SOUTHERN UNIVERSITY SCHOOL OF NURSING NURSING CARE PLAN Level I

10/23/2011 Nneka Anyanwu STUDENT NAME _______________________________________________________________DATE__________________________________ Nursing 201

COURSE TITLE & NUMBER ____________________________________________________________________________________________ CLIENT INFORMATION

AB Clients initials _________________Age _____________ Sex _____________ Religion ______________________________________________

Socio-Cultural Background ______________________________________________________________________________________________ Growth & Development Stage (Erikson, Piaget, or Kohlberg) __________________________________________________________________ MEDICAL DIAGNOSIS DATA Diabetes II, Abnormality of Gait, Symbolic Dysfunction (NOS) , Osteoarthritis (NOS), Pneumonia Primary Diagnosis ______________________________________________________________________________________________________ Salivary Gland Absence, Depressive Disorder Secondary Diagnosis ____________________________________________________________________________________________________

65

Baptist

African American

Eriksons Ego Integrity vs. Despair

N/A 4/13/2007 120.5 kg Date of Surgery ___________________________ Admission Date ___________________________Admission Weight (kg) ________________ N/A Type of Surgery ________________________________________________________________________________________________________ Jefferson Manor Nursing Home Clinical area of health care agency _________________________________________________________________________________________ High Risk for Falls, Cannot complete ADLs Unattended Reason for admission ____________________________________________________________________________________________________ Assmt (include med & Doc) (2) ______________ WATSONS CARATIVE FACTORS _____________________________________ Nursing Diagnosis (2) ______________ Helping and trusting relationship Planning (2) ______________ ______________________________________________________________________ Intervention (1) ______________ Rationale ( 1) ______________ COMMUNITY RESOURCE_____________________________________________ Evaluation (1) ______________ APA/grammar (1) ______________ YMCA Baton Rouge / Community Mental Health Center (Baton Rouge) Total _____/10 x 100 _______________

ASSESSMENT (Include current & past medical history, and pertinent diagnostic findings with interpretations)

Client is a 65 year old African American female. Her primary language is English. Client is a former housewife and sitter and was admitted to Jefferson Manor for risk of falls and unable to complete ADLs on 4/17/2007. Client mobilizes with the use of a walking cane. Client is diagnosed with Diabetes II, Abnormality of Gait, Symbolic Dysfunction (NOS) , Osteoarthritis (NOS), Pneumonia, Salivary Gland Absence, and Depressive Disorder. She has allergies to Sulfa drugs with no previous hospitalization or surgeries. The client does not smoke, drink or intake of recreational drugs. Date of last physical 2/3/11, date of initial physical is unknown. Patient needs daily partial assistance with ADLs due to cognitive impairment. Client admission vitals were Temp- 98, P- 76, R-20 BP- 138/74, HT 71 WT 151.5 kg. Clients admission pupils were equal round and reactive to light and accommodation. Peripheral pulses -+2, Radial pulses- +2, Femoral pulses +2, posterior tibial +2 , brachial pulse - +2, apical heart rate was 90, no edema noted. Nail beds were pink and blood flow returned in less than 3 seconds. Admission breath sounds were clear, non labored, normal depth and no cough noted. Abdomen soft and non distended, urine color yellow and continent. No bowel or urinary complaints.

Recent assessment of the client showed that the Client is alert and is oriented to person but not to time nor place. Patient needs daily partial assistance with ADLs due to cognitive impairment. Current assessment vitals were Temp98.1, P- 82, R-18 BP- 132/78, HT 71 WT 120.5 kg. The client current assessment pupils were equal round and reactive to light and accommodation. Peripheral pulses -+2, Radial pulses- +2, Femoral pulses +2, posterior tibial +2 , brachial pulse - +2, apical heart rate was 92, no edema noted. Nail beds were pink and blood flow returned in less than 3 seconds. The client current assessment breath sounds were clear, non labored, normal depth and no cough noted. Abdomen soft and non distended, urine color yellow and continent. Strong upper bilateral extremity strength, but weak right lower extremity strength, with strong left lower extremity strength. Client has a abnormal gait. Client has no amputations, paralysis or prosthetic devices, although she uses a walker to help with her gait and mobility. Client has no skin discolorizations, and no wound or lesions noted on skin nor scalp. Client has partially impaired vision, but wears no devices. Hearing is intact.

Comments after being graded

Pertinent Diagnostic Procedures and Interpretation (Please Date Labs) Diagnostic Procedure Pre and Post Procedure Nursing Implications Normal Findings/Values for this Procedure Clients Results for this Diagnostic Procedure (Admit) Date N/A

Date: Client's Results for this Diagnostic Procedure (Recent) DATE: 10/20/11 3.48L 5.4 10.2 30.6 88 33.4 12.4 242 8.5 DATE: 10/22/11 53 39 6 1 0 2.9 2.1 0.3 0.1 0.0 DATE:10/22/11 143 3.3L Interpretation of These Findings as Applicable to this Client & Explain trends

CBC RBC mill/uL WBC 1000/uL Hgb gm/dl Hct % MCV fl MCHC gm/dl RDW % Platelets1000/uL MPV fl DIFF Neutrophils% Lym % Mono % Eosino % Baso % Neut A Lym A Mono A Eos A Basos A CHEMISTRY Sodium (Na) Potassium (K) Before: Explain to the procedure to the patient. Tell the patient that no fasting or special preparation is required. During: Collect 7 to 10ml of venous blood in a red-top tube. Thoroughly mix the blood with anticoagulant by tilting the tube. Avoid Hemolysis. List on the laboratory slip any drugs or other patient factors that may affect RBC levels. If patient is receiving an IV infusion, obtain blood from the opposite arm. After: Apply pressure or pressure dressing to the venipuncture site for bleeding. 3.8-5.30 4.0-11.0 12.0-16.0 37.0-47.0 80-100 31.0-37.0 12.1-14.9 150-375 6.5-12.0

Within Normal Range ( WNR) ( WNR) ( WNR) LOW ( WNR) ( WNR) ( WNR) ( WNR) ( WNR)

44-81 21-47 2-11 0-7 0-2 1.5-10.0 1.3-2.9 0.1-1.0 0.0-0.7 0.0-0.2 136-145 3.5-5.1

( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) LOW

Chloride (Cl) CO2 Glucose BUN Creatinine Calcium Diagnostic Procedures Pre and Post Procedure Nursing Implications

100-109 22-33 70-100 5-25 0.57-1.25 8.8-10.6 Normal Findings/Values for this Procedure

Clients Results for this Diagnostic Procedure (Admit)

106 25 95 10 0.65 8.3L Client's Results for this Diagnostic Procedure (Most recent values)

( WNR) ( WNR) ( WNR) ( WNR) ( WNR) LOW Interpretation of These Findings as Applicable to this Client & Explain trends

Bleeding Time PT

N/A N/A

N/A N/A N/A

DATE:

DATE:

PTT N/A INR ARTERIAL BLOOD GASES PH PCO2 PO2 HCO3 SaO2 CULTURE & SENSITIVITY SOURCE N/A BODY SITE N/A N/A : DATE: DATE:

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N/A

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DATE:

DATE:

REPORT

Diagnostic Procedures Pre and Post Procedure Nursing Implications

Normal Findings/Values for this Procedure

Clients Results for this Diagnostic Procedure (Admit)

Client's Results for this Diagnostic Procedure (Most recent value)

Interpretation of These Findings as Applicable to this Client & Explain trends

URINALYSIS Color Clarity SpGr pH Ur Prot Ur Glucose Ur Ketone Hgb Ur Bili urine Urobil Leukocyte esterase Nitrate WBC Ur RBC urine Epith Ur

DATE N/A
Before: Explain the procedure to the patient. During: Collect a fresh urine specimen in a urine container. Have the patient begin to urinate into a bedpan, urinal, or toilet, then stop urinating. This washes urine out of the distal part of the urethra. Correctly position a sterile urine container and have the patient void 3-4 ounces of urine. Cap the container, and allow the patient to finish voiding. After Transport the urine specimen to the laboratory promptly. If the specimen cannot be processed immediately, refrigerate it.

Yellow Clear 1.001-1.035 5.0-8.0 NEG NEG NEG NEG NEG NEG NEG NEG 0-5 0-5 0-5

DATE:2/5/11 Lt Yellow Clear 1.008 5.0 NEG NEG NEG NEG NEG NEG NEG NEG 0-5 0-1 0-1

( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR) ( WNR)

DATE

DATE:

DIAGNOSTIC STUDIES Diagnostic Procedures Pre and Post Procedure Nursing Implications Normal Findings/Values for this Procedure Clients Results for this Diagnostic Procedure (Admit) Client's Results for this Diagnostic Procedure (Most recent values) DATE: N/A N/A N/A Interpretation of These Findings as Applicable to this Client & Explain trends

OTHER TEST N/A Rubella (OB) N/A Coombs (OB) N/A Bilirubin Level (OB) N/A N/A N/A

DATE N/A N/A N/A

NURSING CARE PLAN ASSESSMENT

UNIVERSAL REQUISITES

DEVELOPMENTAL REQUISITES Ego Development Outcome: Generation vs Self Absorption or Stagnation

HEALTH DEVIATIONS PATHOLOGY & SIGNS & SYMPTOMS Pneumonia: Pneumonia is an inflammation of your lungs, usually caused by infection. Bacteria, viruses, fungi or parasites can cause pneumonia. Pneumonia is a particular concern if you're older than 65 or have a chronic illness or impaired Symptoms of pneumonia caused by bacteria in otherwise healthy people younger than 65 usually come on suddenly. They often start during or after an upper respiratory infection, such as influenza or a cold, and may include: Cough, often producing mucus (sputum) from the lungs. Mucus may be rusty or green or tinged with blood. Fever, which may be less common in older adults. Shaking, "teeth-chattering" chills (one time only or many times).Fast, often shallow, breathing and the feeling of being short of breath. Chest wall pain that is often made worse by coughing or breathing in. Fast heartbeat. Feeling very tired (fatigue) or feeling very weak (malaise).Nausea and vomiting (Smeltzer 799).

SELF-CARE DEFICITS

Air: Vital signs were: 108/62, P: 110, R: 16, T; 98.0, The vital sign were stable. Clients breath sounds were Basic Strengths: Production and audible with no evidence of Care. crackle. Client stated short of Work is most crucial; Erikson breath Chest shape was observed that the middle age is when symmetrical both in anterior and we tend to be occupied with creative posterior diameter.. and meaningful work and with issues Clients peripheral pulses were 2+ surrounding family. Also, middle for the following areas: radial, adult hood is when we expect to be femoral, carotid, posterior tibia and in charge. pedal. There was no sign of edema in clients right and left The significant task is to pass culture extremities. and transmit values of culture through family and working to establish a stable environment, Water and Food: Client has no Strength comes through care of difficulty in swallowing; client was on a regular diet.. Admit others and production of something Wt. was 164.10 kg;. Mucous that contributes to the betterment of society, which Erickson calls membrane was moist and pink generativity so when we are at this with all natural teeth., She states stage we often fear inactivty and no urinary or bowel complaints. meaninglessness.

Client has diabetes. Patient states pain is 7 out of 10 on Pain scale Patient has generalized weakness. Patient has abnormality of gait and weakness on feet. Patient is at risk for falls Patient complains of pain Client has cognitive impairment

Elimination: Client was continent. Abdomen was soft and not

distended; bowel sounds were audible in all four quadrants. There was no bladder distension, Urine was yellow. Client states last bowel movement 10/23/11. Activity and Rest: Client is able to feed self, but needs assistance when dressing. Client also needs partial assistance in grooming, bathing and other activities of daily living. Client states she sleeps 6 or more hours a day uninterrupted. ROM present in upper extremities but left leg obvious weakness in strength. Motor function and coordination impaired. Client pupils equally round and reactive to light and accommodation. Language was clear. Solitude and Social Interaction: Personal safety practices were intact. Patient husband visits daily. Normalcy: Mood was calm. Insight and judgment was present, No phobias, suicidal ideation or hallucination were present. Copes with pain by using distraction techniques as watching TV or walking around with husband.

Schizophrenia is a brain disorder that affects the way a person acts, thinks, and sees the world. People with schizophrenia have an altered perception of reality, often a significant loss of contact with reality. They may see or hear things that dont exist, speak in strange or confusing ways, believe that others are trying to harm them, or feel like theyre being constantly watched. With such a blurred line between the real and the imaginary, schizophrenia makes it difficult even frighteningto negotiate the activities of daily life. In response, people with schizophrenia may withdraw from the outside world or act out in confusion and fear. In this early phase, people with schizophrenia often seem eccentric, unmotivated, emotionless, and reclusive. They isolate themselves, start neglecting their appearance, say peculiar things, and show a general indifference to life. They may abandon hobbies and activities, and their performance at work or school deteriorates. Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. (Formerly referred to as noninsulin-dependent diabetes mellitus, NIDDM for short, and adult-onset diabetes.)

Signs and Symptoms include : Feeling thirsty. Having to urinate more than usual. Feeling more hungry than usual. Losing weight without trying to. Feeling very tired. Feeling cranky. Other signs of type 2 diabetes may include: Infections and cuts and bruises that heal slowly. Blurred vision. Tingling or numbness in your hands or feet. Trouble with skin, gum, or bladder infections.

NURSING DIAGNOSIS NANDA LIST

PLAN Nursing Outcomes/Goals Classification (NOC) SHORT-TERM/LONG-TERM

Short term goal:. After 8 hours of nursing intervention, the patient will be able to maintain airway patency and clear secretions readily.

IMPLEMENTATION Nursing Interventions Classifications (NIC) and Rationales (cite source) Assess respirations: note quality, rate, pattern, depth, and breathing effort.( Both rapid, shallow breathing patterns and hypoventilation affect gas exchange.) -Demonstrate the use of a incentive spirometer. (Prevents or reduces
atelectasis and promotes reexpansion of small airways..)

EVALUATION OUTCOMES/REVISIONS

Ineffective airway clearance related to retained secretions as manifested by patient recurrent productive cough.

Patient states that her cough is better managed, and demonstrated the use of a incentive spirometer.

Long term goal: Client will be able demonstrate use of devices for proper breathing techniques to prevent cough by November 10, 2011.

Assess patients ability to cough effectively to clear secretions. Note quantity, color, and consistency of sputum. (Retained secretions impair gas exchange.) Encourage fluid intake and deep breathing (This provides for adequate oxygenation and better diluted secretions.)

NURSING CARE PLAN NURSING DIAGNOSIS NANDA LIST PLAN Nursing Outcomes/Goals Classification (NOC) SHORT-TERM/LONG-TERM
Short term goal:. Client will describe how pain will be managed by October 26, 2011 Long term goal: Client will perform activities of recovery with reported acceptable level of pain by November 10, 2011.

IMPLEMENTATION Nursing Interventions Classifications (NIC) and Rationales (cite source)

Assess and document the intensity of the pain and discomfort after any known painproducing procedure, with each new report of pain, and at regular intervals. Rationale: Systematic ongoing assessment and documentation provide direction for the pain treatment plan; adjustments are based on the clients responses. The clients report of pain is the single most reliable indicator of pain. (Ackley, 605) Administer a back rub, unless contraindicated. Rationale: Back rubs help loosen muscles and are indicated for the treatment of moderate to severe pain. (Ackley, 605) Patient will be taught correct positioning to relieve pain and less stress on muscles. Rationale: Incorrect body positioning stresses the joints causing pain..(Ackley, 605)

EVALUATION OUTCOMES/REVISIONS

Acute pain as manifested by client verbalizing back pain and grimacing.

Patient state and demonstrated the correct way to position herself to ease her pain and verbalized ways her pain can be managed.

Instructor Feedback________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

NURSING CARE PLAN NURSING DIAGNOSIS NANDA LIST PLAN Nursing Outcomes/Goals Classification (NOC) SHORT-TERM/LONG-TERM
Short term goal:. Patient will ask questions where new information needs clarification by the end of the clinical shift. Long term goal: Client will identify new sources for enhancing knowledge in the topic of diabetes by November 10, 2011.

IMPLEMENTATION Nursing Interventions Classifications (NIC) and Rationales (cite source)

Be able to explain, answer questions and correct misconceptions for patient. Rationale: Patient should be able to understand the importance of taking insulin and at what times is it most important to take it. (Ackley, 605) Determine exactly what the patient wishes to know and to what level he wants to enhance knowledge and understanding. Rationale: Patient is able to express amount of interest in teaching. Direct patient to other sources of information, such as libraries, internet, or professional organizations. Rationale: Provide them with printouts provided by the hospital, an independent research results in patient developing confidence in knowledge.

EVALUATION OUTCOMES/REVISIONS

Knowledge deficit related to client questions of signs and symptoms of hyperglycemia and hypoglycemia.

Outcome met. Patient questioned the acts of insulin and why it was important to take dosages same time. Patient was given information from the computer and referred to websites for further help.

Instructor Feedback________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

NURSING CARE PLAN NURSING DIAGNOSIS NANDA LIST PLAN Nursing Outcomes/Goals Classification (NOC) SHORT-TERM/LONG-TERM
Short Term: After 3-4 hours of nursing interventions, the patient will use identified techniques to improve activity tolerance Long Term: After 2-3 days of nursing interventions, the patient will report measurable increase in activity tolerance.

IMPLEMENTATION Nursing Interventions Classifications (NIC) and Rationales (cite source) Establish Rapport (To gain clients participation and cooperation in the nurse patient interaction) Monitor and record Vital Signs (To obtain baseline data) Assess patients general condition (To note for any abnormalities and deformities present within the body) Adjust clients daily activities and reduce intensity of level. Discontinue activities that cause undesired psychological changes (To prevent strain and overexertion) Instruct client in unfamiliar activities and in alternate ways of conserve energy (To conserve energy and promote safety)

EVALUATION OUTCOMES/REVISIONS

Activity intolerance related to limited range of motion as observed

Patient was able to keep a diary of ADLs and improved activity tolerance.

Instructor Feedback________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

MEDICATION FORM

DRUG Clients weight (kg) 120.5 KG Generic name: Insulin Determir Trade name: Levemir Classification:Intermediatelong acting insulin, Antidiabetic

CALCULATION

ACTION Why is patient receiving medication? Treatment of insulin dependent diabetes mellitus, also non insulin dependent diabetes unresponsive to treatment with diet and oral hypoglycemic.

SIDE EFFECTS/ CONTRAINDICATIONS

NURSING IMPLICATIONS/ PATIENT TEACHIING

a. Be certain to give the correct type of insulin. b. Prepare the correct dosage. Have another nurse double-check the dose before you administer the injection. c. Use the correct syringe. Never use a regular syringe for insulin. Use a syringe calibrated in "units." d. Before drawing up the insulin, gently "roll" the bottle between your palms to mix and warm the solution. e. Eliminate all air bubbles from the syringe. One small air bubble may displace 2 or 3 units of insulin. f. Cleanse the skin with alcohol and allow to dry. This helps avoid pitting of the skin. g. Give the injection subcutaneously. Rotate the injection site with each dose. (Rotating the sites prevents tissue necrosis.) Refer to figure 1-9 for injection sites. h. Always check to see

Fatigue, mental confusion, loss of consciousness, headache, hypothermia, uticaria, redness, hypoglycemia. Hunger, nausea, edema, pain or warmth at injection site, atrophy or hypertrophy of subcutaneous fat tissue.

Recommended dose: 0.2-0.40 U/kg Clients dose: 28 Units per day

whether the patient is and has been eating his normal diet.

Generic name: Risperdone Trade name: Risperdal Classification: Atypical Antipsychotic

Treatment of schizophrenia, bipolar disorder, and behavior problems of people with autism. It is also used for anxiety, OCD, resistant depression, tourette syndrome, and eating disorders.

Recommended dose: PO (Adults): 1 mg twice daily, increased by 12 mg/day no more frequently than every 24 hrs to 48 mg daily Clients dose: 3mg 1PO Q AM

Weight gain, sedation, dysphoria, insomnia, sexual dysfunction, low blood pressure, high blood pressure, muscle stiffness, constipation and stuffy nose. Contraindicated in patients with diabetes and older patients being treated for dementia.

Monitor patients mental status (orientation, mood, behavior) before and periodically during therapy Assess weight initially and throughout therapy Monitor mood changes. Monitor blood pressure (sitting, standing, lying down) and pulse before and frequently during initial dose titration. Inform patient of the possibility of extrapyramidal symptoms. Instruct patient to report these symptoms immediately to health care professional Advise patient to change positions slowly to minimize orthostatic hypotension Advise patient to use sunscreen and protective clothing when exposed to the sun to prevent photosensitivity reactions. Extremes in temperature should also be avoided; this drug impairs body temperature regulation Instruct patient to notify health care professional promptly if sore throat, fever, unusual bleeding or bruising, rash, or tremors occur.

MEDICATION FORM

DRUG Clients weight (kg) 120.5 KG Generic name: Metformin Trade name: Glucophage Classification: Antidiabetic

CALCULATION

ACTION

SIDE EFFECTS/ CONTRAINDICATIONS

Recommended dose: The recommended starting dosage of metformin is 500 mg twice daily Clients dose: 1000mg 1 PO BID

Why is patient receiving medication? Improves tissue sensitivity Abdominal pain, bitter or to insulin, increase metallic taste, diarrhea, glucose transport into anorexia, garlic, ginseng skeletal muscles and fat, may increase and hypoglycemic effects, suppresses DRUG INTERACTIONS: gluconeogenesis and captopril, furosemide, hepatic production of nifedipine may increase glucose, thus lowering risk of hypoglycemia. blood glucose levels USES: type 2 diabetes mellitus in pts not controlled with diet alone. May be used in oral sulfonylurea.

NURSING IMPLICATIONS/ PATIENT TEACHIING

Be aware that hypoglycemia is not a risk when drug is taken in recommended therapeutic doses unless combined with other drugs which lower blood glucose. Report to physician immediately S&S of infection, which increase the risk of lactic acidosis (e.g., abdominal pains, nausea, and vomiting, anorexia). Always check to see whether the patient is and has been eating her normal diet.

DRUG Clients weight (kg) 120.5 KG Generic name: Benzatropine Trade name: Cogentin Classification: Anticholinergic Recommended dose: The recommended benztropine dosage is 1 mg to 4 mg once or twice a day Clients dose: 2mg tablet PO TID

CALCULATION

ACTION Why is patient receiving medication? Benzatropine is used in patients to reduce the side effects of antipsychotic treatment, such as parkinsonism and akathisia. Benzatropine is also a second-line drug for the treatment of Parkinson's disease. It improves tremor and rigidity but not bradykinesia. Benzatropine is also sometimes used for the treatment of dystonia, a rare disorder that causes abnormal muscle contraction, resulting in twisting postures of limbs, trunk, or face.

SIDE EFFECTS/ CONTRAINDICATIONS

NURSING IMPLICATIONS/ PATIENT TEACHIING

Assess bowel function daily. Monitor for constipation, abdominal pain, distention, or absence of bowel sounds Monitor intake and output ratios and assess patient for urinary retention (dysuria, distended abdomen, infrequent voiding of small amounts, overflow incontinence)Patients with mental illness are at risk of developing exaggerated symptoms of their disorder during early therapy with benztropine. Withhold drug and notify physician or other health care professional if significant behavioral changes occur Caution patient to change positions slowly to minimize orthostatic hypotension Instruct patient to notify health care professional if difficulty with urination, constipation, abdominal discomfort, rapid or pounding heartbeat, confusion, eye pain, or rash occurs Advise patient to confer with health care professional before taking OTC medications, especially cold remedies, or drinking alcoholic beverages.

Contraindicated in: Hypersensitivity Children <3 yr Angle-closure glaucoma Tardive dyskinesia

Side Effects confusion, depression, dizziness, hallucinations, headache, sedation, weakness: blurred vision, dry eyes, mydriasis, . arrhythmias, hypotension, palpitations, tachycardiaconstipation, dry mouth, ileus, nausea. , urinary retention. decreased sweating.

MEDICATION FORM

DRUG Clients weight (kg) 120.5 KG Generic name: Guaifenesin Trade name: Mucinex Classification: Expectorant Recommended dose: 200400 mg PO q 4 hr. Do not exceed 2.4 g/day. Clients dose: 100 mg/ml PO PRN

CALCULATION

ACTION

SIDE EFFECTS/ CONTRAINDICATIONS

Why is patient receiving medication? Enhances the output of Headache, dizziness respiratory tract fluid by Rash, urticaria Nausea, reducing adhesiveness vomiting, GI discomfort and surface tension, facilitating the removal Contraindications: of viscous mucus. Allergy, thyroid disease Symptomatic relief of respiratory conditions characterized by dry, nonproductive cough and in the presence of mucus in the respiratory tract.

NURSING IMPLICATIONS/ PATIENT TEACHIING

Monitor reaction to drug; persistent cough for more than 1 wk, fever, rash, or persistent headache may indicate a more serious condition. Some ER or SR formulations may be cut in half but cannot be crushed or chewed. Mucinex cannot be crushed, chewed, or cut. Do not take for longer than 1 wk; if fever, rash, or headache occur, consult health care provider. You may experience these side effects: Nausea, vomiting (eat frequent small meals); dizziness, headache (avoid driving or operating dangerous machinery). Report fever, rash, severe vomiting, persistent cough.

References: Ackley, E. J., & Ladwig, G. (2005). Nursing diagnosis handbook, a guide to planning care Chicago IL. Mosby Inc.