Clinical Preparation & Journal Form
Student Name:wolieDate: 10/24/2011
1. Biographical Data: DOB: 09/25/1959, Female, 61 y.o.a.
Age & Sex: 61 years and female
Culture and Religion: Christian
Living Arrangements: nursing home
People in Home (number and relationship): 1 roommate
Reason for hospitalization: MRSA isolation, Post-op or left knee replacement
Past Health History (other hospitalizations & surgeries): Right knee replacement (2010). Hysterectomy, Cholecystectomy
Date of admission: 10/12/2011
Admitting Diagnosis: Macular degeneration, COPD, Asthma, GERD, Rheumatoid arthritis, Hypertension
Anticipated Nursing Plan of Care: maintain airway patency,enhance nutritional intake, relieve and control painprevent or minimize development of myocardial complication.
Frequency of Vital Signs: once dailyBlood sugar:normal
Activity: activity is as tolerated by pt.
Expected Nursing Care: Nursing care is to ensure pt pain level is as low as possible. Help pt get back to her normal life.
Anatomy, Physiology and Pathophysiology related to patients admitting diagnosis: patient’s legs were swollen and edema also noted around the legs because of the surgry, patient also has impaired airway clearanceas a result of asthma and copd.
General Appearance: the pt. is clean and well groomed had a shower this morning. Hair is free of dirt, lumps or masses. Hair looks health, facial features are symmetrical, and mouth is clean and free of any odor. pt able to perform adl with minimal assistance. skin around arm, leg and abdomen is clean, free of bruises, bumps or cuts.
Vital Signs: 134/77, temp=98.1, p= 70, and respiration = 20.
Comfort: the pt. states that she was comfortable as pain was properly managed by the health care team.
Communication: alert and clear
Cardiovascular: the pt has some form of hypertension. The blood pressure is a little high, but in all the vital sign this morning is normal.
Respiratory: the pt has clear and strong breath sounds and also normal on auscultation. On percussions I could hear resonance.
Genitourinary: not done
Gastrointestinal: on inspection the abdomen is symmetrical, with no abnormal swelling, no bruises. On auscultation bowel sounds present on all 4 quadrants. On percussion tympany was heard on all quadrant.
Skin/Wound. The surgical wound area looks clean and dry, with the sterile strips in place. Edemaof about 2+ present at the ankle and around leg.
Neurological: I checked her reflexes they were normal.
Musculoskeletal: physical therapy did ROM as tolerated by the pt.
Activity: activity tolerance was encouraging.
Access Devices: none
Equipment: wheel chair, ice pack. And other physical therapy equipment.
Abnormal Lab and/or X-ray results/Significance to diagnosis: a lab test was done to check for MRSA and was negative for the 2nd time.
5. Medication Sheet.
1. Name(s) of Medication: Prinivil / lisinopril
Pharmacological Action: blocks the conversion of angiotensin 1to the vasoconstrictor angiotensin 11
Use (for your patient): hypertension
Route and Dosage: PO. 20mg once daily can be increased up to 20- 40
Is this a safe dosage? yes
Is this dose within recommended range? yes
Contraindications and Precautions: contraindicated in hypersensitivity, history of angioedema with previous use of ACEinhibitors, can cause death to fetus, use cautiously in renal impairment, hepatic impairment.
Potential Adverse Side Effects: dizziness, drowsiness, fatigue, headache, insomnia, vertigo, weakness. edema
Side effects seen with your patient: edema, fatigue, headache.
Applicable lab values:
Nursing Implications: monitor blood pressure and pulse frequently, assess for signs of angioedema, mornitor weight, mornitor BUN, creatinine.
2. Name(s) of Medication: enoxaparin / Lovenox
Pharmacological Action: potentitate the inhibitory effect of antithrombin on factot Xa and thrombin.
Use (for your patient): to prevent venous thromboembolism.
Route and Dosage: IV subcut. 30mg
Is this a safe dosage? yes
Is this dose within recommended range? yes
Contraindications and Precautions: hypersensitivity to specific agents or pork product, some product containing sulfites or benzyl alcohol. Use cautiously in severe liver or kidney disease.
Potential Adverse Side Effects: dizziness, headache, insomnia, edema, nausea, vomiting, urinary retention, bleeding.
Side effects seen with your patient: edema
Applicable lab values: none
Nursing Implications: assess for signs of bleeding and hemorrhage, evidence of additional or increased thrombosis.
List of 3 nursing diagnosis for your patient based on assessment findings:
1.risk for decreased cardiac output
2.Acute pain related to disruption of skin, tissue, and muscle integrity, evidence by report of pain.
3.impaired gas exchange r/t altered oxygen supply.
Reflections on the week:
This week felt better than the 1st week as things became a bit clearer. I stared this day in the dining, helping the patients with their meal they seem happy that we were there to help. We fed some and passed trays to those who could feed themselves. What I enjoyed most here was the happiness in the faces of the patients when we brought them their food. After the dining time we went in to listen to report and during the report was told that there no changes on my patient. (Ms. M.S). coming out of the report room we found the wound nurse ready to do some wound dressing so we went with her the 1st patient we met was a male, he had two bed sores on both heels. They could not be staged since they both had eschar on them. The wound care nurse said they were unstage pressure ulcers. She the just the basic cleaning and dressing of the wound as there not much she could do since she cant get under the eschar. The next patient fell on her right knee , the knee was not broken but had a large hematoma around it. The wound nurse cleaned, and packed the wound and also put some compression socks on the knee to help bring down the swellings. The third patent we met was the most interesting; she had lymph edema on both legs. The swelling and accumulation of fluid on the legs has caused two big opens on the skin behind the leg. The wound nurse cleaned the wound and used a dry dressing to help collect the drains from the wound and around the legs. Then I went to my assigned patient(M.S) for the day, she had a medical history of Macular degeneration, COPD, Asthma, GERD, Rheumatoid arthritis, Hypertension. Admited for post –op left knee replacement and MRSA. Her medications were: Multivitamin PO bid Lovenox 30mg q12h for 10 days Senna 2 tabs PO at bedtime Bactroban bid for 5 days Zocor 10mg PO at bedtime Zantac 150mg PO q4h prn Prinivil 20 mg PO once a day Advair
Tylenol 650mg prn Lortab q4h prn Oscal with vitD She was in the physical therapy room having her therapy for the day I was with her and she had a total of two and half hour therapy. then we went to her room with her to do a complete physical assessment on her. All her signs were normal as seen above. I also got to see a patient who was on peg tube, I leant how to flush a peg tube, listen to abnormal bowel sound on a peg tube patient, and also check for placement. This patient also had one sided weakness as a result of stroke. I saw for the first time how that affects the eyes, ears trachea, hand, legs and also the various systems. This made all these things I have been though in class clearer. It also helped to see a catheter emptied too. I think the hands on makes things clearer. I interacted well with the patient , peers especially the patient as they like to be talked to and to be listen to. They had so much to say I was surprise as to how they freely gave out their in formations about themselves. And how much they wanted us to use them as a learning tool. I was more comfortable doing the catheter empting, peg tube, vital signs, but I still will like to see more of the charts I an still not comfortable with reading it and find information from it. The doctors writing seems unreadable to me but I believe with time I will get used to it. Skills that are not comfortable to me are patient assessment and also interacting with the patient. I will want to do more hands on, more patient interaction, I also want to be able to coordinate my day better as get confused on what to do next. I am still a bit confused about a lot of things but in all I think it will be well. I just need to relax and take it one step at a time.