications: Hypersensitivity, child *2 mo
Precautions: Impaired renal function, pregnancy (C), impaired hepatic function, lactation
NURSING CONSIDERATIONS
Assess:
• Allergic reaction: burning, stinging, swelling, redness
• Renal function studies; check for crystalluria
Administer:
• Using aseptic technique, use sterile gloves
• Enough medication to cover burns completely; keep covered with medication at all times
• After cleansing debris before each application; bathe daily
• Analgesic before application if needed
Perform/provide:
• Storage at room temperature in dry place
Evaluate:
• Therapeutic response: relief of infection
Teach patient/family:
• That drug may be continued until graft can be done
TRIAMCINOLONE
Func. class.: Corticosteroid
Chem. class.: Glucocorticoid, intermediate-acting
Action: Decreases inflammation by suppression of migration of polymorphonuclear leukocytes, fibroblasts, reversal to increase capillary permeability and lysosomal stabilization
Uses: Severe inflammation, immunosuppression, neoplasms, asthma (steroid dependent), collagen, respiratory, dermatologic disorders
Dosage and routes:
• Adult: PO 4-48 mg/day in divided doses qd-qid; IM 40 mg qwk (acetonide, or diacetate), 5-48 mg into neoplasms (diacetate, acetonide), 2-40 mg into joint or soft tissue (diacetate, acetonide), 0.5 mg/sq in of affected intralesional skin (hexacetonide), 2-20 mg into joint or soft tissue (hexacetonide)
Asthma
• Adult: INH 2 tid-qid, not to exceed 16 INH/day
• Child 6-12 yr: INH 1-2 tid-qid, not to exceed 12 INH/day
Available forms: Tabs 1, 2, 4, 8, 16 mg; syr 2 mg/5 ml, 4.85 mg/5 ml; inj 25, 40 mg/ml diacetate; inj 3, 10, 40 mg/ml acetonide; inj 20, 5 mg/ml hexacetonide
Side effects/adverse reactions:
INTEG: Acne, poor wound healing, ecchymosis, petechiae
CNS: Depression, flushing, sweating, headache, mood changes
CV: Hypertension, circulatory collapse, thrombophlebitis, embolism, tachycardia, edema
HEMA: Thrombocytopenia
MS: Fractures, osteoporosis, weakness
GI: Diarrhea, nausea, abdominal distention, GI hemorrhage, increased appetite, pancreatitis
EENT: Fungal infections, increased intraocular pressure, blurred vision
Contraindications: Psychosis, hypersensitivity, idiopathic thrombocytopenia, acute glomerulonephritis, amebiasis, fungal infections, nonasthmatic bronchial disease, child *2 yr, AIDS, TB
Precautions: Pregnancy , diabetes mellitus, glaucoma, osteoporosis, seizure disorders, ulcerative colitis, CHF, myasthenia gravis, renal disease, esophagitis, peptic ulcer
Pharmacokinetics:
PO/IM: Peak 1-2 hr, 2 days, 1-6 wk (IM), half-life 2-5 hr
Interactions/incompatibilities:
• Decreased action of triamcinolone: cholestyramine, colestipol, barbiturates, rifampin, ephedrine, phenytoin, theophylline
• Decreased effects of: anticoagulants, anticonvulsants, antidiabetics, ambenonium, neostigmine, isoniazid, toxoids, vaccines, anticholinesterases, salicylates, somatrem
• Increased side effects: alcohol, salicylates, indomethacin, amphotericin B, digitalis, cyclosporine, diuretics
• Increased action of triamcinolone: salicylates, estrogens, indomethacin, oral contraceptives, ketoconazole, macrolide antibiotics
Lab test interferences:
Increase: Cholesterol, Na, blood glucose, uric acid, Ca, urine glucose
Decrease: Ca, K, T4, T3, thyroid 131I uptake test, urine 17-OHCS, 17-KS, PBI
False negative: Skin allergy tests
NURSING CONSIDERATIONS
Assess:
• K, blood sugar, urine glucose while on long-term therapy; hypokalemia and hyperglycemia
• Weight daily; notify physician if weekly gain *5 lb
• B/P q4h, pulse; notify physician if chest pain occurs
• I&O ratio; be alert for decreasing urinary output and increasing edema
• Plasma cortisol levels during long-term therapy (normal level: 138-635 nmol/L SI units when drawn at 8 AM)
• Infection: increased temperature, WBC, even after withdrawal of medication; drug masks infection symptoms
• K depletion: paresthesias, fatigue, nausea, vomiting, depression, polyuria, dysrhythmias, weakness
• Edema, hypertension, cardiac symptoms
• Mental status: affect, mood, behavioral changes, aggression
Administer:
• After shaking suspension (parenteral)
• Titrated dose; use lowest effective dose
• IM injection deeply in large mass; rotate sites; avoid deltoid; use 21G needle
• In one dose in AM to prevent adrenal suppression; avoid SC administration; may damage tissue
• With food or milk to decrease GI symptoms
Perform/provide:
• Assistance with ambulation in patient with bone tissue disease to prevent fractures
Evaluate:
• Therapeutic response: ease of respirations, decreased inflammation
Teach patient/family:
• That ID as steroid user should be carried
• To notify physician if therapeutic response decreases; dosage adjustment may be needed
• Not to discontinue this medication abruptly; adrenal crisis can result
• To avoid OTC products: salicylates, alcohol in cough products, cold preparations unless directed by physician
• About cushingoid symptoms
Symptoms of adrenal insufficiency: nausea, anorexia, fatigue, dizziness, dyspnea, weakness, joint pain
HOLISTIC HUMAN RESPONSES/
Functional Developmental Physiological Psychological
Dimensions Cognitive Emotional Self-Conceptual
Wellness & Well-being Relative decline in physical development, changes in appetite, food intake, sleep & elimination patterns. B&W p.316 H/O CA, Anemia, NIDDM, COPD ,A.Fib, Current necrotizing pneumonia, cathexia, empyemia Client aware of health problems and the need for interventions Discouraged with his present state of health, but accepting of necessary rehab. Activities. Frustrated with self limitations.

Self-Expression Reflection, reminiscence, self-actualizing pursuits within physical capabilities. B&W p 898 Neat, clean, well groomed; articulate; Affective response consistent with norms. Articulate; expresses self well. Concerned about his future at home. “Who will help me take care of my tubes at home?” Client expresses accep-tance of stage in life but not physical limitations.

Skin & Tissue Integrity Skin more fragile - less elastic, less SC fat, blood vessels more fragile; Increases risk of skin tears. Vascular insufficiency increases risk of decubitus ulcer B&W p 974 Warm, pale, good turgor. Reddened area on coccyx Understands import. of being turned in bed, moving extremities, & ingesting adequate fluids & food. Good personal hygiene. Client demonstrates a little anxiety about the possibility of developing a decubitis ulcer. Client verbalizes anxiety about possibility of skin & tissue breakdown
Nutrition Body maintenance and repair, type and quality of food, calories must be rich in nutrients. Lowered calorie requirements due to lower BMR B&W p 1082 Cachexia secondary to malnutrition, poor intake. TPN q 12 hrs, supplements Client understands his need to increase the food intake for adequate nutrition & healing. Client does not like hospital food but tries to eat as much as possible. He also dislikes his supplements. Client wants to gain weight stating, ”I try to eat more than I want.”
Fluid Balance Decreased renal concentra-tion fx. Increased loss amounts of water & salt, muting of thirst response, decreased intake. B&W p1558 Good skin turgor, no edema I&O’s q shift Client understands the need for adequate fluid intake. No emotional relationship seen with regard to fluid balance. Understands importance of adequate fluid intake in health maintenance.

Elimination Loss of muscle tone in bladder & bowel changes elimination patterns, that vary with diet, lifestyle, & medications. B&W p 1136 Continent of bowel & bladder. Uses toilet with assistance. Bowel sounds present X4. Urine clear & yellow Client recognizes the need for regular bowel schedule. Non-verbalized discomfort with having to go to the bathroom while in bed. Client verbalizes no concerns.

Oxygenation Some loss of lung elasticity; pO2 decreased, especially if smoked. B&W p 1227 Resp. rate 18-24/min. lung sounds slightly diminished Understands the need for O2 and reason for SOB. Does not like the idea of needing O2 & inhalers to control SOB. Client admits to periods of SOB, and pain with coughing.

Sleep-RestPatterns/Pain Incr. Time to get to sleep, incr.# times awaken, decrease total sleep time. Daytime naps may compensate. B&W p 1321 Client naps several times during day, sleep-rest poor at night. Being turned q2hrs and pain from chest tube wakes up. Verbalized that being turned q 2 hrs interrupted his sleep & causes pain in chest tube site. Client does express some anxiety R/T SOB and pain that wakes him up sometimes. Client aware of problems. Accepts situation
Neurosensory Integration Less blood flow to brain causes low O2 supply, neuro. function, reduced senses, equilibrium, gait, depression. Diminished sight, hearing, taste, smell, & sensation. B&W p 1360 No psych problems were evident. Memory good. Wears glasses. Uses glasses consistently. Client displays some con-cern of neurosensory integration R/T pain. As he has no apparent neurosensory loss, there is no apparent impact on his self control.

Mobility Voluntarily controlled, muscles strength declines, joint changes Card./resp. fitness declines. B&W p 1426 AROM all extremities. Verbalized under-standing of limitat-ions & how he will compensate for them upon D/C. Intends to walk as soon as chest tube is out Frustrated with the need to be in bed due to his chest tube. He does not allow his physical disabilities to negatively affect his concept of self, there is concern about improvement in future.

Berger, 1992
Manifestation Categories
Spiritual Identified
Social-Cultural Life-Structural Sexual Environmental NursingDiagnosis Functional Dimensions
Independence is important. Involved with wife & adult children Role as husband & father still intact. Increased dependent role. Retired railroad worker. Monogamous- married with 2 adult children. Excellent relationship with wife. Client wants to go home, but worries how he is going to his health. Self care deficit R/T physical limitations, and frustration over loss of independence AEB in ability to maintain cleanliness of tube insertion site( right posterior chest), changing clothes (Potential) Wellness & Well-being
His inability to sustain prolonged activity is forcing a change in type of recreational activities. He used to walk around the neighborhood. Role as a member of society has changed due to poor health, and it concerns him. Is happy with his marriage. Taking active part in therapy. Trying to improve food intake & increase mobility. Impaired social inter-action R/T inability to sustain prolonged activity AEB SOB, and use of continual O2. (Actual) Self-Expression
Client has been bed ridden for 115 days & has not been outside Must change position q 2 hrs & apply silvadene to coccyx to prevent decubiti; wear sunscreen when outside & continue good hygiene. Skin in genital area is intact. There is sensation. Necessity of being in bed or W/C encourages decubitis development. Must change position q 2 hrs. Risk for impaired skin integrity R/T immobility, mechanical pressure & sheer, NIDDM. AEB reddened area on coccyx. (Potential) Skin & Tissue Integrity
Lack of social interaction maybe contributing to malnutrition, lack of appetite. C.S. must make adjustments that will allow him to interact socially in order to encourage good nutrition. Nutrition has influence over energy levels required for sex. Meals are offered 3X daily, supplements in between, and TPN q 12 hrs. Nutrition altered, less than body requirements R/TMalnutrition/infection/ AEB poor food intake, weight loss.(Actual) Nutrition
Client does not drink, even socially. Needs to incorporate adequate fluid intake as part of his daily routine. No noted effect of fluid balance on clients sexuality. Fluids must be offered to client frequently since he is bed ridden. Risk for fluid volume deficit R/T insufficient intake AEB low intake of PO fluids.(Potential) Fluid Balance
Client states it is very uncomfortable to use bathroom while in bed. Bed rest does limit clients privacy & affects bowel motility. N/A. Meds, bed rest, & hospital environment may affect bowel motility. High risk for diarrhea R/T meds AEB loose stools.(Potential) Elimination
Change in activities due to SOB, use of O2, chest tube. Cannot go for walks as used to. If wishes, client could participate in activities with use of O2. Lack of adequate oxygenation could interfere with sexuality. General hospital environment not affecting oxygenation. Client on wall O2. Ineffective breathing pattern related to decreased lung expansion secondary to pus in the pleural space AEB asymmetrical chest expansion and decreased breath sounds over affected area.(Actual) Oxygenation
Men should not show signs of pain. Social believe. Pain and being turned q 2 hrs disturbs sleep/rest patterns which affects his nocturnal rhythms. Lack of sleep and pain may affect sex life. Hospital environment, pain, & SOB disrupt sleep-rest patterns. Sleep pattern disturbance R/T pain and hospital routine AEB clients c/o being awakened q 2 hrs. (Actual) Sleep-RestPatterns/ Pain
Mental alertness & ability to function are important for any culture / gender. Bed rest, use of O2, SOB, all impedes ability to interact with others. N/A Hospital environment and routines may affect alertness. Pain, chest related to biologic factors (tissue trauma) and physjcal factors (chest tube insertion- sertion) AEB Pt reporting pain at insertion site of 6 on a 1-10 scale when moved(Actual) Neurosensory Integration
Ability to move around and/or sit with friends and family is very important to client. Chronic lung disease makes it difficult for sustained mobility. Sustained physical activity impaired due to low O2 levels influence sexual activities. Bed rest until chest tube is out. Ineffective Airway Clearance R/T decreased flexibility of lung tissue AEB fungal infection of lungs, chest tube, fluid presence (Actual) Mobility
Doenges, 1993
LIST OF NURSING DIAGNOSIS.

1. Ineffective breathing pattern related to decreased lung expansion secondary to pus in the pleural space AEB asymmetrical chest expansion and decreased breath sounds over affected area. (Combination of Doenges p.197 and Tucker p.304 Patient Care Standard for Thoracic Empyema)
2. Ineffective Airway Clearance R/T decreased flexibility of lung tissue AEB fungal infection of lungs, chest tube, fluid presence . Doenges, p. 164
3. Pain, chest related to biologic factors (tissue trauma) and physjcal factors (chest tube insertion- sertion) AEB Pt reporting pain at insertion site of 6 on a 1-10 scale when moved
4. Nutrition altered, less than body requirements R/TMalnutrition/infection/ AEB poor food intake, weight loss. Doenges p.

5. Self care deficit R/T physical limitations, and frustration over loss of independence AEB in ability to maintain cleanliness of tube insertion site( right posterior chest), changing clothes Doenges , p. 383
6. Impaired social inter-action R/T inability to sustain prolonged activity AEB SOB, and use of continual O2. (Actual)
7. Risk for impaired skin integrity R/T immobility, mechanical pressure & sheer, NIDDM. AEB reddened area on coccyx. (Potential)
8. Risk for fluid volume deficit R/T insufficient intake AEB low intake of PO fluids. (Potential)
9. High risk for diarrhea R/T meds AEB loose stools. (Potential)
10. Sleep pattern disturbance R/T pain and hospital routine AEB clients c/o being awakened q 2 hrs. (Actual)
#1. NURSING DIAGNOSIS: Ineffective breathing pattern related to decreased lung expansion secondary to pus in the pleura space AEB asymmetrical chest expansion and decreased breath sounds over affected area. (Combination of Doenges p.197 and Tucker p.304 Patient Care Standard for Thoracic Empyema)
Intervention /Action Rationales Evaluation / Outcome Criteria
1. Assess chest movement, noting signs of asymmetry Signs of asymmetry may indicate pus or fluid in pleural cavity. Tucker p.304 Pt. Showed greater expansion of chest on left side ( opposite tube insertion)
2. Auscultate breath sounds q2h to 4h for adventitious or decreased sounds Breath sounds may be diminished or absent in a lobe, lung segment, or entire lung field (unilateral). Atelectatic area will have no breath sounds, and partially collapsed lapsed areas have decreased sounds. Doenges, p. 197 Breath sounds distinctly less on left side near tube insertion point
3. Monitor BP, T, R, and apical pulse q2h to 4h to assess for infective process Change in values from baseline for pt)may indicate infection starting . i.e. sustained increase in temp. Tucker , p. 304 BP 114/55, P 84, T 97.4, R 24
4. Administer oxygen per nasal cannula at 2 to 6 L / min as ordered unless contraindicated to treat hypoxia. Place patient in a sitting position with head of bed elevated 60 to 90 degrees to maximize breathing Promotes maximal inspiration; enhances lung expansion and ventilation in unaffected side. Doenges, p. 197 & Tucker , p. 304 Pt. Stated that he breaths easier with O2 and HOB in 60 degree position.

5. Encourage use of incentive spirometer. Rationale To assist Pt . maintaining maximal inspiratory effort; effective when used by post operative patients to prevent development of atelectasis and pneumonia. Tucker , p. 304 Pt demonstrated correct use and knowledge of incentive spirometer. Pt. Did so by placing mouth piece between teeth, closing the lips around the mouth piece, inhaling through mouth only, and taking a slow deep breaths. Pt held breath for 3-5 seconds Pt. remove mouth piece and exhale slowly. ( Procedure from Tucker p. 328)
Monitoring chest tube
6. Check suction control chamber for correct amount of suction (by water level, wall regulator at correct setting) Maintains prescribed intrapleural negativity, which promotes optimum lung expansion and/or fluid drainage. Doenges, p. 198 Chest tube to wall seal set at 20cm with continuous suction of 50 -60 mm Hg. All tubes patent with no signs of leakage ( air or fluid) around seals.

NDX #1. Con’t Intervention /Action Rationales Evaluation / Outcome Criteria
7. Check fluid level in water-seal chamber / bottle; maintain at prescribed level Water in a sealed chamber serves as a barrier that prevents atmospheric air from entering the pleural space should the suction source be disconnected and aids in evaluating whether the chest drainage system is functioning appropriately. Sufficient water in bottle 1/2 full to provide barrier.
OUTCOME/GOAL STATEMENT: Short Term Goal: Pt. Will maintain an effective breathing pattern as evidenced by the following: normal rate, rhythm, and depth of respirations. Long Term goal: Pt. Will ABG’s Blood gases within normal range. Doenges, p. 197 & Tucker , p. 304
#2. NURSING DIAGNOSIS: Ineffective Airway Clearance R/T decreased flexibility of lung tissue AEB fungal infection of lungs, chest tube, fluid presence . Doenges, p. 164
Intervention /Action Rationales Evaluation / Outcome Criteria
1. Assess rate / depth of respirations and chest move- ment, Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung. Doenges, p. 164 Pt Respirations rate at 24 and shallow
2. Demonstrate / help patient learn to perform coughing, e g., splinting chest and effective coughing while in upright position. Deep breathing facilitates maximum expansion of the lung’s smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. Pt. Demonstrated splinting procedures when demonstrating proper use of incentive spirometer as noted in NDX # 1
3. Suction as indicated. Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffec- tive cough or decreased level of consciousness. Pt stated “ I can do this myself” when offered assistance. Pt used yager device effectively.

4. Force fluids to at least 2500 ml / d (unless contraindicated). Offer warm, rather than cold, fluids. Fluids (especially warm liquids) aid in mobilization and expectoration of secretions. Pt I & O noted @ 225 ml urine between 08:30 and 13:30. Pt drank 250 ml at breakfast. Poor skin tugor and dry skin noted.

NDX #2. Con’t
OUTCOME/GOAL STATEMENT: .Short Term: Pt. Will continue to use oral suction to relieve mucous build up. . Pt will show no signs of cyanosis. Pt will demonstrate patent airway with breath sounds clearing. Pt will drink 2500 ml qd. Long Term: Pt’s skin turgor will improve by increasing fluid intake. Doenges p. 164
#3. NURSING DIAGNOSIS: Pain, chest related to surgical incision, (tissue trauma) and physical factors (chest tube insertion-) AEB Pt reporting pain at insertion site of 6 on a 1-10 scale when moved. Doenges, p. 190
Intervention /Action Rationales Evaluation / Outcome Criteria
1. Assess for presence of pain (verbal and nonverbal): rate pain on scale of ( 1-10) Use of rating scale aids patient in assess- ing level of pain and provides tool for evaluating effectiveness of analgesics, enhancing patient control of pain. Pt. Reports pain at 6 when moved in bed and during heavy breathing
2. Evaluate effectiveness of drug regimen. Encourage sufficient medication to control pain; change medication or time span as appropriate. Pain perception and pain relief is subjective and thus pain management is best left to the patient’s discretion. Pt reports pain is decreased 30 min after given Tylenol PRN
3. Provide comfort measures, e.g.. frequent changes of position, back rubs, support with pillows. Relieves discomfort and augments therapeutic effects of analgesia. Pt verbalizes need to sit in chair or move from chair back to bed.

4. Assist with self-care activities, breathing / arm exercises, and ambulation. Prevents undue fatigue and incisional strain. Encouragement and physical assistance / support may be needed for some time before the patient is able or confident enough to perform these activities because of pain or fear of pain. Pt. Verbalizes concern about pain and care of wound site after discharged.

OUTCOME/GOAL STATEMENT: .Short Term: Pt will experiences decreased pain and verbalizes pain relief with use of analgesics Long Term: Improved breathing pattern and Increased activity with pain management
#4. NURSING DIAGNOSIS: Nutrition altered, less than body requirements R/T surgical procedures ( pleural tube insertion ) AEB decreased subcutaneous fat/ muscle mass, poor muscle tone. Doenges, p. 1042
Intervention /Action Rationales Evaluation / Outcome Criteria
1. Assess nutritional status continually, during daily nursing care, noting energy level: condition of skin, nails, hair, oral cavity, desire to eat/ anorexia. Provides the opportunity to observe deviations from normal. Patients baseline and influences choice of interventions. Pt. Suffers from cachexia 2nd to malnutrition. Signs of wasting include poor skin turgor and loss of muscle mass
2. Document oral intake by use of 24-hour recall, food history, calorie counts .as appropriate. Identifies imbalance between estimated nutritional requirements and actual intake. TPN @ 79cc / hr 24 hr infusion through PICC line in R forearm. TPN will be monitored through out shift. Pump and tube will remain patent and operational and patent.

3. Assess gag reflex, ability to chew / swallow, and motor skills when progressing to transitional feedings. May require additional interventions, e.g., retraining by dysphagia expert (speech therapist) or long-term nutritional support. Pt’s gag reflex intake AEB ability to eat and swallow solid food without complication
4. Allow adequate time for chewing, swallowing, savoring food: provide socialization and feeding assistance as indicated. Patients needs encouragement/assistance to overcome underlying problems such as anorexia, fatigue, muscular weakness. Pt. Is given time to eat meals. Pt does this with limited assistance
5. Refer to nutritional team / registered dietitian. Aids in the identification of nutrient deficits and need for parenteral nutritional intervention. Caloric and nutritutional status calculated by dietitian on 9/18/96
Calculate basal energy expenditure using formula based on sex, height, weight, age, and estimated energy requirements. Provides an estimation of calorie and protein needs. Total caloric intake prescribed @ '1500 qd with 40% fat content and amino acids @ 65%. TPN solution adjusted for proper electrolyte and vitamin balance.

OUTCOME/GOAL STATEMENT: Short Term: Client will eat at least 75% of prescribed food at each meal. Long Term: Prior to discharge, Pt. will show stable and or increased weight gain and be free of signs of malnutrition.

#5. NURSING DIAGNOSIS: Self care deficit R/T physical limitations, and frustration over loss of independence AEB in ability to maintain cleanliness of tube insertion site( right posterior chest), changing clothes Doenges , p. 383
Intervention /Action Rationales Evaluation / Outcome Criteria
1. Identify reason for difficulty in dressing / self-care, e.g., physical limitations in motion: apathy / depression; Underlying cause affects choice of interventions / strategies. Problem may be minimized by adaptation of clothing or may require consultation from other specialists. Pt states that he can’t reach tube insertion site.

2. Be alert to underlying meaning of verbal statements. May direct a question to another, such as “Are you cold?” Meaning, “I am cold and need additional clothing.” Pt. Verbalizes concern for SO caring for him after he gets home “I can’t expect her to do it all” May indicate that he feels powerless to “do it all”
3. Supervise but allow as much autonomy as possible. Eases the frustration over lost independence. Pt. Can do ADL’s with limited assistance. Cannot reach tube site to clean or maintain.

4. Allot plenty of time to perform tasks. Tasks which were once easy (e.g., dressing, bathing) are now complicated by decreased motor skills or cognitive and physical change. Time and patience can reduce chaos resulting from trying to hasten this process. Limited assistance in ADL’s and following Pt’s direction allows Pt to have control. Home health aide / RN needs to understand this after discharge.

OUTCOME/GOAL STATEMENT: Short Term: Pt will verbalize feelings of concern regarding at home maintenance of self with SO prior to discharge. Long Term: (after discharge) Pt will work with home health care giver to relief frustration and avoid further depression.
Medicine