DOMINICAN COLLEGE

DIVISION OF NURSING
NR 223
Student: Samantha Miller
Room #: 250

Date: 11/5/2014___
Patient's Initials: S.F.

RR: 18bpm

Temp: 97 degree F

Age: 93/ Female ___

O2 sat: 89%

BP: 110/60mm/Hg_

Current Diagnoses: Other and unspecified Hyperlipidemia, Depressive Disorder NEC,

Dementia CCE with Behavioral Disturbances, Cerebral Thrombosis with Infarct,
Essential Hypertension, Insomnia Unspecified, Delusional Disorder
Medical Diagnosis and Definition of Medical Diagnosis:
Failure to Thrive r/t depression
Definition: Subjective state in which an individual sees limited or no alternatives or
personal choices available and is unable to mobilize energy on own behalf
Activity Level: Willingness to thrive: 3= Sometimes demonstrated
Diet: Regular solids. Thin liquids with s/a by mouth. Regular
Current Treatments: (Define)
1. Pain assessment 3 times per day.
2. Weights: Monthly weights 1 time per day every 5th month during the day.
3. Alarm: Bed alarm in place. Check placement and function 3 times per day(day,
evening, night)
4. Alarm: Chair alarm in place.
5. Assess: Skin and foot evaluation 1 time every Monday evening.
6. Apply to sacral area topical 3 times per day during day, evening, night.

Laboratory and/or Diagnostic Tests:

Clinical Report:
Glucose: 105 HI
Test

Result

Glucose
Sodium
Potassium
Chloride
CO2
BUN

141
4.4
103
27
19

Abnormal Reference

Units

105 HI

mg/dL
mmo1/L
mmo1/L
mm01/L
mmo1/L
mg/dL

70-99
133-145
3.3-5.3
96-108
22-29
8-23

Previous
Result
115 HI
141
4.6
101
26
21

Date
06/02/2014
06/02/2014
06/02/2014
06/02/2014
06/02/2014
06/02/2014

Creatinine
e-GFR
e-GFR,
African
American
BUN/Creat
Ratio
Calcium

0.75
72
87

0.60-1.30
>60
>60

25.3

10.0-28.0

9.0

8.6-10.4

mg/dL
mL/ min
mL, min

mg/dL

0.86
62
75

06/02/2014
06/02/2014
06/02/2014

24.4

06/02/2014

9.3

06/02/2014

Current Medications
Name
(generic &
brand name)

Classification

Dosage

Laxative

PO 2 tablets, 5 mL of
granules or 10 to 15
mL of syrup, usually at
bedtime (max, 15 mL
twice daily of syrup).

Senna
(Sennosides)

Action
Directly acts on
intestinal mucosa by
altering water and
electrolyte secretion,
inducing peristalsis
and defecation.

PR 1 suppository at
bedtime; may repeat in
2h.

Fluticasone
propionate
(FLONASE)

Respiratory
inhalant
combination

Inhalation 1 inhalation
(250/50) twice daily
(morning and evening,
approximately 12 h
apart)

Side Effects and

Contraindications
Nausea, vomiting, or
other symptoms of
appendicitis; acute
surgical abdomen; fecal
impaction; intestinal
obstruction; undiagnosed
abdominal pain

Nursing Implications

Inhibits multiple cell

types (eg, mast cells)
and mediator
production or
secretion (eg,
histamine) involved
in the asthmatic
response.

Primary treatment of
status asthmatics or other
acute episodes of asthma
or COPD in which
intensive measures are
required; hypersensitivity
to any component of the
product; severe
hypersensitivity to milk
proteins (Advair Diskus).

Administer at bedtime on
empty stomach.
Shake liquid solution
before administering.
Dissolve granules before
administering.
Give oral dosages with
full glass of water or juice.
Administer suppository
with patient lying on left
side.
Prime aerosol inhalation
before using the first time
by releasing 4 test sprays
into the air away from
face, shaking canister well
for 5 sec before each
spray.
If inhaler has not been
used for more than 4 wk
or if it is dropped, prime
inhaler again by shaking
well before each spray and
releasing 2 test sprays
away from the face.

Simvastatin
(Zocor)

Antihyperlipide
mic

Usual dosage range: 5

to 40 mg orally once a
day in the evening.
Patients with CHD or
at high risk of CHD:
Initial dose: 10 to 20
mg orally once a day in
the evening started
simultaneously with
diet and exercise.
Patients at high risk for
a CHD event due to
existing CHD, diabetes,
peripheral vascular
disease, history of
stroke or other
cerebrovascular
disease:
Initial dose: 40 mg
orally once a day in the
evening

Inhibits HMG-CoA
reductase enzyme,
which reduces
cholesterol synthesis

Pregnancy (X),
breastfeeding,
hypersensitivity, active
hepatic disease
Side effects:
CNS: Headache,
cognitive impairment
GI: Nausea, constipation,
diarrhea, dyspepsia,
flatus, abdominal pain,
liver dysfunction,
pancreatitis,
hyperglycemia
INTEG: Rash, pruritus
MS: Muscle cramps,
myalgia, myositis,
myopathy
RESP: Upper respiratory
tract infection

Shake inhaler well for 5

sec before use.
Assessment
History: Allergy to
simvastatin, fungal
byproducts; impaired
hepatic function;
pregnancy; lactation
Physical: Orientation,
affect; liver evaluation,
abdominal examination;
lipid studies, liver
function tests
Interventions
Ensure that patient has
tried a cholesterollowering diet regimen for
36 mo before beginning
therapy.
Give in the evening;
highest rates of
cholesterol synthesis are
between midnight and 5
AM.
Advise patient that this
drug cannot be taken
during pregnancy; advise
patient to use barrier
contraceptives.
Arrange for regular

follow-up during longterm therapy. Consider

reducing dose if
cholesterol falls below
target.
Teaching points
Take drug in the evening.
Do not drink grapefruit
juice while using this
drug.
Have periodic blood tests.
This drug cannot be taken
during pregnancy; using
barrier contraceptives is
recommended.
You may experience these
side effects: Nausea (eat
frequent small meals);
headache, muscle and
joint aches and pains (may
lessen); sensitivity to light
(use a suncreen and wear
protective clothing).
Report severe GI upset,
changes in vision, unusual
bleeding or bruising, dark
urine or light-colored
stools, fever, muscle pain,
or soreness.

Oral
anesthetic
LOZENGES
(BenzocaineMenthol)

CLOPIDOGR
EL (Plavix)

Platelet
aggregation
inhibitor

Allow 1 lozenge (10-15

mg) to dissolve slowly
in mouth; may repeat
every 2 hours as
needed.

Recent MI, stroke,

peripheral arterial
disease, TIA:
Adult:
PO 75 mg/day
with/without aspirin.
Acute coronary
syndrome: PO loading
dose 300 mg then 75.

Ester local
anesthetic blocks
both the initiation
and conduction of
nerve impulses by
decreasing the
neuronal
membranes
permeability to
sodium ions, which
results in inhibition
of depolarization
with resultant
blockage of
conduction.
Inhibits ADPinduced platelet
aggregation

Numbness of the mouth

or throat.
Severe allergic reactions
(rash; hives; itching;
difficulty breathing;
tightness in the chest;
swelling of the mouth,
face, lips, or tongue).

Assessment (Pre-administration):
VS, monitor for dyspnea,
weakness, tachycardia.
Why hold or not give this med?
S/S of hypersensitivity
Evaluation:
Check after giving.
Improvement of throat irritation.

Hypersensitivity, active
bleeding
Side effects:
CNS: Headache,
dizziness, depression,
syncope, hypoesthesia,
neuralgia, confusion,
hallucinations
CV: Edema,
hypertension, chest pain
HEMA: Epistaxis,
purpura

Assessment & Drug Effects

Carefully monitor for and

immediately report S&S
of GI bleeding, especially
when coadministered with
NSAIDs, aspirin, heparin,
or warfarin.
Lab tests: Periodic platelet
count and lipid profile.
Evaluate patients with
unexplained fever or
infection for
myelotoxicity.

Patient & Family Education

Report promptly any

unusual bleeding (e.g.,
black, tarry stools).
Avoid chronic aspirin or
NSAID use unless
approved by physician.
Do not breast feed while
taking this drug.

Dominican College
Division of Nursing
Nursing Care Plan
Student: _Samantha Miller_________________________ Client's Initials: S.F.____________ Date: 11/5/2014_____________
ASSESSMENT

NURSING
DIAGNOSIS

GOALS &
OUTCOME
CRITERIA

Subjective Data:
1.
It feels like
a prison in here
2.
I dont like
it here
3.
I dont
want any friends

P: The patient is sad

and does not want
to participate in any
activities or have
any friends.

Goal:
1. Get patient not
to slouch so much
by having them be
more active.

Objective Data:
1. Slumps in her
wheelchair
2. Does not speak
unless spoken to
3. Does not want to
participate in any
activities
4. Seems to be in
pain at times.

E: This patient was

in the Holocaust and
is having problems
in her new
environment, saying
it feels like a
prison in here is
probably saying she
is having flashbacks
of the Holocaust
being here in the
nursing home. She
does not want to be
monitored all the
time, she wants to

NURSING ACTIONS

1. Teach
alternative
coping
strategies
such as
physical
activity.

RATIONALE

1. EBN: As the
number of
minutes of
exercise
increased,
hopelessness
decreased in
prison inmates
(Cashin, Potter,
& Butler, 2008).
EB: In college
students,
physical activity
each week was
associated with
decreased
feelings of
hopelessness
(Taliaferro,
Rienzo, & Pigg,

EVALUATION

be free.
S: The fact that she
slouches, does not
speak, and does not
participate in
activities shows that
she is depressed.

2008).
2. Patient will
verbalize
importance of
communicating
with others.

2. Educate
patient on
the
importance
of
communicat
ing with
others.

2. EBN: Accurate
information
allows the
redefining and
transforming of
hope (Duggleby
& Wright, 2005;
Duggleby,
Williams, &
Wright, 2009).
EB: Educational
interventions
may decrease
hopelessness
related to the
threat of breast
cancer in young
women (Fry &
Prentice-Dunn,
2006).

3. Patient will be
free of any pain
which will give
the patient the will
to be more active
and be in a good
mood.

3. Assess for
pain and
respond
with
appropriate
measures
for pain
relief.

3. EB: Pain that

interferes with
mood and
enjoyment in life
results in
feelings of
hopelessness for
clients with

Outcome Criteria:
Decision-Making,
Hope, Mood
Equilibrium,
Good Nutritional
Status
Has a presence of
Hope as
evidenced by the
following
indicators:
Expresses
expectation of a
positive time
spent in the
home/Expresses
faith/Expresses
will to participate.

advanced cancer
(Mystakidou et
al, 2007b).