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Assignment: COA 11/11/15

B, G Provider: C A

Sex: F Weight: Code Status: 01 : 00 Food : 00 Diet: 00 Floor:

Age: 90 Y Height: Alerts: 00 Allergies: 00 Env. Allergies: 00 BMI: Medical-Surgical

Student: amy addison Assignment: COA 11/11/15 Submitted: 11/14/2015 08:01

Clinical Assignment Grading

Assignment Objectives No assignment objectives entered.

Clinical Set-up Details First Day of Clinical: 11/11/2015 Primary Diagnosis: Respiratory distress

Provider Name: A, C Secondary Diagnosis:

Student Details: Patient Details:

First Initial: a Identifier 1: G Last Name: addison Identifier 2: B Credentials: SPN Gender: F Age: 90 Years

Pre-Clinical Manager

Patient Info Identifier: B, G Gender: F Age: 90 Y Nurse Initials: a addison, SPN

Diagnosis (1)

Primary Diagnosis: Respiratory distress syndrome Patho-: Respiratory distress is a syndrome in which the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination. In practice, it may be classified as either hypoxemic or hypercapnic

Respiratory failure can arise from an abnormality in any of the components of the respiratory system, including the airways, alveoli, central nervous system (CNS), peripheral nervous system, respiratory muscles, and chest wall. Patients who have hypoperfusion secondary to cardiogenic, hypovolemic, or septic often present with respiratory failure.

Ventilatory capacity is the maximal spontaneous ventilation that can be maintained without development of respiratory muscle fatigue. Ventilatory demand is the spontaneous minute ventilation that results in a stable Pa CO2.

Normally, ventilatory capacity greatly exceeds ventilatory demand. Respiratory failure may result from either a reduction in ventilatory capacity or an increase in ventilatory demand (or both). Ventilatory capacity can be decreased by a process involving any of the functional components of the respiratory system and its controller. Ventilatory demand is augmented by an increase in minute ventilation and/or an increase in the . The specific treatment depends on the etiology of respiratory distress. Patient are generally prescribed bed rest during early phases, however ambulation s soon as possible to help ventilate atelectatic areas of the lung. The goal is to assure adequate oxygen to delivery to tissues, generally achieved with an arterial oxygen saturation greater than 90%. Supplemental oxygen is administered via nasal prongs or face mask; however in patients with severe hypoxemia, intubation and mechanical ventilation are often required. Therapeutic Regimen: Treatment of the respiratory distress syndrome includes both supportive measures and correction of the underlying . Various pharmacological interventions have been proposed to limit the severity of lung injury and enhance the healing process, including exogenous surfactant, inhaled vasodilators (mainly nitric oxide), corticosteroids, prostaglandin E1, antioxidants (N-acetylcysteine), ketoconazole and other substances. Some of these interventions are administered via the airways, for example inhaled nitric oxide or liquid ventilation with perfluorocarbons. Some have beneficial effects on surrogate end-points such as pulmonary gas exchange. Nebulizer treatments to dilate airway and supplemental oxygen. Maintain semi/high fowler's position to allow for lung expansion, use of incentive spirometer, frequent turning. Adequate caloric and protein intake to meet patient's respiratory needs. Current Health Problems and Related Functional Changes: Depressive disorder not elsewhere specified, anxiety state unspecified, with depressive features, other cerebral degenerations, Alzheimer's disease, disorders of lipoid metabolism, unspecified hyperlipidemia, chronic ischemic heart disease/ coronary atherosclerosis, unspecified esophageal reflux, essential , , peptic ulcer, .

Medications (10)

Medication:Mirtazapine Tablet - (Remeron) Classification:Antidepressant: tricyclic Route: Oral Dose: 15mg Frequency:once daily at bedtime Date 11/11/2015 Ordered: Comments and Additional Info: Therapeutic Effect: N/A Decreased Action: Contraindications: N/A N/A or Adverse Reactions: Life Threatening Considerations: Dizziness, drowsiness, orthostatic , ECG N/A changes, blurred vision, diarrhea, dry mouth, nausea, vomiting, paralytic ileus, increased appetite, , agranulocytosis, , eosinophilia, leukopenia Recommended Dose Ranges: Interventions: N/A Blood studies CBC, leukocytes, differential, cardiac enzymes, lipid profile, blood , LFT's serum creatinine/BUN if patient is receiving long-term . Weigh weekly appetite may increase with product. Teach patient that therapeutic effects may take 2-3 weeks to take effect and that there is decreased sedation with increased doses and not to discontinue abruptly. To avoid alcohol and other CNS depressants

Medication:Lorazepam Tablet - (Ativan) Classification:Antianxiety Route: Oral Dose: 0.5mg Frequency:twice daily Date 11/11/2015 Ordered: Comments and Additional Medication Info: Therapeutic Effect: N/A Decreased anxiety, restlessness, Action: Contraindications: N/A N/A Side Effects or Adverse Reactions: Life Threatening Considerations: Dizziness, drowsiness, confusion, , N/A unsteadiness, orthostatic hypotension, blurred vision, constipation, dry moat, nausea, vomiting, anorexia, diarrhea, Recommended Dose Ranges: Nursing Interventions: N/A Assess decrease in anxiety, mental status, mood, sensorium, affect, sleeping pattern, drowsiness, dizziness, suicidal tendencies. assist with ambulation during beginning therapy, since drowsiness ,dizziness occurs. each patient that product may be take with food, to rise slowly from sitting position because fainting may occur, especially in geriatric patients.

Medication:Ranitidine Tablet - (Zantac) Classification:H2-Histamine receptor antagonist Route: Oral Dose: 150mg Frequency:once daily Date 11/11/2015 Ordered: Comments and Additional Medication Info: Therapeutic Effect: N/A Decreased abdominal pain, heartburn

Action: Contraindications: N/A N/A Side Effects or Adverse Reactions: Life Threatening Considerations: Headache, sleeplessness, dizziness, confusion, N/A agitation, depression, tachycardia, abdominal pain, diarrhea, nausea, vomiting Recommended Dose Ranges: Nursing Interventions: N/A Assess GI nausea, vomiting, diarrhea, cramps, abdominal discomfort, ,, report immediately. I&O ratio BUN, creatinine LFT,s, serum, stool guaiac before, periodically during therapy. Teach to avoid driving , other hazardous activities until stabilized on product

Medication:Acetaminophen Tablet - (Tylenol, Genapap) Classification:Non opioid analgesic Route: Oral Dose: 500mg Frequency:twice daily Date 11/11/2015 Ordered: Comments and Additional Medication Info: Therapeutic Effect: N/A Absence of pain/ Action: Contraindications: N/A N/A Side Effects or Adverse Reactions: Life Threatening Considerations: Nausea , vomiting, abdominal pain, hepatotoxicity, N/A hepatic , GI bleeding Recommended Dose Ranges: Nursing Interventions: N/A Renal /hepatic/ blood status if receiving high -dose therapy. Teach patient that product may be taken with food , that drowsiness may worsen at beginning of treatment

Medication:Levothyroxine (T4) Tablet - (Levothroid, Levoxyl, Classification:Thyroid Hormone Synthroid, Unithroid) Route: Oral Dose: 75mcg Frequency:once daily Date 11/11/2015 Ordered: Comments and Additional Medication Info: Therapeutic Effect: N/A Absence of depression, increased weight loss, , , appetite, absence of constipation, peripheral , cold intolerance, pale cool, dry , brittle nails, alopecia, coarse hair, stupor ,coma, rosy cheeks Action: Contraindications: N/A N/A Side Effects or Adverse Reactions: Life Threatening Considerations: Anxiety, insomnia, tremors, headache, thyroid storm, N/A excitability, tachycardia, palpitations, angina, dysrhythmias, , nausea, diarrhea, increased or decreased appetite, menstrual irregularities, weight loss, heat intolerance, alopecia Recommended Dose Ranges: Nursing Interventions: N/A Assess B/P , pulse periodically during treatment, weigh daily in same clothing, using same scale at same time of day. Increased excitability, nervousness which may indicate too high dose of medication, usually after 1-3 weeks of treatment. Cardiac status , angina palpitations, and change in . teach patient that product is not a but controls symptoms; that treatment is lifelong, full effect may take up to 6 weeks

Medication:Furosemide Tablet - (Lasix) Classification:Loop duiretic Route: Oral Dose: 20mg Frequency:once daily Date 11/11/2015 Ordered: Comments and Additional Medication Info: Therapeutic Effect: N/A Improvement in edema of feet, legs, sacral area, increase in urine output, decreased B/P, decreased calcium levels Action: Contraindications: N/A -- Side Effects or Adverse Reactions: Life Threatening Considerations: Headache, fatigue, weakness, vertigo, orthostatic -- hypotension, hypokalemia, hypochloremic ,, hypomagnesaemia, hypereruricemia, hypocalcemia, , hyperglycemia Recommended Dose Ranges: Nursing Interventions: N/A Assess weight, I &O to determine fluid loss, assess B/P lying, standing, postural hypotension may occur. Teach patient the need to discuss high- potassium diet or potassium replacement with prescriber. To rise slowly from lying or sitting position because orthostatic hypotension may occur

Medication:Docusate Sodium Capsule - (Colace) Classification:Stool Softener Route: Oral Dose: 100mg Frequency:once daily Date 11/11/2015 Ordered: Comments and Additional Medication Info: Therapeutic Effect: N/A Decrease in constipation Action: Contraindications: N/A N/A Side Effects or Adverse Reactions: Life Threatening Considerations: Nausea, anorexia, cramps, diarrhea N/A Recommended Dose Ranges: Nursing Interventions: N/A Assess cause of constipation, identify whether fluids , bulk, or exercise missing from lifestyle. Teach Patient that normal bowel movements do not always occur daily

Medication:Metoprolol Tablet - (Lopressor) Classification:Antihypertensive Route: Oral Dose: 75mg Frequency:once daily Date 11/11/2015 Ordered: Comments and Additional Medication Info: Therapeutic Effect: N/A Decreased B/P after 1-2 weeks, decreased angina Action: Contraindications: N/A N/A Side Effects or Adverse Reactions: Life Threatening Considerations: Insomnia, dizziness, hypotension, palpitations, nausea, N/A vomiting diarrhea, dry mouth, hiccups Recommended Dose Ranges: Nursing Interventions: N/A Assess baselines of renal, hepatic studies before therapy begins. Teach patient to take immediately after meals, to take at bedtime to prevent effects of orthostatic hypotension

Medication:Ferrous Sulfate Extended-Release Tablet (iron Classification:Hematinic sulfate) - (Slow-Fe) Route: Oral Dose: 325mg Frequency:once daily Date 11/11/2015 Ordered:

Comments and Additional Medication Info: Therapeutic Effect: N/A Improvement in Hct, Hgh, reticulocytes, decreased fatigue, weakness Action: Contraindications: N/A N/A Side Effects or Adverse Reactions: Life Threatening Considerations: Nausea, constipation, epigastric pain, black and red -- tarry stools, vomiting, diarrhea Recommended Dose Ranges: Nursing Interventions: N/A Teach patient that iron will turn stool black or dark green, assess cause of iron loss or , including salicylates, sulfonamides, antimalarials . Blood studies Hct, Hgh, reticulocytes, bilirubin before treatment, at least monthly.

Medication:Amlodipine Tablet - (Norvasc) Classification:Antihypertensive Route: Oral Dose: 10mg Frequency:once daily Date 11/11/2015 Ordered: Comments and Additional Medication Info: Therapeutic Effect: N/A Decreased angina pain, decreased B/P, increased exercise tolerance Action: Contraindications: N/A N/A Side Effects or Adverse Reactions: Life Threatening Considerations: Headache,fatigue, dizziness, anxiety, depression, N/A peripheral edema, bradycardia, hypotension, insomnia, somnolence, palpitations, , nausea, vomiting, diarrhea, gastric ,upset , constipation, flatulence, anorexia, gingival , dyspepsia, muscle cramps, Recommended Dose Ranges: Nursing Interventions: N/A Assess cardiac status, ; B/P, pulse, respirations, ECG. Teach patient to avoid hazardous activities until stabilized on product, dizziness is no longer a problem, to avoid OTC products unless directed by prescriber.To comply in all areas of medical regimen; diet, exercise, stress reduction, product therapy and smoking cessation. To change position slowly to prevent orthostatic hypotension and to avoid grapefruit juice and alcohol

Clinical Grading:

Clinical 34% Grade:

Remarks: Amy, the pathophysiology for the diagnosis of Respiratory Distress Syndrome is very adwquate. However, you failed to address the of this medical condition. HINT: Restlessness, cyanosis, low oxygen levels, confusion, fatigue, ETC.

Care Plan Details

Care Plan

Priority -- : Respiratory distress Created By: a addison, SPN 11/13/2015 | 18:49 syndrome Nursing Diagnosis: ADDED-Ineffective breathing pattern

Status: Active Type: Actual

Related To ADDED-Narrowing of the airway Evidenced By ADDED-Shortness of breath with activity ADDED-Oxygen saturation of 86%

Expected Outcome Measurement/Time Frame Comments ADDED-Patient's oxygen saturation will be 90-100% within 1-2 hours ADDED-Increased activity tolerance within 1-2 weeks

Interventions Rationale Comments ADDED-Position patient in To allow for good lung excursion and chest expansio semi/high fowler's n ADDED-Encourage diaphramagtic To relax muscles and increase patient's oxygen level breathing ADDED-Provide reassurance and Anxiety can increase SOB and allay anxiety ADDED-Pace and schedule To prevent fatigue and excessive oxygen demand activities ADDED-Monitor facial grimaces If pain is a contributing factor to activity intolerance, during activities premedicate as ordered

Care Plan Grading:

Care Plan 30% Grade:

Remarks: Excellent!

Charting Details

System Assessments

Complete Physical Assessment - Head-to-Toe Created By: a addison, SPN 11/13/2015 | 11:52

Complete Physical Assessment - Head-to-Toe

Integumentary: Skin is uniform in color, with blemishes noted on face and arms. Has good skin turgor and skin's temperature is within normal limits.Thick head of hair, evenly distributed. Nails are intact and clean. Head/neck: Head is rounded and symmetrical, neck muscles are equal in size. No masses palpated. Ears/nose/throat: Nose straight and uniform in color, no discharge or flaring noted. Oral cavity pink and moist. Eyes/vision: Pupils round, equal and reactive to light ad accommodation. No edema or tenderness over lacrimal gland and no tearing. Respiratory: Normal breath sounds on lung fields without dyspnea. Cardiovascular: Chest is symmetrical, brisk capillary refill. Heart sound regular. Lymphatic: Lymph nodes non palpable Abdomen: Abdomen flat, tender and non distended, with audible bowel sounds of 16 sounds per minute. Musculoskeletal: ROM to upper and lower extremities, no swelling noted, joints move freely Neurologic: Alert and oriented to person.

Vital Signs

Chart Time Temperature Respirations Pulse Oxygenation Notes Entry By (F) (Resp/min) (Beats/min)(mmHg) 11/13/2015 96.9 18 76 132/78 Saturation: a 11:09 Site: Site: Site: Left arm 96% addiso Tympanic Radial Position: Site: Digital n, SPN Sitting probe, finger Amount: 1.5 L/min Delivery Method: Nasal cannula

General Orders

Code Status Created By: a addison, SPN 11/11/2015 | 08:00

Status: Active Intervention: Do not resuscitate

Patient Card

Order Description Category Status Last Discontinued Entry By Date/Time Performed By 11/11/2015 Do not resuscitate Code Status Active ------a | 08:00 addison, SPN 11/11/2015 08:00 11/13/2015 Respiratory distress Care Plan Active ------a | 18:49 syndrome-ADDED- addison, Ineffective breathing SPN pattern 11/13/2015 18:49

Charting Grading:

Charting 26% Grade:

Remarks:

Competencies No competencies entered.

Remarks:

Overall Grading:

Care Plan 30% Pre-Clinical Manager Grade: 34% Charting 26% Grade: Grade:

Overall Grade: 90%

Remarks:

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