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Julie B - 51 yr old Female from Moline - 212 lbs - 5'5 - (4 (Vitals…
Julie B - 51 yr old Female from Moline - 212 lbs - 5'5 -
2
background
medical history
carpal tunnel
firbomyalgia
T12 compression fracture
thyroid cancer
GERD
arthritis
diverticultis
barretts esophagus
depression
hypothyroidsm
comorbitities
diatbetes
hypertension
hyperlipidemia
COPD
coronary atery disease
obesity
no recent hospitalizations
1
admitted to ICU:
3/18/20
stopped taking BP med (losartan) 5 days ago because presctiption ran out
TIA symptoms
weakness of lower extremities, speech changes, numbness, & tingling in the face
diagnosis
: hypertensive crisis, transient ischemic attack
IV left forearm
input: 450 mL, output: 500 mL
transferred to 7 South 3/19/20 (In my care)
carb control diet, cardiac diabetic
allergic to sulfa antibitoics
full code, high fall risk
lives at home with daughter,husband
1 L of O2
1:1 transfer
AC & HS glucose checks
3
Medications
hospital
aspirin (salicylates)
atorvastatin (hmg coa reductase inhibitors)
carvedilol (beta blocker)
heparin (antithrombotics) (DVT ppx)
insulin aspart
insulin aspart/lispro
insulin detemir
levothyroxine (thyroid hormone)
losartan (angiotensin II receptor antagonists)
PRN meds
labetalol (beta blocker)
LORazepam (benzodiazepines)
traMADol (alalgesic)
protonix (pronton pump inhibitor(GI ppx)
potassium (electrolyte supplement)
hydroclorothiazide (diuretic)(HTN)
home
albuterol inhaler (bronchodilator)(COPD)
aspirin 81mg (NSAID)
insulin kwikpen (pancreatics) (diabetes), 60 units subQ
Catapres (central alpha agonists) (HTN)
hydroclorothiazide (diuretic)(HTN)
HUMALOG (pancreatics) (insulin)
levothyrozine (thyroid hormone)
losartan (angiotensin II receptor antagonists)
melatonin (sedative)
Prilosec (proton pump inhibitor)
Zofran (antiemetic)
traMADol (analgesic)
Ambien (sedative)
Colace (stool softener)
albuterol (adrenergic)
metoprolol (beta blocker)
Miralax (osmotic laxative)
Tylenol (analgesic)(arthritis pain)
5
Tests
CT angiography chest wo contrast 3/18/20
aorta: ascending aortic aneurysm 4 X 3.9 cm
heart: normal in size
lungs: mild bilateral atalectasis
no evidence of PE
CT angiography abdomen pelvis w & wo contrast 3/18/20
no abdominal aortic aneurysm
diverticulosis w mild circumferential wall thickening in sigmoid colon
CT head wo contrast 3/18/20
no hemorrhage or mass
no evidence of acute infarction
EKG
no acute ischemic changes
4
Labs
potassium
2.7 3/19
2.7 3/18
glucose
246 3/18/20
150-200 3/19/20
WBC
12.94 3/18/20
12.69 3/19/20
CPK TOTAL
583 (H) 3/18/20 - muscle damage from hypertensive crisis?
glucose urinary
500 3/18/2020 (diabetes)
BUN 23 3/19 (^, possible kidney injury) chronic diabetes
troponins negative (<0.06) indicating no heart attack
Vitals
BP - range 145/90-165/95
92-95% o2 on 1L
heart rate: range 70-85
maintained orientation x4
neuro checks: sluggish pupils at beginning of shift, PERLA by the end of shift
neuro: push/pull bilatterally strong
lungs clear
pulses palpable bilaterally
8
interventions
+ rationales
assessments
deterioration of condition: continued paralysis, numbness, tingling, changes with speech
assess patient’s baseline by talking with the patient family (brother & husband present) to ascertain information
assess trends neuro status by monitoring changes in LOC, speech. PERLA, push/pull, and improvenemtns in tingling/ weakness
assess respiratory status
assess changes in blood pressure, heart rate, and rhythm, oxygen saturation
assess patient's bed alarm is set & call right is always within reach
assess INR for heparin at therpeutic level ( 2.2 )
assess BP prior to giving meds to ensure not hypotensive
assess I &O input: 450 mL, output: 500 mL. No bowel movements - 100% meals eaten
assess gait
assess lab values
interventions
maintain bedrest & provide a relaxing environement
(decreases intercranial pressure) effective - patient remained calm and was able to sleep in quiet room w lights off
administer miralax & colace stool softeners to prevent straining
(bearing down ^ intercranial pressure) patient was not able to have a BM during my shift. would be effective had she gone
maintain oxygenation status to keep pulse ox at least about 90%
(reduces hypoxemia)
administer heparin
(prevent clot formation while in hospital)
administer antihypertensives
(control damage to blood vessels)
ensure call light and personal items is within reach with every interaction
(patient has to be able to reach her call light so she is able to call for assistance when she needs it)
ensure bed alarm is set and bed is in lowest setting
(so we know when she gets up and can come help)
use gait belt and walker when assisting patient to bathroom
(ensures stablitiy)
maintain environemnt free of clutter
(prevent tripping on something)
ensure patient is wearing "fall risk" wristband all times
(communicates to others patient is at risk for falling)
slippers or nonskid socks when walking
(provides more traction)
monitor heart rate & rhymth (patient in normal SR during my shift, heart rate WNL)
(hypokalemia can cause abnormalities in heart rate &conduction)
adminster presceibed PO potassium
(K level is at 2.7 - WNL is 3.5-5)
assess for signs of metabolic alkalosis such as tachycardia, hypoventilation, tetany, mental status changes
(associated with hypokalemia)
educate proper use of laxatives
(colace & miralax coule be responsbile for low K
encourage high potassium foods such as oranages, bananas, tomatoes, and dried fruit
(to increase serum K)
evaluate barriers to taking BP meds daily
(helps to identfiy and elimante obstacles)
educate the complications that can result from discontinuation of BP meds
(more likely to adhere when knowing the risks)
involve patient's family (brother & husband) in plan of care.very involved
(someone else to hold patient accountable)
encourage patient to take her own BP at home
(provides tangible results to indicate Losartan works to lower BP)
assess for causes of ineffective coping (patient's son passed away a year ago)
(helps determine what else is going on in patient's life)
help patient set realistic goals such as walking every day, eating well & taking her BP med
(helps patient feel more in control)
allow time and offereing self for the chance for the patient to express herself emotionally
(helps comfort patient by showing her I can and she can express herself without judgement)
encourage the patient to recognize her strengths (such as being an involved mother to her daughter)
(helps highlight positive attributes)
provide touch therapy by putting hand on shoulder as patient is expressing fears
(provides comfort someone is listening)
provide information
(patient is best equipped to make decisions for plan of care)
7
Nursing Diagnoses --> interventions
6
Pathophysiology:
transient ischemic attack
+ comorbidities
loss of blood supply to the brain causes loss of function
flow of blood is interrupted by clot or occlusion CT of head showed no evidence of acute infarction (temporary - not stroke )(TIA)
an ischemic attack can also be result of rupture of vessel. CT of head showed no hemorrhage
brain tissue can be damaged due to lack of oxygen. malfunction due to lack of O2 ~3min
depending on where in brain TIA occurs will determine symptoms
middle cerebral artery : symptoms speech, brocas area.
risk factor:
atherosclerosis: blood has hard time getting to brain cholesterol in artery.patient has HX of hyperlipedmia, coronary artery disease
TIA is temporary loss of blood flow to brain therefore no permanent damage, resolves on its own within 24 hr
if it was a stroke, brain tissue would die off - TIA risk factor for impending stroke
age: risk factor. patient is only 51 (young) (comorbidies in check)
risk factor: HTN. patient has long history of HTN
HTN - blood cells move faster & bump into walls of vessels - high pressure causes thickened walls
HTN - pressure can cause ballooning out of vessel (aneurysm) patient's CT of chest revealed ascending aoritc aneurysm
patient has obesity with ^ HTN
patient is diabetic which causes changes in the blood vessels and is another risk factor
10
teaching
cant just stop taking BP meds (Losartan) importance of controlling BP to stop growth of aortic aneurysm & prevention of stroke
TIA could be sign of impending stroke
signs/symptoms of hypertensive crisis such as chest pain & shortness of breath = seek medical treatment
continual checks of blood glucose and insulin administration to prevent hyperglycemia and damage to vessels
s/s stroke:sudden weakness, numbness, confusion, vision changes could be a sign and seek medical treatment ASAP
educate need watch diet & get exercise to help lower weight and control BP
diet: cut back on salt - retains water , HTN
emphasize importance of not smoking
9
discharge planning
/explain solutions
meticulous control of blood pressure (including new presctipion)
dietitan consultation to help control weight, BP, & diabetes (low salt, sugar, fat)
follow up appointment with primary care physician
PT/OT referral to address weakness & tingling in face and lower extremities
make sure drugs are going to a pharmacy that is convenitent for patient and she will be able to obtain
11
how will the nursing plan of care be implemented? :check:
patient & family involvment - family very close help look after each other
patient self-regulating- communicating if something doesn't feel "right"
delegation to techs to check blood sugar, vitals
nursing focused assessments (neuro & cardiovascular)
Pathophysiology
:
ascending aortic aneurysm
- relate comorbidities
for this patient, she has an
ascending aortic aneurysm
= is a widening or bugling of the aorta just above her heart
it originates in the left ventricle of the heart and extends down into the lower extremities
it is the largest artery in the body
aneurysm can happen in any artery of the body, aorta most common
bulge is 1.5 x normal diamter normal 2.7 cm, patient's is (4 x 3.9 cm)
weakness of the wall develops from chronic high BP in this patient's case
possibility of rupture - hemorrhage, or bleeding out, is possible
possibility of clot formation
symptoms
can happen as a result of build-up of fat (patient has hx of hyperlidemia)
risk factors
: smoking, HTN, hyperlipidemia, COPD, age (due to calcification), genetics (patient's mom also had same aneurysm)