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Nursing Care Plan Course: NUR 1210L Instructor: Dates of Care: 12, 13, 19 & 20 Sept 96 Date Submitted: 11/15/96 Student Names: Anthony Bernardi, SN/SPJC HOLISTIC NURSING CARE PLAN STUDENT Anthony Bernardi GRADE DATE November 15, 1996 Client's Clinical Picture (5) (Initial Cephacaudal assessment) Textbook Description of Diagnosis (5) Summary of Client's Progress (5) Completion of Holistic NCP Tool (30) NURSING DIAGNOSIS (15) GOALS (10) INTERVENTIONS (10) RATIONALES (5) EVALUATIONS (10) REFERENCES (5) TABLE OF CONTENTS SUBJECT PAGE # Cover Page 1 Grading Point Scale 2 Table of Contents 3 Summary Page 4 Client's Clinical Picture (Cephacaudal Assessment) 5 Medical Diagnosis 6 Textbook Description of Disease 6-12 Treatments and Procedures 13 Summary of Caregiver Progress Notes 14 Diagnostic Values Out Of Normal Range Clinical Implications 16 Radiology 17 Medications 18-52 Holistic Nursing Care Plan Form 53-62 List of Nursing Diagnosis 65 Five Nursing Diagnoses 66-70 References 71 CLIENT CLINICAL PICTURE: Please see attached Cephacaudal Assessment (Pages 5) MEDICAL DIAGNOSIS: Current diagnosis:Necrotizing pneumonia, cachexia secondary to malnutrition / infection, hypothroidism, NIDDM, empyema RUI, Aspergilloma, RUI, and depression. HX: HTN, atrial fibrillation, COPD, asthma TEXTBOOK DESCRIPTION OF DIAGNOSIS: See attached Disease Process Description (pages 6-12-) SUMMARY OF CAREGIVER PROGRESS NOTES: See attached Caregiver Progress Notes (page 14-15) CLIENT CLINICAL PICTURE Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for " atypical chest pain and hemoptysis". V/S BP 114/51, P 84, R 24, T 97.4. He seems alert and oriented x 3 and cheerful.

Bowel sounds present x 4. Pt. has a red area on his coccyx. Silvadene treatments have been started. Pt.

Has a fungal lung infection with a pleural suction drainage tube inserted in his chest . Pt is extremely thin with poor skin turgor with a diagnosis of cachexia ( wasting) secondary to malnutrition and infection. Patient is no known allergies to drugs but is allergic to aerosol sprays disinfectants and dust. Advanced directives on chart. Code status DNR.

Primary physician Dr. R, Thoracic surgeon Dr. L. Psychology Dr.W. There is PT, OT Dietary and Infectious Disease consults when necessary.

He lives with his wife who he has been married to for 56 years. His son and his daughter come to visit him. He does not smoke. He wears dentures but did not bring them. He dose not use a hearing aid but he does have a hearing deficit. Pt.

is able to do all his ADL's with limited assistance. He wants to get better and leave the HSP. Pt. Stated' 90 days is to long to be here". Pt. States that he is concerned about caring for his tube site when he goes home and does not feel that his wife can do this for him.

Diet: Pureed Hi protein, low fat, anti-dumping with Calorie count (all meals) and drink supplements between meals. TPN @ 79cc/hr 12hr around the clock through PICC line MEDICAL DIAGNOSIS: Empyema, Hemoptysis, Necrotizing pneumonia, Aspergillosis (Aspergillus fumigatus) cachexia secondary to malnutrition/infection, hypothyroidism, Diabetes Type II melitius , and depression. PATHOPHYSIOLOGY HEMOPTYSIS: Expectoration of blood arising from the oral cavity, larynx, trachea, bronchi or lungs (Tabor's, 17th ed. 1989 p.879) CACHEXIA SECONDARY TO MALNUTRITION/INFECTION : The state of ill health, malnutrition, and wasting It may occur in any chronic diseases, certain malignancies and advanced pulmonary tuberculosis. (Tabor's, 17th ed. 1989 p.287) NECROTIZING PNEUMONIA: Aspiration pneumonia.

Aspiration pneumonia is frequently called necrotizing pneumonia because of the pathologic changes in the lungs. It usually follows aspiration of material in the mouth into the trachea and subsequently the lungs. The aspirated material. Either food, water, or vomitus, is the triggering mechanism for the pathology of this type of pneumonia. If the aspirated material is an inert substance (e.g. barium or nonacid stomach contents), the initial manifestation is usually caused by obstruction of airways.

When the aspirated materials contain gastric acid, there is chemical injury to the lung parenchyma with infection as a secondary event usually 48 to 72 hours later. The infecting organism is usually one of the normal oropharyngeal flora. The clinical manifestations proceed as those of a classic pneunococcal or streptococcal pneumonia. Fungi may also be a cause of pneumonia. These infections are not transmitted from person to person, and the patient does not have to be placed in isolation.

The clinical manifestations are similar to those of bacterial pneumonia. Skin and serology tests are available to assist in identifying the infecting organism. However, identification of the organism In a sputum specimen or in other body fluids is the best diagnostic indicator. (Lewis, S.M. & Collier, p. 643-644) ASPERGILLOSIS INFECTIONS : There are several forms of Aspergillosis infections.

All are caused by one or more of the many different Aspergillus fungus species; only a few of these organisms are capable of producing disease in humans. These species are spread through the air and can be found almost any place in the world. Because these spores are inhaled, they usually affect the lungs or other airway passages such as the bronchial tubes, nose and sinuses. The fungi can be invasive, affecting any tissue, mucous membrane or vital organ of the body. Allergic Bronchopulmonary Aspergillosis (ABPA) is an immune disorder that occurs in people with asthma or chronic obstructive pulmonary disease (COPD) infected with Aspergillosis fungi. It causes an excess of certain white blood cells (eosinophils), an infiltration of the lungs, and impaction of the bronchial tubes with eosinophils and Aspergillus organisms.

Symptoms of this disease may consist of fever, shortness of breath (dyspnea), chest pain, wheezing, a cough with sputum (with or without blood) or a generalized feeling of ill-health (malaise). This form of Aspergillosis is not usually invasive, but it can lead to a chronic dilation of the bronchial tubes (bronchiectasis). Pulmonary Mycetoma, also known as Aspergilloma or fungus ball, is a form of Aspergillosis that often occurs as a result of the Aspergillus fungus growing together (colonization) in a cavity of the lungs. These cavities are usually caused by other pulmonary diseases such as tuberculosis, sarcoidosis, histoplasmosis or coccioidomycosis. The fungus ball can be seen on x-rays. This form of Aspergillosis is characterized by a chronic cough, weight loss, a generalized feeling of ill-health (malaise) and the spitting up of blood (hemoptysis). Fulminative or Invasive Aspergillosis is another form of this disorder that can cause distribution of the Aspergillus fungus to other parts of the body.

This disease can progress from a localized infection to a widespread erosion and ulceration of the bronchial system and an inflammation of the vascular system (vasculitis). Vasculitis is a narrowing of the inside of a blood vessel that can obstruct the flow of blood to the tissues. This lack of blood can cause damage to the tissues (necrosis), and a possible formation of blood clots (thrombosis). Invasive Aspergillosis is usually first confined to the lungs but it can spread through the blood to other organs especially the liver, brain, kidneys, skin, gastrointestinal tract and other sites. This can be a very serious disease which can have a slow or rapid course. It is seen in those whose immune system has been weakened by other illnesses, especially people with cancer (e.g., Leukemia, Hodgkin's Disease), kidney transplant patients or those undergoing certain drug therapies.

Occasionally, Aspergillosis can cause Infective Endocarditis which is an infection of the inner lining of the heart muscle (endocardium). A type of infective endocarditis, prosthetic valvular endocarditis (PVE), may develop in patients who have previously had artificial (prosthetic) heart valve replacement. This infection may occur as a result of contamination of the operating room area by the Aspergillus spores. Drug addicts are also more susceptible to this form of Aspergillosis. Mycetoma, also known as Madura Foot, is a chronic infection produced by Aspergillosis as well as several other fungi. It is a progressive fungal disease that is characterized by lesions of the foot, face, trunk, hand or leg. These lesions can cause swelling, hardening, pus formation, sinus drainage and abscesses that can lead to bone destruction and deformities.

It is more commonly seen in tropical climates. Aspergillosis is a group of infectious diseases that are caused by the inhalation of the Aspergillus fungus. The spores that cause these infections can be found in decaying vegetable matter, grains, grass, leaves, soil, wet paint, air conditioning systems, on refrigerator walls and in construction and fireproofing materials. It is not known why most people resist infection from this common fungus, and why others are more susceptible to infection. A weakened immune system, or an abnormal immune response to the fungus, may cause the fungus to proliferate and become a threat to one's health. Aspergillosis is a rare disorder that affects males and females in equal numbers. It is seen more often in those people who have chronic respiratory problems or whose immune system has been weakened by other serious illnesses or drug therapy.

DEPRESSION: Depression is the most common functional disorder. Signs of depression include sadness, low energy, diminished memory and concentration, sleeping disturbances, appetite disturbance, with withdrawal, irritability, alcohol abuse, expressed feelings of helplessness and hopelessness, apathy, impaired attention span, and expression of suicidal wishes. Depression is often treatable and reversible through use of antidepressant medications and counseling. (Brunner/ Suddarth, 1988) HYPERTENSION: Hypertension can be defined arbitrarily as persistent levels of blood pressure in which the systolic pressure is above 140 mm Hg and the diastolic pressure is above 90 mm Hg. In the elderly population, hypertension is defined as systolic pressure above 160 mm Hg and diastolic pressure above 90 mm Hg. Hypertension is a major cause of heart failure, stroke, and kidney failure.

It is called the "silent killer" because the person who has it is often symptom free. Gerontological Considerations: Changes in the peripheral vascular system are responsible for the changes in blood pressure that occur with age. As the age related process of atherosclerosis evolves, the ability of the vessels to distend and recoil is reduced. Consequently, the aorta and large arteries are less able to accommodate the ejected stroke volume, and a decrease in cardiac output and increase in peripheral resistance result. Systolic blood pressure increases as a result of the increased peripheral resistance, and pulse pressure widens subsequent to the diastolic fall that accompanies reduced distensibility of the aorta. The risk factors for high blood pressure that are present in the population in general continue into old age.

These are approximately the same for elderly men and women. (Brunner/ Suddarth, 1988) CHRONIC OBSTRUCTIVE PULMONARY DISEASE : Chronic obstructive pulmonary disease (COPD) is the most common cause of death and disability due to lung disease in the United States. COPD is a broad classification that includes a group of conditions associated with chronic obstruction of air flow entering or leaving the lungs. Airway obstruction is diffuse airway narrowing, causing increased resistance to air bronchiectasis, emphysema, and asthma. Basically, the person with COPD has (1) excessive secretion of mucus within the airways not due to specific causes (bronchitis or bronchiectasis), (2) an increase in the size of the air spaces distal to the terminal bronchioles with loss of alveolar walls and elastic recoil of the lungs (emphysema), and (3) narrowing of the bronchial airways that varies in severity (asthma). As a result there is a subsequent derangement of airway dynamics for example, loss of elasticity and obstruction of air flow. There is often an overlap of these conditions.

(Brunner/ Suddarth, 1988 ) ASTHMA : Asthma is an intermittent, reversible, obstructive airway disease characterized by increased responsiveness of the trachea and bronchi to various stimuli. This results in narrowing of the airways, causing dyspnea This narrowing of the airway changes in degree, either spontaneously or because of therapy. Asthma differs from other obstructive lung diseases in that it is a reversible process, and patients may exhibit no symptoms for a prolonged period of time. Asthma is a reversible diffuse airway obstruction. The obstruction is caused by one or more of three developments: (1) contraction of muscles surrounding the bronchi, which narrows the airway (2) swelling of membranes that line the bronchi and (3) filling of the bronchi with thick mucus.

In addition, there is bronchial muscle enlargement, mucous gland enlargement, thick, tenacious sputum, and hyperinflation or air trapping in the alveoli but most of what is known involves the immunologic system and the autonomic nervous system. (Brunner/ Suddarth, 1988 ATRIAL FIBRILLATION: Atrial fibrillation (disorganized and uncoordinated twitching of atrial musculature) is usually associated with atherosclerotic heart disease, rheumatic heart disease, CHF, thyrotoxicosis, or pulmonale, or congenital heart disease. Atrial fibrillation is characterized by the following- lowing: Rate: An atrial rate of 350 to 600 beats per minute ventricular response usually 120 to 200 beats per minute. P waves: No discernible P waves: irregular undulation, termed fibrillary or "f" waves, is seen; PR interval cannot be measured. QRS complex: Usually normal. Conduction: Usually normal through the ventricles. Characterized by an irregular ventricular response, because the AV node is incapable of responding to the rapid atrial rate.

Impulses that are transmitted cause the ventricles to respond irregularly. Rhythm: Irregular and usually rapid, unless controlled. Irregularity of rhythm is due to concealed conduction within the AV node. A rapid ventricular response reduces the time for ventricular filling and hence the stroke volume. The atrial kick, which is 25 to 30% of the cardiac output, is also lost. Congestive heart failure frequently follows.

There is usually a pulse deficit, the numerical difference between apical and radial pulse rates. Treatment is directed toward eliminating the cause, decreasing the atrial irritability, and decreasing the rate of the ventricular response. In patients with chronic atrial fibrillation, anticoagulant therapy may be used to prevent thromboemboli from forming in the atria. Drugs of choice to treat atrial fibrillation are similar to those used in the treatment of paroxysmal atrial tachycardia, digitalis preparation is used to slow the heart rate, and an antidysrhythmic such as quinidine is used to correct the dysrhythmia. (Brunner, & Suddarth 1988).

TYPE II DIABETES MELLITUS: In diabetes, insulin is not secreted in proportion to blood glucose levels because of several possible factors: deficiency in the production of insulin by the beta cells, insensitivity of the insulin secretory mechanism of the beta cells, delayed or insufficient release of insulin, or excessive inactivation by chemical inhibitors or "binders" in the circulation. In some non-insulin dependent persons with diabetes, however, insulin secretion is increased, resulting in higher , circulating insulin levels. Although excess insulin is present, it is not utilized because of an inadequate number of insulin receptors present on cells. This mechanism has been observed in obese patients. With weight loss, the number of insulin receptors on the cells increases, thereby allowing glucose to enter the cell.

This may result in return of a normal glucose tolerance. (Burner/ Suddarth, 1988 ) HYPOTHYROIDISM : Hypothyroidism is a condition in which there is a slow progression of thyroid hypofunction, followed by symptoms indicating thyroid failure. More than 95% of patients with hypothyroidism have primary dysfunction of the thyroid gland itself. When the thyroid dysfunction is due to failure of the pituitary gland, it is known as secondary hypothyroidism; when failure of the hypothalamus is the underlying cause, the term tertiary hypothyroidism is used. When thyroid deficiency is present at birth, the condition is known as cretinism.

In such instances, the mother may also suffer from thyroid deficiency. (Brunner/ Suddarth, 1988) TREATMENTS AND PROCEDURES Patients activity orders are as tolerated with wheel chair transport. Pt needs partial assist with ADLs. He is continent of B & B with assistance Needs to be turned in bed Q 2 hr, elevate heels in bed . Pt has a special mattress.

Encourage I.S. Q 1 hr w/a. IV flush q shift peripheral line. PICC line flush. Chest tube to water seal to 20cm, with cont. suction 55-60 wall green. DO NOT DISCONTINUE SUCTION. Chest tube dressing change no deviations from present form.

Accurate I&O's . VS. Q shift and prn. with lung sounds assessment. Skin assessment q 2 hr with wound assessment at the same time(abrasion on the back ) and finger ulceration.

FSGs q 6 hr with Sliding scale coverage. Weight every week on Monday. SUMMARY OF CARE GIVER NOTES: All times are approximate 07:30 Received report on G.B. from night shift. 08:00 Spoke with G.B.

before breakfast was delivered. Vital signs taken and noted. Insured patency of chest drainage tubes and amount of fluid from last shift. Noted time and initialed on collecting container. 09:00 09:00 medications given and noted 09:30 Assisted G.B. with ADL's.

Pt stated that he wasn't very hungry. Pt. Ate only 25% of solid food. Noted intake of 250ml. Urine output after breakfast 225ml.

Pt. Performed own bed bath and oral care. Lotion applied to Pt. Pt. Helped into bedside commode.

Curtains drawn for privacy. 10:30 Dressing change on tube insertion site as ordered. Skin assessment done and lung sounds checked. Check position of G.B. He had re-positioned himself for comfort 10:45 X-Ray of G.B. performed in room. G.B.

dressed and assisted into wheel chair. 11:00 Reported pt status to Team Leader. 11:00 Documented morning activities in appropriate charts, i.e. Nsg Notes, treatment book and V/S charts. 11:15 Returned to room to interview G.B. . Pt was cheerful but stated that he was feeling tired and wanted to be helped back into bed.

11:45 Noted I & O 12:00 G. B. In bed resting comfortably. Reported pt status to team leader and report off floor to post-conference. DIAGNOSTIC VALUES OUT OF NORMAL RANGE CLINICAL IMPLICATIONS BUN 32H 10-26 A.

Increased BUN levels (azotemia) 1. The most common cause of increased BUN level is inadequate excretion due to kidney disease or urinary obstruction, frequently- : occurring in cases of prostate enlargement. (A) An increased BUN of 50 to 150 mg / 100 ml indicates serious impairment of renal function. (Fishbach p. 312) Creatinine .5H 0.7-1.4 A disorder of kidney function reduces excretion of creatinine, resulting in increased levels of blood creatinine. The test is used to diagnose impaired renal function.

It is a more specific and sensitive indicator of kidney disease than BUN, although in chronic renal disease, BUN correlates more accurately with symptoms of uremia than does the blood creatinine.( (Fishbach p. 312) WBC 10.4H 5-10 A. Leukocytosis (white blood cell count above l0000 / gl) 1. Leukocytosis is usually due to an increase of only one type of White cell and is given the name of the type of cell that shows white cell and is given the name of the type of cell that shows the main increase. .In increase in circulating leukocytes is rarely due to a proportional increase in leukocytes of all types. When it occurs it is usually to hemoconcentration. Leukocytosis occurs in acute infections in which the degree of increase of white cells depends on, 1.

The severity of the infection, 2. The patient's resistance, 3. The patient's age.(Fishbach p. 25.) RBC 2.96L 4.2-5.6 Decreased RBC Values . Anemia, a condition in which there is a reduction in the number of circulating RBCs, in the amount of hemoglobin, and/or in the volume of packed cell(hematocrit).(Fishbach p.

41) HGB 10.L 13.1-17.2 Anemia HCT 29.3L 39-50 decreased hematocrit values are an indicator of anemia. In hematocrit of 30 or less means the patient is moderately to severely anemic. ALBUMIN 3.1l 3.9-5 decreased albumin levels severe hypoalbuminemia is often associated with edema and decreased transport function such as hypocalcemia. Decreased albumin levels are caused by many different conditions i.e. Nephrosis (Fishbach p.

363) LY# 1.2L 1.8-2.6 Anemia MCH 34H 26-34 An increase of the MCH is associated with macrocytic anemia. MCV 99.2H 87 -103 Note VA values differ from Fishbach. F the MCV is greater than 103 mm3, the red cell 5 are macrocy tic. PLT 433H 150-350 Abnormally increased numbers of platelets (thrombocythemial thrombocytosis) occur in iron-deficiency and posthemorrhagic anemia acute infections and many other diseases. In 50% of those patients who exhibit an unexpected increase in plate- lets, a malignancy will be found. This malignancy is usually disseminated, advanced, or inoperable.

MPV 6.3L 8 -10L This test is done in the investigation of various hematologic disorders such as thrombocytopenic purpura, and study of alcoholics under treatment. Na+ 135 135-148 Hyponatremia usually reflects a relative excess of body water rather than a low total body sodium. K 4.6 2.7-4.5 Hyperphosphatemia (increased phosphorus levels) The most common causes of elevated blood phosphate levels are in association with kidney dysfunction and uremia. This is because phosphate is so closely regulated by the kidneys. Renal insufficiency and severe nephritis (accompanied by elevated- : BUN and creatine) Albumin 3.1 3.8-5.0 albumin is a protein that is formed in the liver and that helps to maintain normal distribution of water in the body (colloidal osmotic pressure).

It also helps in the transport of blood constituents such as ions, pigments, bilirubin, hormones, fatty acids, enzymes, and certain drugs. Decreased albumin levelsDecreased albumin levels are caused by many different conditions- inadequate iron intake, Severe liver diseases Malabsorption, Starvation, excessive administration of IV glucose in water RADIOLOGY F/Y empyema status no change since 9/3/96. F/U - bilateral sever pulmonary emphysema & interstitial fibrosis. CBC shows high levels of WBC's and bends indicative of ongoing infection. Chemistry shows elevated liver enzymes. UA and C&S are negative.

Blood cultures are also negative. Sputum C&S and Gram Stain show WBC* 25, Eph.*10 and presence of Alpha streptococcus & neisseria. LABS AND X-RAYS: CXR done on 9/3 shows normal heart size, no change in the status of pulmonary fibrosis, emphysema but there is new fluid in R major fissure. Echo done 7/22 reveals L ventricular systolic dysfunction and ejection fraction of 31%. ECG done 7/29 shows Arterial Fibrillation.

CT-scan of chest is ordered. MEDICATIONS ALBUTEROL Albuterol, Proventil, Proventil Repetabs, Salbutamol, Ventolin, Ventolin Rotacaps, Volmax Func. class.: Adrenergic b2 agonist Action: Causes bronchodilation by action on b2 (pulmonary) receptors by increasing levels of cAMP, which relaxes smooth muscle; produces bronchodilation, CNS, cardiac stimulation, as well as increased diuresis and gastric acid secretion; longer acting than isoproterenol Uses: Prevention of exercise-induced asthma, bronchospasm, production of premature labor Dosage and routes: To prevent exercise-induced asthma • Adult: INH 2 puffs 15 min before exercising, NEB/LPPB 5 mg tid-qid Bronchospasm • Adult: INH 1-2 puffs q4-6h PO 2-4 mg tid-qid, not to exceed 8 mg Prevention of premature labor Available forms: Aerosol 90 mg/actuation; tabs 2, 4 mg; syr 2 mg/5 ml, cont rel 4, 8 mg Side effects/adverse reactions: CNS: Tremors, anxiety, insomnia, headache, dizziness, stimulation, restlessness, hallucinations, flushing, irritability EENT: Dry nose, irritation of nose and throat CV: Palpitations, tachycardia, hypertension, angina, hypotension, dysrhythmias GI: Heartburn, nausea, vomiting MS: Muscle cramps Contraindications: Hypersensitivity to sympathomimetics, tachydysrhythmias, severe cardiac disease Precautions: Lactation, pregnancy , cardiac disorders, hyperthyroidism, diabetes mellitus, hypertension, prostatic hypertrophy, narrow-angle glaucoma, seizures, exercise-induced bronchospasm (aerosol) in children *12 years Pharmacokinetics: Well absorbed PO, extensively metabolized in the liver, excreted in urine, crosses placenta, breast milk, blood-brain barrier PO: Onset hr, peak 2 hr, duration 4-6 hr, half-life 2 hr PO-ER: Onset hour; peak 2-3 hr; duration 12 hr INH: Onset 5-15 min, peak 1-1 hr, duration 4-6 hr, half-life 4 hr Interactions/incompatibilities: • Increased action of aerosol bronchodilators • Increased action of albuterol: tricyclic antidepressants, MAOIs, other adrenergics • May inhibit action of albuterol: other b-blockers NURSING CONSIDERATIONS Assess: • Respiratory function: vital capacity, forced expiratory volume, ABGs, lung sounds, heart rate and rhythm (baseline) • That patient has not received theophylline therapy before giving dose • Client's ability to self-medicate • For evidence of allergic reactions Administer: • After shaking, exhale, place mouthpiece in mouth, inhale slowly, hold breath, remove, exhale slowly • Gum, sips of water for dry mouth • PO with meals to decrease gastric irritation • Syrup to children (no alcohol, sugar) Perform/provide: • Storage in light-resistant container, do not expose to temperatures over 86 F (30 C) Evaluate: • Therapeutic response: absence of dyspnea, wheezing after 1 hr, improved airway exchange, improved ABGs Teach patient/family: • Not to use OTC medications; extra stimulation may occur • Use of inhaler; review package insert with patient • To avoid getting aerosol in eyes; blurring may result • To wash inhaler in warm water qd and dry • To avoid smoking, smoke-filled rooms, persons with respiratory infections • That paradoxical bronchospasm may occur and to stop drug immediately • To limit caffeine products such as chocolate, coffee, tea, and colas Treatment of overdose: Administer a b2-adrenergic blocker PANCRELIPASE Creon Capsules, Func. class.: Digestant Chem. class.: Pancreatic enzyme-bovine/porcine Action: Pancreatic enzyme needed for proper pancreatic functioning Uses: Exocrine pancreatic secretion insufficiency, cystic fibrosis (digestive aid), steatorrhea, pancreatic enzyme deficiency Dosage and routes: • Adult and child: PO 1-3 caps/tabs ac or with meals, or 1 caps/tab with snack or 1-2 pdr pkt ac Available forms: Tab 8000, 11,000, 30,000 U; caps 8000, 30,000 U; enteric coated caps 4000, 5000, 20,000, 25,000 U; powd 16,800 U Side effects/adverse reactions: GI: Anorexia, nausea, vomiting, diarrhea GU: Hyperuricuria, hyperuricemia Contraindications: Allergy to pork, chronic pancreatic disease Precautions: Pregnancy Interactions/incompatibilities: • Decreased absorption: cimetidine, antacids, oral iron NURSING CONSIDERATIONS Assess: • I&O ratio; watch for increasing urinary output • Fecal fat, nitrogen, pro-time during treatment • For polyuria, polydipsia, polyphagia (may indicate diabetes mellitus) Administer: • After antacid or cimetidine; decreased pH inactivates drug • Powder mixed in prepared fruit for infants, children • Whole, not crushed or chewed (enteric coated) • Low-fat diet to decrease GI symptoms • Powder mixed with pureed fruit; take tabs with or before food Perform/provide: • Storage in tight container at room temperature Evaluate: • FOR ALLERGY TO PORK DIGOXIN Digoxin, Lanoxicaps, Lanoxin Func. class.: Antidysrhythmic, cardiac glycoside Chem.

class.: Digitalis preparation Action: Inhibits the sodium-potassium ATPase, which makes more calcium available for contractile proteins, resulting in increased cardiac output Uses: CHF, atrial fibrillation, atrial flutter, atrial tachycardia, rapid digitalization in these disorders Dosage and routes: • Adult: IV 0.5 mg given over *5 min, then PO 0.125-0.5 mg qd in divided doses q4-6hr as needed • Elderly: PO 0.125 mg qd maintenance • Child *2 yr: PO 0.02-0.04 mg/kg divided q8h over 24 hr; maintenance 0.006-0.012 mg/kg qd in divided doses q12hr; IV loading dose 0.015-0.035 mg/kg over *5 min • Child 1 mo-2 yr: IV 0.03-0.05 mg/kg in divided doses over *5 min q48h; change to PO as soon as possible; PO 0.035-0.060 mg/kg divided in 3 doses over 24 hr; maintenance 0.01-0.02 mg/kg in divided doses q12h • Neonates: IV loading dose 0.02-0.03 mg/kg over *5 min in divided doses q4-8h; change to PO as soon as possible; PO loading dose 0.035 mg/kg divided q8h over 24h; maintenance 0.01 mg/kg in divided doses q12hr • Premature infants: IV 0.015-0.025 mg/kg divided in 3 doses over 24 hr, given over *5 min; maintenance 0.003-0.009 mg/kg in divided doses q12h Available forms: Caps 50, 100, 200 mg; elix 50 mg/ml; tabs 125, 250, 500 mg; inj 100, 250 mg/ml Side effects/adverse reactions: CNS: Headache, drowsiness, apathy, confusion, disorientation, fatigue, depression, hallucinations CV: Dysrhythmias, hypotension, bradycardia, AV block EENT: Blurred vision, yellow-green halos, photophobia, diplopia GI: Nausea, vomiting, anorexia, abdominal pain, diarrhea Contraindications: Hypersensitivity to digitalis, ventricular fibrillation, ventricular tachycardia, carotid sinus syndrome, 2nd or 3rd degree heart block Precautions: Renal disease, acute MI, AV block, severe respiratory disease, hypothyroidism, elderly, pregnancy , sinus nodal disease, lactation, hypokalemia Pharmacokinetics: PO: Onset -2 hr, peak 6-8 hrs, duration 3-4 days IV: Onset 5-30 min, peak 1-5 hr, duration variable, half-life 1.5 days excreted in urine Interactions/incompatibilities: • Hypokalemia: diuretics, amphotericin B, carbenicillin, ticarcillin, corticosteroids, piperacillin • Decreased digoxin level: thyroid agents • Increased blood levels: propantheline bromide, spironolactone quinidine, verapamil, aminoglycosides PO, amiodarone, anticholinergics, quinine • Increased bradycardia: b-adrenergic blockers, antidysrythmics • Toxicity: adrenergics, amphotericin, corticosteroids, diuretics, glucose, insulin, reserpine, succinylcholine, quinidine, thioamines • Incompatible with acids, alkalies, Ca salts Lab test interferences: Increase: CPK NURSING CONSIDERATIONS Assess: • Apical pulse for 1 min before giving drug; if pulse *60 in adult or *90 in an infant, take again in 1 hr; if *60 in adult, call physician; note rate, rhythm, character • Electrolytes: K, Na, Cl, Mg, Ca; renal function stu ...

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