Opioid: Inhibits synthesis of prostaglandins and binds to opiate receptors in

Analgesics: Thought to produce analgesia by inhibiting prostaglandin CNS and peripherally blocks pain impulse generation; produces antipyresis
and other substances that sensitize pain receptors. Drug may relieve by direct action on hypothalamic heat-regulating center; causes cough
fever through central action in the hypothalamic heat-regulating center. suppression by direct central action in medulla; may produce generalized
CNS depression.
Nursing Considerations: 
Effective therapy is dependent on adequate calcium intake. Nursing Considerations: 
Monitor calcium level; this level times the phosphate level shouldn’t Black Box Warning: Monitor patients for respiratory depression, especially
Ca: 12.3 Labs exceed 70. After dosage adjustment, determine calcium level daily until within first 24 to 72 hours of drug initiation or after dosage increase.
level returns to normal. Once level is within normal limits, determine Serious, life-threatening, or fatal respiratory depression may occur.
calcium level at least twice weekly. If hypercalcemia occurs, stop drug Alert: Carefully monitor vital signs, pain level, respiratory status, and
and notify prescriber but resume after calcium level returns to normal. sedation level in all patients receiving opioids, especially those receiving IV
Patient should receive adequate daily intake of calcium. Observe for drugs, even those given postoperatively.
hypocalcemia, bone pain, and weakness before and during therapy. Alert: If patient is taking opioids with serotonergic drugs, watch for signs
Monitor phosphate level, especially in patients with hypoparathyroidism and symptoms of serotonin syndrome (agitation, hallucinations, rapid HR,
and patients on dialysis. fever, excessive sweating, shivering or shaking, muscle twitching or
Make sure patient taking calcitriol maintains adequate fluid status. stiffness, trouble with coordination, nausea, vomiting, diarrhea), especially
The symptoms of vitamin D intoxication include headache, somnolence, when starting treatment or increasing dosages. Signs and symptoms may
weakness, irritability, HTN, arrhythmias, conjunctivitis, photophobia, occur within several hours of coadministration but may also occur later,
rhinorrhea, nausea, vomiting, constipation, polydipsia, pancreatitis, especially after dosage increase. Discontinue the opioid, serotonergic drug,
metallic taste, dry mouth, anorexia, nephrocalcinosis, polyuria, nocturia, or both if serotonin syndrome is suspected. 
weight loss, bone and muscle pain, pruritus, hyperthermia, and Use lowest initial dose in patients with renal or hepatic impairment, and
decreased libido. observe closely for adverse events such as respiratory depression.
Protect drug from heat and light. Monitor liver and kidney function. Acetaminophen elimination may be
increased in patients with hepatic impairment.
Monitor patient’s ability to urinate; report urine retention.
Periodically reevaluate patient’s need for therapy. (Lippincott Advisor for
Education, n.d.)

Medication Review

Medication Review
This Pt is suffering from so many comorbidities and infections, there is a lot
of pain involved. This drug is only given if the other 2 pain medications do
not work. 
Opioid: Unknown. Binds with opioid receptors in the CNS, altering Calcitriol: 3.125 MG PO BID
perception of and emotional response to pain. Hydrocodone/Acetaminophen 10/325 mg PO q4h

Nursing Considerations: 
Boxed Warning: Monitor patients for respiratory depression, 
Alert: Monitor patient for signs and symptoms of adrenal insufficiency  Medication
Medication
Alert: Carefully monitor vital signs, pain level, respiratory status, and sedation Monitor the interaction
level in all patients receiving opioids, especially those receiving IV drugs, of these 2 drugs
even those given postoperatively.
Reassess patient’s level of pain at least 15 and 30 minutes after giving
parenterally and 30 minutes after giving orally. During wound care the patient
Boxed Warning: Keep opioid antagonist (naloxone) and resuscitation experienced pain. No verbal rating
equipment available. given. Pain indicated by loud Bronchodilator: Relaxes bronchial, uterine, and
Monitor circulatory, respiratory, bladder, and bowel functions carefully. Drug moans and sounds coming from vascular smooth muscle by stimulating beta2
may cause hypotension, urine retention, nausea, vomiting, ileus, or altered the pt while turning and moving receptors Corticosteroids Exhibits potent glucocorticoid Bronchodilator: Relaxes bronchial smooth muscle by stimulating beta2
level of consciousness regardless of the route. her from side to side to change activity and weak mineralocorticoid activity. Drug receptors; also inhibits release of mediators from mast cells in the airway.
If respirations drop below 12 breaths/minute, withhold dose and notify the dressings. Nursing Considerations:  inhibits mast cells, macrophages, and mediators Trazadone 50 mg PO bedtime
prescriber. Drug may decrease sensitivity of spirometry (such as leukotrienes) involved in inflammation:.  Nursing Considerations: 
 Watch for pruritus and skin flushing. used for diagnosis of asthma. Alert: As with other inhaled beta agonists, drug can produce paradoxical
Morphine is drug of choice in relieving MI pain; may cause transient Monitor patient for effectiveness. Using drug Nursing Considerations:  bronchospasm or life-threatening CV effects. If this occurs, stop drug
decrease in BP. alone may not be adequate to control asthma Alert: When transferring from systemic immediately and notify prescriber.
An around-the-clock regimen best manages severe, chronic pain. Verify Medication Review corticosteroid to inhalation drug, use caution and Drug may worsen diabetes mellitus and ketoacidosis. Medication Review
in some patients. Long-term control
patient has a breakthrough pain medication prescribed in addition to the Contact medications may be needed. Alert: Drug may gradually decrease corticosteroid dose to prevent Monitor potassium level, as drug may temporarily decrease potassium
around-the-clock medication. Morphine Sulfate 2 MG IV Q12H PRN Isolation cause paradoxical bronchospasm. Monitor adrenal insufficiency. Inhalation drug doesn’t level. The compatibility of levalbuterol mixed with other drugs in a
Morphine may worsen or mask gallbladder pain. patient closely; discontinue drug immediately remove the need for systemic corticosteroid therapy nebulizer hasn’t been established. (Lippincott Advisor for Education, n.d.).
 (Lippincott Advisor for Education, n.d.) Assessment in some situations. If bronchospasm occurs after
and use alternative therapy if paradoxical Antibiotic: Unknown. Inhibits CNS neuronal uptake of serotonin;
bronchospasm occurs. Bronchospasm with inhalation use, stop therapy and treat with a
not a tricyclic derivative.
inhaled formulations frequently occurs with bronchodilator. Lung function may improve within 24
Orders first use of new canister or vial. (Lippincott hours of starting therapy, but maximum benefit may
Insulin: Regulates glucose metabolism by stimulating peripheral glucose Nursing Considerations: 
Advisor for Education, n.d.) not be achieved for 1 to 2 weeks or longer. Watch for Exposure to tobacco smoke accounts
uptake and inhibiting hepatic glucose production. Monitor patient for signs and symptoms of serotonin syndrome
Candida infections of the mouth or pharynx. Alert: for an estimated 80% to 90% of cases (mental status changes, tachycardia, labile BP, hyperreflexia,
Corticosteroids may increase risk of developing of chronic obstructive pulmonary
Nursing Considerations:  incoordination, nausea, vomiting, diarrhea) or NMS
Open wound on right lower quadrant. serious or fatal infections in patients exposed to viral disease
Don’t mix combination insulins with other insulins. (hyperthermia, muscle rigidity, rapidly fluctuating vital signs,
Subcutaneous tissue exposed. illnesses, such as chickenpox or measles. Monitor Passive smoking (i.e., secondhand
Rotate injection sites to reduce risk of lipodystrophy. mental status change). If these signs and symptoms occur,
Minimal drainage, green pus along the bone mineral density in patients at risk for smoke)
Subcut administration is usually made into thighs, arms, buttocks, or immediately discontinue trazodone and any other serotonergic,
edges, some erythema. Dressing decreased bone mineral content (prolonged Increased age
abdomen. The time course of the action of insulin mixtures may vary among antidopaminergic, or antipsychotic drugs.
change performed daily per MD immobilization, family history of osteoporosis, Occupational exposure—dust,
patients and in the same patient depending on time of day, injection site, Record mood changes. Monitor patient for suicidal tendencies
orders. Cleaned with sterile saline and postmenopausal status). Monitor patients for Medication Review chemicals
blood supply, temperature, and physical activity. Observe injection sites for and allow only minimum supply of drug.
dressing in clean gauze stip. Pt is hypercorticism and adrenal suppression and if they Indoor and outdoor air pollution
reactions, such as redness, swelling, itching, or burning.  Assess patient and Consider evaluating patients who haven’t had an iridectomy for
unable to verbalize discomfort, but Medication Review  occur, reduce dosage slowly. (Lippincott Advisor for Genetic abnormalities, including a
notify prescriber for signs and symptoms of hypoglycemia (sweating, shaking, narrow-angle glaucoma risk factors. (Lippincott Advisor for
pain is indicated by loud moans. This Education, n.d.) deficiency of alpha1-antitrypsin, an
Vancomycin 750 mg IV once  trembling, confusion, headache, irritability, hunger, rapid, pulse, nausea) and Education, n.d.)
Medication would is due to cellulitis, that later was
hyperglycemia (drowsiness, fruity breath odor, frequent urination, thirst). enzyme inhibitor that normally
infected but another organism, counteracts the destruction of lung
Monitor blood glucose level and adjust insulin dosages as needed with
Morganella morganii. Which is also tissue by certain other enzymes 
medical supervision. Increase frequency of glucose monitoring in patients
slow to healing due to DM II  (Hinkle, 7/29/19)
Medication Review who are acutely ill or under emotional stress, or if changes in diet, exercise, or
Medication reivew medication regimen occur. These situations may affect rate of insulin
absorption. Mild episodes of hypoglycemia may be treated with oral glucose.
More severe episodes of hypoglycemia, such as coma, seizure, or neurologic
impairment, may be treated with IM or subcut glucagon or concentrated IV
Albuterol: 3 ml RT q6h  glucose. Periodically measure HbA1c levels.  (Lippincott Advisor for Education,
Antibiotic: Hinders bacterial cell-wall synthesis, damaging the bacterial Budesonide: 0.5 mg RT BID Levalbuterol: 1.25 mg RT q6h
n.d.) Obesity (i.e., ≥20% over desired body
plasma membrane and making the cell more vulnerable to osmotic
weight or body mass index ≥30 kg/
pressure. Also interferes with RNA synthesis.
Wound Assessment m2)
Nursing Considerations:  Age equal to or greater than 45 years
Monitor patient’s fluid balance and watch for oliguria and cloudy urine. Medication Medication Medication Previously identified impaired fasting
Monitor patient carefully for vancomycin flushing syndrome (red-man Labs
Labs  syndrome), which can occur if drug is infused too rapidly. Signs and
glucose or impaired glucose tolerance
Medication Review Hypertension (≥140/90 mm Hg)
symptoms include maculopapular rash on face, neck, trunk, and limbs
and pruritus and hypotension caused by histamine release. If wheezing, High-density lipoprotein (HDL)
People with COPD commonly become symptomatic during the middle adult years, and the incidence
urticaria, or pain and muscle spasm of the chest and back occur, stop Risk Factors cholesterol level ≤35 mg/dL (0.90
of the disease increases with age. Although certain aspects of lung function normally decrease with
infusion and notify prescriber. mmol/L) and/or triglyceride level ≥250
Patient had this on the right lower quadrant of age—for example, vital capacity and forced expiratory volume in 1 second (FEV1)—COPD accentuates
Don’t give drug IM.
I met with the patient's pasture very briefly in the her abdomen and accelerates these physiologic changes as described later. In COPD, the airflow limitation is both mg/dL (2.8 mmol/L)  (Hinkle, 7/29/19)
Assess renal function (BUN, creatinine level and CrCl, urinalysis, and
morning. progressive and associated with the lungs’ abnormal inflammatory response to noxious particles or
urine output) before and during therapy.
Later in the afternoon the patient's daughters pH: 7.36= norm A break in skin integrity almost always precedes gases. The inflammatory response occurs throughout the proximal and peripheral airways, lung
Carefully monitor serum concentrations of vancomycin to adjust IV
came to see her. I was able to ask them PaCO2: 42 = norm cellulitis formation, allowing for the introduction parenchyma, and pulmonary vasculature (GOLD, 2015). Because of the chronic inflammation and the Humalog: sliding scale IM asdir Indication Glucose: 160 = High
dosage requirements.
questions in regard to her spirituality. PaO2: 106 = high of organisms. (See Appearance of the skin in body’s attempts to repair it, changes and narrowing occur in the airways. In the proximal airways
Monitor patient for signs and symptoms of superinfection. CDAD can
Patient is Nazerene. When the subject of her HCO3: 23.4 = norm cellulitis.) (trachea and bronchi greater than 2 mm in diameter), changes include increased numbers of goblet Risk Factors
occur up to 2 months after therapy ends. (Lippincott Advisor for
religion was brought up, her face lit up and she As the offending organism invades the cells and enlarged submucosal glands, both of which lead to hypersecretion of mucus. In the
Education, n.d.)
was really wanting to engage in the converstion. compromised area, it overwhelms the defensive peripheral airways (bronchioles less than 2 mm diameter), inflammation causes thickening of the Medication Labs
According to her daughters she loves discussing cells—including the neutrophils, eosinophils, airway wall, peribronchial fibrosis, exudate in the airway, and overall airway narrowing (obstructive
the bible and her religion. basophils, and mast cells—that normally contain bronchiolitis) (Hinkle, 7/29/19)
According to pointloma.edu, "The Church of the and localize inflammation.
Nazarene is an international Protestant As cellulitis progresses, the organism invades The two main problems related to insulin in type 2 diabetes are insulin resistance and impaired insulin secretion. Insulin resistance refers to a decreased
denomination within the holiness tradition. In tissue around the initial wound site. (Lippincott tissue sensitivity to insulin. Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. In Pt S/S:
fact, the Church of the Nazarene is the largest Advisor for Education, n.d.) type 2 diabetes, these intracellular reactions are diminished, making insulin less effective at stimulating glucose uptake by the tissues and at regulating Dyspnea
denomination in the classical Wesleyan-Holiness Labs glucose release by the liver. The exact mechanisms that lead to insulin resistance and impaired insulin secretion in type 2 diabetes are unknown, although Orthopnea
tradition." O2 3 L per min Assessment genetic factors are thought to play a role.
Study performed in the Weight gain (rapid)
I also asked if her spiritual beliefs had any PATHO To overcome insulin resistance and to prevent the buildup of glucose in the blood, increased amounts of insulin must be secreted to maintain the glucose
late afternoon, Dependent edema
determination on the type of care she needs level at a normal or slightly elevated level. If the beta cells cannot keep up with the increased demand for insulin, the glucose level rises and type 2
Specialist states she is Abdominal bloating or discomfort
while in the hospital. Daughters replied w/ no, diabetes develops. Insulin resistance may also lead to metabolic syndrome, which is a constellation of symptoms, including hypertension,
able to swallow, but PATHO Sleep disturbance (anxiety or air
patient replied with a head shake Labs  Allergies:  hypercholesterolemia, abdominal obesity, and other abnormities (Hinkle, 7/29/19)
someone would need Orders  hunger)
Ciprofloxacin
to feed her and Fatigue
Penicillamine
encourage/remind her Decreased exercise tolerance
Bumetanide PATHO
Muscle wasting or weakness
to swallow Breathing pattern is unlabored, Metronidazole Anorexia or nausea
increase BUN and creatinine levels may alter mentation. Pt was admitted even, no adventitious sounds Assessment
Diclofenac Lightheadedness or dizziness
for AMS. As of today, she still has AMS. She is AO x1 to name only and noted in upper or lower lobes. Linezolid Diabetes 
only able to repeat certain words (nurseslabs.com, n.d) Cellulitis COPD Unexplained confusion or altered
Spirituality  Pt is on 3 L of O2  Estradiol Type II  mental status
SpO2 stayed at 100% Baclofen
Results  Resting tachycardia
throughout entire shift.  O2 Penicillamine
Chest Xray:  Cool or vasoconstricted extremities
monitor placed on left ear lobe. NSAIDS Condition that develops from the heart's inability to fill with or eject blood efficiently, resulting in reduced cardiac output
Rationale Probable mild CHF  (Hinkle, 7/29/19)
Atorvastatin PATHO and increased fluid buildup in the heart and/or lungs Dx Testing
PMH PMH PMH Heart Usually due to a structural or functional disorder that impairs ventricular systolic or diastolic function vs pneumonia w/
BUN: 19 = w/in normal Failure  Types of heart failure include right-sided or left-sided, systolic or diastolic, and acute or chronic  effusions
Allergies
Altered Renal Tissue Perfusion r/t ESRD range but on the higher Classification of heart failure, as described by the New York Heart Association, is based on the relationship between
Note mentation status and review lab result such as BUN and creatinine Bedside Swallow Study
Intervention As Evidenced by BUN of 19, creatinine of 2.4, dialysis scheduled q3wk, and end. PMH symptoms and the effort necessary to produce them. Nursing DX
levels. (nurseslabs.com, n.d) anuria Creatinine: 2.4 = high Assessment PMH 73 yr old female. Admitted for May result from acute or chronic systolic or diastolic heart failure (Lippincott Advisor for Education, n.d.)
Respiratory developing AMS during
Failure dialysis Full Assessment: 
PMH Pt is laying semi-fowlers. Oriented to
person only. Emotion status is calm.
Orders PMH Code Pt makes eye contact but is unable to
Assessment
Nursing Dx PMH status Hyperlipidemia follow commands. Left and right
In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are Chief Fluid Volume Excess The patient will demonstrate balanced
PMH pupils are PERRLA. Unable to assess intake and output. by end of shift
Intervention Intervention impaired. Ventilatory failure mechanisms leading to acute respiratory failure PMH Complaint r/t medical diagnosis of HF and ESRD
include impaired function of the central nervous system (i.e., drug overdose, head grip strength, pt is unable to lift arms
PMH As Evidenced by severe edema on lower
trauma, infection, hemorrhage, and sleep apnea), neuromuscular dysfunction (i.e., on her own. No vision or hearing Goal not met, Pt didn't have any intake
End Stage extremities
Pt is on dialysis 3xs a week. A&O x 1 myasthenia gravis, Guillain–Barré syndrome, amyotrophic lateral sclerosis, and Lipids are insoluble in plasma, and circulating lipids are carried in lipoproteins. problems noted. Skin color is within Indication or output throughout my shift
Renal DNR
Pt has not eaten or drank anything spinal cord trauma), musculoskeletal dysfunction (i.e., chest trauma, The body has five major lipoproteins, each with a different function: normal limits for patient, dry , good
Disease AMS during HD elasticity noted. Other integumentary
throughout entire shift kyphoscoliosis, and malnutrition), and pulmonary dysfunction (i.e., COPD, asthma, Bacterial Chylomicrons are very large particles that carry dietary lipids.
Labs PATHO Very-low-density lipoproteins (VLDLs) carry endogenous triglycerides and, to a lesser degree, notes will be in the box for wound
Findings:  and cystic fibrosis). (Hinkle, 7/29/19) Pneumonia
cholesterol and cholesterol esters. care. Pt is immobile and no voluntary Intervention
Behavior changes Obesity
Assess patient emotional/psychological factors affecting the current Confusion Low-density lipoproteins (LDLs) carry cholesterol esters. movements noted. Oral cavity is dry
Monitor BP, ascertain patient’s usual range. (nurseslabs.com, n.d) GCS  Goal/Outcome
situation. (nurseslabs.com, n.d) Disorientation Hypertension Intermediate-density lipoproteins (IDL) carry cholesterol esters and triglycerides. and pink, no teeth noted. Irregular Intervention Intervention
Fall Risk apical pulse with atrial fibrillation.
Orders Inability to concentrate High-density lipoproteins (HDLs) carry cholesterol esters.
Weakness and fatigue Metabolism of lipoproteins depends on the liver and intestines. Tachycardia noted along with cold
Coarse, thinning hair PATHO Abnormal lipoprotein production or a lipoprotein receptor abnormality leads to overproduction extremities. Breathing pattern regular,
GCS Rating: 7
Dry, flaky skin or impaired removal of lipoproteins. uneven, and unlabored bilaterally on
PATHO Synthesis of chylomicrons or VLDLs or decreased metabolic breakdown leads to elevated 3 L of O2. 
Rationale Thin, brittle nails
As renal function declines, the end products of protein metabolism (normally excreted triglyceride levels. Monitor the patient’s vital signs. (Lippincott Administer prescribed medications; monitor their effect. Consult with the dietitian or nutritional services, as
Rationale Edema (feet, hands, sacrum) appropriate. (Lippincott Advisor for Education, n.d.)
Assessment in urine) accumulate in the blood. Uremia develops and adversely affects every system PATHO An underlying disorder leads to a disruption in lipoprotein levels. Advisor for Education, n.d.) (Lippincott Advisor for Education, n.d.)
Anorexia, nausea, and vomiting
Goals/Outcomes in the body. The greater the buildup of waste products, the more pronounced the Accelerated development of atherosclerosis occurs. (Lippincott Advisor for Education, n.d.)
Anemia
symptoms. PATHO
Loss of muscle strength Fat cells grow larger in response
The rate of decline in renal function and progression of ESKD is related to the
(Hinkle, 7/29/19) to dietary intake.
GFR may increase rennin and raise BP. (nurseslabs.com, n.d) underlying disorder, the urinary excretion of protein, and the presence of hypertension.
The disease tends to progress more rapidly in patients who excrete significant amounts When the cells can no longer Rationale Rationale
Stress or depression may be increasing the effect of an illness or Blood pressure is the product of cardiac output multiplied by peripheral resistance. Cardiac output is the product of
Rationale
of protein or have elevated blood pressure than in those without these conditions. expand, they multiply.
depression might be the result of being forced into inactivity. Pt is the heart rate multiplied by the stroke volume. Each time the heart contracts, pressure is transferred from the
(Hinkle, 7/29/19) With weight loss, the fat cells get
nonverbal, however based on facial expressions her mood would contraction of the heart muscle to the blood and then pressure is exerted by the blood as it flows through the blood
smaller but the number of fat cells Dx Testing
change throughout the day from complete confusion and anxious, to Medication vessels. Hypertension can result from increases in cardiac output, increases in peripheral resistance (constriction of
doesn't change. (Lippincott Labs This is to determine if the patient is able to swallow and
calm when i would stay in her room with her holding her Patient's vital signs fluctuates due to comorbidities. This is done to try and get some of the edema reduced in the
Fludrocortisone 0.1 mg po daily Advisor for Education, n.d.) the blood vessels), or both. Increases in cardiac output are often related to an expansion in vascular volume. the type of food that should be given to the patient to
hand.(nurseslabs.com, n.d) We want to monitor the patient's blood pressure body. The patient did not show signs of medication effect. No
Labs Although no precise cause can be identified for most cases of hypertension, it is understood that hypertension is a improved nutritional status.
K: 3.1 = Low and respiratory status for physical decline due to urinary output has been observed.
multifactorial condition. Because hypertension can be a sign, it is most likely to have many causes, just as fever has
Na: 138 = Norm For this disease fluid overload.
Head CT Scan:  many causes (Hinkle, 7/29/19)
Organism enters the upper airway and multiplies in the epithelium. process you would
It then spreads to the lungs via secretions or the blood. No acute intracranial
Wound Assessment abnormality and stable. want to do labs on: 
Patient will maintain "patient normal" blood pressure by end of shift A gel-like substance forms as microorganisms and phagocytic cells break down. HDL and LDL
This substance consolidates within the lower airway structure. Medication However, these labs
Assessment Medication
Goal not met: Inflammation occurs and involves the alveoli, alveolar ducts, and interstitial spaces were not in my patient's
Medication Review surrounding the alveolar walls. Wound Assessment
Patient's BP was really high in the morning, dropped throughout the chart.
day, then was high again by the end of shift With lobar pneumonia, inflammation starts in one area and may extend to one or more
lobes. In bronchopneumonia, it starts simultaneously in several areas, producing BPs and PR throughout Carvedilol 3.125 MG PO BID Clonidine 0.1 MG PO Q6H PRN
Assessment 0700/1100 Indication
patchy, diffuse consolidation. In atypical pneumonia, inflammation is confined to the shift:
alveolar ducts and interstitial spaces. (Lippincott Advisor for Education, n.d.) 0700: 146/73     121
Risk Factors
Causes Open wound at her left arm 0900: 91/55     119
Medication Review Medication Review
fistula. This would is also infected 0930: 91/55     118
and deep enough to require 1000: 67/30      126
Mineralocorticoid: Increases sodium resorption and potassium
packing. Dressing is clean, dry,     1100: 89/49       129    
and hydrogen secretion at the distal convoluted tubules of Stage III pressure wound Antihypertensive: Thought to stimulate alpha2 receptors
and intact. No bleeding or serous Assessment    1110: 120/47       64     Antihypertensive: Nonselective beta blocker with
nephrons. noted on sacrum. Skin break and inhibit the central vasomotor centers, decreasing
fluid leaking. MD orders to clean Chest Xray: w/ subcutaneous tissue alpha-blocking activity.
sympathetic outflow to the heart, kidneys, and peripheral
Nursing Considerations:  and change every 2 days. Probable mild CHF vs exposed, scant drainage, vasculature and lowering peripheral vascular resistance,
Drug is used with cortisone or hydrocortisone in adrenal pneumonia w/ wound edges attached, Nursing Considerations: 
BP, and HR.
insufficiency. Dx Test effusions undermining at edges, wound If drug must be stopped, do so gradually over 1 to 2
Alert: Monitor patient’s BP and electrolyte levels. If HTN occurs, base is moist and pink with weeks, if possible.
Assessment:  Nursing Considerations: 
notify prescriber and expect dosage to be decreased or an No Monitor patient with HF for worsened condition, renal
some green discharge along Patient is completely immobile Drug may be given to lower BP rapidly in some Major Risk Factors
antihypertensive given as necessary. pneumonia dysfunction, or fluid retention; diuretics may need to
edges. Infection of with a BMI high enough to hypertensive emergencies. Indicative for my Pt 
Monitor patient for indications that dosage adjustment is at this time be increased.
Acinetobacter noted in this indicate morbid obesity She is Monitor BP and pulse rate frequently. Dosage is usually
necessary, such as remission or exacerbation of the disease and wounds as well, Pressure Monitor patient with diabetes closely; drug may mask Advancing adult age
as risk of DVTs and PE r/t to her adjusted to patient’s BP and tolerance.
stress (surgery, infection, trauma). wound would be related to signs of hypoglycemia, or hyperglycemia may be Family history
comorbidities Older adults may be more sensitive to drug’s hypotensive
Weigh patient daily; notify prescriber about sudden weight gain. immobility, with severe worsened. Gender-related:
Medication effects than patients who are younger.
Unless contraindicated, give low-sodium diet that’s high in obesity, and slow healing Hypotension can occur. Observe patient for dizziness Women have greater risks at 65
Anemia Observe patient for tolerance to drug’s therapeutic effects,
potassium and protein. Potassium supplements may be needed. related to DM II. MD orders or light-headedness for 1 hour after giving each new years of age and later
which may require increased dosage.
Monitor patient for infection; drug may mask signs of infection. dressing change every day. dose. Reduce dose in patient with HR less than 55 Overweight/obesity
When stopping therapy in patients receiving both
Drug may cause adverse effects similar to those of beats/minute. Poor diet habits, particularly if it
clonidine and a beta blocker, gradually withdraw the beta
glucocorticoids. (Lippincott Advisor for Education, n.d.) Medication Labs  Monitor older adults carefully; drug levels are about
blocker several days before gradually stopping clonidine includes too much salt
Patho associated w/ ESRD 50% higher in older adults than in patients who are Sedentary lifestyle
to minimize adverse reactions.
Ca: 12.3 = High younger. (Lippincott Advisor for Education, n.d.) Stress
Don’t stop drug before surgery.
Brade Scale Assessment Indication of prolonged  (Lippincott Advisor for Education, n.d.)  Sleep apnea
bedrest Chronic kidney disease
Clindamycin 150 mg PO q8h
Heart disease (left ventricular
Hct: 27.3 = Low Anemia develops as a result of inadequate erythropoietin production, the Braden Scale Score: 10
hypertrophy, heart failure, angina,
Hgb: 8.3 = Low  shortened lifespan of RBCs, nutritional deficiencies, and the patient’s tendency to
myocardial infarction)
RBC: 3.06 = Low  bleed, particularly from the GI tract. Erythropoietin, a substance normally produced Labs  Indication
Labs 
RDW: 21.7 = High by the kidneys, stimulates bone marrow to produce RBCs. In ESKD, erythropoietin Medication Review Heparin: 2000 units IV daily
MCHC: 30.4 = Low production decreases and profound anemia results, producing fatigue, angina, and
MCV: 89.2 = Normal shortness of breath. (Hinkle, 7/29/19)

Antibiotic: Inhibits bacterial protein synthesis by binding to the 50S Medication Review
subunit of the ribosome. Labs

Nursing Consideration:
Nursing Dx  Anticoagulant: Accelerates formation of antithrombin III–thrombin complex and
IM injection may raise CK level in response to muscle irritation.
deactivates thrombin, preventing conversion of fibrinogen to fibrin.
Monitor renal, hepatic, and hematopoietic functions during prolonged
therapy. Observe patient for signs and symptoms of superinfection.
Nursing Considerations: 
Alert: Don’t give opioid antidiarrheals to treat drug-induced diarrhea; they PT: 15.5 = high
Monitor patients for hyperkalemia during therapy.
may prolong and worsen this condition. INR: 1.32 = high
Alert: Check order and vial carefully; heparin comes in various concentrations.
Boxed Warning: Diarrhea, colitis, and pseudomembranous colitis have Both PT and INR being
Draw blood for PTT 4 to 6 hours after subcut dose or after starting infusion.
developed up to 2 months after cessation of drug therapy. high is and indicative
Avoid IM injections of other drugs to prevent or minimize hematoma.
Drug doesn’t penetrate blood-brain barrier. (Lippincott Advisor for of prescribed
Monitor PTT regularly. Anticoagulation is present when PTT values are 11/2 to 2 times the
Education, n.d.) medication.
normal control values. Monitor platelet count regularly.  Regularly inspect patient for
bleeding gums, bruises on arms or legs, petechiae, nosebleeds, melena, tarry stools,
hematuria, and hematemesis. Monitor vital signs. Alert: To treat severe overdose, use
protamine sulfate, a heparin antagonist. Dosage is based on the dose of heparin, its route
Neutrophils: 79 = of administration, and the time since it was given. Abrupt withdrawal may cause increased
High coagulability; warfarin therapy usually overlaps heparin therapy for continuation of
WBC: 25.8 Labs prophylaxis or treatment. (Lippincott Advisor for Education, n.d.)
Indication of Infection

Impaired Skin Integrity r/t complete immobility

As Evidenced by: Stage III pressure wound on sacrum, infection wound on
lower left quadrant of abdomen, infected fistula wound on left AC.

Chief  Dx Risk Nursing

Patient Complaint Testing Factors Diagnosis
Intervention Intervention Intervention

no further skin breakdown throughout the day by end of

Observe wounds, noting characteristics of wound size, Assess the patient's skin, noting color, moisture, texture, and
Collaborate with a wound specialist, as shift
Medication Orders Intervention appearance, and drainage. (Lippincott Advisor for Education, temperature. Also observe for erythema, edema, and Goals/Outcomes
After assessment wounds, there was no further skin
PMH Pathology n.d.) appropriate. (Lippincott Advisor for Education, n.d.) tenderness. (Lippincott Advisor for Education, n.d.)
breakdown 

Rationale Rationale
Rationale

Allergies Code Medication Rationale

Results Spirituality
Status Review   Patient has severe edema related to HF and renal failure. It's
The wound specialist sees the wound under that dressings
important to assess the patients skin to make sure there isn't further
 Make sure if the wounds are bleeding or secreting every day. 2 of the patients dressings are scheduled for
skin break down on current pressure wounds and to prevent new
sanguineous fluid. We want to make sure the dressings stay daily changing and the other 2 are schedule for every other
pressure wounds occurring. She has several infections, it's
clean and dry to prevent further infection day changing. The wound care nurse is able to collaborate
important to assess current wounds for signs of inflammation and
with the RN on shift to report any changes to the wounds.
fever for further progression of infection.
Wound Scale Goals/
Assessment Labs
Assessment Assessment Outcomes