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    Nursing Care Plan Essay (8591 words)

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    Course: NUR 1210LInstructor: Dates of Care: 12, 13, 19 & 20 Sept 96Date Submitted: 11/15/96Student Names: Anthony Bernardi, SN/SPJCHOLISTIC NURSING CARE PLANSTUDENT Anthony BernardiGRADEDATE November 15, 1996Client’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 CONTENTSSUBJECT 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 71CLIENT 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 lineMEDICAL 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 PROCEDURESPatients activity orders are as tolerated with wheel chair transport.

    Pt needs partial assist with ADLs. He is continent of B & B with assistanceNeeds 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 approximate07:30 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 noted09:30 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 comfort10:45 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 IMPLICATIONSBUN 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 AnemiaHCT 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 AnemiaMCH 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 RADIOLOGYF/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 ALBUTEROLAlbuterol, Proventil, Proventil Repetabs, Salbutamol, Ventolin, Ventolin Rotacaps, VolmaxFunc. class. : Adrenergic b2 agonistAction: 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 isoproterenolUses: Prevention of exercise-induced asthma, bronchospasm, production of premature laborDosage and routes:To prevent exercise-induced asthma• Adult: INH 2 puffs 15 min before exercising, NEB/LPPB 5 mg tid-qidBronchospasm• Adult: INH 1-2 puffs q4-6h PO 2-4 mg tid-qid, not to exceed 8 mgPrevention of premature laborAvailable forms: Aerosol 90 mg/actuation; tabs 2, 4 mg; syr 2 mg/5 ml, cont rel 4, 8 mgSide effects/adverse reactions:CNS: Tremors, anxiety, insomnia, headache, dizziness, stimulation, restlessness, hallucinations, flushing, irritabilityEENT: Dry nose, irritation of nose and throatCV: Palpitations, tachycardia, hypertension, angina, hypotension, dysrhythmiasGI: Heartburn, nausea, vomitingMS: Muscle crampsContraindications: Hypersensitivity to sympathomimetics, tachydysrhythmias, severe cardiac diseasePrecautions: Lactation, pregnancy ?, cardiac disorders, hyperthyroidism, diabetes mellitus, hypertension, prostatic hypertrophy, narrow-angle glaucoma, seizures, exercise-induced bronchospasm (aerosol) in children *12 yearsPharmacokinetics: Well absorbed PO, extensively metabolized in the liver, excreted in urine, crosses placenta, breast milk, blood-brain barrierPO: Onset ? hr, peak 2? hr, duration 4-6 hr, half-life 2? hrPO-ER: Onset ? hour; peak 2-3 hr; duration 12 hrINH: Onset 5-15 min, peak 1-1? hr, duration 4-6 hr, half-life 4 hrInteractions/incompatibilities:• Increased action of aerosol bronchodilators• Increased action of albuterol: tricyclic antidepressants, MAOIs, other adrenergics• May inhibit action of albuterol: other b-blockersNURSING CONSIDERATIONSAssess:• 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 reactionsAdminister:• 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 ABGsTeach 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 blockerPANCRELIPASECreon Capsules, Func. class. : DigestantChem. class.

    : Pancreatic enzyme-bovine/porcineAction: Pancreatic enzyme needed for proper pancreatic functioning Uses: Exocrine pancreatic secretion insufficiency, cystic fibrosis (digestive aid), steatorrhea, pancreatic enzyme deficiencyDosage 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 acAvailable 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 USide effects/adverse reactions:GI: Anorexia, nausea, vomiting, diarrheaGU: Hyperuricuria, hyperuricemiaContraindications: Allergy to pork, chronic pancreatic diseasePrecautions: Pregnancy ?Interactions/incompatibilities:• Decreased absorption: cimetidine, antacids, oral ironNURSING CONSIDERATIONSAssess:• 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 foodPerform/provide:• Storage in tight container at room temperatureEvaluate:• FOR ALLERGY TO PORKDIGOXINDigoxin, Lanoxicaps, LanoxinFunc. class. : Antidysrhythmic, cardiac glycosideChem. class.

    : Digitalis preparationAction: Inhibits the sodium-potassium ATPase, which makes more calcium available for contractile proteins, resulting in increased cardiac outputUses: CHF, atrial fibrillation, atrial flutter, atrial tachycardia, rapid digitalization in these disordersDosage 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 q12hAvailable forms: Caps 50, 100, 200 mg; elix 50 mg/ml; tabs 125, 250, 500 mg; inj 100, 250 mg/mlSide effects/adverse reactions:CNS: Headache, drowsiness, apathy, confusion, disorientation, fatigue, depression, hallucinationsCV: Dysrhythmias, hypotension, bradycardia, AV blockEENT: Blurred vision, yellow-green halos, photophobia, diplopiaGI: Nausea, vomiting, anorexia, abdominal pain, diarrheaContraindications: Hypersensitivity to digitalis, ventricular fibrillation, ventricular tachycardia, carotid sinus syndrome, 2nd or 3rd degree heart blockPrecautions: Renal disease, acute MI, AV block, severe respiratory disease, hypothyroidism, elderly, pregnancy ?, sinus nodal disease, lactation, hypokalemiaPharmacokinetics:PO: Onset ?-2 hr, peak 6-8 hrs, duration 3-4 daysIV: Onset 5-30 min, peak 1-5 hr, duration variable, half-life 1.

    5 days excreted in urineInteractions/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 saltsLab test interferences:Increase: CPKNURSING CONSIDERATIONSAssess:• 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, rhythmAdminister:• 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 necessaryPerform/provide:• Storage protected from lightEvaluate: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 coughTreatment of overdose: Discontinue drug; administer K; monitor ECG, administer an adrenergic blocking agent, digoxin immune FABFOSINOPRILMonoprilFunc. class. : AntihypertensiveChem. class.

    : Angiotension-converting enzyme (ACE) inhibitorAction: Selectively suppresses renin-angiotensin-aldosterone system; inhibits ACE; prevents conversion of angiotensin I to angiotensin II; results in dilation of arterial, venous vesselsUses: Hypertension, alone or in combination with thiazide diureticsDosage and routes:• Adult: PO 10 mg qd initially, then 20-40 mg/day divided bid or qdAvailable forms: Tabs 10, 20 mgSide effects/adverse reactions:CV: Hypotension, chest pain, palpitations, angina, orthostatic hypotensionGU: Proteinuria, Increased BUN, creatinine, decreased libidoHEMA: Decreased Hct, Hgb, eosinophilia, leukopenia, neutropeniaINTEG: Angioedema, rash, flushing, sweating, photosensitivity, pruritusRESP: Cough, sinusitis, dyspnea, bronchospasmMETA: HyperkalemiaGI: Nausea, constipation, vomiting, diarrheaCNS: Insomnia, paresthesia, headache, dizziness, fatigue, memory disturbance, tremor, mood changeMS: Arthralgia, myalgiaContraindications: Hypersensitivity to ACE inhibitors, pregnancy (D), lactation, childrenPrecautions: Impaired liver function, hypovolemia, blood dyscrasias, CHF, COPD, asthma, elderlyPharmacokinetics: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: allopurinolLab test interferences:False positive: Urine acetoneNURSING CONSIDERATIONSAssess:• 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, dysuriaAdminister:• IV infusion of 0. 9% NaCl (as ordered) to expand fluid volume if severe hypotension occursPerform/provide:• Storage in tight container at 86? F (30? C) or less• Supine or Trendelenburg position for severe hypotensionEvaluate:• Therapeutic response: decrease in B/PTeach 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, hemodialysisFLUOCINONIDEFlucinolone, Fluocinolone Acetonide, Fluonid, Flurosyn, Synalar, Synalar-HP, Synemol, Fluocinonide, Lidemol, Lidex, Lidex-E, Vasoderm, Vasoderm EFunc. class.

    : Topical corticosteroidChem. class. : Synthetic fluorinated agent, group II potencyAction: Possesses antipruritic, antiinflammatory actionsUses: Psoriasis, eczema, contact dermatitis, pruritusDosage and routes:• Adult and child: Apply to affected area tid-qidAvailable 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 infectionContraindications: Hypersensitivity to corticosteroids, fungal infectionsPrecautions: Pregnancy (C), lactation, viral infections, bacterial infectionsNURSING CONSIDERATIONSAssess:• Temperature: if fever develops, drug should be discontinuedAdminister:• 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 areaPerform/provide:• Cleansing before application of drug• Treatment for a few days after area has cleared• Storage at room temperatureEvaluate:• Therapeutic response: absence of severe itching, patches on skin, flakingTeach patient/family:• To avoid sunlight on affected area; burns may occurINSULIN,Beef NPH Iletin II, Humulin N, Iletin NPH, Insulatard NPH, NPH Iletin I, Pork NPH Iletin II, Novolin N, NPH Insulin, NPH Purified PorkFunc. class. : AntidiabeticChem. class.

    : Exogenous unmodified insulinAction: Decreases blood sugar; indirectly increases blood pyruvate, lactate; decreases phosphate, potassiumUses: Ketoacidosis, type I (IDDM), type II (NIDDM) diabetes mellitus, hyperkalemiaDosage and routes:• Adult: SC dosage individualized by blood, urine glucose, usual dose 7-26 U; may increase by 2-10 U/day if neededAvailable forms: SC 100 U/mlSide effects/adverse reactions:CNS: Headache, lethargy, tremors, weakness, fatigue, delirium, sweatingCV: Tachycardia, palpitationsEENT: Blurred vision, dry mouthGI: Hunger, nauseaMETA: HypoglycemiaINTEG: Flushing, rash, urticaria, warmth, lipodystrophy, lipohypertrophySYST: AnaphylaxisContraindications: Hypersensitivity to protaminePrecautions: 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, epinephrinePharmacokinetics:SC: Onset 1-2 hr, peak 4-12 hr, duration 18-24 hrMetabolized by liver, muscle, kidneys; excreted in urineLab test interferences:Increase: VMADecrease: K, CaInterference: Liver function studies, thyroid function studiesNURSING CONSIDERATIONSAssess:• 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 timeAdminister:• 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 porkPerform/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 sitesEvaluate:• Therapeutic response: decrease in polyuria, polydipsia, polyphagia, clear sensorium, absence of dizziness, stable gaitTeach 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 physicianTreatment of overdose: Glucose 25g IV, via dextrose 50% solution, 50 ml or 1 mg glucagonITRACONAZOLESporanoxFunc. class. : AntifungalChem. class.

    : Triazole derivativeAction: Alters cell membranes and inhibits several fungal enzymesUses: 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 dosesAvailable forms: Caps 100 mgSide effects/adverse reactions:GU: Gynecomastia, impotence, decreased libidoINTEG: Pruritus, fever, rash, CNS: Headache, dizziness, insomnia, somnolence, depressionGI: Nausea, vomiting, anorexia, diarrhea, cramps, abdominal pain, flatulence, GI bleeding, hepatotoxicityMISC: Edema, fatigue, malaise, hypertension, hypokalemia, tinnitusContraindications: Hypersensitivity, lactation, fungal meningitis, coadministration with terfenadinePrecautions: 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 boundInteractions/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 increasedNURSING CONSIDERATIONSAssess:• 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, fatigueAdminister:• 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 presentPerform/provide:• Storage in tight container at room temperatureEvaluate:• Therapeutic response: decreased fever, malaise, rash, negative C&S for infecting organismTeach 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)ISOSORBIDEIsmoticFunc. class. : Miscellaneous ophthalmic agentAction: Increases osmotic gradient between plasma and ocular fluids, which decreases intraocular pressureUses: Reduces intraocular pressure from glaucoma and cataract surgeryDosage and routes:• Adult: PO 1. 5 g/kg, then increase to 1-3 g/kg bid-qidAvailable forms: Sol 45%Side effects/adverse reactions:CNS: Headache, light-headedness, irritability, lethargy, syncope, confusion, dizziness, vertigo, disorientationGI: Nausea, vomiting, anorexia, diarrhea, cramps, thirstINTEG: RashMETA: Hypernatremia, hyperosmolarityContraindications: Hypersensitivity, anuria, severe renal disease, pulmonary edema, hemorrhagic glaucoma, dehydrationPrecautions: Pregnancy ?, patients on Na-restricted dietNURSING CONSIDERATIONSAssess:• I&O; report decrease in urinary output• Electrolytes during treatmentAdminister:• After pouring over ice (oral)Evaluate:• Therapeutic response: decreased intraocular pressureLEVOTHYROXINE SODIUMFunc.

    class. : Thyroid hormoneChem. class. : Levoisomer of thyroxineAction: Increases metabolic rates, increases cardiac output, O2 consumption, body temperature, blood volume, growth, development at cellular levelUses: Hypothyroidism, myxedema coma, thyroid hormone replacement, cretinism, thyrotoxicosisDosage 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 responseMild hypothyroidism• Initial 50 mg qd; increase by 25-50 mg at interval of 2-4 wkCretinism• Child: IV 0.

    025-0. 05 mg qd, may increase by 0. 05-0. 1 mg PO q2-3wkMyxedema 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 possibleAvailable 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 mgSide effects/adverse reactions:CNS: Anxiety, insomnia, tremors, headache, thyroid stormCV: Tachycardia, palpitations, angina, dysrhythmias, hypertension, cardiac arrestGI: Nausea, diarrhea, increased or decreased appetite, crampsMISC: Menstrual irregularities, weight loss, sweating, heat intolerance, feverContraindications: Adrenal insufficiency, myocardial infarction, thyrotoxicosisPrecautions: Elderly, angina pectoris, hypertension, ischemia, cardiac disease, pregnancy (A), lactationPharmacokinetics:IV/PO: Peak 12-48 hr, half-life 6-7 days; distributed throughout body tissuesInteractions/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 drugsLab test interferences:Increase: CPK, LDH, AST, PBI, blood glucoseDecrease: TSH, 131I uptake test, uric acid, triglyceridesNURSING CONSIDERATIONSAssess:• 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 VSAdminister:• 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 diseasesPerform/provide:• Storage in tight, light-resistant container; sol should be discarded if not used immediately• Removal of medication 4 wk before RAIU testEvaluate:• 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 cheeksTeach 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 breadMAGNESIUM SALTSConcentrated Phillip’s Milk of Magnesia, Milk of Magnesia, Phillip’s Milk of MagnesiaFunc. class. : Laxative, salineAction: Increases osmotic pressure, draws fluid into colon neutralizes HClUses: Constipation, bowel preparation before surgery or examinationDosage 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 mgSide effects/adverse reactions:CNS: Muscle weakness, flushing, sweating, confusion, sedation, depressed reflexes, flaccid, paralysis, hypothermiaGI: Nausea, vomiting, anorexia, crampsCV: Hypotension, heart block, circulatory collapseMETA: Electrolyte, fluid imbalancesContraindications: Hypersensitivity, renal diseases, abdominal pain, nausea/vomiting, obstruction, acute surgical abdomen, rectal bleedingPrecautions: Pregnancy (B)Pharmacokinetics:PO: Peak 1-2 hr; excreted in fecesInteractions/incompatibilities:• Increased CNS depression: CNS depressants, barbiturates, narcotics, anestheticsNURSING CONSIDERATIONSAssess:• 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 reflexesAdminister:• With 8 oz H2OEvaluate:• Therapeutic response: decreased constipationTeach 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 tastePIPERACILLIN SODIUMPipracilFunc. class.

    : Broad-spectrum antibioticChem. class. : Extended-spectrum penicillinAction: Interferes with cell wall replication of susceptible organisms; osmotically unstable cell wall swells and bursts from osmotic pressureUses: 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 q4-6hProphylaxis of surgical infections • Adult: IV 2g ?-1 hr before procedure; may be repeated during surgery or after surgeryAvailable forms: Inj IM, IV 2, 3, 4, 40 g; IV INF 2, 3, 4 gSide effects/adverse reactions:HEMA: Anemia, increased bleeding time, bone marrow depressionGI: Nausea, vomiting, diarrhea, increased AST, ALT, abdominal pain, glossitis, colitisGU: Oliguria, proteinuria, hematuria, vaginitis, moniliasis, glomerulonephritisCNS: Lethargy, hallucinations, anxiety, depression, twitching, coma, convulsionsMETA: Hypokalemia, hypernatremiaContraindications: Hypersensitivity to penicillins; neonatesPrecautions: Pregnancy (B); hypersensitivity to cephalosporins; CHFPharmacokinetics:IM: Peak 30-50 minIV: Peak 20-30 minHalf-life 0. 7-1.

    33 hr; excreted in urine, bile, breast milk; crosses placentaInteractions/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 CLab test interferences:False positive: Urine glucose, urine protein, Coombs’ testNURSING CONSIDERATIONSAssess:• 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, KardexAdminister:• 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 completedPerform/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 refrigeratedEvaluate:• Therapeutic response: absence of fever, purulent drainage, redness, inflammationTeach 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 diarrheaTreatment of overdose: Withdraw drug, maintain airway, administer epinephrine, aminophylline, O2, IV corticosteroids for anaphylaxisSILVER SULFADIAZINE (topical)Silvadene, SSD, SSD AFFunc. class.

    : Local antiinfectiveChem. class. : SulfonamideAction: Interferes with bacterial cell wall synthesis, broad-spectrumUses: Burns (2nd, 3rd degree); prevention of wound sepsisDosage and routes:• Adult and child: TOP apply 1/16 in to affected area qd-bidAvailable forms: Cream 10 mg/gSide effects/adverse reactions:INTEG: Rash, urticaria, stinging, burning, itching, pain, skin necrosis, erythemaHEMA: Reversible leukopeniaContraindications: Hypersensitivity, child *2 moPrecautions: Impaired renal function, pregnancy (C), impaired hepatic function, lactationNURSING CONSIDERATIONSAssess:• Allergic reaction: burning, stinging, swelling, redness• Renal function studies; check for crystalluriaAdminister:• 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 neededPerform/provide:• Storage at room temperature in dry placeEvaluate:• Therapeutic response: relief of infectionTeach patient/family:• That drug may be continued until graft can be doneTRIAMCINOLONEFunc. class. : CorticosteroidChem.

    class. : Glucocorticoid, intermediate-actingAction: Decreases inflammation by suppression of migration of polymorphonuclear leukocytes, fibroblasts, reversal to increase capillary permeability and lysosomal stabilizationUses: Severe inflammation, immunosuppression, neoplasms, asthma (steroid dependent), collagen, respiratory, dermatologic disordersDosage 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/dayAvailable 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 hexacetonideSide effects/adverse reactions:INTEG: Acne, poor wound healing, ecchymosis, petechiaeCNS: Depression, flushing, sweating, headache, mood changesCV: Hypertension, circulatory collapse, thrombophlebitis, embolism, tachycardia, edemaHEMA: ThrombocytopeniaMS: Fractures, osteoporosis, weaknessGI: Diarrhea, nausea, abdominal distention, GI hemorrhage, increased appetite, pancreatitisEENT: Fungal infections, increased intraocular pressure, blurred visionContraindications: Psychosis, hypersensitivity, idiopathic thrombocytopenia, acute glomerulonephritis, amebiasis, fungal infections, nonasthmatic bronchial disease, child *2 yr, AIDS, TBPrecautions: Pregnancy ?, diabetes mellitus, glaucoma, osteoporosis, seizure disorders, ulcerative colitis, CHF, myasthenia gravis, renal disease, esophagitis, peptic ulcerPharmacokinetics:PO/IM: Peak 1-2 hr, 2 days, 1-6 wk (IM), half-life 2-5 hrInteractions/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 antibioticsLab test interferences:Increase: Cholesterol, Na, blood glucose, uric acid, Ca, urine glucoseDecrease: Ca, K, T4, T3, thyroid 131I uptake test, urine 17-OHCS, 17-KS, PBIFalse negative: Skin allergy testsNURSING CONSIDERATIONSAssess:• 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, aggressionAdminister:• 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 symptomsPerform/provide:• Assistance with ambulation in patient with bone tissue disease to prevent fracturesEvaluate:• Therapeutic response: ease of respirations, decreased inflammationTeach 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 symptomsSymptoms of adrenal insufficiency: nausea, anorexia, fatigue, dizziness, dyspnea, weakness, joint painHOLISTIC HUMAN RESPONSES/Functional Developmental Physiological Psychological Dimensions Cognitive Emotional Self-ConceptualWellness & 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 breakdownNutrition 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

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