102719_Level 3#2

Weatherford College ADN Program Clinical Portfolio Level III, IV Student Name: Clinical Date:10-25-19 Assessment Include a complete head to toe assessment of the patient. History of Present Illness (HPI): Pt is 45 y/o Caucasian male admitted 10/24/19. Pt came into ER with HTN (191/85) and difficult to urinate for 2days. Pt has uncontrolled DM II (blood glucose 395). Stable vital signs ( BP 191/ 85) T- 36.7 C, R- 16 RA, P- 87 O2 sat-98% RA) Pt stated he was prescribed 9 different antihypertensive medication, and did not take any of them. Pt now admitted to Med Surg 3 for monitoring blood pressure. Plan is to discharge home 10/26/19. Subjective: Pt stated he did not take blood pressure medication for 3weeks. “Doctors have been playing with my blood pressure medication, every time I visited them, they changed my medication. They must not know what they are doing, that’s why I don’t take the medication.” Objective: N: AAOx3, pleasant affect, conversational HEENT: Facial features symmetrical, EOMS intact bilat., nares patent bilat., no septum deviation noted, nasal mucosa pink, no ear drainage bilat., oral mucosa pink, tongue protrudes midline, swallow reflex intact, no JVD noted, non-tender nodes upon palpation, trachea midline, carotid pulses present bilat., thyroid non-palpable. CV: S1 and S2 present, murmur, radial pulses present bilat. 2+, pedal pulses dimished bilat. Pitting Edema (+1), warm lower extremities on palpation bilat. capillary refill less than 3 seconds. Pulm: room air, unlabored respirations, deep inhalation, clear breath sounds upon auscultation x5 lobes. GI: bowel sounds present x4 quads, last BM reported 10/23/19 GU: continent, distended abdomen, painful on palpation over bladder area, urine as yellow, cloudy with foul smell. MS: full ROM upper extremities, muscle strength 5/5 upper extremities bilat without pain, full ROM lower extremities, muscle strength 5/5 bilat without pain. Revised Spring 2018-CB Patient Analysis

Weatherford College ADN Program Clinical Portfolio Level III, IV INTEG: no tenting noted, PIV access in R wrist, no redness and swelling. Warm on palpation on both feet. Dry and intact Antecedents Primary Problem With Definition PMH: HTN, DMII, peyronie’s disease, emphysematous cystitis, retinopathy, venous stasis of LE, MRSA positive RLE, OSA, obesity hypoventilation syndrome Primary Medical Diagnosis: Hypertention Risk Factors: Obesity(BMI : 45.4), Hx of smoking for 15 yrs, DM II, physical inactivity, stress, decreased GFR (41) High-sodium, high-saturated fat diet Primary Conceptual Problem: Perfusion: the flow of blood through arteries and capillaries delivering nutrients and oxygen to cell and removing cellular waste. Pathophysiology of Primary Medical Diagnosis Include a description of the physiological process that occurs in the disease to the cellular level. Hypertension: Blood pressure is the result of cardiac output multiplied by peripheral resistance. Each time the heart contracts, pressure is transferred from the heart muscle to the blood and then pressure is forced by the blood as it flows through the blood vessels. Increases in cardiac output and constriction of the blood vessels lead to expand vascular volume and it causes blood pressure elevated. (Hinkle, 2018) Complete Problem List Label the top three prioritized problems. Problem (S/S, Manifestations, Labs, psychosocial, etc) Related Concept HTN - elevated BP (191/85) - persistent elevated systolic BP 190-210 -murmur heart sound - High-sodium, high-saturated fat diet Perfusion DM II -uncontrolled blood glucose (316) -polydipsia -slow healing ulcer -retinopathy Metabolism Revised Spring 2018-CB

Weatherford College ADN Program Clinical Portfolio Level III, IV Prioritized Problem #1 and related concept Hypertension - Perfusion Attributes Include the data specific to the patient that is pertinent to the prioritized problem. Physical Assessment Lab/ Diagnostics Associated Medications -Elevated BP :191/85 -pitting +1 edema on lower extremities bilat. -diminished dorsal pedal bilat. -murmur sound on auscultation persistent elevated systolic BP 190-210 BUN – 35 (Elevated) Creatinine-1.9(Elevated) GFR-41 (Decreased) Chest X ray- Cardiomegaly EKG Lasix-Furosemide- 40mg P.O. daily Antecedents Specific to the prioritized problem PMH: HTN, DMII, peyronie’s disease, emphysematous cystitis, retinopathy, venous stasis of LE, MRSA positive RLE, OSA, obesity hypoventilation syndrome Risk Factors: Obesity(BMI : 45.4), Hx of smoking for 15 yrs, DM II, physical inactivity, stress, decreased GFR (41) High-sodium, high-saturated fat diet Goals Teamwork and Collaboration to Meet Goal Justify why this person should be included Short Term (for your shift): Pt’s systolic blood pressure will be lowered below 150 mmHg. Dietitian: they assist pt to eat heart healthy diet and educate pt to choose appropriate food for heart disease Long Term: Pt will maintain systolic blood pressure between 120 and 130 mmHg. Plan of Care Interventions Rationale with reference in APA Positive Outcomes Negative Outcomes Administer antihypertensive medication as ordered. Loop diuretic medication inhibit water and sodium reabsorption. Decreased fluid volume facilitate to lower blood pressure. (Hinkle, 2018) Pt,s blood pressure has been lowered. Pt’s blood pressure is not controlled. Potassium is below 3.5 mEq/L Pt is dehydrated. Assess blood pressure every 2 hour. Blood pressure medication cause a drop in blood pressure. Pt’s blood pressure has been controlled. Pt’s blood pressure has been elevated or decreased compared to Revised Spring 2018-CB Problem Number 1 Analysis

Weatherford College ADN Program Clinical Portfolio Level III, IV (medical surgical nursing, 10 th ed) base line. Educate pt about DASH diet. Studies suggest that diets high in fruits, vegetables, and low-fat dairy products can prevent the development of hypertension and lower elevated blood pressure (Hinkle, 2018) Pt understands DASH diet and pt knows what to choose for their meal. Pt is unable to choose low sodium and low fat diet. Educate pt regarding HTN complication. The excessive pressure on your artery walls caused by high blood pressure can damage your blood vessels, as well as organs in your body. The higher your blood pressure and the longer it goes uncontrolled, the greater the damage. (mayo clinic, 2018) Pt verbalizes understanding of HTN and its long term effects on target organ. Pt is unable to verbalizes understanding of HTN and its long term effects on target organ. Instruct pt to change position slowly. Instruct pt who are taking antihypertensives to change position slowly to be careful when getting out of bed and ambulating until medication’s effects are fully known. (medical surgical nursing, 10th ed) pt moves slowly when he is getting out of bed. Pt fell when he is getting of bed. Evaluation Was your goal met? Partially (lowerd BP- 171/ 79) What would you recommend to the next shift based on your evaluation? BP has been lowered (171/81) systolic blood pressure still need to be lower than 150. I would reinforce of pt education regarding importance of adhering to medical treatment. Revised Spring 2018-CB

Weatherford College ADN Program Clinical Portfolio Level III, IV If they get too high and stay high, it can cause damage or complications to the body over the course of many years. (American Diabetes Association, 2019) Educate pt regarding diabetic complication People with diabetes have a higher risk of developing infections. diabetes is a leading cause of cardiovascular disease, blindness, kidney failure, and lower limb amputation. (American Diabetes Association, 2019) Pt verbalizes understanding of DM II and its long term effects on target organ. Pt is unable to verbalizes understanding of DM II and its long term effects on target organ. Instruct pt about diabetic diet. Diabetic meal plan helps pt to control blood sugar , manage your weight and control heart disease risk factors, such as high blood pressure and high blood fats. (mayo clinic,2019) Pt understands diabetic diet and pt knows what to choose for their meal. Pt is unable to verbalize diabetic diet. Monitor s/sx of hypoglycemia. diabetic hypoglycemia can lead to seizures and loss of consciousness (Lippicott, 2017) Pt will have optimal blood glucose. Pt will have s/sx of hypoglycemia. Evaluation Was your goal met? Yes What would you recommend to the next shift based on your evaluation? For the next shift I would recommend to continue with the course of treatment and to closely monitor for s/sx of hypoglycemia. Revised Spring 2018-CB

Weatherford College ADN Program Clinical Portfolio Level III, IV Prioritized Problem #3 and related concept Discharge Instruction – Pt education Attributes Include the data specific to the patient that is pertinent to the prioritized problem. Physical Assessment Lab/ Diagnostics Associated Medications -refuse to take antihypertensive medication -refuse to modify dietary style to low sodium and low fat NA NA Antecedents Specific to the prioritized problem PMH: HTN, DMII, peyronie’s disease, emphysematous cystitis, retinopathy, venous stasis of LE, MRSA positive RLE, OSA, obesity hypoventilation syndrome Risk Factors: Misinterpretation of medical treatment No family support. Unable to drive due to retinopathy Goals Teamwork and Collaboration to Meet Goal Justify why this person should be included Short Term (for your shift):Pt will verbalize the willingness to take antihypertensives. Social Worker: They can assist pt to get finance resources. Long Term: Pt will maintain effective therapeutic regimen management ( maintain BP in normal range) Plan of Care Interventions Rationale with reference in APA Positive Outcomes Negative Outcomes Educate long term care for uncontrolled HTN High blood pressure can damage heart and brain. Controlling blood pressure to lower your risk for serious further complication. (CDC, 2014) Pt understands and verbalize willingness to manage BP. Pt’s BP remains elevated. Educate long term care for uncontrolled DMII Diabetes increases your risk for many serious health problems. With the correct treatment and Pt understands and verbalize willingness to modify dietary style and improve physical activity. Pt refuses to to modify dietary style and improve physical activity. Revised Spring 2018-CB Problem Number 3 Analysis

Weatherford College ADN Program Clinical Portfolio Level III, IV Medication Order (Medication, dose, route, frequency) Drug Classification Indication & Safe Dose Range Side Effects Nursing Considerations Patient Teaching Humalog (Lispro) SubQ Sliding scale 71-150 : 0 uint 151-200: 1 unit 201-250: 2units 251-300: 3units 301-350: 4units Greater 350: 6units/ call physician Antidiabetics To improve glycemic control in pt with diabetes mellitus II 4 unit @ 700 (BS: 316) 2units @ 1100 (BS: 249) Max Dose- patient dependent hypoglycemia, hypokalemia Severe: acute bronchospasm respiratory paralysis ventricular arrhythmias Monitor blood glucose levels. Make sure pt eats within 30mins. Monitor s/sx of hypoglycemia. frequent pulmonary assessment for dyspnea, wheezing , or persistent coughing. Educate patient s/sx of hypoglycemic episodes and report to health care providers if pt experience. Instruct patient to rotate injection sites and of the importance of avoiding lipodystrophy. Lantus SubQ daily 10 unit antidiabetic To improve glycemic control in pt with diabetes mellitus II Max Dose- patient dependent hypoglycemia, hypokalemia Severe: acute bronchospasm respiratory paralysis ventricular arrhythmias Monitor blood glucose levels. Monitor s/sx of hypoglycemia. Educate patient s/sx of hypoglycemic episodes and report to health care providers if pt experience. Instruct patient to rotate injection sites and of the importance of avoiding lipodystrophy Lasix- Furosemide- Antihypertensive, diuretic Hypertension- vertigo, headache orthostatic Monitor for signs of Inform patient they might Revised Spring 2018-CB Medication Analysis

Weatherford College ADN Program Clinical Portfolio Level III, IV 40mg P.O. daily Reference dose-40 mg P.O. b.i.d. Max Dose- 600 mg/day P.O. Order: 40 mg daily This is a safe dose for this pt. hypotension blurred vision, tinnitus, polyuria, nocturia Agranulocytosis, aplastic anemia, dehydration, hypokalemia, hypocalcemia, hypomagnesemia hypokalemia. Keep track of vital signs. Monitor I&O and electrolytes need a potassium or magnesium supplement Inform patient to report ringing in the ears, sore throat, and fever, could be toxicity. Enoxaparin (Lovenox) 60 mg SubQ daily Anticoagulant To prevent PE and DVT in pts. 60 mg SubQ once daily for 6-11 days. Max Dose in 24 hrs: 60 mg This is a safe dose for this pt. confusion, pain, edema, nausea and diarrhea, irritation at injection site hemorrhage, dyspnea, angioedema inspect pts. for signs of excessive bleeding such as bleeding gums, bruises, petechiae, nosebleeds, or tarry stools. Instruct the pt. and family to monitor for signs of excessive bleeding and notify their healthcare team immediately. Zyvox (Linezolid) 600mg PO Q12hr Antibiotics Positive MRSA Max Dose 600 mg PO BID This is a safe dose for this pt. Thrombophlebitis Neutropenia leukopenia thrombocytopenia pruritus Nausea and vomiting may be symptoms of lactic acidosis. Monitor patient for unexplained acidosis or low bicarbonate level monitor platelet count. Teach patient to avoid eating large quantities of tyramine- containing foods (aged cheeses) during therapy. Albumin 25% 25mg/100ml Plasma volume expanders Hypovolemia pulmonary edema from vascular Monitor vital signs carefully. Tell patient to report adverse Revised Spring 2018-CB

Weatherford College ADN Program Clinical Portfolio Level III, IV Hinkle, J.L., Cheever, K. H. (2018). Lippincott’s CoursePoint for Hinkle & Cheever: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing . Philadelphia, PA. Wolters Kluwer. Lippincott. (2017). Nursing 2018 Drug Handbook . Philadelphia, PA: LWW. Sommer, S., Johnson, J., Roberts, K., Redding, S. R., Churchill, L., Davila, L. ... Knippa, A. (2016). Medical Surgical Nursing (10th ed.) Retrieved from https://www.atitesting.com Mayo Clinic. (2019). Hypertension: Symptoms & Cause Retrieved from https://www.mayoclinic.org /diseases-conditions/high-blood-pressure/symptoms-causes/syc-20373410 American Diabetes Association. (2019). Diabetes Risk . Retrieved from https://www.diabetes.org/diabetes-risk Centers for Disease Control and Prevention. (2014). Controlling Blood Pressure. Retrieved from https://www.cdc.gov/bloodpressure/control.htm Revised Spring 2018-CB Reference Page

Weatherford College ADN Program Clinical Portfolio Level III, IV Age :45__ Sex :M Code Status : Full Primary Diagnosis : __HTN_____________________ _______________________________________ Associated Concept: Perfuson PMH: HTN, DMII, peyronie’s disease, emphysematous cystitis, retinopathy, venous stasis of LE, MRSA positive RLE, OSA, obesity hypoventilation syndrome _____________________________________ _________________________________________ Core Measures : AMI___ CHF___ Pneumonia___ SCIP___ VTE___ CHF___ Stroke___ Inpatient Psych___ Ped Asthma___ Tobacco___ Vaccines Pneumonia: Declined Flu Vaccine: Declined Social Hx: Marital Status______single_________________________________________ Past Employment__ Heavy Equipment Operator ______ Ethnicity: Caucasian_____________________________ Primary Language_: English___________________________________________ Religion: __Christian __________________________________________________ POA___N/A____________________________________________________ Allergies : Latex & Meds List of Allergies: _PCN_________ ___________________________________________________ ___________________________________________________ Isolation : Universal Activity : Up Adlib Language : English Metabolism Daily Weight : 299.5 lbs / 136___ kg Yesterday: ___299lbs / _136__ kg Height : __172.7CM__________ BMI : 45.4 Diet : / Regular / heart-healthy diet _____________ BSG : AC – HS Last HgBA1C : _9%________ BG Results : Lines and Tubes Line: Type _PIV_ Site__R___ Guage 20_Fluid/Rate_75ml/ hr_ Line: Type _____ Site_____ Guage____ Fluid/Rate______ Line: Type _____ Site_____ Guage____ Fluid/Rate______ Drain : Type ________ Site_____ Location______ Suction: ____ Drain : Type ________ Site_____ Location______ Suction: ____ Drain : Type ________ Site_____ Location______ Suction: ____ Other: ______________________________________________ 07 314 08 09 10 11 271 12 13 14 15 Lab Results (Indicate whether High or Low) Date WBC Neut. Lymph. Mon. Eos. Baso Hgb Hct Platelet 10/25 4.2 18.1 11.2 4.0 0.5 11 34.4 191 Total Intake previous shift: NA L L L Total Intake for your shift: NA PO Chemistry IV #1 Date Na K Ca Cl BUN Creat ALT AST Bili IV #2 10/24 135 4.5 7.9 10.1 35 1.9 20 15 0.3 IVPB L L H H Other Total output previous shift: Date BNP PT INR aPTT GFR Total Output for your shift: 41.0 Void L Drain Urine Tests : Cultures : urine culture Yellow Cloudy Drain Other: Diagnostics : Chest X ray, CT -Abdomen& Pevis Revised Spring 2018-CB Data Collection Tool

Weatherford College ADN Program Clinical Portfolio Level III, IV Vitals : Notes 0700 Took bedside shift report. Pt. is stable in bed(Semi- fowler) and remained sleeping during report. Admitting dx- HTN and difficult to urinate 0800 Pt. lying in bed (semi fowler’s) talking on the phone. Pt. denied pain Pt wantedto drink sprite. Distended lower abdomen. Administer Insulin Humalog & Lantus R upper arms. Pt stated he is hungry. Pt did not want to put on hospital gown. He wanted to lower the room temp. PIV(R)- no s/sx infection, dry& intact Vital - 191/85 P; 87 T:37 R16 O2:98% 0900 Passed morning meds. Administer Lasix (PO)and Lovox (Sub Q). Discussed pts. goals for today. Pt. wanted to urinate w/no pain 1000 Pt is sleeping in bed (semi-fowler) 1100 Vital - 171/85 P:86 T:37 R16 O2:98% Pt is talking on the phone. Pt stated he did not need anything at that moment. Blood Glucose: 271 1200 Pt ate grilled Chicken salad. He ate everything on plate. Pt. is stable and reports no pain at this time. Call light is within reach. 1300 Head to toe assessment performed. Vital - 172/78 P:88 T:36.7 R16 O2:96% 1400 Pt. is in bed watching TV (semi-fowler) Time BP Pulse T Resp SpO2 Pain 0800 191/ 85 87 37 16 98 0 1100 171/ 79 86 36.7 16 98 0 1300 172/ 78 88 36.7 16 96 0 Pain Assessment Pt. denies pain. Neurological AAOx3, pleasant affect, conversational Head, Eyes, Ears, Nose, Throat Facial features symmetrical, EOMS intact bilat., nares patent bilat., no septum deviation noted, nasal mucosa pink, no ear drainage bilat., oral mucosa pink, tongue protrudes midline, swallow reflex intact, no JVD noted, non-tender nodes upon palpation, trachea midline, carotid pulses present bilat., thyroid non-palpable Respiratory room air, unlabored respirations, deep inhalation, clear breath sounds upon auscultation. Cardiovascular S1 and S2 present, murmur, radial pulses present bilat. 2+, pedal pulses dimished bilat. Pitting Edema (+1), warm lower extremities on palpation bilat. capillary refill less than 3 seconds. Gastrointestinal bowel sounds present x4 quads, last BM reported 10/23/19 Renal / Urinary continent, distended abdomen, painful on palpation over bladder area, urine as yellow, cloudy with foul smell. Musculoskeletal MS: full ROM upper extremities, muscle strength 5/5 upper extremities bilat without pain, full ROM lower extremities, muscle strength 5/5 bilat without Revised Spring 2018-CB Collection Tool

Weatherford College ADN Program Clinical Portfolio Level III, IV pain. He denied pain. Pt urinated with no pain 200ml/cloudy and yellow Skin/Hair/Nails and Wounds No tenting noted, PIV access in R wrist, no redness and swelling. Warm on palpation on both feet. Dry and intact Revised Spring 2018-CB