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Our patient is an 88 y/o Female :<3:, Lab Draw :lock:, Chief Complaint …

- - - - Patient is taking this drug to prevent stress ulcers while hospitalized
        
        Nursing Considerations :pen:
        
        Pharmacist to renally dose if CrCl is less than 50 mL/min or on CRRT (from patient’s MAR)
        
        Lab Draw :lock:
        
        Patient’s CrCl is 30.8 mL/minute
        
        Nursing Implications :silhouettes:
        
        1 more item...
    - - Assessment :pencil2:
        
        0800 10/24/2020 Auscultated lungs, bases and apexes, anteriorly, laterally, and posteriorly. Respirations shallow, even, and unlabored. Free of adventitious breath sounds. Respiration rate of 16 bpm. O2 saturation by pulse oximetry at 100% on room air. Suggested incentive spirometry to prevent pneumonia, patient declines.
        
        Incentive Spirometry :recycle:
        
        1430 10/24/2020 Encouraged patient to use incentive spirometer, patient agrees after education. Coached patient to perform 10 deep inspirations, patient completed 10 inspirations with a peak achievement of 400 mls.
- - - - Yellow nonskid socks bilaterally applied to feet 10/24/2020 :check:
  - - - Patient lunch tray arrives. Patient eats 50% of tray. Prepared water with nectar thickener and served to patient. Opened containers for patient and provided spoon. Supervised patient while eating and drinking, prompted patient to chew slowly and observed esophageal movement indicative of appropriate swallowing. Cleaned patient’s face, clothes, and table after meal.
  - - - 1200 on 10/24/2020 Helped patient transfer from bed to bedside chair using gait belt for support. 2-person assist. Patient dangled legs momentarily before full transfer/pivot. Patient moaned in pain, stabilized patient on chair. Organized patient’s table and positioned legs and feet under table comfortably. Unfastened gait belt. Patient stable and secure on chair. Call bell left in patient’s hand, told patient to call if needed.
- - - - Established B/V AICD
        
        Assessment :pencil2: :<3:
        
        0800 10/24/2020 Noted patient’s pacemaker device, auscultated heart. Heartbeat soft/quiet, regular rate and rhythm.
    - - Dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis, aplastic anemia, agranulocytosis. (Nursing Drug Handbook, 2019)
        
        Patient response to Medication :<3:
        
        Patient is hypokalemic. Furosemide has depleted the patient's potassium, interventions are found below
      - Preventative Med Order :pen:
        
        Magnesium oxide (Mag-Ox) 400 mg PO daily
        
        Therapeutic use for our patient :question:
        
        Patient is taking this medication to prevent hypomagnesemia due to depletion by loop diuretic usage
        
        Nursing Considerations :silhouettes:
        
        Use cautiously in any degree of renal insufficiency, may require decreased dosage due to age related decrease in renal function. (Nursing Drug Handbook, 2019)
        
        Lab Draw :lock:
        
        Patient's Creatinine on 10/23/2020 is 0.72, WNL (Key, 2018)
        
        Patient's BUN level on 10/23/2020 is 10, WNL (Key, 2018)
    - - Patient takes this drug to slow the progression of heart failure
      - Nursing Consideration :silhouettes:
        
        Hold if SBP <100 mmHg, DBP <50 bpm, or HR <50 bpm, or patient is on pressor or inotrope. (From patient’s MAR)
    - - Sacubitril-Valsartan (Entresto) 24-26 mg PO BID
        
        Patient is taking this drug to prevent cardiovascular death related to CHF
        
        Nursing Considerations :silhouettes:
        
        Hold if SBP <100 mmHg, DBP <50 mmHg, or patient is on pressor. Notify prescriber to consider holding medication or reduce dose for a reduction of eGFR of 25% or greater. Do not crush this dosage form. (From patient’s MAR)
        
        Lab Draw :lock:
        
        Patient's GFR is 85, within normal limits due to age related decline (Key, 2018)
    - - Hematocrit on 10/23/2020 is 25.4, which is low
        
        Nursing Implications :silhouettes:
        
        Renal vasoconstriction often accompanies CHF and can cause
        long-standing renal ischemia. (Silverberg et al., 2004)
        
        This reduces the amount of
        erythropoietin produced in the kidney and leads to anemia. (Silverberg et al., 2004)
      - Hemoglobin level on 10/23/2020 is 8.2, which is low, same implications as hematocrit
    - - Nursing Diagnosis #1 :star:
        
        Decreased cardiac output related to altered afterload/systemic vascular resistance as evidenced by abnormal ECG (Doenges, Moorhouse, Murr, 2019)
        
        Patient will display vital signs within acceptable limits, dysrhythmias absent or controlled, and no symptoms of failure, for example, hemodynamic parameters within acceptable limits and urinary output adequate within 48 hours. (Doenges, Moorhouse, Murr, 2019)
        
        Nursing Intervention #1 :check:
        
        1.) Auscultate apical pulse; assess heart rate, rhythm, and document dysrhythmia if telemetry available. Rationale: Tachycardia is usually present, even at rest, to compensate for decreased ventricular contractility. Premature atrial contractions (PACs), paroxysmal atrial tachycardia (PAT), PVCs, multifocal atrial tachycardia (MAT), and AF are common dysrhythmias associated with HF, although others may also occur. (Doenges, Moorhouse, Murr, 2019)
        
        Nursing Intervention #2 :check:
        
        2.) Inspect skin for pallor and cyanosis. Rationale: Pallor is indicative of diminished peripheral perfusion secondary to inadequate cardiac output, vasoconstriction, and anemia. Cyanosis may develop in refractory HF. Dependent areas are often blue or mottled as venous congestion increases. (Doenges, Moorhouse, Murr, 2019)
        
        Nursing Intervention #3 :check:
        
        3.) Administer medications, as indicated, for example: Rationale: A variety of medications (usually a combination of a diuretic, an ACEI, or ARB and beta blocker) may be used to increase stroke volume, improve contractility, and reduce congestion. Note: New first line drugs that have recently been approved for treatment of heart failure include sacubitril/valsartan (Entresto) and ivabradine. These drugs are given to improve outcomes in certain types of heart failure associated with low ventricular output or to patients who are unable to respond well to beta blockers. (Doenges, Moorhouse, Murr, 2019)
  - - - Colectomy
        
        Patient prescribed multivitamin, (Theragran) 1 tablet PO daily which can help her absorb more vitamins after colectomy to prevent malnutrition
  - - - Assessment :pencil2:
        
        0800 10/24/2020 Patient’s left eye not reactive to light, sluggish to accommodate. Right eye reactive to light, rapid accommodation.
        
        Potential Sequelae of Macular Degeneration :checkered_flag:
        
        1430 10/24/2020 Patient calls and requests help, tray spilled, and tea glass spilled. Dried patient’s lap, tray, table, floor. Dried all surfaces, removed empty glass from room. Patient likely could not see well enough to coordinate herself to grab what she needed from her table. Stabilized patient at bedside in chair. Patient states she is “getting tired of living. It’s just too hard.” Listened to patient, provided emotional support.
        
        Intervention :!:
        
        Patient could benefit from palliative care with a personal assistant who helps her eat, reach things, dress, bathe, and perform ADLs. This would prevent accidents, help the patient get consistent nutrition, and potentially improve QoL.
        
        1 more item...
- - - - Lidocaine(Lidoderm) patch 5% transdermal q 24 hrs
        
        Remove old patch before application of new patch, check for skin irritation. (From patient’s MAR)
        
        Implementation :check:
        
        0800 10/24/2020 Patient complains of constant pain radiating in lower back, with an “aching” quality, rated as 6/10. Prepared back, applied lidocaine patch, labeled with initials, time, and date.
        
        0830 10/24/2020 Asked patient if back pain relieved, patient reported “some” relief.
        Unrelieved pain rated as 4/10, acceptable to patient.
    - - Patient had exploratory laparotomy performed on 10/8/2020, mechanical ventilation required. Patient extubated on 10/9/2020
        
        Assessment :pen:
        
        3-inch right upper quadrant incision 1 inch superior and lateral to umbilicus, edges approximated, skin bunching, free of erythema and edema
        
        0800 10/24/2020 Assessed patient’s abdominal incision, sutures clean, dry, well approximated. Skin bunching present, free of exudate, erythema, and edema. Abdomen soft, nondistended. Auscultated all 4 quadrants, active bowel sounds in each.
        
        Bedside Swallow test revealed profound oropharyngeal dysphagia on 10/9/2020 after extubation
        
        Impaired swallowing related to profound dysphagia as evidenced by inability to pass bedside swallow test on 10/9/2020. (Doenges, Moorhouse, Murr, 2019)
        
        Goal :tada:
        
        Patient will demonstrate feeding methods appropriate to individual situation, with aspiration prevented within 4 hours. (Doenges, Moorhouse, Murr, 2019)
        
        1.) Have suction equipment available at bedside/in the dining area, especially during early feeding efforts. Rationale: Timely intervention may prevent or limit effects of aspiration. (Doenges, Moorhouse, Murr, 2019)
        
        Nursing Intervention #2 :check:
        
        2.) Assist patient with head control or support, and position based on specific dysfunction. Rationale: Counteracts hyperextension, aiding in prevention of aspiration and enhancing the ability to swallow. Optimal positioning can facilitate intake and reduce risk of aspiration-head back for decreased posterior propulsion of tongue, head turned to the weak side for unilateral pharyngeal paralysis. (Doenges, Moorhouse, Murr, 2019)
        
        Nursing Intervention #3 :check:
        
        3.) Feed slowly, allowing 30 to 45 minutes for meals. Rationale: Feeling rushed can increase stress and level of frustration, may increase risk of aspiration, and may result in patient’s terminating meal early.
        (Doenges, Moorhouse, Murr, 2019)
        
        Priority Patient Teaching :silhouettes: :checkered_flag:
        
        Patient should be taught continued aspiration prevention measures such as sitting in a 90° angle while eating and drinking and continued thickening of all liquids, with chopped diet after discharge. Patient is a retired widow who lives in an assisted living facility where nurses and staff will be notified of the patient’s plan of care upon discharge to continue aspiration precautions until the patient passes a bedside swallow test.
        
        Patient response :check:
        
        1 more item...
        
        WBC on 10/23/2020 at 5.8. WNL, suggestive of absence of infection after surgery
        
        Oral temperature on 10/24/2020 at 0740 is 98.1 F, which suggests absence of fever
    - - Vitals :<3:
        
        BP at 0740 on 10/24/2020 is 114/75, Right arm, lying. Pulse in right radial is 73 bpm
        
        Serial BP and Pulse :<3:
        
        BP at 1030 on 10/24/2020 is 142/74 Right arm, lying. Pulse in right radial is 69 bpm
        
        BP at 1320 on 10/24/2020 is 150/71 in right arm, sitting. Pulse is 74 bpm, right radial.
        
        :<3:Serial BP and Pulse
        
        1 more item...
      - Carvedilol (Coreg) 12.5 mg PO BID
        
        Hold if SBP <100 mmHg, DBP <50 bpm, or HR <50 bpm, or patient is on pressor or inotrope. (From patient’s MAR
    - - Speech therapy ordered 5 days a week for 45 minutes per day for 10 days
        
        Patient's speech clear on 10/24/2020. Patient able to express feelings and desires throughout shift
    - - Potassium lab on 10/21/2020 showed a 3.0 potassium level
        
        Subsequent lab draw :lock:
        
        Potassium level drawn on 10/23/2020 was 3.2, trending upward but still low
        
        Patient is prescribed potassium supplement
        
        Med Order :pen:
        
        Potassium bicarbonate (K-Lyte) disintegrating tablet 25 mEq PO BID
        
        Nursing Considerations :silhouettes:
        
        Do NOT crush or chew to effervescent tablet. Dissolve 1 effervescent tablet in 3-4 ounces of cold water or juice and drink slowly. (From patient’s MAR)
        
        Patient has been eating potassium-rich foods
        (bananas, potatoes)
        to raise potassium level
        
        Lab Draw :lock:
        
        Blood Glucose level at 1100 on 10/24/2020 was at 99. Patient had eaten a banana before this glucose result. This level is appropriate for the timing of the test. (Key, 2018)
      - Patient asks what foods contain potassium to supplement diet due to hypokalemia. Educated patient of potassium-rich foods available, such as pinto beans, bananas, leafy greens, potatoes, oranges, and prunes.
    - - Precautionary order :forbidden:
        
        No B/P or sticks in left arm due to blood clot/DVT in left upper extremity :check:
        
        :forbidden:
        
        IV discontinued on 10/23/2020
      - DOPPLER ordered for suspected DVT
        
        Blood clot/DVT confirmed by radiology. Superficial blood clot in distal cephalic vein reported
        
        Rivaroxaban (Xarelto) 15 mg PO daily with dinner
        
        Nursing Considerations :silhouettes:
        
        Give this drug with food. (From patient’s MAR)
        
        Nursing Considerations :silhouettes:
        
        Contraindicated in severe renal impairment (CCr <30 ml/min) (Key, 2018)
        
        Lab Draw :lock:
        
        1 more item...
        
        PT level drawn on 10/23/2020 is 14.2, which is high. Patient prescribed Rivaroxaban
        
        Nursing Diagnosis #2 :star:
        
        Ineffective peripheral tissue perfusion related to immobility as evidenced by DOPPLER results visualizing superficial blood clot in distal cephalic vein. (Doenges, Moorhouse, Murr, 2019)
        
        Goal :tada:
        
        Patient will demonstrate improved perfusion as evidenced by peripheral pulses present, equal skin color, and temperature normal and absence of edema within 36 hours.
        (Doenges, Moorhouse, Murr, 2019)
        
        1.) Assess degree and characteristics of discomfort and pain, using standardized pain checklist. Rationale: Degree of pain is directly related to extent of circulatory deficit, inflammatory process, degree of tissue ischemia, and extent of edema associated with thrombus development. Changes in characteristics of pain may indicate development of complications. (Doenges, Moorhouse, Murr, 2019)
        
        2.) Administer pharmacological measures, as indicated: such as Factor Xa inhibitors, e.g. rivaroxaban (Xarelto). Rationale: These drugs have been approved for treating DVT and PE and for prevention of recurrences. Benefits of these agents include no need for heparin bridging, and drugs can be given in fixed doses without routine coagulation monitoring. (Doenges, Moorhouse, Murr, 2019)
        
        3.) Initiate active or passive exercises while in bed or chair; for example, flex, extend, and rotate feet periodically. Assist with ambulation as needed as soon as patient is out of bed. Rationale: These measures are designed to increase venous return from lower extremities and reduce venous return.
        (Doenges, Moorhouse, Murr, 2019)
        
        Assessed patient’s upper left arm, warm, dry, slightly edematous and erythematous, did not massage. Left grip slightly weaker than right.
- - - - The patient’s diet is NDD3 chopped, which made it easier for the patient to swallow the food, but her trays are only being 50% eaten, which is not ideal. Having an assistant help feed the patient would likely increase the nutrients in her diet.
- - - - Patient lives in her own room in an assisted living facility
        
        1230 10/24/2020 Patient mentions pet cat and points to photograph in frame on table. Patient states she call her "baby." :smiley:
        
        Holistic Considerations :checkered_flag:
        
        Interacting with animals has been shown to decrease levels of cortisol (a stress-related hormone) and lower blood pressure. Other studies have found that animals can reduce loneliness, increase feelings of social support, and boost your mood. (The power of pets, 2020)
    - - DNR, Patient has ACP doucuments